Clinical outcome in all-arthroscopic versus mini-open rotator cuff repair in small to medium-sized tears: a randomized controlled trial in 100 patients with 1-year follow-up

A Comparative Analysis of Functional Recovery in Surgical Rotator Cuff Tear Repair: Mini-Open Versus All-Arthroscopic Techniques

INTRODUCTION

 Rotator cuff tears frequently lead to shoulder pain and impaired function, often necessitating surgical intervention to achieve the best results. The choice between mini-open and all-arthroscopic techniques remains a subject of debate, with each approach offering unique advantages and challenges. This study seeks to evaluate and compare the functional outcomes of surgical repair utilizing these two techniques, offering valuable insights into their relative effectiveness.

MATERIAL AND METHODS

 This retrospective observational study was conducted at Shree Krishna Hospital, Karamsad, involving patients treated surgically for rotator cuff tears over the past five years. Clinical records were reviewed to identify patients who underwent either mini-open or all-arthroscopic repair. Follow-up assessments were conducted using the Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) score and the Visual Analog Scale (VAS) for pain. A statistical analysis was performed to compare outcomes between the two groups.

RESULTS

 A total of 33 patients were included, with 16 undergoing mini-open repair and 17 undergoing all-arthroscopic repair. The mean follow-up duration was 31.06 months for mini-open repair and 20.4 months for all-arthroscopic repair. No statistically significant variances were observed in the postoperative Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) scores or Visual Analog Scale (VAS) scores between the two groups. Both techniques demonstrated satisfactory functional recovery and pain relief at long-term follow-up.

CONCLUSION

Our study provides evidence of comparable outcomes between mini-open and all-arthroscopic techniques for rotator cuff repair. Despite limitations such as a small sample size and the subjective nature of Quick DASH scores, both approaches offer promising results in terms of functional improvement and pain reduction. Further research is needed to assess short-term outcomes, cost-effectiveness, and patient satisfaction, but our findings support the continued use of both techniques in clinical practice.

Arthroscopic shoulder suspensioplasty in painful hemiplegic shoulder subluxation-a case series

Background

Inferior glenohumeral subluxation (GHS) can cause disabling pain in hemiplegics. Conservative treatments have not been proven to be effective or maintained over time. A few studies have shown the benefits of surgical treatment. The objective of our study was to evaluate the medium-term clinical and radiological results of arthroscopic glenohumeral suspensioplasty surgery by biceps tenodesis in the setting of painful GHS in hemiplegics.

Methods

We conducted a retrospective study of patients who underwent arthroscopic glenohumeral suspensioplasty. The assessment, at a minimum of 1 year, included a clinical evaluation (pectoralis major spasticity, pain, range of motion, satisfaction) and a radiographic evaluation (Dursun classification, height of subacromial space).

Results

Five patients with a mean age of 51 years (36-72 years) were included at a mean follow-up of 40 months (12-70). Satisfaction was good in 80% of patients. Pain decreased in all patients, but not significantly. Four patients (80%) would repeat the procedure if it were necessary. In all patients, a reduction in GHS over time was observed, with a reduction in subacromial height, except in 1 patient who suffered a tenodesis rupture during a fall.

Conclusion

Our results suggest that arthroscopic glenohumeral suspensioplasty by biceps tenodesis may be a therapeutic option in hemiplegic patients with painful GHS.

Sequential Release and Muscle Slide of Irreparable Rotator Cuff Tears Results in Linear Gains in Tendon Mobility

Purpose

The purposes of this study were to examine the technique of the supraspinatus and infraspinatus muscle slide for the treatment of rotator cuff tears and to quantify the amount of release and resultant tendon excursion at their insertion sites in cadavers.

Methods

Twelve shoulders in 6 human cadavers were dissected. Their average age at time of death was 84 years. Though a large open posterior incision, artificial rotator cuff tears were created, if not already present. Standard arthroscopic release was completed. Muscle slide technique was then performed for the supraspinatus and infraspinatus muscles in quartiles, with tendon excursion measured at each interval.

Results

The average muscle length from its most medial border to the tendinous insertion was 130 mm and 145.8 mm for the supraspinatus and infraspinatus, respectively. Progressive release of the muscle origin from lateral to medial in 25% increments corresponded to a 6.47-mm lateral shift of the tendon to a maximum of 25.8 mm before complete release of the supraspinatus muscle was achieved. For the infraspinatus, it was an average of 5.38 mm at each 25% interval to a maximum of 21.5 mm. The only restraint to mobility were the motor branches attached to the undersurface of each muscle belly.

Conclusions

An additional 25.8 mm (supraspinatus) and 21.5 mm (infraspinatus) of tendon excursion was produced when 100% of the muscle was released from its underlying fossa. At that juncture, tendon excursion was limited by tension placed on each muscle's respective neurovascular supply. Furthermore, sequential release of each muscle resulted in a predictable and consistent gain in tendon mobility, with an average of 6.47 mm and 5.38 mm for each quartile of muscle release in the supraspinatus and infraspinatus from lateral to medial.

Clinical Relevance

Tension at the repair site is a contributing factor to poor outcomes after arthroscopic rotator cuff repair of massive rotator cuff tears. This study quantifies the tendon mobility that may be gained following additional muscle slide techniques, and the addition of this technique may contribute to a tension-free repair.

Determinants of Operative Time in Arthroscopic Rotator Cuff Repair

Arthroscopic rotator cuff repairs have been reported to take between 72 and 113 min to complete. This team has adopted its practice to reduce rotator cuff repair times. We aimed to determine (1) what factors reduced operative time, and (2) whether arthroscopic rotator cuff repairs could be performed in under 5 min. Consecutive rotator cuff repairs were filmed with the intent of capturing a <5-min repair. A retrospective analysis of prospectively collected data of 2232 patients who underwent primary arthroscopic rotator cuff repair by a single surgeon was performed using Spearman's correlations and multiple linear regression. Cohen's f² values were calculated to quantify effect size. Video footage of a 4-min arthroscopic repair was captured on the 4th case. Backwards stepwise multivariate linear regression found that an undersurface repair technique (f² = 0.08, p < 0.001), fewer surgical anchors (f² = 0.06, p < 0.001), more recent case number (f² = 0.01, p < 0.001), smaller tear size (f² = 0.01, p < 0.001), increased assistant case number (f² = 0.01, p < 0.001), female sex (f² = 0.004, p < 0.001), higher repair quality ranking (f² = 0.006, p < 0.001) and private hospital (f² = 0.005, p < 0.001) were independently associated with a faster operative time. Use of the undersurface repair technique, reduced anchor number, smaller tear size, increased surgeon and assistant surgeon case number, performing repairs in a private hospital and female sex independently lowered operative time. A <5-min repair was captured.

Arthroscopic versus mini-open rotator cuff repair: A meta-analysis

BACKGROUND

An all-arthroscopic rotator cuff repair (ASR) may result in less postoperative pain and better functional outcomes than the mini-open (MOR) approach. This meta-analysis provides an updated assessment of the current literature which compares the clinical outcomes of mini-open versus all arthroscopic rotator cuff repair techniques.

MATERIAL AND METHODS

The main online databases were accessed in October 2021. All the trials directly comparing primary ASR versus MOR for rotator cuff rupture were accessed. Studies concerning revision settings were not eligible, nor where those combining the surgical procedures with other adjuvants.

RESULTS

A total of 21 articles were retrieved. Data from 1644 procedures (ASR = 995, MOR = 649) were collected. The mean follow-up was 26.7 (6.0-56.4) months. Comparability was found between ASR and MOR groups at baseline with regards to age (P = 0.3), gender (P = 0.7) and mean duration of the follow-up (P = 0.7). No difference was found between ASR and MOR with regard to surgical duration (P = 0.05), Constant score (P = 0.2), University of California at Los Angeles Shoulder (P = 0.3), American Shoulder and Elbow Surgeons Shoulder (P = 0.5), VAS (P = 0.2), forward flexion (P = 0.3), abduction (P = 0.3), external rotation (P = 0.2), internal rotation (P = 0.7), re-tear (P = 0.9), adhesive capsulitis (P = 0.5).

CONCLUSION

Arthroscopic and mini-open rotator cuff repair result in similar clinical outcomes. Male gender and older age lead to greater rates of rotator cuff re-tears, while longer surgical duration was associated with a greater rate of adhesive capsulitis.

Double-Row Repair With Platelet-Rich Plasma Optimizes Retear Rates After Small to Medium Full-Thickness Rotator Cuff Repair: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

PURPOSE

To compare the different interventions described in the literature for the surgical treatment of small and medium complete rotator cuff tears.

METHODS

A systematic review of randomized controlled trials of small-medium, full-thickness rotator cuff tears published since 2000 was performed. Clinical characteristics, re-tear rates, range of motion (ROM), and patient-reported outcomes (PRO) data were collected. Interventions were compared via arm-based Bayesian network meta-analysis in a random-effects model. Interventions were ranked for each domain (re-tear risk, pain, ROM, and PROs) via surface under the cumulative ranking curves.

RESULTS

A total of 18 studies comprising 2046 shoulders (47% females, mean age 61 ± 3 years, mean follow-up 21 ± 5 months) were included. Interventions that ranked highest for minimizing re-tear risk included arthroscopic single-row repair (A+SR) or double-row repair (A+DR) with or without platelet-rich plasma (PRP). Open repair and A+SR repair with acromioplasty (ACP) ranked highest for pain relief. Interventions that ranked highest for ROM improvement included open repair, PT, and A+DR with or without ACP. Interventions that ranked highest for PROs included arthroscopic footprint microfracture with or without SR, open repair, and A+SR with or without ACP.

CONCLUSIONS

Based on a network meta-analysis of level 1 studies, arthroscopic rotator cuff repair with a SR or DR construct demonstrates similar retear rates, PROs, and clinical outcomes. The highest-ranking treatment for minimizing retears was arthroscopic repair with DR constructs and PRP augmentation, although open repair and arthroscopic SR remain reliable options with excellent clinical outcomes. Addition of PRP to DR constructs trended toward a 56% decreased risk of retear as compared to DR repair alone. Although no single treatment emerged superior, several interventions offered excellent clinical improvements in pain, ROM, and PROs that exceeded minimal clinically important difference thresholds.

