Clinical outcome and repair integrity after rotator cuff repair in patients older than 70 years versus patients younger than 70 years

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

Background

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

Methods

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

Results

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

Conclusion

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

Clinical and Structural Outcomes of Arthroscopic Rotator Cuff Repair in Patients Over 75 Years Are Comparable to Those in Younger Patients: A Propensity Score-Matched Comparative Study

PURPOSE

To compare clinical and structural outcomes of arthroscopic rotator cuff repair (ARCR) in patients over 75 years and those under 75 years and to analyze the factors associated with retear and clinical outcomes after ARCR.

METHODS

This retrospective study reviewed patients who underwent ARCR between 2011 and 2021 with at least 2 years of follow-up. Using propensity score matching for sex, tear size, subscapularis involvement, and follow-up time, this study included 54 patients older than 75 years (group A) and 54 patients younger than 75 years (group B). Cuff integrity was evaluated using magnetic resonance imaging (MRI). Structural and clinical outcomes were compared between the 2 groups.

RESULTS

The mean improvements in external rotation (P = .030) and the American Shoulder and Elbow Surgeons (ASES) score (P = .043) were significantly higher in group A. Visual analog scales for pain and function, ASES score, and Constant score were significantly improved in both groups (all P = .001). On routine postoperative MRI at 6 months, the retear rate was 20.4% (11/54) in group A and 18.5% (10/54) in group B with no statistical difference between the 2 groups (P = .808). Factor analysis in group A showed that follow-up duration (P = .019), tear size in mediolateral dimension (P = .037), occupation ratio (P = .036), and incomplete repair (P = .034) were associated with retear, and mild glenohumeral arthritis (P = .003) and subscapularis involvement (P = .018) were associated with inferior Constant score.

CONCLUSIONS

Clinical and structural outcomes after ARCR in patients aged 75 years or older are comparable to those in patients younger than 75 years.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Rotator Cuff Injuries in the Pediatric Population: A Retrospective Review of Patient Characteristics and Treatment at a Single Center

BACKGROUND

As youth participation in contact and overhead sports has increased in recent decades, so has the occurrence of injuries of the shoulder. Rotator cuff injury (RCI) is an infrequent shoulder pathology in pediatric patients and its description in the literature has been scarce. A greater understanding of RCI characteristics and treatment outcomes in children and adolescents would improve our understanding of this pathology and help to better guide clinical decision-making.

HYPOTHESIS

To identify pediatric patients with magnetic resonance imaging-confirmed RCI treated at a single center to summarize injury characteristics, treatment, and outcomes. It was hypothesized that injuries would occur predominantly in overhead throwing athletes and would demonstrate good outcomes among both operatively and nonoperatively treated patients.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

A retrospective review of pediatric patients (<18 years old) diagnosed with and treated for an RCI between January 1, 2011 and January 31, 2021. Patient demographics, injury mechanism and type, treatment, and outcomes were collected. Descriptive statistics were performed. Bivariate testing was used to compare operatively and nonoperatively treated cohorts.

RESULTS

A total of 52 pediatric patients treated for a rotator cuff avulsion, partial tear, or complete tear were identified. Mean age was 15 years and 67% of patients were male. Injuries were related most commonly to participation in throwing sports. Operative management occurred in 23% of patients, while 77% were managed nonoperatively. Treatment cohorts differed based on tear type, with all complete tears being managed operatively (P < 0.01). Associated shoulder pathology was common, with the most frequent finding being anterior shoulder instability pathology. Return to play was longer for operatively managed patients (7.1 vs 4.5 months; P < 0.01).

CONCLUSION

The present study expands the limited data available regarding RCIs in pediatric patients. Most injuries are associated with sports and involve the supraspinatus tendon. RCIs were associated with good outcomes and low rates of reinjury in patients managed both nonoperative and operatively. RCI should be considered in throwing athletes with shoulder pain, even in skeletally immature patients.

CLINICAL RELEVANCE

This retrospective study fills the hole in the literature by detailing the patterns associated with RCI characteristics and treatment outcomes. In contrast to studies of adult RCIs, our results suggest that outcomes are good regardless of treatment type.

Effect of age and gender in rates of achieving minimal clinically important difference and patient-acceptable symptom state 2 years after arthroscopic superior capsular reconstruction

PURPOSE

This study aimed to evaluate patient-reported outcome measures (PROMs) and the effects of gender and age on achieving clinically significant outcomes in patients undergoing arthroscopic superior capsular reconstruction (ASCR) with a minimum 2-year follow-up.

