Factors Influencing the Reparability and Healing Rates of Rotator Cuff Tears

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.

Obesity is associated with muscle atrophy in rotator cuff tear

Objective

The primary goal of this study is to evaluate the relationship between Body Mass Index (BMI) and muscle atrophy in individuals with rotator cuff tears.

Methods

This study consists of patients with rotator cuff tears identified by MRI from two independent cohorts, the Rotator Cuff Outcomes Workgroup (ROW) and the Multicenter Orthopaedic Outcomes Network (MOON). Presence of atrophy (yes/no) and severity of atrophy (as an ordinal variable) were assessed on MRI by expert physicians. We used multivariable regression models to evaluate the relationship between BMI and muscle atrophy while adjusting for age and sex in each study, conducted sensitivity analyses for full-thickness tear and combined results using inverse variance-weighted meta-analysis.

Results

A total of 539 patients (MOON=395, ROW=144) from the combined cohorts had MRI data available on muscle atrophy. Among these patients, 246 (46%) had atrophy of at least one of the muscles of the rotator cuff and 282 (52%) had full-thickness tears. In meta-analysis across both cohorts, each 5 kg/m2 increase in BMI was associated with a 21% (aOR=1.21, 95% CI=1.02, 1.43) increased odds of having muscle atrophy among individuals with any tear size, and 36% (aOR=1.36, 95% CI=1.01-1.81) increased odds among individuals with full-thickness tear.

Conclusions

Higher BMI was associated with significantly higher odds of muscle atrophy in patiens with rotator cuff tears. More study is needed to unders1tand why and how this relationship exists, as well as whether interventions to reduce BMI may help improve outcomes for these patients.

Level of Evidence

III.

Return to Sports and Activities after Arthroscopic Treatments for Rotator Cuff Lesions in Young Patients Less Than 45-Years-Old: A Systematic Review

Background: To evaluate the outcomes of arthroscopic treatment of rotator cuff tear (RCT) in individuals under 45 years, focusing on their ability to return to sports (RTS) and work, along with different patient-reported outcomes (PROMs). Methods: Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, this systematic review encompassed articles that studied the outcomes of arthroscopic treatment of RCT in the young population (those under 45 years old). The literature search was conducted in PubMed/Medline and EMBASE until 21 May 2024. The primary outcome was the RTS, with secondary outcomes including the return to work and various PROMs. These PROMs included the American Shoulder and Elbow Surgeons (ASES) score and 10 other PROMs. Results: Out of 6267 articles, 15 met the inclusion criteria, involving 659 patients, predominantly male athletes with a weighted mean age of 28.3 years. The RCT etiology (14 studies) was primarily traumatic (72.3%), followed by chronic microtrauma in overhead athletes (16.8%) and non-traumatic (10.9%). The RTS rate (12 studies) varied between 47% and 100%, with a cumulative rate of 75.2%. The cumulative rate of return to the same or higher RTS level (11 studies) was 56.1%. Excluding non-athletes and patients treated with debridement, the RTS rates increased to 79.8% (143/179) overall, with a 61% (108/177) rate of returning to the same or higher level. The return to work (3 studies) was successful in 90.6% of cases. Postoperative ASES scores (5 studies) improved markedly to a weighted post-operative mean of 75.6, with similar positive trends across other PROMs. Conclusions: Young adults undergoing arthroscopic RCT repair typically experience a 75% RTS rate at any level, and 56.1% RTS at the same level. Excluding non-athletes and debridement patients, RTS rates rise to 79.8% (143/179), with 61% (108/177) achieving the same or higher level. Level of evidence: IV, systematic review including case series.

Neighborhood socioeconomic disadvantages influence outcomes following rotator cuff repair in the non-Medicaid population

BACKGROUND

Prior investigations have utilized various surrogate markers of socioeconomic status to assess how health care disparities impact outcomes after rotator cuff repair (RCR). When taken as individual markers, these factors have inconsistent associations. Medicaid insurance status is an accessible marker that has recently been correlated with less optimal outcomes after RCR. Socioeconomic disparities exist within the non-Medicaid population as well and are arguably more difficult to characterize. The Area Deprivation Index (ADI) uses seventeen socioeconomic variables to establish a spectrum of neighborhood health care disparity. The purpose of this study was to determine the influence of neighborhood socioeconomic disadvantages, quantified by ADI, on 2-year patient reported outcome scores following RCR in the non-Medicaid population.

METHODS

A retrospective review of patients who underwent RCR from 2015 to 2020 was performed. All procedures were performed by a group of 7 surgeons at a large academic center. Patient demographics and comorbidities were collected from charts. Rotator cuff tear size was assessed from arthroscopic pictures. ADI scores were calculated based on patients' home addresses using the Neighborhood Atlas tool. The primary outcome measure was American Shoulder and Elbow Surgeons (ASES) score with a minimum follow-up of 2 years. A linear regression analysis with covariate control for age and patient comorbidities was performed.

RESULTS

There were 287 patients with a mean age of 60.11 years. The linear regression model between ADI and 2-year ASES score was significant (P = .02). When controlling for both age and patient comorbidities, every 0.9-point reduction in ADI resulted in a 1-point increase in the ASES score (P = .03). Patients with an ADI of 8, 9, or 10 had lower mean 2-year ASES scores than those with an ADI of 1 (87.08 vs. 93.19, P = .04), but both groups had similar change from preoperative ASES score (40.17 vs. 32.88, P = .12). The change in ASES score at 2-years in our study surpassed all established minimal clinically important difference values irrespective of ADI.

CONCLUSION

Patients with greater levels of disparity in their home neighborhoods have worse final ASES scores at 2 years, but patients significantly improve from their preoperative state regardless of social disadvantages. This is the first study to the authors' knowledge that examines ADI and outcomes following RCR. Providers should be aware that patients with higher ADI scores may have inferior preoperative shoulder function. The results of this study support the utilization of primary RCR in applicable tears regardless of socioeconomic status.