LEVEL OF EVIDENCE

I, systematic review and meta-analysis of level I studies.

Better Short-Term Outcomes After Rotator Cuff Repair in Studies With Poorer Mean Shoulder Scores and Predominantly Small to Medium-Sized Tears at Baseline: A Systematic Review and Meta-analysis

PURPOSE

To perform a meta-analysis to explore factors associated with clinical and structural short-term outcomes in randomized and nonrandomized prospective studies of rotator cuff repair.

METHODS

Medline, clinicaltrials.gov, and Mendeley were searched for literature published from January 2000 to December 2020 to identify randomized controlled trials (RCT) and nonrandomized prospective cohort studies (PCS) describing the outcome of surgical repair of full-thickness rotator cuff tears. Study quality was assessed by two independent reviewers. We calculated standardized mean difference (SMD) from baseline to follow-up in each trial arm, preferably at 12 months follow-up. Between-study heterogeneity of outcomes, small-study effects and rates of retear were assessed. Meta-regression was performed to estimate associations between prespecified variables and clinical and structural outcomes.

RESULTS

Outcomes in 64 RCT and 19 PCS trial arms were analyzed. Median age was 59 years. There was substantial between-study heterogeneity in clinical outcomes (SMD range: .42 to 6.44; I² = 93% in RCT, 88% in PCS) and summary estimates were not calculated. On the basis of multivariate analysis, better clinical outcome was associated with lower (worse) mean outcome value at baseline, smaller tear size, and lower proportion of large-massive tears (R² = 56 and 44%, respectively). Overall retear rate at median 13-month follow-up was 19.9% (interquartile range: 10-30). Higher mean age together with larger tear size and higher proportion of large-massive tears were associated with increased retear rates (R² = 33% and 58%, respectively). Clinical outcome was not significantly related to rate of retear.

CONCLUSIONS

Studies with lower mean outcome values at baseline and predominantly small- to medium-sized tears reported better clinical outcomes. Studies with higher mean age and a predominance of large-massive tears had significantly increased retear rates, but retear rates were not associated with clinical outcome.

LEVEL OF EVIDENCE

Level II, meta-analysis of level I and II studies.

Arthroscopic Versus Mini-open Rotator Cuff Repair: A Randomized Trial and Meta-analysis

BACKGROUND

Patients with complete rotator cuff tears who fail a course of nonoperative therapy can benefit from surgical repair.

PURPOSE

This randomized trial compared mini-open (MO) versus all-arthroscopic (AA) rotator cuff repair.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Patients with rotator cuff tears were randomized to undergo MO or AA repair at 9 centers by 23 surgeons. The primary outcome (Western Ontario Rotator Cuff Index [WORC]) and secondary outcomes (American Shoulder and Elbow Surgeons [ASES] score, Shoulder Pain and Disability Index [SPADI] pain subscale, 12-Item Short Form Health Survey [SF-12], reported medication use, adverse events), as well as measurements of range of motion and strength, were collected at 1 month before surgery; at 2 and 6 weeks postoperatively; and at 3, 6, 12, 18, and 24 months postoperatively. A blinded radiologist evaluated rotator cuff integrity on magnetic resonance imaging (MRI) at baseline and 1 year. Intention-to-treat analysis of covariance with the preoperative WORC score, age, and tear size as covariates assessed continuous outcomes. Sex differences were assessed. A meta-analysis synthesized the primary outcome between MO and AA repair with previous trials.

RESULTS

From 954 patients screened, 411 were ineligible (276 because of recovery with physical therapy), 449 were screened at surgery (175 ineligible), and 274 completed follow-up (138 MO and 136 AA). The AA and MO groups were similar before surgery. WORC scores improved from 40 preoperatively to 89 (AA) and 93 (MO) at 2 years, for an adjusted mean difference of 3.4 (95% CI, -0.4 to 7.2). There were no statistically significant differences between the AA and MO groups at any time point. All secondary patient-reported outcomes were not significantly different between the MO and AA groups, except the 2-year SPADI pain score (8 vs 12, respectively; P = .02). A similar recovery in range of motion and strength occurred in both groups over time. MRI indicated minimal improvement in muscle relative to fat (AA: n = 3; MO: n = 2), with most worsening (AA: n = 25; MO: n = 24) or remaining unchanged (AA: n = 70; MO: n = 70). Opioid use was significantly reduced after surgery (from 21% to 5%). The meta-analysis indicated no significant standardized mean difference between groups in the primary outcome across all pooled studies (standardized mean difference, -0.06 [95% CI, -0.34 to 0.22]).

CONCLUSION

Both AA and MO rotator cuff repair provide large clinical benefits, with few adverse events. There is strong evidence of equivalent clinical improvements.

TRIAL REGISTRATION

NCT00128076.

The effects of nonsteroidal anti-inflammatory medications after rotator cuff surgery: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used for postoperative pain management. However, animal studies have demonstrated negative effects of NSAIDs on bone and tendon healing after commonly performed procedures such as rotator cuff repair. The purpose of this study was to evaluate the effects of postoperative NSAID use on opioid use, pain control, and shoulder outcomes after arthroscopic rotator cuff repair.

METHODS

A randomized, double-blind, placebo-controlled trial of postoperative NSAID use was performed in patients undergoing primary arthroscopic rotator cuff surgery at a single institution. Patients were randomized to receive ibuprofen or placebo for 2 weeks postoperatively, in addition to opioid medication. They were instructed to keep a daily pain diary for the first week after surgery, which was returned at their first postoperative visit for analysis. Visual analog scale (VAS) pain scores, shoulder range of motion, and 12-item Short Form Survey, Disabilities of the Arm, Shoulder and Hand, and American Shoulder and Elbow Surgeons (ASES) scores were collected. Assessment of rotator cuff healing was performed using ultrasound at 1 year postoperatively.

RESULTS

A total of 50 patients in the placebo group and 51 patients in the ibuprofen group were included for analysis. There were no differences in age, race, sex, history of preoperative NSAID or opioid use, or operative findings between groups. The amount of mean total morphine milligram equivalents (MMEs) used in the first postoperative week was lower in the ibuprofen group than in the placebo group (168 MMEs vs. 211 MMEs, P = .04). Early VAS scores on postoperative days 3, 4, 5, and 6 were lower in the ibuprofen group, but there was no difference in mean VAS scores between groups by 6 weeks after surgery. At 6 months, mean forward flexion and the mean ASES score were higher in the ibuprofen group than in the placebo group: 162° vs. 153° (P = .03) and 86 vs. 78 (P = .02), respectively. There were no differences in shoulder motion or 12-item Short Form Survey, Disabilities of the Arm, Shoulder and Hand, or ASES scores at 1 year. At 1 year after surgery, 7 patients in the ibuprofen group had evidence of tendon retear diagnosed on ultrasound (5 partial and 2 full thickness) compared with 13 patients in the placebo group (5 partial and 8 full thickness), but this difference was not statistically significant (P = .20).

CONCLUSION

Postoperative ibuprofen use reduces opioid requirements and decreases patient pain levels in the first week after arthroscopic rotator cuff repair. In addition, ibuprofen use after rotator cuff repair does not lead to an increased risk of tendon retear.

Retear rates after rotator cuff surgery: a systematic review and meta-analysis

Background

Rotator cuff retear (RCR) is one of the main postoperative drawbacks. RCR can be considered a multifactorial issue, which causes are related either to biological than biomechanical factors. The aim of this study was to define the incidence of RCR after surgical treatment at different time points and to identify the main factors influencing the postoperative rotator cuff (RC) healing.

Methods

A systematic review and meta-analysis were performed following the PRISMA guidelines. A comprehensive search of the literature was carried out in July 2020, using PubMed and Cochrane Library databases. Only level 1 and 2 clinical evidence studies were included. Studies were included if patients with preoperative repairable full-thickness RC tears were treated surgically, and if studies reported postoperative RCR confirmed by imaging diagnostic. The association between timing of retear and follow-up time points were investigated using an inverse-variance method of pooling data. A subgroup meta-analysis was performed using the DerSimonian and Laird method for the estimation of the between-study variance, i.e., τ². The association between retear rate after surgery and patients’ age, preoperative tear size, fatty infiltration, postoperative rehabilitation protocol, surgical techniques, and RC repairs was determined by expressing the effect measure in terms of odds ratio (OR) with 95% confidence interval (CI). The Mantel-Haenszel method with 95% CIs was used.

Results

Thirty-one articles were included in this study. The percentage of RCR after surgery was 15% at 3 months follow-up, 21% at 3–6 months follow-up, 16% at 6–12 months follow-up, 21% at 12–24 months follow-up, 16% at follow-up longer than 24 months. The main factors influencing RC healing are both patient-related (i.e., age, larger tear size, fatty infiltration) and not patient-related (i.e., postoperative rehabilitation protocol, surgical techniques, and procedures).

Conclusions

Postoperative RC healing is influenced by patient-related and non-patient-related factors. Further high-level clinical studies are needed to provide highly relevant clinical results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04634-6.

Conservative versus accelerated rehabilitation after rotator cuff repair: a systematic review and meta-analysis

Background

The purpose of this systematic review and meta-analysis is to compare the conservative and accelerated rehabilitation protocols in patients who underwent arthroscopic rotator cuff repair in terms of clinical outcomes and range of motions at 3, 6, 12, and 24-month follow-up.

Methods

According to PRISMA guidelines, a systematic review of the literature was performed. For each included article, the following data has been extracted: authors, year, study design, level of evidence, demographic characteristics, follow-up, clinical outcomes, range of motions, and retear events. A meta-analysis was performed to compare accelerated versus conservative rehabilitation protocols after arthroscopic rotator cuff repair. The retear rate, postoperative Constant-Murley score and range of motions at 3, 6, 12, and 24 months of follow-up were the outcomes measured.

