Osteolysis is observed around both bioabsorbable and nonabsorbable anchors on serial magnetic resonance images of patients undergoing arthroscopic rotator cuff repair

Proximal Tibia Fracture Through Suture Augmentation Sites Following ACL/MCL Repairs: A Case Report

CASE

A 35-year-old man sustained a proximal tibia fracture from a low-energy mechanism 1 year after anterior cruciate and medial collateral ligament repairs with suture augmentation (SA). The fracture propagated through both tibial SA anchor sites. Following intramedullary tibial nailing, he returned to his prior level of function.

CONCLUSION

While complications of SA for ligamentous procedures are rare, these techniques are being implemented more frequently and the full complication profile is yet to be determined. Our report documents a new complication and potential risk factors that surgeons should consider when performing SA for multiligament knee surgery in active individuals.

Biodegradable vs nonbiodegradable suture anchors for rotator cuff repair: a systematic review and meta-analysis

Purpose

The use of non-biodegradable suture anchors (NBSA) in arthroscopic rotator cuff repair (RCR) has increased significantly. However, several complications such as migration, chondral damage, revision, and imaging difficulties have been reported. Meanwhile, the effectiveness of biodegradable suture anchors (BSA) in overcoming such complications and achieving functional outcomes requires further study. Thus, we aim to compare the clinical outcomes and complications of RCR using BSA and NBSA using direct comparison studies.

Methods

Two independent reviewers conducted systematic searches in PubMed, Embase, Cochrane Library, and Web of Science from conception to September 2022. Using the RoB 2 and ROBINS-I tools, we assessed the included studies for bias. We applied GRADE to appraise our evidence. Our PROSPERO registration number is CRD42022354347.

Results

Six studies (two randomized controlled trials, one retrospective cohort, and three case-control studies) involving 423 patients were included (211 patients received BSA and 212 patients received NBSA). BSA was comparable to NBSA in forward flexion, abduction, external rotation, Constant-Murley score, and perianchor cyst formation (P = 0.97, 0.81, 0.56, 0.29, and 0.56, respectively). Retear rates were slightly higher while tendon healing was reduced in BSA compared to NBSA, but the differences were not significant (P = 0.35 and 0.35, respectively).

Conclusion

BSA and NBSA appear to yield similar shoulder functions and complications in rotator cuff repairs.

SARS-Cov-2 related shoulder pain and stiffness associated to humeral osteolysis after arthroscopic rotator cuff repair: A case report

INTRODUCTION AND IMPORTANCE

Complications using bioresorbable anchors in arthroscopic rotator cuff surgery include osteolysis, aseptic synovitis, and foreign body reaction. However, the precise triggering factors are unknown.

CASE PRESENTATION

A healthy, 63-year-old male patient underwent rotator cuff repair using 7PLGA/b-TCP anchors. Nine months after surgery he returned to the senior author because of right shoulder pain and stiffness, pain in the right hand, foot and leg, and presence of erythematous patches at the aforementioned joints following SARS-Cov-2 infection, as well as increasing in blood inflammatory markers. Magnetic Resonance Arthrography (Arthro-MRI) showed no rotator cuff tendons re-tear but intra-articular synovitis, subacromial bursitis and humeral osteitis. A diagnostic arthroscopy, intra-articular fluid collection, biopsy and joint lavage was performed to rule out a septic arthritis. Co-amoxicillin 2.2 g intravenous treatment was administered following samples. Histological analysis of synovial tissue showed fibrin-exudative synovitis, while humeral bone biopsy showed an anchor resorption reaction. All microbiological analysis showed sterile samples. Three months post-lavage follow-up physical examination showed painless, recovered mobility, while Arthro-MRI showed a significant post-refixation remodeling of the rotator cuff tendons and reduction in humeral head osteitis and synovitis.

CLINICAL DISCUSSION

The abrupt onset of symptomatology and the close chronological link with SARS-Cov-2 infection suggests a causal relationship between clinical and radiological manifestations and the infection itself, with clinical and radiological manifestation being a viral host response reaction to SARS-Cov-2 infection.

CONCLUSION

Shoulder pain, stiffness and humeral osteitis could be manifestations of a viral host response to SARS-Cov-2 infection.

Osteolysis Following the Use of Polyetheretherketone Suture Anchors in Hand and Wrist Surgery: A Preliminary Study

PURPOSE

The objective of this study was to investigate and describe the presence of osteolysis after implantation of polyetheretherketone (PEEK) suture anchors in the hand and wrist.