Risk factors influencing postoperative outcome of arthroscopic rotator cuff repair and construction of a nomogram prediction model

OBJECTIVE

To investigate the risk factors influencing the postoperative outcome of arthroscopic rotator cuff repair (ARCR) and develop a nomogram prediction model.

METHODS

A retrospective study was conducted on 302 patients who underwent ARCR from January 2019 to August 2023. Patients were categorized into two groups: a control group with 150 patients showing good recovery and an observation group with 152 patients exhibiting poor recovery. Relevant clinical data were collected and statistically analyzed. A nomogram model was constructed based on the results of multivariate logistic regression analysis. The model's accuracy, discrimination, and clinical utility were evaluated using calibration charts, AUC, c-index, and decision curve analysis. Internal validation was performed through self-random sampling.

RESULTS

Univariate and multivariate regression analysis identified having a frozen shoulder, large rotator cuff tear, increased intraoperative rivet use, diabetes, and traumatic tear as predictive risk factors for poor postoperative outcomes. These factors were utilized to develop a clinical predictive nomogram. The nomogram model demonstrated excellent predictive accuracy for poor postoperative outcomes, both internally and externally. The unadjusted concordance index (C-index) was 0.793 [95% confidence interval (CI), 0.825-0.995]. The AUC for the nomogram was 0.788. Decision curve analysis revealed that the predictive model was clinically useful when the threshold probability ranged from 20 to 60%.

CONCLUSION

The presence of a frozen shoulder, large rotator cuff tear, increased intraoperative rivet use, diabetes, and traumatic tear elevate the risk of suboptimal outcomes following ARCR. Conversely, having a higher preoperative University of California at Los Angeles Shoulder Rating Scale score mitigates this risk. This study introduces a novel nomogram model, exhibiting relatively high accuracy, which enables clinicians to precisely assess the postoperative adverse risk among patients with rotator cuff injuries requiring arthroscopic repair at the outset of treatment.

Achilles tendon assessment on quantitative MRI: Sources of variability and relationships to tendinopathy

Quantitative MRI (qMRI) measures are useful in assessing musculoskeletal tissues, but application to tendon has been limited. The purposes of this study were to optimize, identify sources of variability, and establish reproducibility of qMRI to assess Achilles tendon. Additionally, preliminarily estimates of effect of tendon pathology on qMRI metrics and structure-function relationships between qMRI measures and ankle performance were examined. T1, T1ρ, T2, and T2* maps of the Achilles tendon were obtained using a 3T MRI scanner. In participants with asymptomatic tendons (n = 21), MRI procedures were repeated twice, and region of interest selection was performed by three raters. Variance decomposition and reproducibility statistics were completed. To estimate the effect of pathology, qMRI measures from individuals with asymptomatic tendons were compared to qMRI measures from a pilot group of individuals with Achilles tendinopathy (n = 7). Relationships between qMRI and ankle performance measures were assessed. Between-participant variation accounted for the majority of variability (46.7%-64.0%) in all qMRI measures except T2*. ICCs met or exceeded 0.7 for all qMRI measures when averaged across raters or scans. Relaxation times were significantly longer in tendinopathic tendons (mean (SD) T1: 977.8 (208.6) ms, T1ρ: 35.4 (7.1) ms, T2: 42.8 (7.9) ms, T2*: 14.1 (7.6) ms, n = 7) compared to asymptomatic control tendons (T1: 691.7 (32.4) ms, T1ρ: 24.0 (3.6) ms, T2: 24.4 (7.5) ms, T2*: 9.5 (3.4) ms, n = 21) (p < 0.011 for all comparisons). T1 related to functional performance measures in symptomatic and asymptomatic groups. Study findings suggest that qMRI is reliable to assess the Achilles tendon. qMRI quantitatively assesses the presence of tendon pathology and relates to functional performance outcomes, supporting the utility of incorporating qMRI in research and clinic.

Lower Trapezius Transfer for Irreparable Posterosuperior Rotator Cuff Tears

PURPOSE OF REVIEW

Functionally irreparable posterosuperior rotator cuff tears (FIRCT) represent a substantial source of morbidity for many patients. Several surgical options can be considered for the salvage of FICRTs. Transfer of the tendon of the lower trapezius to the greater tuberosity, originally described for surgical management of the paralytic shoulder, has emerged as an attractive option, particularly for patients with external rotation lag and those looking for strength restoration. The purpose of this publication is to review the indications, surgical technique, and reported outcomes of this procedure.

RECENT FINDINGS

Lower trapezius transfer (LTT) to the greater tuberosity in patients with irreparable posterosuperior rotator cuff tears has been reported to be associated with satisfactory outcomes and low reoperation rates. It seems to be particularly effective in improving external rotation motion and strength, even when the teres minor is involved. In patients with a reparable infraspinatus, minimal fatty infiltration, and an intact teres minor, the outcome of LTT may be similar to that of superior capsule reconstruction (SCR), but LTT is more beneficial otherwise. The hospital cost of LTT has been reported to be less than the cost of SCR and equivalent to the cost of reverse arthroplasty. When reverse arthroplasty has been performed after a failed LTT, the outcome and complication rates do not seem to increase. LTT provides satisfactory outcomes for many patients with a posterosuperior FIRCT, particularly when they present preoperatively with an external rotation lag sign, involvement of the teres minor, or a desire to improve strength.