METHODS

Patients undergoing ASCR for irreparable rotator cuff tear between 2013 and 2020 were reviewed. Preoperative and minimum 2-year postoperative PROMs were collected, including American Shoulder and Elbow Surgeons (ASES), Constant, single assessment numeric evaluation (SANE), and visual analog scale (VAS) scores. Minimal clinically important difference (MCID) and patient-acceptable symptomatic state (PASS) were calculated for each functional score and analyzed according to age and gender. The percentages of patients achieving MCID and PASS were recorded.

RESULTS

The study included 83 patients, with a mean follow-up of 3.5 ± 1.4 years. Significant improvements were found in ASES, Constant, SANE, and VAS for all groups based on gender and age. Based on receiver-operating characteristic curves, all scores had acceptable areas under the curve for PASS. Values for PASS and MCID were 81.5 and 10.3 for ASES; 61.5 and 6.2 for Constant; 82.5 and 11.5 for SANE and 1.5 and 1.1 for VAS, respectively. Analysis of achieving MCID and PASS showed no difference between the groups in the majority of outcome measures. However, female patients achieved the SANE thresholds for PASS at significantly higher rates than male patients. Patients ≥65 years old achieved ASES and Constant thresholds for MCID at significantly higher rates than patients ˂65 years old.

CONCLUSION

Most patients achieved MCID and PASS at a 2-year follow-up. Patients showed comparable rates of MCID and PASS achievement on most outcome tools based on age and gender. Female patients achieved PASS on SANE at significantly higher rates than male patients and older patients achieved MCID on ASES and Constant at higher rates than young patients. Thus, age is a stronger factor for achieving MCID than gender.

LEVEL OF EVIDENCE

Level II.

Differences in Clinical Outcomes Between Patients With Retear After Supraspinatus Tendon Repair and Those With Intact Repair at 5-Year Follow-up

BACKGROUND

It is well known that rotator cuff repair is associated with an overall retear rate of 21% to 26%. However, a cuff retear may not necessarily be associated with poor clinical outcomes.

HYPOTHESIS

There would be no difference in clinical outcomes between patients with a cuff retear and those with an intact repair at a midterm follow-up of 5 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective study was conducted involving patients who received arthroscopic complete repair of the supraspinatus tendon between January 2009 and December 2017. Patients who did not have a postoperative magnetic resonance imaging (MRI) scan or who had a follow-up of <5 years were excluded. Clinical outcomes, including the visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, and active forward flexion (FF) of the involved shoulder were assessed at the 2-year and 5-year follow-up points.

RESULTS

The study group included 105 patients with a mean follow-up of 85 months. MRI scans were performed at a mean of 20 months. Fourteen full-thickness cuff retears and 91 intact repairs were identified using postoperative MRI scans. Significant improvement in VAS score, ASES score, and FF were found between the preoperative assessment and the 2 designated follow-up points (2 years and 5 years) in both the cuff retear and the intact repair groups (P < .001). The VAS and ASES scores at the 2-year follow-up for the intact repair group were 1.8 ± 2.0 and 80.7 ± 18.1, respectively. The corresponding values for the retear group were 2.3 ± 2.2 and 71.9 ± 19.5, respectively. No significant difference was found between the 2 groups in the VAS and ASES scores at the 2-year follow-up. However, patients with an intact repair had a better VAS score (1.4 ± 1.8; P = .049) and ASES score (81.7 ± 17; P = .019) than those with a cuff retear at the 5-year assessment (3.0 ± 2.8 and 67.1 ± 22.9, respectively). In the intact repair group, 91% of patients achieved the minimal clinically important difference for the 5-year VAS score, compared with 54% in the cuff retear group (P < .001). The corresponding values for the 5-year ASES score were 80% and 54%, respectively (P = .044). FF measurements at the 5-year follow-up in patients with intact repair and those with a cuff retear were 161°± 23° and 144°± 37°, respectively (P = .059). Continuous improvement in VAS score and FF between the 2-year and 5-year follow-up was observed in the intact repair group (P = .005 and P = .04, respectively).

CONCLUSION

The patients with an intact repair had better VAS and ASES scores compared with those who had a cuff retear at a midterm follow-up of 5 years. Between the 2-year and the 5-year follow-up, some further improvement was observed in the VAS score and FF in the intact repair group.

Effect of Exosomes From Bone Marrow-Derived Mesenchymal Stromal Cells and Adipose-Derived Stromal Cells on Bone-Tendon Healing in a Murine Rotator Cuff Injury Model

Background

Bone-tendon injury is characterized by poor self-healing. It is established that exosomes are favorable for tissue repair and regeneration. However, their effect on bone-tendon healing has not yet been determined.