METHODS

Patients who underwent hand or wrist surgery using PEEK suture anchor(s) at a large academic institution from January 2019 to January 2021 were identified. Patients without accessible intraoperative fluoroscopic imaging were excluded. Patient demographics, type of procedure, and suture anchor material were recorded. The suture anchor tunnel size was measured on sequential radiographs and recorded as percentage change. Descriptive statistics were used to summarize findings.

RESULTS

A total of 26 PEEK suture anchors in 14 patients were included, with an average follow-up of 12.0 months (range, 1.5-24.1 months). Twenty-seven percent of the anchors (7/26) demonstrated osteolysis at final follow-up, as defined by enlargement of tunnel size by >30%. In all anchors, the tunnel size increased by 19.1% on average (range, -7.7% to 56.1%) by final follow-up.

CONCLUSIONS

Polyetheretherketone suture anchors may be associated with the development of osteolysis in hand and wrist surgery. The clinical implications of osteolysis in the smaller bones of the hand and wrist remain unclear.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

ACR Appropriateness Criteria® Chronic Shoulder Pain: 2022 Update

Chronic shoulder pain is an extremely common presenting complaint. Potential pain generators include the rotator cuff tendons, biceps tendon, labrum, glenohumeral articular cartilage, acromioclavicular joint, bones, suprascapular and axillary nerves, and the joint capsule/synovium. Radiographs are typically the initial imaging study obtained in patients with chronic shoulder pain. Further imaging may often be required, with modality chosen based on patient symptoms and physical examination findings, which may lead the clinician to suspect a specific pain generator. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Evaluation of Radiographic Changes 5 Years After Arthroscopic Rotator Cuff Repair

Background:

Radiographic changes in the glenohumeral joint often occur after rotator cuff repair; however, the details of the progression and underlying causes remain unknown.

Purpose:

To retrospectively evaluate the timing and frequency of radiographic changes after arthroscopic rotator cuff repair and to clarify the predictive factors that affect the onset of such changes using multivariate analysis.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

We retrospectively reviewed 100 patients with 5 years of follow-up after arthroscopic rotator cuff repair and evaluated the postoperative shift in radiographic findings on plain radiographs every year during follow-up. Factors related to osteoarthritis, acromial spur re-formation, and greater tuberosity resorption at 5 years after surgery were evaluated using logistic regression analyses. Explanatory variables included preoperative factors, intraoperative factors, and postoperative retear. Baseline variables significant in the univariate analyses were included in the multivariate models.

Results:

Of the 100 patients, 12 developed osteoarthritis, 26 developed acromial spur formation, and 16 developed greater tuberosity resorption at 5 years after surgery. The incidence and grade of osteoarthritis and acromial spur gradually increased over time postoperatively. On the other hand, greater tuberosity resorption developed within 2 years after surgery but did not progress later. Multivariate analysis showed that a larger anteroposterior tear size (odds ratio [OR], 1.09; 95% CI, 1.01-1.17; P = .037) was a risk factor for postoperative osteoarthritis. Early retear (OR, 10.26; 95% CI, 1.03-102.40; P = .047) was a risk factor for acromial spur re-formation. Roughness of the greater tuberosity (OR, 9.07; 95% CI, 1.13-72.82; P = .038) and larger number of suture anchors (OR, 3.34; 95% CI, 1.66-6.74; P = .001) were risk factors for greater tuberosity resorption.

Conclusion:

Our study showed that radiographic changes occurred in 40% of patients within 5 years after arthroscopic rotator cuff repair. While the osteoarthritic changes and acromial spur re-formation gradually progressed postoperatively, the greater tuberosity resorption stopped within 2 years after surgery. Tear size, morphology of the greater tuberosity, and the number of suture anchors can affect radiographic changes. Furthermore, this study suggested that acromial spur re-formation may be an indicator of early retears.

Cystic lesions of the humeral head on magnetic resonance imaging: a pictorial review