The Association between the Extent of the Osteoarthritic Meniscus Degeneration and Cigarette Smoking-A Pilot Study

Background and Objectives: The negative effects of smoking on the musculoskeletal system were presented by many authors, although the relationship between smoking and osteoarthritis remains unclear. The aim of this paper was to investigate the negative effects of smoking on meniscal tissue in osteoarthritic knees by microscopic examination, by adapting the Bonar scoring system and its modifications. Materials and Methods: The study involved 34 patients with varus knees, from whom 65 samples of knee menisci were obtained. The mean age in the studied group was 65.385 years. The smoking status of the patients concluded that there were 13 smokers and 21 nonsmokers. Results: Among smokers, the mean classical Bonar score was 8.42 and the mean modified Bonar score was 6.65, while nonsmokers were characterized by scores of 8.51 and 7.35, respectively. There was a statistically significant negative correlation between the number of cigarettes and the collagen in the medial meniscus (p = 0.0197). Moreover, in the medial meniscus, the modified Bonar score correlated negatively with the number of cigarettes (p = 0.0180). Similarly, such a correlation was observed between the number of cigarettes and the modified Bonar score in the lateral meniscus (p = 0.04571). Furthermore, no correlation was identified between the number of cigarettes and the classical Bonar score in the lateral meniscus. There was a statistically significant difference in the collagen variable value between the smokers and nonsmokers groups (p = 0.04525). Conclusions: The microscopic investigation showed no differences in the menisci of smokers and nonsmokers, except for the collagen, which was more organized in smokers. Moreover, the modified Bonar score was correlated negatively with the number of cigarettes, which supports the role of neovascularization in meniscus pathology under the influence of tobacco smoking.

Management of irreparable subscapularis tears: Current concepts

Primary repair of acute subscapularis (SSC) tears provides excellent results, but tendon retraction, muscle atrophy, fatty infiltration, and humeral head migration may render a more chronic tear irreparable. These irreparable SSC tears present a diagnostic and treatment challenge for orthopaedic surgeons. Careful physical examination and imaging evaluation can help to distinguish those with reparable versus irreparable tears, but they are still not very reliable due to the methodological limitations of current evidence. Therefore, future research using 3D and quantitative measurement techniques is necessary to better predict the irreparability of the SSC. When conservative treatment of an irreparable SSC tear fails, reversed shoulder arthroplasty has been established as the preferred treatment option for older, low-demand patients with arthropathy, providing reliable improvements in pain and function. In younger patients without significant arthropathy, musculotendinous transfers are the treatment of choice. The pectoralis major transfer is historically the most frequently performed procedure and provides improved range of motion and pain relief, but fails to adequately restore strength and shoulder function. The latissimus dorsi transfer has gained increased interest over the last few years due to its biomechanical superiority, and early clinical studies suggest improved outcomes as well. More recently, anterior capsular reconstruction has been proposed as an alternative to musculotendinous transfers, but clinical data are completely lacking. Future high-quality randomised controlled trials are necessary to reliably compare the different musculotendinous transfers and anterior capsular reconstruction.

Outcomes After Rotator Cuff Repair With Transverse Scapular Ligament Release in Patients With Severe Fatty Degeneration of the Infraspinatus

BACKGROUND

In some large to massive rotator cuff tears (RCTs), fatty degeneration (FD) is more severe in the infraspinatus than the supraspinatus muscle, and in such cases, suprascapular neuropathy is highly suspected. Nerve release at the suprascapular notch might alleviate this problem.

PURPOSE

To evaluate the effects of the transverse scapular ligament (TSL) release in patients with large to massive RCTs with more severe FD of the infraspinatus than the supraspinatus.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between September 2017 and January 2022, arthroscopic TSL release with rotator cuff repair was performed in patients with large to massive RCTs and more severe FD of the infraspinatus muscle than the supraspinatus muscle (TSL group). Cuff integrity, FD, and atrophy of cuff muscles were evaluated using preoperative and 1-year postoperative magnetic resonance imaging. In addition, results were compared with those of patients who did not undergo TSL release during arthroscopic large to massive rotator cuff repair (NTSL group).

RESULTS

A total of 103 patients-20 in the TSL group and 83 in the NTSL group-were included. Group preoperative characteristics, including tear size and supraspinatus FD, were not significantly different, but infraspinatus FD (TSL vs NTSL; grade, 0-4, 0/0/5/10/5 vs 1/33/42/4/3) and atrophy (grade, 1-3. 3/9/8 vs 56/20/7) differed significantly (P < .001). Healing failure occurred in 13 of 20 (65%) patients in the TSL group and 30 of 83 (36%) patients in the NTSL group, which was a statistically significant difference (P = .019). Postoperatively, infraspinatus FD and atrophy were more severe in the TSL group than in the NTSL group (P < .001), and supraspinatus FD was more severe in the TSL group (P = .029). Seven patients in the TSL group achieved healing, but FD and atrophy of the supraspinatus and the infraspinatus showed no improvement in this group (all, P > .05).

CONCLUSION

In patients with more FD in the infraspinatus than the supraspinatus muscle, TSL release appeared to have no benefit for cuff healing or FD reversal in cuff muscles. The possibility of suprascapular nerve entrapment remains in patients with more FD in the infraspinatus than the supraspinatus, and this potential nerve problem is not properly addressed by TSL release alone.

Improved Yet Varied Clinical Outcomes Observed With Comparison of Arthroscopic Superior Capsular Reconstruction Versus Arthroscopy-Assisted Lower Trapezius Transfer for Patients With Irreparable Rotator Cuff Tears

PURPOSE

To evaluate the outcomes of arthroscopic superior capsular reconstruction (SCR) and arthroscopy-assisted lower trapezius tendon transfer (LTT) for posterosuperior irreparable rotator cuff tears (IRCTs).

METHODS

Over an almost 6-year period (October 2015 to March 2021), all patients who underwent IRCT surgery with a minimum 12-month follow-up period were identified. For patients with a substantial active external rotation (ER) deficit or lag sign, LTT was preferentially selected. Patient-reported outcome scores included the visual analog scale (VAS) pain score, strength score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Single Assessment Numeric Evaluation (SANE) score, and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score.