Purpose

To compare the effectiveness of exosomes derived from adipose-derived mesenchymal stromal cells (ADSC-Exos) and bone marrow-derived mesenchymal stromal cells (BMSC-Exos) on bone-tendon interface healing in murine rotator cuff injury model and explore the underlying mechanisms thereof.

Study Design

Controlled laboratory study.

Methods

A total of 63 male C57BL6 mice with rotator cuff injuries underwent surgery and were randomly assigned to a control group treated without exosomes (n = 21), an ADSC-Exos group (n = 21), or a BMSC-Exos group (n = 21). The mice were sacrificed 4 or 8 weeks after surgery, and tissues were collected for histologic examination and radiographic and biomechanical testing. For exosome tracing in vivo, mice were sacrificed 7 days after surgery. A series of functional assays (radiographic evaluation, proliferation assay, Alizarin Red staining, alkaline phosphatase staining and activity, Alcian blue staining, quantitative polymerase chain reaction analyses, and glycosaminoglycans quantification) were conducted to evaluate the effect of exosomes on the cellular behaviors of the BMSCs in vitro. A statistical analysis of multiple-group comparisons was performed by 1-way analysis of variance, followed by the Bonferroni post hoc test to assess the differences between the 2 groups.

Results

The ADSCs and BMSCs were positive for surface markers CD29 and CD90 and negative for surface markers CD34 and CD45 and could differentiate into osteoblasts, chondrocytes, and adipocytes. Exosomes showed a cup- or sphere-shaped morphology and were positive for CD63 and TGS101. Local injection of ADSC-Exos and BMSC-Exos could recruit BMSCs and promote osteogenesis, chondrogenesis, and bone-tendon healing. In vitro, ADSC-Exos and BMSC-Exos could significantly promote the proliferation, migration, osteogenic differentiation, and chondrogenic differentiation ability of BMSCs. In vivo, ADSC-Exos and BMSC-Exos significantly accelerated bone-tendon injury healing, with no significant statistical difference between them.

Conclusion

ADSC-Exos and BMSC-Exos exhibited similar therapeutic effects on bone-tendon healing in our murine animal model.

Clinical Relevance

ADSC-Exos and BMSC-Exos may be used to develop a new cell-free therapy method for promoting rotator cuff injury repair.

Factors associated with healing failure after early repair of acute, trauma-related rotator cuff tears

BACKGROUND

Healing failure after rotator cuff repair is a challenging problem. Acute, trauma-related tears are considered a separate entity and are often treated surgically. The aim of this study was to identify factors associated with healing failure in previously asymptomatic patients with trauma-related rotator cuff tears treated with early arthroscopic repair.

METHODS

This study included 62 consecutively recruited patients (23% women; median age, 61 years; age range, 42-75 years) with acute symptoms in a previously asymptomatic shoulder and a magnetic resonance imaging-verified full-thickness rotator cuff tear after shoulder trauma. All patients were offered, and underwent, early arthroscopic repair, during which a biopsy specimen was harvested from the supraspinatus tendon and analyzed for signs of degeneration. Of the patients, 57 (92%) completed 1-year follow-up and underwent assessment of repair integrity on magnetic resonance images according to the Sugaya classification. Risk factors for healing failure were investigated using a causal-relation diagram where age, body mass index, tendon degeneration (Bonar score), diabetes mellitus, fatty infiltration (FI), sex, smoking, tear location regarding integrity of the rotator cable, and tear size (number of ruptured tendons and tendon retraction) were included and analyzed.

RESULTS

Healing failure at 1 year was identified in 37% of patients (n = 21). A high degree of FI of the supraspinatus muscle (P = .01), a tear location including disruption of rotator cable integrity (P = .01), and old age (P = .03) were associated with healing failure. Tendon degeneration as determined by histopathology was not associated with healing failure at 1-year follow-up (P = .63).

CONCLUSION

Older age, increased FI of the supraspinatus muscle, and a tear including disruption of the rotator cable increased the risk of healing failure after early arthroscopic repair in patients with trauma-related full-thickness rotator cuff tears.