Results

The search strategy yielded 16 level I-II clinical studies. A total of 1424 patients, with 732 patients and 692 in the accelerated and conservative group, were included. The average age (mean ± standard deviation) was 56.1 ± 8.7 and 56.6 ± 9 in the accelerated and conservative group. The mean follow-up was 12.5 months, ranging from 2 to 24 months. The meta-analysis showed no statistically significant differences in terms of retear rate between the groups (P = 0.29). The superiority of the accelerated group was demonstrated in terms of external rotation (P < 0.05) at 3-month follow-up; in terms of forward elevation, external rotation, abduction (P < 0.05), but not in terms of Constant-Murley score at 6-month follow-up; in terms of forward elevation (P < 0.05) at 12-month follow-up. No significant differences between the two group were highlighted at 24-month follow-up.

Conclusions

No statistically significant differences in the retear rate among the accelerated and conservative group have been demonstrated. On the other hand, statistically and clinically significant differences were found in terms of external rotation at 3 and 6 months of follow-up in favour of the accelerated group. However, no differences between the two groups were detected at 24 months follow-up.

Update on all-arthroscopic vs. mini-open rotator cuff repair: A systematic review and meta-analysis

Purpose

To provide an updated comparison between modern arthroscopic and mini-open repairs for treating rotator cuff tears.

Methods

Multiple online databases were searched from 2010 to October 1st, 2020. A meta-analysis was conducted for patient-reported outcomes and complications.

Results

Eleven studies were included. Majority of patients underwent mini-open repair (MOR) compared to arthroscopic repair (AR) (57.4% vs 42.6%). A meta-analysis found statistically significant differences (p < 0.05) in patient-reported outcomes favouring AR. While retear rates were higher in AR (p = 0.03) analysis of retear rates for arthroscopic double row and mini-open repairs, yielded no differences between groups (p = 0.48).

Conclusion

Patients undergoing AR for rotator cuff tears had improved post-operative clinical outcomes in some functional outcomes compared to MOR. Modern arthroscopic double row repair result in similar failure rates to open repair techniques.

Level of evidence

Level III, Systematic Review of Level I-III studies.

Patch augmentation surgery for rotator cuff repair: the PARCS mixed-methods feasibility study

BACKGROUND

A rotator cuff tear is a common, disabling shoulder problem. Symptoms may include pain, weakness, lack of shoulder mobility and sleep disturbance. Many patients require surgery to repair the tear; however, there is a high failure rate. There is a need to improve the outcome of rotator cuff surgery, and the use of patch augmentation (on-lay or bridging) to provide support to the healing process and improve patient outcomes holds promise. Patches have been made using different materials (e.g. human/animal skin or tissue and synthetic materials) and processes (e.g. woven or mesh).

OBJECTIVES

The aim of the Patch Augmented Rotator Cuff Surgery (PARCS) feasibility study was to determine the design of a definitive randomised controlled trial assessing the clinical effectiveness and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and feasible.

DESIGN

A mixed-methods feasibility study of a randomised controlled trial.

DATA SOURCES

MEDLINE, EMBASE and the Cochrane Library databases were searched between April 2006 and August 2018.

METHODS

The project involved six stages: a systematic review of clinical evidence, a survey of the British Elbow and Shoulder Society's surgical membership, a survey of surgeon triallists, focus groups and interviews with stakeholders, a two-round Delphi study administered via online questionnaires and a 2-day consensus meeting. The various stakeholders (including patients, surgeons and industry representatives) were involved in stages 2-6.

RESULTS

The systematic review comprised 52 studies; only 15 were comparative and, of these, 11 were observational (search conducted in August 2018). These studies were typically small (median number of participants 26, range 5-152 participants). There was some evidence to support the use of patches, although most comparative studies were at a serious risk of bias. Little to no published clinical evidence was available for a number of patches in clinical use. The membership survey of British Elbow and Shoulder surgeons [105 (21%) responses received] identified a variety of patches in use. Twenty-four surgeons (77%) completed the triallist survey relating to trial design. Four focus groups were conducted, involving 24 stakeholders. Differing views were held on a number of aspects of trial design, including the appropriate patient population (e.g. patient age) to participate. Agreement on the key research questions and the outline of two potential randomised controlled trials were achieved through the Delphi study [29 (67%)] and the consensus meeting that 22 participants attended.

LIMITATIONS

The main limitation was that the findings were influenced by the participants, who are not necessarily representative of the views of the relevant stakeholder groups.

CONCLUSION

The need for further clinical studies was clear, particularly given the range and number of different patches available.

FUTURE WORK

Randomised comparisons of on-lay patch use for completed rotator cuff repairs and bridging patch use for partial rotator cuff repairs were identified as areas for further research. The value of an observational study to assess safety concerns of patch use was also highlighted. These elements are included in the trial designs proposed in this study.

STUDY REGISTRATION

The systematic review is registered as PROSPERO CRD42017057908.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 13. See the NIHR Journals Library website for further project information.

Clinical outcomes and cost-utility of rotator cuff repair surgery by open and arthroscopic techniques: study protocol for a randomised clinical trial

INTRODUCTION

Rotator cuff injuries account for up to 70% of pain in the shoulder. However, there remains no consensus on the best surgical treatment for patients with rotator cuff injuries, in terms of the cost-effectiveness and cost-utility of open and arthroscopic methods for rotator cuff repair. The objective of this trial is to compare the efficacy, cost-effectiveness and cost-utility of open and arthroscopic procedures for rotator cuff repair.

METHODS AND ANALYSIS

The trial is a two-group, parallel-design, randomised controlled trial. A total of 100 patients with symptomatic rotator cuff lesions will be allocated in either open or arthroscopic technique in a 1:1 ratio, considering smoking (yes or no), lesion size (≤3 cm or >3 cm) and diabetes (present or absent) as stratification factors. All patients will be included in the same rehabilitation programme after the intervention. The primary outcome measure will be the Constant-Murley Score and the EuroQol-5D-3L score at 48 weeks postsurgery. Secondary outcomes include cost-effectiveness, cost-utility, pain, complications and clinical analysis, using the Simple Shoulder Test, Visual Analogue Pain Scale (VAS), integrity of the repair evaluated through MRI, and complications and failures of the proposed methods. For the cost-effectiveness analysis, we will use the VAS and the Constant-Murley Score as measures of effectiveness. For the cost-utility analysis, we will use the EuroQol-5D-3L as a measure of utility in terms of incremental cost per quality-adjusted life-years.

ETHICS AND DISSEMINATION

The study has been approved by the local research ethics committee of both institutions: Hospital Israelita Albert Einstein and Hospital Alvorada Moema/Hospital Pró-Cardíaco. The results will be published in a peer-reviewed, open access journal.

TRIAL REGISTRATION NUMBER

NCT04146987.

A Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears

Background and objectives: Our research aimed to evaluate the quality of reporting of randomized controlled trials (RCTs) linked to rotator cuff (RC) tears. The present study analyzed factors connected to the quality of the RCTs and trends in the quality of reporting through time. Materials and Methods: The online databases used to search all RCTs on the topic of RC surgery completed until March 2020 were PubMed and Ovid (MEDLINE). The quality of reporting was evaluated using the modified Coleman methodology score (MCMS) and the consolidated standards of reporting trials (CONSORT). Results: The online search found 957 articles. Finally, 183 studies were included in the quantitative synthesis. A total of 97 (53%) of 183 studies had a level of evidence I and 86 (47%) of 183 studies had a level of evidence II, according to the Oxford Center of Evidence Based Medicine (EBM). A statistically significant difference in MCMS between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had, on average, the highest Coleman score. The average number of CONSORT checklist items for each article across all analyzed RCTs was 21.67. The 37 studies completed up to 2010 averaged a number of checklist items of 19.97 and the studies completed between 2011 and 2019 averaged a number of checklist items of 22.10. A statistically significant difference in the number of checklist items between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had on average more checklist items. However, low correlation (0.26) between the number of checklist items for each article and the respective Coleman score was found. On the other hand, articles with the CONSORT diagram had a significantly high Coleman score. Conclusions: An improvement in the quantity and quality of RCTs relating to RC surgery over the analyzed period was found.

No difference in long-term outcome between open and arthroscopic rotator cuff repair: a prospective, randomized study

Background

Arthroscopic rotator cuff repair techniques have almost replaced open repairs. Short- and mid-term studies have shown comparable outcomes, with no clear superiority of either procedure. The aim of this study was to compare the long-term clinical and imaging outcomes following arthroscopic or open rotator cuff repair.

Methods

Forty patients with magnetic resonance imaging (MRI)–documented, symptomatic supraspinatus or supraspinatus and infraspinatus tears were randomized to undergo arthroscopic or open rotator cuff repair. Clinical and radiographic follow-up was obtained at 6 weeks, 3 months, 1 year, 2 years, and >10 years postoperatively. Clinical assessment included measurement of active range of motion, visual analog scale score for pain, functional scoring according to the Constant-Murley score (CS), and assessment of the Subjective Shoulder Value. Imaging included conventional radiography and MRI for the assessment of cuff integrity and alteration of the deltoid muscle.

Results

We enrolled 20 patients with a mean age of 60 years (range, 50-71 years; standard deviation [SD], 6 years) in the arthroscopic surgery group and 20 patients with a mean age of 55 years (range, 39-67 years; SD, 8 years) in the open surgery group. More than 10 years’ follow-up was available for 13 patients in the arthroscopic surgery group and 11 patients in the open surgery group, with mean follow-up periods of 13.8 years (range, 11.9-15.2 years; SD, 1.1 years) and 13.1 years (range, 11.7-15 years; SD, 1.1 years), respectively. No statistically significant differences in clinical outcomes were identified between the 2 groups: The median absolute CS was 79 points (range, 14-84 points) in the arthroscopic surgery group and 84 points (range, 56-90 points) in the open surgery group (P = .177). The median relative CS was 94% (range, 20%-99%) and 96% (range, 65%-111%), respectively (P = .429). The median Subjective Shoulder Value was 93% (range, 20%-100%) and 93% (range, 10%-100%), respectively (P = .976). MRI evaluation showed a retear rate of 30% equally distributed between the 2 groups. Neither fatty infiltration of the deltoid muscle, deltoid muscle volume, nor the deltoid origin were different between the 2 groups.