RESULTS

We included 32 SCR patients and 72 LTT patients. Preoperatively, LTT patients had more advanced teres minor fatty infiltration (0.3 vs 1.1, P = .009), a higher global fatty infiltration index (1.5 vs 1.9, P = .035), and a higher presence of the ER lag sign (15.6% vs 48.6%, P < .001). At a mean follow-up of 2.9 ± 1.3 years (range, 1.0-6.3 years), no differences in patient-reported outcome scores were observed. Postoperatively, SCR patients had a lower VAS score (0.3 vs 1.1, P = .017), higher forward elevation (FE) (156° vs 143°, P = .004), and higher FE strength (4.8 vs 4.5, P = .005) and showed greater improvements in the VAS score (6.8 vs 5.1, P = .009), FE (56° vs 31°, P = .004), and FE strength (1.0 vs 0.4, P < .001). LTT patients showed greater improvement in ER (17° vs 29°, P = .026). There was no statistically significant between-cohort difference in complication rate (9.4% vs 12.5%, P = .645) or reoperation rate (3.1% vs 10%, P = .231).

CONCLUSIONS

With adequate selection criteria, both SCR and LTT provided improved clinical outcomes for posterosuperior IRCTs. Additionally, SCR led to better pain relief and restoration of FE whereas LTT provided more reliable improvement in ER.

LEVEL OF EVIDENCE

Level III, treatment study with retrospective cohort comparison.

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

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

Decline in Separate Incision Autograft for Spine Surgery Over the Past Decade: A Fading "gold standard"

BACKGROUND

Spinal fusion is a common procedure for which bone grafting is a critical component. Although iliac crest (separate incision autograft) is typically referred to as the "gold standard" grafting material, it seems to be used less and less frequently.

METHODS

The 2010 to Q3 2020 MSpine PearlDiver data set was used to identify patients receiving separate incision autograft versus local autograft/allograft/graft supplement for spinal fusion. Grafting trends over the decade were determined. Patient age, sex, Elixhauser Comorbidity Index, smoking status, insurance plan, region of the country where the surgery was conducted, and surgeon specialty were characterized and compared by the type of bone graft using univariate and multivariate analyses.

RESULTS

Of 373,569 spinal bone grafting procedures, separate incision autografts were used for 32,401 (8.67%). A gradual decline was observed from 2010 (10.57% of spinal grafting procedures) to 2020 (4.69%, P -value < 0.00001). Independent predictors of having had a separate incision autograft in order of decreasing odds included surgeon specialty (relative to neurosurgery, orthopaedic odds ratio [OR], 2.45), smoking status (relative to nonsmokers, smokers OR, 1.45), region of the country (relative to Midwest, Northeast OR, 1.11; West OR, 1.42; and South OR, 1.48), insurance (relative to commercial, Medicare OR, 1.14), younger age (OR, 1.04 per decade increase), and lower Elixhauser Comorbidity Index (OR, 0.95 per two-point increase) ( P < 0.0001 for each).

CONCLUSION

Iliac crest autograft continues to be referred to as the gold standard grafting material for spine fusions. However, the use of this has faded over the past decade to only 4.69% of spinal fusions in 2020. While some patient factors had an effect on when separate incision autograft was used, nonsurgical factors, including surgeon specialty, geographic region where the surgery was conducted, and insurance factors, suggested that external factors/physician training influence this choice.

Healthcare costs of failed rotator cuff repairs

Background

The goal of this study was to estimate the short-term (∼2 years) healthcare costs of failed primary arthroscopic rotator cuff repair (RCR) in the United States.

Methods

A review of current literature was performed to estimate the number of RCR performed in the United States in the year 2022 and the rate of progression of these patients to lose repair continuity, reach clinical failure, and progress to nonoperative intervention and revision procedures. A review of the current literature was performed to estimate the costs incurred by these failures over the ensuing 2-year postoperative time period.

Results

The direct and indirect healthcare costs of structural and clinical failure of primary RCR performed in 2022 are estimated to reach $438,892,670 in the short-term postoperative period. The majority of the costs come from the estimated $229,390,898 in nonoperative management that these patients undergo after they reach clinical failure.

Conclusion

The short-term healthcare costs of failed arthroscopic RCR performed in the United States in 2022 are predicted to be $438,892,670. Although RCR improves quality of life, pain, function, and is cost-effective, there remains great potential for reducing the economic burden of failed RCR repairs on the US society. Investments into research aimed to improve RCR healing rates are warranted.

Clinical Relevance

Although RCR improves quality of life, pain, function, and is cost-effective, this study provides evidence that there remains great potential for reducing the economic burden of failed RCR repairs on the US society. Investments into research aimed to improve RCR healing rates are warranted.

Female Sex and Higher Infraspinatus Fatty Infiltration Are Linked to Dissatisfaction at a Minimum Follow-Up of 4 Years after Arthroscopic Repair of Massive Rotator Cuff Tears

Purpose

To evaluate patient satisfaction at a minimum of 4 years after arthroscopic rotator cuff repair (ARCR) of massive rotator cuff tears (MRCT), to identify preoperative and intraoperative characteristics associated with satisfaction, and to compare clinical outcomes between satisfied and dissatisfied patients.

Methods

A retrospective review on prospectively collected data was conducted on ARCRs of MRCTs performed at 2 institutions between January 2015 and December 2018. Patients with a minimum 4-year follow-up, preoperative and postoperative data, and primary ARCR of MRCTs were included for analysis. Patient satisfaction was analyzed according to patient demographics, patient-reported outcome measures (American Shoulder and Elbow Surgeons score [ASES], visual analog scale [VAS] for pain, Veteran Rands 12-item health survey [VR-12], and Subjective Shoulder Value [SSV]), range of motion (forward flexion [FF], external rotation [ER], and internal rotation [IR]), tear characteristics (fatty infiltration, tendon involvement, and tear size), and clinical significant measures (minimal clinical important difference [MCID], substantial clinical benefit [SCB], and patient-acceptable symptomatic state [PASS]) for ASES and SSV. Rotator cuff healing was also assessed with ultrasound in 38 patients at final follow-up.