Cystic lesions of the humeral head are commonly encountered on routine shoulder magnetic resonance imaging (MRI). Differential diagnoses include degenerative lesions, calcific tendinitis with osseous involvement, perianchor cysts, abscesses and less often, tumours. Degenerative lesions, including subcortical and subchondral cysts, are the most commonly encountered. These may be associated with rotator cuff disease and degenerative joint diseases or considered part of ageing depending on the location of the cystic lesions. For instance, cysts of the bare area of the humeral head are considered benign age-related entities, whereas cysts of the greater or lesser tuberosity may herald rotator cuff disease. Infectious lesions, particularly osteomyelitis and intraosseous (Brodie’s) abscesses, are intramedullary in location and should be suspected in the context of clinical features such as fever and radiological features such as the penumbra sign. Perianchor cysts are postoperative lesions associated with the use of suture anchors in surgeries such as rotator cuff tear repairs. They generally self-resolve over 18 to 24 months. On MRI, the distribution, morphology, and signal characteristics can help point towards a specific diagnosis. The patient’s demographic, clinical presentation, and past surgical history can be discriminatory. Knowledge of different cystic lesions in the humeral head and underlying aetiology can be useful in helping the radiologist develop a more thorough search pattern for associated conditions. Determining the underlying cause of cysts can have important implications on management, such as when differentiating perianchor cysts from infection. This pictorial review outlines the differential diagnoses of humeral head cysts on MRI and provides a diagnostic approach for the radiologist.

3D-Printed Double-Helical Biodegradable Iron Suture Anchor: A Rabbit Rotator Cuff Tear Model

Suture anchors are extensively used in rotator cuff tear surgery. With the advancement of three-dimensional printing technology, biodegradable metal has been developed for orthopedic applications. This study adopted three-dimensional-printed biodegradable Fe suture anchors with double-helical threads and commercialized non-vented screw-type Ti suture anchors with a tapered tip in the experimental and control groups, respectively. The in vitro study showed that the Fe and Ti suture anchors exhibited a similar ultimate failure load in 20-pound-per-cubic-foot polyurethane foam blocks and rabbit bone. In static immersion tests, the corrosion rate of Fe suture anchors was 0.049 ± 0.002 mm/year. The in vivo study was performed on New Zealand white rabbits and SAs were employed to reattach the ruptured supraspinatus tendon. The in vivo ultimate failure load of the Fe suture anchors was superior to that of the Ti suture anchors at 6 weeks. Micro-computed tomography showed that the bone volume fraction and bone surface density in the Fe suture anchors group 2 and 6 weeks after surgery were superior, and the histology confirmed that the increased bone volume around the anchor was attributable to mineralized osteocytes. The three-dimensional-printed Fe suture anchors outperformed the currently used Ti suture anchors.

Periimplant osteolysis does not affect the outcome of rotator cuff repair: a systematic review and meta-analysis

PURPOSE

The goal of this study was to perform a systematic review and meta-analysis to compare the clinical and radiologic outcomes of rotator cuff repair, depending on the presence of developed periimplant osteolysis (PIO) after using suture anchors.

METHODS

The electronic databases of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for articles published up until October 2019 to find relevant articles comparing the outcomes of rotator cuff repair between the periimplant osteolysis group and non-periimplant osteolysis group. Data searching, extraction, analysis, and quality assessment were performed according to the Cochrane Collaboration guidelines. The results are presented as risk ratio (RR) for binary outcomes and standardised mean difference (SMD) for continuous outcomes with 95% confidence intervals (CI).

RESULTS

Six clinical studies were included. No significant differences were found between the group with periimplant osteolysis and the group without periimplant osteolysis regarding retear rate (RR = 1.34; 95% CI 0.93-1.94; I² = 28%), postoperative clinical scores (SMD = 0.29; 95% CI - 0.26 to 0.83; I² = 80%) and range of motion (ROM); forward flexion (SMD = 0.39; 95% CI - 0.16 to 0.93; I² = 0%), external rotation (SMD = - 0.10; 95% CI - 0.64 to 0.45; I² = 0%) and internal rotation (SMD = - 0.37; 95% CI - 0.92 to 0.17; I² = 0%).

CONCLUSION

The presence of periimplant osteolysis after rotator cuff repair with suture anchor does not affect the clinical outcomes such as retear rate, clinical scoring, and ROM. However, as there was no standard consensus on the criteria for evaluating periimplant osteolysis, this result may not fully reflect the effect of periimplant osteolysis depending on its severity.

LEVEL OF EVIDENCE

Level IV.

Comparison of Occurrence of Bone Tunnel Laceration, Clinical Results, and Cuff Repair Integrity of Transosseous Arthroscopic Rotator Cuff Repair With and Without Lateral Cortical Augmentation

Purpose

To compare the occurrence of bone tunnel laceration, the short-term clinical results, and cuff repair integrity of transosseous arthroscopic rotator cuff repair (ARCR) using a tunneling device, with and without lateral cortical augmentation.