Conclusion

In a small cohort of patients, we could not document any difference in clinical and radiographic outcomes at long-term follow-up between arthroscopic and open rotator cuff repair. The postulated harm to the deltoid muscle with the open technique could not be confirmed.

A Comparison of the Clinical Outcomes between Arthroscopic and Open Rotator Cuff Repair in Patients with Rotator Cuff Tear: A Nonrandomized Clinical Trial

Background

Several researchers have investigated the clinical outcomes in patients with rotator cuff tear who compared open and arthroscopic surgeries; however, there are limited studies that have compared the outcomes of arthroscopic and open rotator cuff repair. This study was aimed to compare the clinical outcomes of the patients who underwent rotator cuff repair using either arthroscopic or open repair techniques.

Materials and Methods

This is a prospective cohort study in which 51 patients who underwent either open or arthroscopic rotator cuff repair were studied. Twenty-six patients underwent open repair, and 25 patients had an arthroscopic repair. Patients were followed for 6-36 months. The outcome of the two groups was evaluated using the Universal California Los Angles (UCLA) score.

Results

The mean tear size was 4.93 ± 2.3 cm² in the open surgery group and 4.99 ± 2.3 cm² in the arthroscopic group (P = 0.93). All patients showed significant improvement in their scores for pain, active forward flexion, active abduction, and function at the time of follow-up. Improvement in scores within each group was significant, but the comparison of the two techniques was not statistically significant in pain, active abduction, active forward flexion, and UCLA, but in function, the open surgery group was superior (P < 0.05).

Conclusion

This study revealed that short-term outcomes for arthroscopic and open cuff repair are similar, except in function, which was significantly better in the open surgery.

The Postoperative Rotator Cuff

MR imaging interpretation following rotator cuff repair can be challenging and requires familiarity with various types of rotator cuff tear, their surgical treatments, normal postoperative MR imaging appearance, and complications. This article reviews the common surgical procedures for the reparable and nonreparable massive rotator cuff tears, their expected postoperative MR imaging findings, and imaging appearance of a range of complications.

Surgery and physiotherapy were both successful in the treatment of small, acute, traumatic rotator cuff tears: a prospective randomized trial

BACKGROUND

Previous randomized trials on cuff repair have included mainly degenerative tears, but studies on acute traumatic tears are lacking. We aimed to compare early surgical repair with nonoperative treatment for traumatic supraspinatus tears.

METHODS

We did a 2-center randomized controlled trial of patients with small rotator cuff tears mainly involving supraspinatus, comparing surgical repair (n = 32) and physiotherapy (n = 26). The primary outcome was a group difference in the Constant-Murley score at 12-month follow-up. Secondary outcomes were differences in the Western Ontario Rotator Cuff index, pain (Numerical Rating Scale 0-10), and Euro quality-of-life-visual analog scale. We used magnetic resonance imaging to assess retear rate, tear progression, fatty infiltration, and atrophy.

RESULTS

The mean age was 59.7 years (range, 44-77 years), median sagittal tear size was 9.7 mm (range, 4-21 mm), and baseline characteristics were well balanced between the 2 groups. The repair group had a median Constant-Murley of 83 (25 quartile range [QR]) and the physiotherapy group 78 (QR, 22) at 12 months, with the between-group difference in medians of 4.5 (-5 to 9, 95% confidence interval; P = .68). The corresponding values for the Western Ontario Rotator Cuff index were 91% (QR, 24) vs. 86% (QR, 24), with the between-group difference of 5.0 (-4 to 9, 95% confidence interval; P = .62). There was no difference in Numerical Rating Scale or in Euro quality-of-life-visual analog scale. Retear was found in 6.5% of repaired patients and tear progression >5 mm in 29.2% of unrepaired patients.

CONCLUSIONS

We found no significant differences in clinical outcomes between cuff repair and nonoperative treatment at 12-month follow-up. Approximately one third of unrepaired patients had a tear enlargement of more than 5 mm.

Effects of arthroscopic vs. mini-open rotator cuff repair on function, pain & range of motion. A systematic review and meta-analysis

Objective

To assess the effectiveness of arthroscopic versus mini-open rotator cuff repair on function, pain and range of motion at 3-, 6- and 12-month follow ups.

Design

Systematic review and meta-analysis of randomized controlled trials.

Setting

Clinical setting.

Participants

Patients 18 years and older with a rotator cuff tear.

Intervention/Comparison

Arthroscopic/mini-open rotator cuff repair surgery followed by post operative rehabilitation.

Main outcome measures

Function and pain.

Results

Six RCTs (n = 670) were included. The pooled results, demonstrated no significant difference between arthroscopic and mini open approach to rotator cuff repair on function (very low quality, 4 RCTs, 495 patients, SMD 0.00, 3-month; very low quality, 4 RCTs, 495 patients, SMD -0.01, 6-month; very low quality, 3 RCTs, 462 patients, SMD -0.09, 12-months). For pain, the pooled results, were not statistically different between groups (very low quality, 3 RCTs, 254 patients, MD -0.21, 3-month; very low quality, 3 RCTs, 254 patients, MD -0.03, 6-month; very low quality, 2 RCTs, 194 patients, MD -0.35, 12-months).

Conclusion

The effects of arthroscopic compared to mini-open rotator cuff repair, on function, pain and range of motion are too small to be clinically important at 3-, 6- and 12-month follow ups.

Surgical repair versus conservative treatment and subacromial decompression for the treatment of rotator cuff tears

Aims

The purpose of this study was to compare the effectiveness of surgical repair to conservative treatment and subacromial decompression for the treatment of chronic/degenerative tears of the rotator cuff.

Materials and Methods

PubMed, Cochrane database, and Medline were searched for randomized controlled trials published until March 2018. Included studies were assessed for methodological quality, and data were extracted for statistical analysis. The systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

Results

Six studies were included. Surgical repair resulted in a statistically significantly better Constant–Murley Score (CMS) at one year compared with conservative treatment (mean difference 6.15; p = 0.002) and subacromial decompression alone (mean difference 5.81; p = 0.0004). In the conservatively treated group, 11.9% of patients eventually crossed over to surgical repair.

Conclusion

The results of this review show that surgical repair results in significantly improved outcomes when compared with either conservative treatment or subacromial decompression alone for degenerative rotator cuff tears in older patients. However, the magnitude of the difference in outcomes between surgery and conservative treatment may be small and the ‘success rate’ of conservative treatment may be high, allowing surgeons to be judicious in choosing those patients who are most likely to benefit from surgery. Cite this article: Bone Joint J 2019;101-B:1100–1106.

The Natural History of Full-Thickness Rotator Cuff Tears in Randomized Controlled Trials: A Systematic Review and Meta-analysis

BACKGROUND

Rotator cuff tears are the most common tendon injury in the adult population, resulting in substantial morbidity. The optimum management for these patients is not known.

PURPOSE

To assess the overall treatment response to all interventions in full-thickness rotator cuff tears among patients enrolled in randomized clinical trials.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Randomized controlled trials (RCTs) were identified from a systematic search of Medline, Embase, CINHAL, and the Cochrane Central Register of Controlled Trials. Patients were aged ≥18 years with a full-thickness rotator cuff tear. The primary outcome measure was change in Constant shoulder score from baseline to 52 weeks. A meta-analysis to assess treatment response was calculated via the standardized mean change in scores.

RESULTS

A total of 57 RCTs were included. The pooled standardized mean change as compared with baseline was 1.42 (95% CI, 0.80-2.04) at 3 months, 2.73 (95% CI, 1.06-4.40) at 6 months, and 3.18 (95% CI, 1.64-4.71) at 12 months. Graphic plots of treatment response demonstrated a sustained improvement in outcomes in nonoperative trial arms and all operative subgroup arms.

CONCLUSION

Patients with full-thickness rotator cuff tears demonstrated a consistent pattern of improvement in Constant score with nonoperative and operative care. The natural history of patients with rotator cuff tears included in RCTs is to improve over time, whether treated operatively or nonoperatively.

Do elderly patients gain as much benefit from arthroscopic rotator cuff repair as their younger peers?

BACKGROUND

This study was conducted to ascertain whether patients aged older than 75 years achieve outcomes after arthroscopic rotator cuff repair comparable to younger patients.

METHODS

Arthroscopic cuff repair was performed in 60 shoulders of 59 patients aged older than 75 years. A control group of 60 younger patients, matched for sex, tear size, and American Society of Anesthesiology Functional Classification grade were included. Surgery occurred from 2006 to 2016. Prospective outcomes were the Constant score (CS), Subjective Shoulder Value, pain, satisfaction, and operative complications. Mean follow-up was 29 months.

RESULTS

The elderly group was a mean age of 78 years compared with 59 years for controls. Tear sizes were 25 massive, 20 large, 12 medium, and 3 small. The CS improved by 25.1 points in elderly patients compared with 23.7 points for controls (P = .742). Pain improved by 7.5 of 15 in elderly patients vs. 6.2 of 15 in controls (P = .055). Fifty-five of 59 older patients were satisfied compared with 52 of 60 controls (P = .378). The overall complication rate did not differ between the groups (P = .509). Both groups had 1 infection and 1 stiffness. An acromioclavicular joint cyst developed in 1 younger patient, and a traumatic retear occurred in 1 patient. Subsequent reverse total shoulder arthroplasty was performed in 4 elderly patients at a mean of 28 months after cuff repair. Massive tears had higher risk for subsequent reverse total shoulder arthroplasty (P = .026).

CONCLUSION

Elderly patients benefit as much from arthroscopic rotator cuff repair as their younger counterparts. Similar improvements in CS, Subjective Shoulder Value, pain, and satisfaction occurred for both elderly and control patients. Arthroscopic repair was safe and effective in both groups. Even elderly patients with massive tears showed clinically significant improvements. Arthroscopic rotator cuff repair should be considered as a valuable treatment irrespective of age.