Results

A total of 100 patients met the study's criteria. Overall, 89% of patients were satisfied with ARCR of a MRCT. Female sex (P = .007) and increased preoperative infraspinatus fatty infiltration (P = .005) were negatively associated with satisfaction. Those in the dissatisfied cohort had significantly lower postoperative ASES (80.7 vs 55.7; P = .002), VR-12 (49 vs 37.1; P = .002), and SSV scores (88.1 vs 56; P = .003), higher VAS pain (1.1 vs 4.1; P = .002) and lower postoperative range of motion in FF (147° vs 117°; P = .04), ER (46° vs 26°; P = .003), and IR (L2 vs L4; P = .04). Rotator cuff healing did not have an influence on patient satisfaction (P = .306). Satisfied patients were more likely to return to work than dissatisfied patients (97% vs 55%; P < .001).

Conclusions

Nearly 90% of patients who undergo ARCR for MRCTs are satisfied at a minimum 4-year follow-up. Negative preoperative factors include female sex and increased preoperative infraspinatus fatty infiltration, but no association was observed with rotator cuff healing. Furthermore, dissatisfied patients were less likely to report a clinically important functional improvement.

Level of Evidence

Level IV, prognostic case series.

Postoperative Rehabilitation Following Rotator Cuff Repair

Postoperative rehabilitation following rotator cuff repair is essential for a positive patient outcome. Each patient should have a program tailored to their individual tear and repair characteristics. Their plan should be advanced according to their progress, with therapist and surgeon communication. The rehabilitation progresses through 4 stages. This begins with a period of immobilization, passive range of motion, and protecting the repair and ends with functional and sport-specific exercises. Rehabilitation advances in progress-based steps during 24 weeks. The rehabilitation process aims to balance healing of the tendon repair and the risk of postoperative stiffness.

A Step-by-Step Approach to Arthroscopic Repair of Massive Rotator Cuff Tears

Arthroscopic repair of massive rotator cuff tears can be technically challenging but is achievable in many cases. Performing adequate releases are important for successful tendon mobility and avoiding excessive tension in the final repair, thus restoring the native anatomy and biomechanics. This Technical Note provides a step-by-step approach to release and mobilize massive rotator cuff tears to or near anatomical tendon footprints.

Older age and higher body mass index are independent risk factors for tendon healing in small- to medium-sized rotator cuff tears

PURPOSE

Many previous research efforts have been made to identify prognostic factors for rotator cuff healing. However, majority of these studies were conducted with heterogeneous cohorts consisted of different tear characteristics. Healing properties of a rotator cuff tear may differ depending on tear characteristics such as tear size or fatty infiltration. Therefore, studies with subgroups confined by these variables may reflect more accurate results. This study aims to investigate predictive factors for rotator cuff healing in a subgroup with small- to medium-sized tears without significant fatty infiltration.

METHODS

This retrospective case-control study was conducted with 94 patients with small- to medium-sized rotator cuff tears. Mean age of patients was 56.0 ± 9.0 years and mean follow-up duration was 38.3 ± 8.1 months. Post-operative magnetic resonance imaging assessment showed that there were 75 (79.8%) successfully healed repairs and 19 (20.2%) healing failures. Age, gender, hand dominancy, body mass index (BMI), smoking habit, diabetes, corticosteroid injection, baseline clinical status, duration of surgery and biceps procedure were variables evaluated as predictive factors.

RESULTS

Both study groups showed significant improvement from baseline regarding clinical outcome measures (p < 0.05). However, successfully healed patients had significantly higher post-operative functional scores and lower pain scores (p < 0.05). The univariate analysis revealed that healing was significantly affected by age (p = 0.004), BMI (p = 0.01) and diabetes (p = 0.03). In the multivariate analysis, age (p = 0.02) and BMI (p = 0.02) were found to be significant independent factors for healing. Cutoff values for oldest age and highest BMI were 63 years and 28.1 kg/m², respectively, for a successful healing according to receiver-operating characteristic curve analysis.

CONCLUSION

Healing failure after rotator cuff repair in small- to medium-sized tears is associated with poorer outcomes. Age and BMI are independent predictive factors for healing. A successful repair is more likely in patients younger than 63 years and with BMI less than 28.1 kg/m². Surgeons should consider this information during risk assessment, decision making and patient counselling.

LEVEL OF EVIDENCE

Level III.

The Hybridge Technique: A Combined Technique of Suture Bridge and Tension Band for an Arthroscopic Eco-Responsible Rotator Cuff Repair

Arthroscopic rotator cuff repair is mainly based on 2 proven biomechanical concepts: suture bridge and tension band. This Technical Note describes the use of a combination of these 2 techniques to repair extensive lesions with only 3 anchors. Besides being less expensive, the use of a limited number of anchors is part of a global medicoeconomic and eco-responsible approach to our surgical activities.

Insurance status is not a predictor of rotator cuff tear magnitude

Background

Rotator cuff tear (RCT) chronicity is an important factor in considering treatment options and outcomes for surgical repair. Many factors may contribute to delayed treatment, including timely access to care due to insurance status. The purpose of this study was to evaluate the relationship between the magnitude of RCT on presentation and insurance status. We hypothesize that publicly insured patients will have a greater incidence of chronic RCTs and shoulder pathology on initial presentation.