Comparison of Outcomes after Arthroscopic Rotator Cuff Repair between Elderly and Younger Patient Groups: A Systematic Review and Meta-Analysis of Comparative Studies

This study aimed to compare the outcomes of arthroscopic rotator cuff repair (ARCR) surgery between younger and older patients. We performed this systematic review and meta-analysis of cohort studies comparing outcomes between patients older than 65 to 70 years and a younger group following arthroscopic rotator cuff repair surgery. We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and other sources for relevant studies up to 13 September 2022, and then assessed the quality of included studies using the Newcastle-Ottawa Scale (NOS). We used random-effects meta-analysis for data synthesis. The primary outcomes were pain and shoulder functions, while secondary outcomes included re-tear rate, shoulder range of motion (ROM), abduction muscle power, quality of life, and complications. Five non-randomized controlled trials, with 671 participants (197 older and 474 younger patients), were included. The quality of the studies was all fairly good, with NOS scores ≥ 7. The results showed no significant differences between the older and younger groups in terms of Constant score improvement, re-tear rate, or other outcomes such as pain level improvement, muscle power, and shoulder ROM. These findings suggest that ARCR surgery in older patients can achieve a non-inferior healing rate and shoulder function compared to younger patients.

Repair of rotator cuff tears in patients aged 75 years and older: Does it make sense? A systematic review

Background

Rotator cuff injuries are common, and morbidity increases with age. The asymptomatic full-thickness tear rate is 40% in the over 75-year-old population.

Purpose

This study aimed to systematically review the literature on the outcomes of rotator cuff repair among >75 years old patients.

Study design

Systematic review.

Methods

A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search was performed in the electronic databases of PubMed, Medline, Embase, and The Cochrane Library. Studies in English evaluating repair of full-thickness rotator cuff tears in patients aged >75 years were included.

Results

Six studies were reviewed, including 311 patients (313 shoulders) treated with arthroscopic and/or open rotator cuff repair. Sixty-one patients were lost to follow-up, leaving 252 shoulders with outcome data. Patients in this age group demonstrated a significant improvement in the clinical and functional scores after rotator cuff repair, with a high satisfaction rate. The mean American Shoulder and Elbow Surgeons scores improved from 43.8 (range, 42.0-45.5) preoperatively to 85.3 (range, 84.0 to 86.5) postoperatively, and the mean Constant scores improved from 45.4 (range, 34.7-55.5) to 78.6 (range, 67.0-91.6). Pain, evaluated in all studies by the visual analog scale for pain, showed a significant improvement at the last follow-up compared with the mean preoperative score. Furthermore, range of motion and return to daily activities and sports gained marked improvements.

Conclusion

Rotator cuff repair in patients aged >75 years could achieve high clinical success rates with good outcomes and pain relief. Although patients in this age group are at a high risk of retear, rotator cuff repair may offer a good option with significant functional and clinical improvement.

Arthroscopic Repair Benefits Reparable Rotator Cuff Tear Patients Aged 65 Years or Older With a History of Traumatic Events

PURPOSE

To evaluate the clinical outcomes of arthroscopic rotator cuff repair at 2-year follow-up in patients aged 65 years or older with a history of traumatic events divided into groups based on symptom duration (<3 months, 3-6 months, and >6 months from injury to surgery) and to compared patient-reported outcomes among the 3 groups.

METHODS

Between 2015 and 2020, 110 patients who met the inclusion criteria were enrolled in this study; these patients were divided into 3 groups according to symptom duration: less than 3 months (group A), 3 to 6 months (group B) and more than 6 months (group C). Preoperative and 2-year postoperative clinical outcomes were compared, including American Shoulder and Elbow Surgeons, Constant-Murley, University of California, Los Angeles, Simple Shoulder Test, and visual analog scale scores; forward elevation; external rotation; and internal rotation. The minimal clinically important difference (MCID), patient acceptable symptom state, substantial clinical benefit, and maximum outcome improvement were also compared among the groups.

RESULTS

The American Shoulder and Elbow Surgeons score, as the primary outcome, improved significantly from 41.0 ± 18.5 to 85.4 ± 8.1 in group A, from 53.7 ± 14.3 to 86.3 ± 11.7 in group B, and from 49.7 ± 18.5 to 83.9 ± 11.9 in group C. All the other parameters showed statistically significant improvements at 2-year follow-up in each group (all P < .05). There was no significant difference in each parameter among the 3 groups except the visual analog scale score, which did not achieve the MCID. Overall, 86 patients (78.2%) exceeded the MCID, 87 patients (79.1%) achieved the patient acceptable symptom state, 77 patients (70.0%) achieved substantial clinical benefit, and 62 patients (56.4%) achieved maximum outcome improvement without significant differences among the 3 groups.

CONCLUSIONS

In rotator cuff tear patients aged 65 years or older with a history of traumatic events, arthroscopic rotator cuff repair significantly improves clinical outcomes at 2-year follow-up regardless of symptom duration if the tear is fully reparable.

LEVEL OF EVIDENCE

Level III, prognostic retrospective study.