Inferior outcome of rotator cuff repair in chronic hemodialytic patients

BACKGROUND

Repair of rotator cuff tears has yielded excellent functional outcomes in recent decades; however, poor outcomes and dissatisfaction have been noted in specific groups. Spontaneous tendon rupture has been reported in patients receiving long-term hemodialysis owing to alteration of tendon structure, which might impede functional recovery after rotator cuff repair. The purpose of the present study was to compare the clinical outcomes between hemodialysis and non-hemodialysis patients after rotator cuff repair.

METHODS

We retrospectively reviewed patients who underwent mini-open rotator cuff repair from Jan 2013 to Jan 2017. A total of 14 patients under chronic hemodialysis (HD) were matched to non-hemodialysis (NHD) patients at a 1:2 ratio according to age, gender, tear size, severity of fatty infiltration and history of diabetes. Pre- and post-operative functional outcome was assessed using the simple shoulder test (SST), American Shoulder and Elbow Surgeons (ASES), Shoulder Rating Scale of the University of California at Los Angeles (UCLA) and visual analog scale (VAS) scores. Clinical functional outcome at the last follow-up was adopted for comparison of the HD and NHD groups.

RESULTS

A total of 42 patients were enrolled in this comparative study, with a mean age of 66.64 ± 1.68 years in the HD group and 65.71 ± 5.40 years in the NHD group. At the final clinical assessment, the post-operative functional outcome was significantly improved in both groups (p < 0.001). However, the functional outcome of the HD group was significantly inferior to that of the NHD group in terms of the SST score (6.50 ± 2.24 vs 9.39 ± 1.87, p < 0.001), ASES score (63.17 ± 15.93 vs 86.96 ± 11.43, p < 0.001), UCLA score (20.14 ± 7.71 vs 29.82 ± 5.08, p < 0.001) and VAS score (3.00 ± 0.96 vs 1.21 ± 1.03, p < 0.001).

CONCLUSION

The improvement of pain and functional improvement of long-term hemodialysis patients were inferior to those of patients without hemodialysis after mini-open rotator cuff repair.

Long-term results of arthroscopic and mini-open repair of small- to medium-size full-thickness rotator cuff tears

BACKGROUND

This retrospective cohort study evaluated functional outcome and structural integrity after arthroscopic- or mini-open repair of small- to medium-size rotator cuff tears assessed at long-term follow-up.

METHODS

All patients operated between 2001 and 2004 were invited to participate. Functional outcome was measured by Constant-Murley Score, Disability of Arm, Shoulder and Hand and Oxford Shoulder Score. Quality of life was assessed with EuroQol Health 5 Dimension. Patient satisfaction was assessed in terms of pain and overall result. Structural integrity of the rotator cuff repair was determined using ultrasound.

RESULTS

Of the eligible 62 patients, 44 patients were available for follow-up. After a mean of 11.3 years, 76% of the patients had good to excellent functional outcome on the Constant-Murley Score (median 82, range 29-95). The majority of patients reported good results on both Disability of Arm, Shoulder and Hand and Oxford Shoulder Score (median Disability of Arm, Shoulder and Hand 5.0, range 1.0-54; median Oxford Shoulder Score 19, range 13-39). The quality of life was also good (mean EuroQol Health 5 Dimension utility score 0.88, standard deviation 0.12). Eighty per cent was satisfied with the overall result. Ultrasound examination revealed structural integrity in 76% of all cases.

CONCLUSION

This study shows that functional outcome is good and structural integrity is high for the majority of patients 11.3 years after repair of small- to medium-size rotator cuff lesions.

Outcomes of arthroscopic rotator cuff repair with muscle advancement for massive rotator cuff tears

BACKGROUND

We performed arthroscopic rotator cuff repair (ARCR) combined with miniopen supraspinatus and infraspinatus muscle advancement for massive rotator cuff tears (RCTs) to decrease tension at the repair site with the goal of reduction of the failure rate. We evaluated the clinical outcomes and failure rate after this procedure.

METHODS

This study included 47 patients diagnosed with chronic massive RCTs between October 2010 and March 2015. Of these patients, 21 underwent transosseous equivalent (TOE) ARCR only (control group), and 26 underwent TOE ARCR with muscle advancement (study group). We evaluated shoulder clinical outcomes at preoperative and postoperative assessments and also measured muscle strength and the acromiohumeral interval (AHI) at the same time in both groups. Failure rates were calculated in both groups by evaluating the cuff integrity with postoperative magnetic resonance imaging.

RESULTS

Although there was statistically significant improvement for the mean clinical scores in the both groups, there were no significant differences between the 2 groups. The postoperative abduction muscle strength and AHI were significantly higher in the study group (46.3 ± 20.6 N and 9.4 ± 2.9 mm; P = .04) than in the control group (34.6 ± 20.0 N and 7.7 ± 3.0 mm; P = .04). The failure rates were significantly lower in the study group than in the control group (23.1% and 52.4%; P = .03).

CONCLUSION

The TOE ARCR with muscle advancement can achieve significantly better abduction muscle strength, wider AHI, and lower failure rates for massive RCTs than the normal TOE ARCR.

Patch-augmented rotator cuff surgery (PARCS) study-protocol for a feasibility study

BACKGROUND

A rotator cuff tear is a common disabling shoulder problem. Symptoms include pain, weakness, lack of shoulder mobility and sleep disturbance. Many patients require surgery to repair the tear; however, there is a high failure rate. There is a pressing need to improve the outcome of rotator cuff surgery and the use of patch augmentation to provide support to the healing process and improve patient outcomes holds new promise. Patches have been made using different materials (e.g. human/animal skin or intestine tissue, and completely synthetic materials) and processes (e.g. woven or a mesh). However, clinical evidence on their use is limited. The aim of the patch-augmented rotator cuff surgery (PARCS) feasibility study is to determine, using a mixed method approach, the design of a definitive randomised trial assessing the effectiveness and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and feasible.

METHODS

The objectives of this six-stage mixed methods feasibility study are to determine current practice, evidence and views about patch use; achieve consensus on the design of a randomised trial to evaluate patch-augmented rotator cuff surgery; and assess the acceptability and feasibility of the proposed design. The six stages will involve a systematic review of clinical evidence, two surveys of surgeons, focus groups and interviews with stakeholders, a Delphi study and a consensus meeting. The various stakeholders (including patients, surgeons, and representatives from industry, the NHS and regulatory bodies) will be involved across the six stages.

DISCUSSION

The PARCS feasibility study will inform the feasibility and acceptability of a randomised trial of the effectiveness and cost-effectiveness of a patch-augmented rotator cuff surgery. Consensus opinion on the basic design of a randomised trial will be sought.

TRIAL REGISTRATION

Not applicable.

Evaluation of long-term postoperative outcomes between mini-open and arthroscopic repair for isolated supraspinatus tears: a retrospective analysis

BACKGROUND

Despite arthroscopic repair of the rotator cuff is an increasingly popular procedure, the mini-open (MO) repair still remains a viable and appreciated technique. The purpose of the study was to analyze the long-term clinical outcomes of patients with isolated supraspinatus tear undergoing MO or arthroscopic surgery (AS) repair.

PATIENTS AND METHODS

Forty-six patients underwent supraspinatus repair with anchors: 24 with MO technique and 22 with AS procedure. They were evaluated postoperatively at 3, 6, 12 months and 2 years.

RESULTS

The mean surgery time, the mean hospital stay and the average costs were shorter in the MO patients respect to the AS group. Despite an initial better Disabilities of Arm, Shoulder and Hand and Constant Murley Score in the first 6 months of follow-up in the AS group, no differences were detected at 24 months.

CONCLUSION

This study suggests that isolated supraspinatus tears can be treated with a MO or arthroscopic repair procedure with similar clinical outcome in the long-term postoperative period. The mean surgery time and the average costs are less in the MO group respect to the AS group.

A comparison of full arthroscopic and arthroscopic-assisted mini-open repair methods in rotator cuff tears 1-3 cm in size

Introduction

Retrospective evaluation of rotator cuff repair with arthroscopic or arthroscopic-assisted mini-open methods for a diagnosis of non-retracted rotator cuff tear.

Materials and methods

A total of 45 patients underwent rotator cuff repair; Group 1 (n = 24) with arthroscopic-assisted mini-open method and Group 2 (n = 21) with full arthroscopic method.

Results

Within both Group 1 and Group 2, a statistically significant results is p = 0.001. The patients of Group 2 were seen to return to daily life earlier than those of Group 1 (p = 0.001).

Conclusions

Patients where full arthroscopic repair was applied, there was evidence of an earlier return to daily life.

Level of evidence

IV, retrospective comparative study.

Single Portal Technique for Subscapularis Tendon Repair

The fast and steady development of arthroscopy techniques in the last couple of decades led to a drastic increase of arthroscopic rotator cuff repairs over the open procedure. Supraspinatus tears are the most common of all, but the subscapularis tendon tear is a more common injury than expected. Most of the time it presents as a partial tear or is associated with a subsequent rotator cuff tendon injury, especially the supraspinatus. Nowadays, the standard procedure to repair the subscapularis tendon is performed arthroscopically, even though a real superior result over the open repair it is yet to be reported. Ideally less operative time, less scarring, and postoperative pain would be the expected benefits, but no study has compared the long-term outcome of these 2 procedures yet. To maximize possible improvements, we would like to present an arthroscopic technique: a subscapularis tendon repair performed with the aid of an angled suture passer and using a single anterior working portal.

Comparison of Short-term Complications After Rotator Cuff Repair: Open Versus Arthroscopic

PURPOSE

To define and compare the incidence and risk factors for short-term complications after arthroscopic and open rotator cuff repair (RTCR), and to identify independent risk factors for complications after RTCR.

METHODS

All patients who underwent open or arthroscopic RTCR from 2005 to 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Short-term complications were categorized as surgical, medical, mortality, and unplanned 30-day readmission. Univariate analysis allowed the comparison of patient demographics and comorbidities. Propensity score matching was used to control for demographic differences between arthroscopic and open RTCR patient groups. Independent risk factors for complication were identified using multivariate logistic regression.