Methods

Retrospective chart review of patients undergoing RCT repair at an academic tertiary care institution from 2005 to 2019. Demographic data, including age, race, sex, and insurance carrier, were collected. Insurance carriers were categorized into public (Medicare and Medicaid) or private insurance coverage. Individual magnetic resonance imagings were then reviewed by a board-certified musculoskeletal radiologist for supraspinatus (SS), infraspinatus (IS), subscapularis, and biceps tendon tears, as well as acromioclavicular arthritis. In addition, rotator cuff atrophy was evaluated by the scapular ratio. Univariate analysis of variance and logistic regression analyses were used to compare demographics and rotator cuff pathology between those with Medicaid and Medicare, as well as between publicly and privately insured patients.

Results

Of the 492 patients in this study, 192 had private insurance, and 300 had public insurance (Medicaid: 50 and Medicare: 250). Insurance status was not found to be associated with differences in RCTs between Medicare and Medicaid patients. Those with Medicaid or Medicare (public), presented more frequently with SS or IS atrophy (SS atrophy, P = .002; IS atrophy, P = .039) than those with private insurance. However, after adjusting for age, no significant differences in rotator cuff tendon tear or atrophy frequencies were found between insurance groups.

Conclusions

Patients with private and public insurance tend to present with similar chronicity and magnitude of RCTs. Insurance status does not appear to influence timely access to surgical care for patients with RCTs at an academic medical center.

A Scoping Review of Postoperative Rehabilitation Protocols After Superior Capsular Reconstruction for Irreparable Rotator Cuff Tears

Background

Superior capsular reconstruction (SCR) is an option for patients with massive or irreparable rotator cuff tears.

Purpose

To describe the literature on rehabilitation protocols after SCR of rotator cuff tears, with emphasis on the timing of the introduction of motion.

Study Design

Scoping review; Level of evidence, 4.

Methods

We conducted a scoping review of articles published on PubMed, Ovid, Embase, and the Cochrane Library from inception to October 2020. The methodological index for non-randomized studies (MINORS) was used to assess the individual studies. For each article, we summarized the study characteristics, patient demographics, and rehabilitation protocols after SCR: duration of immobilization, initiation of passive range of motion (ROM), active-assisted ROM, active ROM, strengthening, and return to activities. In a subgroup narrative analysis, rehabilitation protocols were stratified by graft type: autograft versus nonautograft (xenograft, allograft, and synthetic).

Results

A total of 21 studies met the search criteria. Six studies had level 3 evidence and 15 had level 4 evidence; 16 studies were considered high quality according to the MINORS score. After SCR, an abduction immobilizer was recommended for a duration of 3 to 6 weeks. Of the 21 studies, 7 (33%) started passive ROM during the first week, and 5 reported strict immobilization without motion for up to 6 weeks. All 8 studies that reported return-to-sports timing recommended delaying return until at least 6 months postoperatively. Passive ROM was recommended earlier for patients with nonautograft versus autograft (χ² = 225; P < .001). There was a high level of heterogeneity in the rehabilitation protocols after SCR.

Conclusion

The majority of published protocols were descriptive. At present, there is little agreement on the published rehabilitation guidelines after SCR, precluding specific clinical best practice suggestions. Although there was a tendency of recommending early motion in nonautograft cases, the optimal protocols based on graft healing and functional outcomes require further verification based on the clinical outcomes from high-quality studies.

Graft Augmentation of Repairable Rotator Cuff Tears: An Algorithmic Approach Based on Healing Rates

We provide our algorithm for tissue augmentation of rotator cuff repairs based on the current available evidence regarding rotator cuff healing. A variety of factors are associated with healing following rotator cuff repair. Increasing tear size and retraction as well as severe fatty degeneration have been associated with worsening rates of tendon healing. Given the correlation between tendon healing and postoperative outcomes, it is important to identify patients at high risk for failure and to modify their treatment accordingly to minimize the risk of early biomechanical failure and maximize the potential for structural healing. One approach that may be used to improve healing is tissue augmentation. Tissue augmentation is the use of tissue patches and scaffolds to provide rotator cuff reinforcement. Surgical management for rotator cuff tears (RCTs) continues to be a challenging task in orthopaedic surgery today. Appropriate treatment measures require an in depth understanding and consideration of the patient's prognostic factors such as age, fatty infiltration of the rotator cuff muscles, bone mineral density, rotator cuff retraction, anteroposterior tear size, work activity, and degenerative changes of the joint. Using these factors within the Rotator Cuff Healing Index, we can determine a patient's surgical treatment that will yield the maximum healing rate. For nonarthritic RCTs, joint-preserving strategies should be first-line treatment options. For young, active patients with a reparable RCT and minimal fatty infiltration, a complete repair can be effective. For young patients with irreparable RCTs, superior capsular reconstructions, and tendon transfers are viable options. For elderly patients with low work activity, an irreparable RCT and significant fatty infiltration, a partial repair with or without graft augmentation can be attempted if minimal to no arthritic changes are seen. LEVEL OF EVIDENCE: Level V, expert opinion.