Methods

A retrospective review of patients who underwent transosseous ARCR from May 2012 to December 2017 was conducted. The inclusion criterion was repairable medium- to massive-sized full-thickness rotator cuff tear. This study included 2 consecutive series of patients undergoing transosseous ARCR with and without lateral cortical augmentation, called the ITO method and AT method, respectively. The incidence of bone tunnel laceration was evaluated intraoperatively. Patients were assessed through a range of motion and Constant scores preoperatively and at final follow-up. Further, magnetic resonance imaging was performed at 24 months postoperatively to examine the repaired rotator cuff integrity.

Results

A total of 121 subjects were included: 33 in the AT group and 88 in the ITO group. The intraoperative bone tunnel laceration occurrence rate was 67% and 4% for the AT and ITO methods, respectively; the difference was significant (P = .001). Anatomic failure rate (Sugaya Ⅲ, Ⅳ, and Ⅴ) rate for medium- to large-sized tears was significantly lower for the ITO than for the AT method (29% vs 65%, P = .004), but not for massive tears (61% vs 69%, P = .515). The mean forward elevation, abduction, external rotation, internal rotation, and Constant score were significantly improved at final follow-up from preoperative values. There were no significant differences between the 2 methods.

Conclusions

Transosseous ARCR using a tunneling device with and without lateral cortical augmentation is a reliable method of improving clinical results at a minimum follow-up of 2 years. The intraoperative occurrence rate of bone tunnel laceration occurrence rate and the anatomic failure rate of medium- to large-sized cuff tear were lower with lateral cortical augmentation than without it.

Level of Evidence

Level Ⅳ, therapeutic cases series.

Factors associated with the development of re-tear following arthroscopic rotator cuff repair: A retrospective comparative study

OBJECTIVE

The aim of this study was to analyze the risk factors for the development of re-tear following Arthroscopic Rotator Cuff Repair (aRCR).

METHODS

This retrospective clinical study included 196 consecutive aRCRs with a minimum 3-year follow-up. Pre- and postoperative clinical and functional outcomes were measured using the Visual Analog Scale (VAS), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), the University of California at Los Angeles Shoulder Rating Scale (UCLA), the Constant-Murley Score (CMS), and the Douleur Neuropathique (DN4) questzionnaire. The Goutallier staging of fatty infiltration, Occupational Ratio (OR), the Acromiohumeral Interval (AHI), Acromioclavicular Joint (ACJ) arthritis, acromion type, Critical Shoulder Angle (CSA), and tangent sign (tan- sign) were evaluated as radiological parameters. Different subgroup parameters were evaluated after dividing the patients into re-tear (-) and re-tear (+) groups, according to clinical and radiological outcomes as well as patient and intraoperative characteristics.

RESULTS

The mean follow-up period was 72.0 ± 15.8 months. The mean age at the time of surgery was 58.4 ± 8.9 years. A significant improvement was found in clinical and functional scores in the re-tear (-) group (P < 0.001 for all). However, the retear (+) group had poorer outcome scores than the re-tear (-) group. Twenty patients (10.2%) had re-tear at the last follow-up. There was a significant difference between groups regarding pre-and postoperative clinical scores, with worse scores in the retear (+) group (P < 0.001 for all). Also, pre-and postoperative pseudoparalysis (P = 0.001 for both), acromioclavicular joint arthritis (ACJ) (P = 0.001), intraoperative rotator cuff wear (P = 0.007) or stiffness (P = 0.025), a longer time period between symptom onset and surgery (P = 0.031), larger tear size (P = 0.010), preoperative shoulder stiffness (P = 0.001), higher duration of postoperative analgesia use (P < 0.001), higher degrees of preoperative Occupational Ratio (OR) (P < 0.001), and higher degrees of fatty degeneration (P < 0.001) were found to be associated with re- tear development.

CONCLUSION

Surgeons should consider the preoperative degree of fatty degeneration, clinical and functional scores, presence of ACJ arthritis, intraoperative tendon quality, tear size and chronicity as well as postoperative prolong analgesic requirement, and development of pseudoparalysis as factors regarding re-tear development risk following aRCR.

LEVEL OF EVIDENCE

Level IV, Therapeutic Study.