RESULTS

Overall, 11,314 RTCRs were identified (24% open, 76% arthroscopic). The mean operative time for open RTCR was 78 minutes compared with 91 minutes for arthroscopic repairs (P < .001). The overall complication rate was 1.3%, with the highest complication unplanned return to the operating room (41 patients, 0.36%). The 30-day readmission was 1.16% (76/6,560 patients) and the mortality rate was 0.03% (3 patients). Total 30-day complications in the propensity-score-matched patient group were higher after open versus arthroscopic repair (1.79% vs 1.17%; P = .006). The overall infection rate after RTCR was 0.56%, with deep wound infection higher in the open repair patient group (P = .003). Multivariate analysis identified age >65 years (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.2-2.3), operative time >90 minutes (OR 1.5; CI 1.1-2.1), and open RTCR (OR 1.6; CI 1.1-2.3) as independent risk factors for complications.

CONCLUSIONS

Short-term complications after RTCR are rare. Total complications are higher after open RTCR in propensity-matched patient groups and in multivariate analysis. Risk factors for complications include patient age >65, operative time >90 minutes, and open repair. Open RTCR is associated with an increased risk of surgical infections.

LEVEL OF EVIDENCE

Level III, retrospective comparative trial.

SYSTEMATIC REVIEW WITH NETWORK META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS OF ROTATOR CUFF TEAR TREATMENT

Objectives: Rotator cuff tear is the leading cause of the decline in quality of life for older adults, but comparative evidence on treatment effectiveness is lacking. This study systematically reviewed the effects of various rotator cuff tear treatments through a Bayesian meta-analysis of the related randomized clinical trials (RCTs).Methods: We searched nine electronic databases for RCTs evaluating rotator cuff tear treatments from their inception through June 2017. A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the National Institute for Health and Care Excellence-Decision Support Unit guidelines (Supplementary Table 1). Outcomes included functional improvement, pain one year after surgical treatment, and tendon structural integrity. The Bayesian network meta-analysis was applied for functional improvement and pain, based on an assumption of consistency and similarity. Tendon integrity was reported descriptively.Results: Fifteen RCTs were selected. Patients undergoing physiotherapy after open surgery showed statistically significant functional improvements compared with those undergoing physiotherapy only (mean differences, 9.1 [credible interval, 0.9-17.4]). Open surgery with physiotherapy was associated with a decrease in pain 1 year after treatment compared with when physiotherapy was combined with arthroscopic rotator cuff surgery, mini open surgery, platelet-rich plasma therapy, or physiotherapy alone (absolute value of mean difference 1.2 to 1.4). The tendon integrity results were inconsistent.Conclusions: Some surgical treatments were associated with significant improvement in function and pain, but evidence regarding their comparative effectiveness is still lacking. A well-designed RCT discussing functional and structural treatment outcomes is needed in future.

No difference in outcome for open versus arthroscopic rotator cuff repair: a prospective comparative trial

PURPOSE

Arthroscopic techniques tend to become the gold standard in rotator cuff repair. However, little data are reported in the literature regarding the improvement of postoperative outcomes and re-tear rate relative to conventional open surgery. The aim of this study was to compare clinical outcomes and cuff integrity after arthroscopic versus open cuff repair.

METHODS

We prospectively assessed clinical outcomes and cuff integrity after an arthroscopic or open rotator cuff repair with a minimum follow-up of 12 months. Clinical evaluation was based on Constant score, Simple Shoulder Value (SSV) and American Shoulder and Elbow Score (ASES). Rotator cuff healing was explored with ultrasound.

RESULTS

44 patients in arthroscopic group A (mean age 56-year-old) and 43 in open group O (mean age 61-year-old) fulfilled the inclusion criteria. Tendons were repaired with a single row technique associated with biceps tenodesis and subacromial decompression. All objective clinical scores significantly improved postoperatively in both groups. No statistical difference was identified between group A and O regarding, respectively, Constant score (72 vs 75 points; p = 0.3), ASES score (88 vs 91 points; p = 0.3), and SSV (81 vs 85%). The overall rate of re-tear (Sugaya type IV or V) reached 7 and 9%, respectively, in group A and O (p = 0.8).

CONCLUSION

This study did not prove any difference of arthroscopic over open surgery in case of rotator cuff repair regarding clinical outcome and cuff integrity at 1-year follow-up.

LEVEL II

Prospective comparative study.

Arthroscopic Versus Open Rotator Cuff Repair: Which Has a Better Complication and 30-Day Readmission Profile?

PURPOSE

To provide a comparative 30-day postoperative analysis of complications and unplanned readmission rates, using the National Surgical Quality Improvement Program database, after open or arthroscopic rotator cuff repair (RCR).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for postoperative complications after open or arthroscopic RCR over an 8-year period, from 2007 through 2014. Patients were identified by use of Current Procedural Terminology codes. The open group contained 3,590 cases (21.8%) and the arthroscopic group had 12,882 cases (78.2%), for a total of 16,472 patients undergoing RCR. The risk of complications was compared between the 2 groups, along with patient demographic characteristics, operative time, length of stay, and unplanned readmission within 30 days. We compared dichotomous variables using the Fisher exact test and continuous variables with 1-way analysis of variance. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated when appropriate.

RESULTS

The open RCR group had a higher prevalence of patients aged 65 years or older and comorbidities such as hypertension, diabetes, chronic obstructive pulmonary disease, smoking, and alcoholism (P < .05). Patients undergoing open RCR had a higher risk of any adverse event when compared with arthroscopic RCR patients (1.48% vs 0.84%; RR, 1.17; 95% CI, 1.05-1.30; P = .0010). They were also at higher risk of return to the operating room within 30 days (0.70% vs 0.26%; RR, 1.36; 95% CI, 1.09-1.69; P = .0004). Open RCR was associated with a longer average hospital stay (0.48 ± 2.7 days vs 0.23 ± 4.2 days, P = .0007), whereas arthroscopic RCR had a longer average operative time (90 ± 45 minutes vs 79 ± 45 minutes, P < .0001).

CONCLUSIONS

Although both open and arthroscopic approaches to RCR had low morbidity, arthroscopy was associated with lower risks of any adverse event and return to the operating room during the initial 30-day postoperative period.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Shoulder-specific outcomes 1 year after nontraumatic full-thickness rotator cuff repair: a systematic literature review and meta-analysis

BACKGROUND

Nontraumatic full-thickness rotator cuff tears are commonly initially treated conservatively. If conservative treatment fails, rotator cuff repair is a viable subsequent option. The objective of the present meta-analysis is to evaluate the shoulder-specific outcomes one year after arthroscopic or mini-open rotator cuff repair of nontraumatic rotator cuff tears.

METHODS

A literature search was conducted in PubMed and EMBASE within the period January 2000 to January 2017. All studies measuring the clinical outcome at 12 months after nontraumatic rotator cuff repair of full-thickness rotator cuff tears were listed.

RESULTS

We included 16 randomized controlled trials that met our inclusion criteria with a total of 1.221 shoulders. At 12 months after rotator cuff repair, the mean Constant score had increased 29.5 points; the mean American Shoulder and Elbow Score score increased by 38.6 points; mean Simple Shoulder Test score was 5.6 points; mean University of California Los Angeles score improved by 13.0 points; and finally, mean Visual Analogue Scale score decreased by 4.1 points.

CONCLUSIONS

Based on this meta-analysis, significant improvements in the shoulder-specific indices are observed 12 months after nontraumatic arthroscopic or mini-open rotator cuff repair.

Postoperative Shoulder Imaging: Rotator Cuff, Labrum, and Biceps Tendon

Imaging interpretation of the postoperative shoulder is a challenging and difficult task for both the radiologist and the orthopedic surgeon. The increasing number of shoulder rotator cuff, labrum, and biceps tendon repairs performed in the United States also makes this task a frequent occurrence. Whether treatment is surgical or conservative, imaging plays a crucial role in patient care. Many imaging findings can be used to predict prognosis and functional outcomes, ultimately affecting treatment. In addition, evolving surgical techniques alter the normal anatomy and imaging appearance of the shoulder such that accepted findings proved to be pathologic in the preoperative setting cannot be as readily described as pathologic after surgery. An understanding of common surgical procedures of the shoulder can aid in recognizing normal expected postoperative findings and discerning common complications. Although magnetic resonance (MR) imaging and MR arthrography are widely used, implementing a multimodality imaging approach for evaluation of the postoperative shoulder can provide additional imaging information that may be decisive and vital to diagnosis. The high spatial resolution of both computed tomography with arthrography and ultrasonography makes them additional modalities to consider, especially when dealing with metal artifact. To provide an accurate radiologic interpretation of high clinical value, radiologists should approach the postoperative shoulder comprehensively with knowledge of the anatomy, surgical techniques and complications, clinical outcomes, and imaging pitfalls. ^©RSNA, 2016.

Arthroscopic, open and mini-open approach for rotator cuff repair: no difference in pain or function at 24 months

BACKGROUND

The New Zealand Rotator Cuff Registry was established in 2009 to collect prospective functional, pain and outcome data on patients undergoing rotator cuff repair (RCR).

METHODS

Information collected included an operation day technical questionnaire completed by the surgeon and Flex Shoulder Function (SF) functional and pain scores preoperatively, immediately post-operatively and at 6, 12 and 24 months. A multivariate analysis was performed analysing the three surgical approaches to determine if there was a difference in pain or functional outcome scores.

RESULTS

A total of 2418 RCRs were included in this paper. There were 418 (17.3%) arthroscopic, 956 (39.5%) mini-open and 1044 (43.2%) open procedures. Twenty-four-month follow-up data were obtained for pain and Flex SF in 71% of patients. At 24 months, there was no difference in the average Flex SF score for the arthroscopic, mini-open and open groups. There was no difference in improvement in Flex SF score at 24 months. At 24 months, there was no difference in mean pain scores. There was no difference in improvement in pain score from preoperation to 24 months. Most patients returned to work within 3 months of surgery, with no difference between the three surgical approaches.

CONCLUSION

RCR has good to excellent outcomes in terms of improvement in pain and function at 2-year follow-up. We found no difference in pain or functional outcome at 24 months between arthroscopic, open and mini-open approaches for RCR.