Current concepts on management of cuff tear

Among pathologies of the shoulder, rotator cuff tear is the most common. Diagnosis of cuff tear around mid twenties is unusual, but the prevalence increases significantly after the age of forty. The prevalence after the age of 60 is around 20-30%. A well recognised feature of cuff tear is being asymptomatic but, tear progression in asymptomatic is a known consequence. The spectrum of cuff tear ranges from partial, full thickness cuff tear with or without retraction. The mainstay of treatment for partial thickness cuff tear is systematic rehabilitation and for the full thickness cuff tear an initial rehabilitation is an accepted management. Failed rehabilitation for 3 months, acute traumatic tear, younger age, intractable pain, good quality muscle would be the indications for repair of a full thickness cuff tear. Though there are defined indications for surgical intervention in the full thickness rotator cuff tear, differentiating an asymptomatic tear that would not progress or identifying a tear that would become better with rehabilitation is an undeniable challenge for even the most experienced surgeon. Rehabilitation in cuff tear consists of strengthening the core stabilizers along with rotator cuff and deltoid muscles. In a symptomatic cuff tear that merits surgical intervention the objective is to do an anatomical foot print repair. In scenarios where the cuff is retracted, one has to settle for a medialised repair. As, a repair done in tension is more likely to fail than a tensionless medialised repair. The success rate of all these non anatomical procedures varies from series to series but it approximates around 60-80%. Augmenting cuff repair to enhance biological healing is a recent advance in rotator cuff repair surgery. The augmentation factors can be growth factors like PRP, scaffolds both auto and allografts. The outcome of these procedures from literature has been variable. As there are no major harmful effects, it can be viewed as another future step in bringing better outcomes to patients having rotator cuff tear surgery. Despite being the commonest shoulder pathology, the rotator cuff tear still remains as a condition with varied presenting features and a wide variety of management options. The goal of the treatment is to achieve pain free shoulders with good function. Correcting altered scapular kinematics by systematic rehabilitation of the shoulder would be the first choice in all partial thickness cuff tear and also as an initial management of full thickness cuff tears. Failure of rehabilitation would be the step forward for a surgical intervention. While embarking on a surgical procedure, correct patient selection, sound surgical technique, appropriate counselling about expected outcome are the most essential in patient satisfaction.

Advantages of 3-dimensional Measurements for Supraspinatus Intramuscular Fatty Evaluation in Patients With Medium to Massive Rotator Cuff Tears: Comparison With a Single Sagittal Slice

BACKGROUND

Fatty infiltration of the rotator cuff muscles is highly related to poor outcomes after rotator cuff tears. Fat fraction (FF) based on traditional 2-dimensional measurements (2D-FF) from a single sagittal Y-view slice cannot determine intramuscular FF in the rotator cuff muscles; the newly developed 3-dimensional method (3D-FF) is supposed to precede 2D measurements for intramuscular FF evaluation in accuracy and reliability.

PURPOSE

(1) To measure 3D-FF and (2) to compare 3D-FF and 2D-FF in terms of quantitative values and intra- and interobserver agreement.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Six-point Dixon magnetic resonance imaging was performed in patients with full-thickness supraspinatus tears. 2D-FF was calculated on a single sagittal Y-view. Semiautomatic segmentation software (ITK-SNAP) was used to reconstruct 3D volumes of the supraspinatus muscle and fat. 3D-FF was obtained by dividing the fat volume by the total volume of the supraspinatus muscle. A paired t test was used to compare the individual differences between 2D-FF and 3D-FF results. Linear regression and Bland-Altman analyses were performed to determine the agreement between 2D-FF and 3D-FF. Intraclass correlation coefficients (ICCs) were calculated to determine intra- and interobserver agreement.

RESULTS

The 3D muscular and fatty models presented an inhomogeneous distribution of intramuscular fat in the supraspinatus, indicating the superiority of 3D-FF over 2D-FF in capturing all muscle morphologic information. 2D-FF was significantly higher than 3D-FF in the supraspinatus with large (19.5% ± 5.9% vs 16.2% ± 3.7%; P = .002) and massive (34.8% ± 13.3% vs 26.2% ± 9.4%; P < .001) rotator cuff tears. 2D-FF overestimated the FF compared with 3D-FF by >50% in 14.7% of all patients and by >15% in 67.6% of patients with large or massive RCTs. The discrepancy between 2D-FF and 3D-FF increased with increasing mean FF. The intra- and interobserver agreement of 3D-FF (ICCs, 0.89-0.99 and 0.89-0.95) was superior to that of 2D-FF (ICCs, 0.71-0.95 and 0.64-0.79).

CONCLUSION

3D-FF indicated an inhomogeneous distribution of intramuscular fat by capturing all muscle and fat morphologic information. In patients with large and massive rotator cuff tears, 2D-FF of the supraspinatus was significantly higher than 3D-FF. 3D-FF was more reliable than 2D-FF for estimating fatty infiltration in the supraspinatus, with better intra- and interobserver agreement.

Two-Year Retrospective Patient-Reported Outcomes Following Superior Capsular Reconstruction

PURPOSE

The purpose of this study was to evaluate the short-term patient-reported outcomes of superior capsular reconstruction (SCR) and identify factors contributing to the success or failure of the procedure at 2 years.

METHODS

A retrospective review was performed on data prospectively collected from the Surgical Outcomes System database. Patient-reported outcomes (PROMs) including American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, visual analog scale for pain, and Veterans RAND 12-Item Health Survey (VR-12) were evaluated at a minimum of 2 years postoperatively and reported using a minimal clinically important difference (MCID) and the percent of maximal possible improvement (MPI). In addition, preoperative and intraoperative variables were evaluated in patients with and without a postoperative improvement in ASES and SANE scores meeting the threshold of MCID.

RESULTS

Two-year follow-up data were available for 350 patients. Statistically significant improvements were noted in all PROMs at 2-year follow-up. In total, 240 patients (68.8%) achieved an MCID improvement of >17.5 in ASES score, and 185 patients (52.9%) achieved an MCID of >29.8 improvement in the SANE score. Primary SCRs were associated with a higher MPI in the ASES score (60.1% ± 39.8% vs 40.4% ± 47.9%; P = .025) and VR-12 physical score (14.0% ± 13.8% vs 8.0% ± 14.7%; P = .028) compared to revision repairs. Only diabetes was identified as a predictor of SANE score improvement (64.5% vs 62.2%; P = .041).