Randomized Controlled Trial of the Clinical Recovery and Biodegradation of Polylactide-co-glycolide Implants Used in the Intramedullary Nailing of Children's Forearm Shaft Fractures with at Least Four Years of Follow-Up

The preferred surgical fixation of forearm shaft fractures in children is Elastic Stable Intramedullary Nailing (ESIN). Due to known disadvantageous effects of metal implants, a new surgical method using biodegradable polylactide-co-glycolide (PLGA) intramedullary nails has been developed but its long-term outcomes are unclear. The aim of this study was to compare the long-term outcomes of Biodegradable Intramedullary Nailing (BIN) to ESIN and assess the biodegradation of the study implants via magnetic resonance imaging (MRI). The study population of the prospective, randomized trial consisted of paediatric patients whose forearm shaft fractures were treated with BIN (n = 19) or ESIN (n = 16). Forearm rotation at minimally four years’ follow-up was the main outcome. There was no clinically significant difference in the recovery of the patients treated with the BIN as compared to those treated with the ESIN. More than half of the implants (57.7%, n = 15/26) were completely degraded, and the rest were degraded almost completely. The PLGA intramedullary nails used in the treatment of forearm shaft fractures in this study resulted in good function and anatomy. No unexpected disadvantages were found in the degradation of the implants. However, two implant failures had occurred in three months postoperatively.

Clinical and radiological outcomes with PEEK suture anchors used in rotator cuff repair: our experience confirm that a perianchor fluid signal on RM does not affect clinical outcome at one year of follow up

Introduction / objectives:

Osteolytic-type reactions of the perianchor bone which in magnetic resonance are manifested as hyperintensity of the signal in T2 images are reported in many studies. The doubt that this reaction of the bone could result in a loss of pull-out in the short and medium term and that it could therefore negatively affect tendon healing is the subject of an increasing number of studies. An osteolytic type signal around absorbable anchors can be explained by the metabilic processes in progress foreseen by the very nature of the material used, however this type of signal is also recognized around sutured implants or made of notoriously inert material. The objective of the present study is to evaluate and compare to the literature data the clinical and radiological results of a group of patients who underwent arthroscopic suture of a rotator cuff tear using polyetherketone (PEEK) suture anchors.

Materials and methods:

Twenty patients, aged between 44 and 73 years, who underwent arthroscopic repair of the rotator cuff for lesions smaller than 4 cm considered reparaible between August 2017 and January 2019, were enrolled in the present study. Patients were evaluated clinically with clinical examination, Constant scale and ASES scale pre and post surgery. MRI either pre and post operation at one year were evaluated to obtain data about tendon healing and evaluate bone reaction to PEEK anchors.

Results:

The mean lesion size was 16.8 mm +/- 7.8 mm and the mean tendon retraction was 15.6 mm +/- 14.9 mm. The mean increase in Constant and ASES scores at the one year-follow up was respectively 36.8 (p<0.01) and 47.2 (p<0.01). MRI analysis showed a tendon signal according to Sugaya classification of type 1 in the 25% of patients, type 2 in the 60% of cases and type 3 in the remaining 15% . Osteolysis was grade 0 in 65%, grade 1 in 30 % and grade 2 in 5% of cases. No anchors pull out or mobilization were reported.

Conclusions:

The presence of a T2 hyperintense signal osteolysis like on MRI control using PEEK anchors for the sutur of rotator cuff lesions does not find correlation whit the final clinical result of the procedure. Indeed, both patients with a major degree of osteolysis and those with degree 0 had an improvement both in terms of clinical and scores evaluation and in termsof tendon healing according to Sugaya’s score found in our cohort. (www.actabiomedica.it)

Editorial Commentary: Taking a "PEEK" at Suture Anchor Composition following Arthroscopic Rotator Cuff Repair: Is Bio Really Better?

The advent of modern suture anchor technology has not only revolutionized arthroscopic treatment options for management of complex shoulder pathology, but also engendered a materials science quest to identify the ultimate composition and design. What began as an open procedure with transosseous suture fixation has evolved dramatically with the widespread adoption of an arthroscopic, anchor-based technique for rotator cuff repair. Currently, a litany of commercially available "hard" and "soft" anchors are flooding the market, with limited qualitative comparisons to suggest superiority of one type. Ideally, suture anchor design should permit preservation of native glenohumeral bone stock with gradual osseointegration, limit disruption of local tissue homeostasis, and maintain time-zero mechanical strength until soft-tissue healing has occurred. At present, a vented, open-anchor architecture may facilitate better biologic incorporation with increased bony ingrowth through access to marrow elements, although these radiographic advantages have not conferred any clinically meaningful differences for our rotator cuff repair patients. For anchor composition, the jury is still out, and we need to continue to critically evaluate for perianchor cyst formation and longer term remodeling. In fact, the true merits of increased bony ingrowth and limited osteolysis may only be realized at the time of revision rotator cuff repair, during which prior implant position or secondary cystic change may further dictate suture anchor design, size, and placement.