Does early motion lead to a higher failure rate or better outcomes after arthroscopic rotator cuff repair? A systematic review of overlapping meta-analyses

BACKGROUND

The aims of the study were as follows: to perform a systematic review of meta-analyses comparing "early motion" and "delayed motion" after arthroscopic rotator cuff repair; to provide a framework to analyze the best available evidence to develop recommendations; and to identify gaps where suggestions could be made for future investigations.

METHODS

Literature searches were performed to identify meta-analyses examining arthroscopic rotator cuff repair with early-motion vs. delayed-motion rehabilitation protocols. Clinical data were extracted, and meta-analysis quality was assessed using the Quality of Reporting of Meta-analyses and Oxman-Guyatt scales.

RESULTS

Nine meta-analyses met inclusion criteria. No clear superiority was noted in clinical outcome scores for early-motion or delayed-motion rehabilitation. Results of tendon healing were found to be either no different or in favor of delayed motion, but no differences were noted in rotator cuff tear recurrence rates postoperatively. The majority of meta-analyses found significantly better range of motion with early motion up to a year postoperatively for forward elevation and up to 6 months for external rotation, but significant differences were not reported for functional improvements and strength at 12 months postoperatively. Subgroup analyses suggested that larger preoperative tear sizes have significantly greater retear rates with early-motion rehabilitation.

CONCLUSIONS

The current highest level of evidence suggests that early-motion rehabilitation after rotator cuff repair results in superior postoperative range of motion up to 1 year. Whereas early motion and delayed motion after cuff repair may lead to comparable functional outcomes and retear rates, concern exists that early motion may result in greater retear rates, particularly with larger tear sizes.

Comparison of clinical outcomes in all-arthroscopic versus mini-open repair of rotator cuff tears: A randomized clinical trial

BACKGROUND

The aim of the study was to compare the clinical outcomes of patients undergoing all-arthroscopic (AA) or mini-open (MO) rotator cuff repair.

METHODS

The present study evaluated 50 patients who had undergone AA repair and 50 patients who had undergone MO repair with a minimum 1-year follow-up. Every patient was asked to complete the Disabilities of the Arm, Shoulder and Hand (DASH) and visual analog scale (VAS) questionnaires. Constant-Murley score (CMS) and active ranges, forward flexion and external rotation, were also evaluated and documented. One year after surgery, ultrasound evaluation was done to determine the integrity of the rotator cuff for each patient.

RESULTS

The average age of enrolled patients at the time of surgery was 53.0 years (range, 40-59 years), and average follow-up was 16.6 months (range, 12-24 months). At 2 weeks, the range of forward flexion in the AA group was larger than that in the MO group (136.5 ± 10.2 vs 132.5 ± 7.7, P = 0.03). On postoperative day 1, the VAS in the MO group was significantly higher than that in the AA group (6.5 ± 0.6 vs 6.1 ± 0.6, P < 0.01). At 1 month, the difference in VAS between both groups reappeared (2.9 ± 0.6 vs 2.6 ± 0.6, P = 0.03). At 1 month, the CMS score of patients in the AA group was higher than that in the MO group (52.8 ± 3.6 vs 50.9 ± 5.0, P = 0.03). At 3 and 6 months, the DASH score of patients in the AA group was lower than that in the MO group (43.8 ± 8.2 vs 47.8 ± 4.4, P < 0.01 and 38.6 ± 4.3 vs 42.7 ± 9.9, P < 0.01, respectively). Mean operative time was longer in the AA group compared with that in the MO group (71.9 ± 17.6 vs 64.7 ± 12.7 minutes, P < 0.01). Five patients (10.0%) in the AA group and 4 patients (8.2%) in the MO group had rotator cuff retear, and 6 patients (12.0%) in the AA group and 8 patients (16.3%) in the MO group had adhesive capsulitis by the end of follow-up. There is no significant difference between the 2 groups in the incidence of complications. We also found that joint exercising at least 3 times per week was associated with better short- and long-term joint function recovery.

CONCLUSIONS

The AA approach was associated with less pain and lower DASH score as well as higher CMS score in the early recovery period. No difference was found between the 2 groups in primary and secondary outcomes in the long term, or incidence of complications such as adhesive capsulitis and rotator cuff retear. In conclusion, we consider that the AA procedure has better recovery at short-term follow-ups, while both techniques are equivalent regarding long-term outcomes.

Effectiveness of open and arthroscopic rotator cuff repair (UKUFF): a randomised controlled trial

AIMS

The appropriate management for patients with a degenerative tear of the rotator cuff remains controversial, but operative treatment, particularly arthroscopic surgery, is increasingly being used. Our aim in this paper was to compare the effectiveness of arthroscopic with open repair of the rotator cuff.

PATIENTS AND METHODS

A total of 273 patients were recruited to a randomised comparison trial (136 to arthroscopic surgery and 137 to open surgery) from 19 teaching and general hospitals in the United Kingdom. The surgeons used their usual preferred method of repair. The Oxford Shoulder Score (OSS), two years post-operatively, was the primary outcome measure. Imaging of the shoulder was performed at one year after surgery. The trial is registered with Current Controlled Trials, ISRCTN97804283.

RESULTS

The mean OSS improved from 26.3 (standard deviation (sd) 8.2) at baseline, to 41.7 (sd 7.9) two years post-operatively for arthroscopic surgery and from 25.0 (sd 8.0) to 41.5 (sd 7.9) for open surgery. Intention-to-treat (ITT) analysis showed no statistical difference between the groups at two years (difference in OSS score -0.76; 95% confidence interval (CI) -2.75 to 1.22; p = 0.452). The confidence interval excluded the pre-determined clinically important difference in the OSS of three points. The rate of re-tear was not significantly different between the two groups (46.4% for arthroscopic and 38.6% for open surgery; 95% CI -6.9 to 25.8; p = 0.256). Healed repairs had the most improved OSS. These findings were the same when analysed per-protocol.

CONCLUSION

There is no evidence of difference in effectiveness between open and arthroscopic repair of rotator cuff tears. The rate of re-tear is high in both groups, for all sizes of tear and ages and this adversely affects the outcome. Cite this article: Bone Joint J 2017;99-B:107-15.

[Controversies in the therapy of rotator cuff tears. Operative or nonoperative treatment, open or arthroscopic repair?]

Rotator cuff tears are a common cause of shoulder pain that may lead to severe impairment of shoulder function with significant limitation of the quality of life. Furthermore, they are associated with high direct and indirect costs.Conservative therapy and various surgical procedures for rotator cuff repair are all possible treatment options. Therefore, the correct treatment for a symptomatic rotator cuff tear is important.The conservative therapy may be considered as an alternative treatment option for a symptomatic rotator cuff tear in patients with small or incomplete tears with no fatty atrophy or tendon retraction, with only slight pain, and in older patients with few functional demands. Surgical treatment is recommended after failed conservative treatment lasting 3-6 months, with the corresponding psychological strain. Moreover, surgical treatment should be considered as a primary treatment option for a symptomatic rotator cuff tear in young patients with high functional demands, patients with a high level of physical strain in their jobs, large tears, and tears where there is already significant muscle atrophy or tendon retraction.Arthroscopic treatment is considered to be the gold standard because of the better cosmetic results and treatment of concomitant pathological conditions, the lower levels of postoperative pain, the potentially lower risk of shoulder stiffness, and more focused adhesiolysis. However, arthroscopy does not improve clinical results. Because of the current financial situation, however, open rotator cuff repair is still a viable alternative.

Costs, quality of life and cost-effectiveness of arthroscopic and open repair for rotator cuff tears: an economic evaluation alongside the UKUFF trial

AIMS

A trial-based comparison of the use of resources, costs and quality of life outcomes of arthroscopic and open surgical management for rotator cuff tears in the United Kingdom NHS was performed using data from the United Kingdom Rotator Cuff Study (UKUFF) randomised controlled trial.

PATIENTS AND METHODS

Using data from 273 patients, healthcare-related use of resources, costs and quality-adjusted life years (QALYs) were estimated at 12 months and 24 months after surgery on an intention-to-treat basis with adjustment for covariates. Uncertainty about the incremental cost-effectiveness ratio for arthroscopic versus open management at 24 months of follow-up was incorporated using bootstrapping. Multiple imputation methods were used to deal with missing data.

RESULTS

There were no significant differences between the arthroscopic and open groups in terms of total mean use and cost of resources or QALYs at any time post-operatively. Open management dominated arthroscopic management in 59.8% of bootstrapped cost and effect differences. The probability that arthroscopic management was cost-effective compared with open management at a willingness-to-pay threshold of £20 000 per QALY gained was 20.9%.

CONCLUSION

There was no significant overall difference in the use or cost of resources or quality of life between arthroscopic and open management in the trial. There was uncertainty about which strategy was most cost-effective. Cite this article: Bone Joint J 2016;98-B:1648-55.

Surgery or conservative treatment for rotator cuff tear: a meta-analysis

PURPOSE

Comparative evidence on treating rotator cuff tear is inconclusive. The objective of this review was to evaluate the evidence on effectiveness of tendon repair in reducing pain and improving function of the shoulder when compared with conservative treatment of symptomatic rotator cuff tear.

METHOD

Search on CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science and Pedro databases. Randomised controlled trials (RCT) comparing surgery and conservative treatment of rotator cuff tear. Study selection and extraction based on the Cochrane Handbook for Systematic reviews of Interventions. Random effects meta-analysis.

RESULTS

Three identified RCTs involved 252 participants (123 cases and 129 controls). The risk of bias was considered low for all three RCTs. For Constant score, statistically insignificant effect size was 5.6 (95% CI -0.41 to 11.62) points in 1-year follow up favouring surgery and below the level of minimal clinically important difference. The respective difference in pain reduction was -0.93 (95% CI -1.65 to -0.21) cm on a 0-10 pain visual analogue scale favouring surgery. The difference was statistically significant (p = 0.012) in 1-year follow up but below the level of minimal clinically important difference.