CONCLUSIONS

SCR is associated with improvement in patient-reported outcomes at short-term follow-up, with 53% to 69% of patients achieving an improvement considered to meet the MCID. Greater improvement is expected when SCR is performed as a primary procedure rather than as a revision procedure for failed rotator cuff repair.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Effect of Physical Therapy and Rehabilitation Timing on Rotator Cuff Repair Revisions and Capsulitis

INTRODUCTION

One variable that could potentially affect failure of a rotator cuff repair (RCR) is the timing of beginning physical therapy (PT) after the procedure. Although many studies have demonstrated decreased stiffness with beginning PT early, studies have also demonstrated that early PT increases repair failure. The goal of this study was to identify revision surgery and capsulitis rates after RCRs from an available database and determine whether an association was present with the timing of PT post-RCR.

METHODS

Medicare patients within the PearlDiver database who underwent RCR were stratified based on the timing of their first PT session postoperatively, and revision surgery and capsulitis rates were determined among the groups for both open and arthroscopic RCR. Demographics and comorbidities of the cohort were also used to formulate a multivariate analysis for revision surgery rate.

RESULTS

The cohort consisted of 64,842 patients who underwent RCR and started PT within 13 weeks of surgery. Starting PT within 1 week postoperatively resulted in a significantly higher revision surgery rate compared with starting PT in weeks 2 to 5, 6 to 9, or 10 to 13 (6.9% vs. 3.6% among all other groups, P = <0.001). The multivariate analysis for revision surgery further demonstrated that starting PT within 1 week postoperatively was associated with a significantly higher rate of revision surgery compared with beginning PT after 1 week (OR = 2.086, P < 0.001). No association was found between timing of beginning PT and capsulitis rates.

CONCLUSION

In the Medicare patient cohort, beginning PT within 1 week postoperatively was associated with a significantly higher revision surgery rate; however, no associated benefit was noted in capsulitis rates for beginning PT early. This calls into question the use of an early passive range of motion protocol for older patient cohort; however, further studies should be completed to conclusively determine the most efficacious time to begin rehabilitation post-RCR.

LEVEL OF EVIDENCE

Level III.

Three-dimensional muscle loss assessment: a novel computed tomography-based quantitative method to evaluate rotator cuff muscle fatty infiltration

BACKGROUND

Rotator cuff fatty infiltration (FI) is one of the most important parameters to predict the outcome of certain shoulder conditions. The primary objective of this study was to define a new computed tomography (CT)-based quantitative 3-dimensional (3D) measure of muscle loss (3DML) based on the rationale of the 2-dimensional (2D) qualitative Goutallier score. The secondary objective of this study was to compare this new measurement method to traditional 2D qualitative assessment of FI according to Goutallier et al and to a 3D quantitative measurement of fatty infiltration (3DFI).

MATERIALS AND METHODS

102 CT scans from healthy shoulders (46) and shoulders with cuff tear arthropathy (21), irreparable rotator cuff tears (18), and primary osteoarthritis (17) were analyzed by 3 experienced shoulder surgeons for subjective grading of fatty infiltration according to Goutallier, and their rotator cuff muscles were manually segmented. Quantitative 3D measurements of fatty infiltration (3DFI) were completed. The volume of muscle fibers without intramuscular fat was then calculated for each rotator cuff muscle and normalized to the patient's scapular volume to account for the effect of body size (NV_fibers). 3D muscle mass (3DMM) was calculated by dividing the NV_fibers value of a given muscle by the mean expected volume in healthy shoulders. 3D muscle loss (3DML) was defined as 1 - (3DMM). The correlation between Goutallier grading, 3DFI, and 3DML was compared using a Spearman rank correlation.

RESULTS

Interobserver reliability for the traditional 2D Goutallier grading was moderate for the infraspinatus (ISP, 0.42) and fair for the supraspinatus (SSP, 0.38), subscapularis (SSC, 0.27) and teres minor (TM, 0.27). 2D Goutallier grading was found to be significantly and highly correlated with 3DFI (SSP, 0.79; ISP, 0.83; SSC, 0.69; TM, 0.45) and 3DML (SSP, 0.87; ISP, 0.85; SSC, 0.69; TM, 0.46) for all 4 rotator cuff muscles (P < .0001). This correlation was significantly higher for 3DML than for the 3DFI for SSP only (P = .01). The mean values of 3DFI and 3DML were 0.9% and 5.3% for Goutallier 0, 2.9% and 25.6% for Goutallier 1, 11.4% and 49.5% for Goutallier 2, 20.7% and 59.7% for Goutallier 3, and 29.3% and 70.2% for Goutallier 4, respectively.

CONCLUSION

The Goutallier score has been helping surgeons by using 2D CT scan slices. However, this grading is associated with suboptimal interobserver agreement. The new measures we propose provide a more consistent assessment that correlates well with Goutallier's principles. As 3DML measurements incorporate atrophy and fatty infiltration, they could become a very reliable index for assessing shoulder muscle function. Future algorithms capable of automatically calculating the 3DML of the cuff could help in the decision process for cuff repair and the choice of anatomic or reverse shoulder arthroplasty.

"Current concepts and expert practice report: Augmentation of rotator cuff repairs"

Rotator cuff tears are common shoulder injuries expected to increase with the growth of the aging population. Although a small subset of patients with low functional demands can be treated nonoperatively, surgical intervention is a cost-effective solution, which can restore shoulder function and help patients return to activity sooner. While multiple surgical options are available, rotator cuff repair is a highly utilized procedure with varying success. Due to a large proportion of rotator cuff repairs still failing to completely heal, this procedure requires careful planning to achieve anatomical and biomechanically stability. New technology and techniques are being explored to help increase the success of rotator cuff repairs with an increasing focus on augmentation. The current article gives a brief overview of pertinent anatomy, treatment options, and challenges in healing of rotator cuff repairs. Thereafter, the merits of different types of rotator cuff repair augmentation available will be discussed as well as the authors' experience in utilizing biologic augmentation and surgical technique.