CONCLUSION

There is limited evidence that surgery is not more effective in treating rotator cuff tear than conservative treatment alone. Thus, a conservative approach is advocated as the initial treatment modality. Implications for Rehabilitation There is limited evidence that surgery is not more effective in treating rotator cuff tear than conservative treatment alone. There was no clinically significant difference between surgery and active physiotherapy in 1-year follow-up in improving Constant score or reducing pain caused by rotator cuff tear. As physiotherapy is less proneness to complications and less expensive than surgery, a conservative approach is advocated as the initial treatment modality to rotator cuff tears.

Clinical effectiveness and cost-effectiveness of open and arthroscopic rotator cuff repair [the UK Rotator Cuff Surgery (UKUFF) randomised trial]

BACKGROUND

Uncertainty exists regarding the best management of patients with degenerative tears of the rotator cuff.

OBJECTIVE

To evaluate the clinical effectiveness and cost-effectiveness of arthroscopic and open rotator cuff repair in patients aged ≥ 50 years with degenerative rotator cuff tendon tears.

DESIGN

Two parallel-group randomised controlled trial.

SETTING

Nineteen teaching and district general hospitals in the UK.

PARTICIPANTS

Patients (n = 273) aged ≥ 50 years with degenerative rotator cuff tendon tears.

INTERVENTIONS

Arthroscopic surgery and open rotator cuff repair, with surgeons using their usual and preferred method of arthroscopic or open repair. Follow-up was by telephone questionnaire at 2 and 8 weeks after surgery and by postal questionnaire at 8, 12 and 24 months after randomisation.

MAIN OUTCOME MEASURES

The Oxford Shoulder Score (OSS) at 24 months was the primary outcome measure. Magnetic resonance imaging evaluation of the shoulder was made at 12 months after surgery to assess the integrity of the repair.

RESULTS

The mean OSS improved from 26.3 [standard deviation (SD) 8.2] at baseline to 41.7 (SD 7.9) at 24 months for arthroscopic surgery and from 25.0 (SD 8.0) at baseline to 41.5 (SD 7.9) at 24 months for open surgery. When effect sizes are shown for the intervention, a negative sign indicates that an open procedure is favoured. For the intention-to-treat analysis, there was no statistical difference between the groups, the difference in OSS score at 24 months was -0.76 [95% confidence interval (CI) -2.75 to 1.22; p = 0.452] and the CI excluded the predetermined clinically important difference in the OSS of 3 points. There was also no statistical difference when the groups were compared per protocol (difference in OSS score -0.46, 95% CI -5.30 to 4.39; p = 0.854). The questionnaire response rate was > 86%. At 8 months, 77% of participants reported that shoulder problems were much or slightly better, and at 24 months this increased to 85%. There were no significant differences in mean cost between the arthroscopic group and the open repair group for any of the component resource-use categories, nor for the total follow-up costs at 24 months. The overall treatment cost at 2 years was £2567 (SD £176) for arthroscopic surgery and £2699 (SD £149) for open surgery, according to intention-to-treat analysis. For the per-protocol analysis there was a significant difference in total initial procedure-related costs between the arthroscopic group and the open repair group, with arthroscopic repair being more costly by £371 (95% CI £135 to £607). Total quality-adjusted life-years accrued at 24 months averaged 1.34 (SD 0.05) in the arthroscopic repair group and 1.35 (SD 0.05) in the open repair group, a non-significant difference of 0.01 (95% CI -0.11 to 0.10). The rate of re-tear was not significantly different across the randomised groups (46.4% and 38.6% for arthroscopic and open surgery, respectively). The participants with tears that were impossible to repair had the lowest OSSs, the participants with re-tears had slightly higher OSSs and the participants with healed repairs had the most improved OSSs. These findings were the same when analysed per protocol.

CONCLUSION

In patients aged > 50 years with a degenerative rotator cuff tear there is no difference in clinical effectiveness or cost-effectiveness between open repair and arthroscopic repair at 2 years for the primary outcome (OSS) and all other prespecified secondary outcomes. Future work should explore new methods to improve tendon healing and reduce the high rate of re-tears observed in this trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN97804283.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 80. See the NIHR Journals Library website for further project information.

Three-dimensional shoulder kinematics normalize after rotator cuff repair

BACKGROUND

Patients with a rotator cuff (RC) tear often exhibit scapular dyskinesia with increased scapular lateral rotation and decreased glenohumeral elevation with arm abduction. We hypothesized that in patients with an RC tear, scapular lateral rotation, and thus glenohumeral elevation, will be restored to normal after RC repair.

METHODS

Shoulder kinematics were quantitatively analyzed in 26 patients with an electromagnetic tracking device (Flock of Birds) before and 1 year after RC repair in this observational case series. We focused on humeral range of motion and scapular kinematics during abduction. The asymptomatic contralateral shoulder was used as the control. Changes in scapular kinematics were associated with the gain in range of motion. Shoulder kinematics were analyzed using a linear mixed model.

RESULTS

Mean arm abduction and forward flexion improved after surgery by 20° (95% confidence interval [CI], 2.7°-36.5°; P = .025) and 13° (95% CI, 1.2°-36.5°; P = .044), respectively. Kinematic analyses showed decreases in mean scapular protraction (ie, internal rotation) and lateral rotation (ie, upward rotation) during abduction by 3° (95% CI, 0.0°-5.2°; P = .046) and 4° (95% CI, 1.6°-8.4°; P = .042), respectively. Glenohumeral elevation increased by 5° (95% CI, 0.6°-9.7°; P = .028) at 80°. Humeral range of motion increased when scapular lateral rotation decreased and posterior tilt increased.

CONCLUSIONS

Scapular kinematics normalize after RC repair toward a symmetrical scapular motion pattern as observed in the asymptomatic contralateral shoulder. The observed changes in scapular kinematics are associated with an increased overall range of motion and suggest restored function of shoulder muscles.

Immunobiological factors aggravating the fatty infiltration on tendons and muscles in rotator cuff lesions

Rotator cuff lesions (RCLs) are a common cause of shoulder pain and dysfunction. The rotator cuff tendons can degenerate and/or tear from the greater tuberosity of the humerus, which is associated with several anatomical, physiological, biochemical, and molecular changes in tendon and muscle. In this article, these pathways are critically reviewed and discussed with various management strategies of RCLs. The article also highlights the immunobiological responses following the RCL and the inherent repair mechanisms elicited by the body. The greatest difficulty in treating this pathology is that the muscle can undergo irreversible fatty infiltration in the setting of chronic tears that is associated with poor surgical outcomes. The article also investigates the key molecular pathways of the muscle homeostasis (mTOR, Rho kinase, AMPK, and Ca(2+)) with the energy metabolism to propose a possible mechanism for fatty infiltration. Future research is warranted to target the key players of these pathways in the management of fatty infiltration and thus RCL.

A 3D finite element model for geometrical and mechanical comparison of different supraspinatus repair techniques

BACKGROUND

Contact pressure and contact area are among the most important mechanical factors studied to predict the effectiveness of a rotator cuff repair. The suture configurations can strongly affect these factors but are rarely correlated with each other. For example, there is a significant difference between the single-row technique and the transosseous or transosseous-like approaches in terms of footprint contact area coverage. A finite element model-based approach is presented and applied to account for various parameters (eg, suture pretension, geometry of the repair, effect of the sutures, geometry of the lesion) and to compare the efficacy of different repair techniques in covering the original footprint.

METHODS

The model allows us to evaluate the effect of parameters such as suture configuration and position and suture pretension. The validity of such an approach was assessed in comparing 3 different repair techniques: single row, transosseous equivalent, and double row.

RESULTS

Results from the application of the models show that the double-row and transosseous-equivalent techniques lead to progressive increase of the contact area compared with the single-row approach, supporting the conclusion that transosseous-equivalent fixation leads to an increase of the contact area and a better distribution of the pressure coverage.

CONCLUSION

The 3-dimensional finite element model approach allows multiple variables to be assessed singularly, weighing the specific influence. Moreover, the approach presented in this study could be a valid tool to predict and to reproduce different configurations, identifying how to reduce the stress over the tendon and when a repair could be effective or not.

Midterm clinical outcomes following arthroscopic transosseous rotator cuff repair

PURPOSE

Arthroscopic transosseous (TO) rotator cuff repair has recently emerged as a new option for surgical treatment of symptomatic rotator cuff tears. Limited data is available regarding outcomes using this technique. This study evaluated midterm clinical outcomes following a novel arthroscopic TO (anchorless) rotator cuff repair technique.

MATERIALS AND METHODS

A consecutive series of 107 patients and 109 shoulders underwent arthroscopic TO (anchorless) rotator cuff repair for a symptomatic full-thickness tear. Pre and postoperative range of motion (ROM) was compared at an average of 11.8 months. Postoperative outcome scores were obtained at an average of 38.0 months. Statistical analysis was performed to compare pre and postoperative ROM data. Univariate analysis was performed using Student's t-test to compare the effect of other clinical characteristics on final outcome.

RESULTS

Statistically significant improvements were noted in forward flexion, external rotation and internal rotation (P < 0.0001). Average postoperative subjective shoulder value was 93.7, simple shoulder test 11.6, and American Shoulder and Elbow Surgeons (ASES) score 94.6. According to ASES scores, results for the 109 shoulders available for final follow-up were excellent in 95 (87.1%), good in 8 (7.3%), fair in 3 (2.8%), and poor in 3 (2.8%). There was no difference in ROM or outcome scores in patients who underwent a concomitant biceps procedure (tenodesis or tenotomy) compared with those who did not. Furthermore, there was no significant difference in outcome between patients who underwent either biceps tenodesis or tenotomy. Age, history of injury preceding the onset of pain, tear size, number of TO tunnels required to perform the repair, and presence of fatty infiltration did not correlate with postoperative ROM or subjective outcome measures at final follow-up. Two complications and four failures were noted.

CONCLUSIONS

Arthroscopic TO rotator cuff repair technique leads to statistically significant midterm improvement in ROM and satisfactory midterm subjective outcome scores with low complication/failure rates in patients with average medium-sized rotator cuff tears with minimal fatty infiltration. Further work is required to evaluate radiographic healing rates with this technique and to compare outcomes following suture anchor repair.

LEVEL OF EVIDENCE

Level IV.