Do Age, Demographics, and Tear Characteristics Affect Outcomes After Rotator Cuff Repair? Results of Over 2000 Rotator Cuff Repairs at 5-Year Follow-up

Background:

The New Zealand Rotator Cuff Registry represents the largest prospective cohort of rotator cuff repairs. Despite this, there are limited medium- to long-term data of rotator cuff repair outcomes.

Purpose:

To (1) analyze the pain and functional outcomes of a large cohort of primary rotator cuff repairs and (2) evaluate the effect of patient factors and tear characteristics on medium-term outcomes.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

This was a multicenter, multisurgeon prospective cohort study of rotator cuff repairs from March 2009 until December 2010. Surgical data were collected by the operating surgeon. Primary outcome measures were the Flexilevel Scale of Shoulder Function (FLEX-SF) and a pain score, collected at baseline, 6, 12, and 24 months, and 5 years. Univariate and multivariate analyses were carried out.

Results:

Overall, 2533 primary rotator cuff repairs were analyzed with 81% follow-up at 5 years. The mean age of the cohort was 56 years. In the 2052 patients with final follow-up data, improvement on the FLEX-SF continued until 24 months postoperatively and remained high at 5 years. Mean improvement in FLEX-SF from baseline to 5 years was 15 points. Patients aged >70 years had lower FLEX-SF scores but no significant difference in improvement compared with patients ≤70 years. The mean anteroposterior tear size was 2.2 cm, and on multivariate analysis, tears >4 cm had worse 5-year FLEX-SF scores. If the affected tendon was easily reducible, there was no difference in FLEX-SF score for retracted or larger tears compared with smaller tears. The reoperation rate was 6.2%.

Conclusion:

Results indicated that rotator cuff repairs provide a sustained clinical improvement out past 5 years. Most functional improvement and pain relief occurred within the first 6 months, but improvement continued out to 24 months. Most population groups did well after rotator cuff repairs, including those >70 years. Tear size >4 cm and tendon reducibility correlated with outcome. Even patients with large tear sizes had clinically significant improvement in FLEX-SF scores after repair.

Comparing Sex-Specific Outcomes After Rotator Cuff Repair: A Meta-analysis

Background

Rotator cuff repair (RCR) is a well-studied procedure. However, the impact of patient sex on outcomes after RCR has not been well studied.

Purpose

To conduct a systematic review and meta-analysis of sex-based differences in outcomes after RCR and to record what proportion of studies examined this as a primary or secondary purpose.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review was performed using multiple databases according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they were written in English, performed on humans, consisted of patients who underwent RCR, evaluated at least 1 of the selected outcomes based on patient sex, and had statistical analysis available for their sex-based claim. Excluded were case reports, review studies, systematic reviews, cadaveric studies, and studies that did not report at least 1 sex-specific outcome or included certain other injuries associated with a rotator cuff injury.

Results

Of 9998 studies screened and 1283 full-text studies reviewed, 11 (0.11%) studies with 2860 patients (1549 male and 1329 female) were included for quantitative analysis. None of these 11 studies examined the impact of patient sex on outcomes after RCR as a primary outcome. Postoperative Constant-Murley scores were analyzed for 7 studies. Male patients had a postoperative Constant-Murley score of 76.77 ± 15.94, while female patients had a postoperative Constant-Murley score of 69.88 ± 17.02. The random-effects model showed that male patients had significantly higher scores than female patients, with a mean difference of 7.33 (95% CI, 5.21-9.46; P < .0001). Analysis of retear rates in 5 studies indicated that there was no difference in the retear rate between sexes (odds ratio, 0.91 [95% CI, 0.49-1.67]).

Conclusion

Female patients had lower postoperative Constant-Murley scores compared with male patients, but there was no difference in the retear rate. However, these results were based on an analysis of only 11 studies. The paucity of studies examining the impact of sex suggests that more research is needed on the impact of patient sex on outcomes after RCR.

Quantifying shoulder activity after rotator cuff repair: Technique and preliminary results

Repair tissue healing after rotator cuff repair remains a significant clinical problem, and excessive shoulder activity after surgical repair is believed to contribute to re-tears. In contrast, small animal studies have demonstrated that complete removal of activity impairs tendon healing and have advocated for an "appropriate" level of activity, but in humans the appropriate amount of shoulder activity to enhance healing is not known. As an initial step toward understanding the relationship between postoperative shoulder activity and repair tissue healing, the objectives of this study were to assess the precision, accuracy, and feasibility of a wrist-worn triaxial accelerometer for measuring shoulder activity. Following assessments of precision (±0.002 g) and accuracy (±0.006 g), feasibility was assessed by measuring 1 week of shoulder activity in 14 rotator cuff repair patients and 8 control subjects. Shoulder activity was reported in terms of volume (mean acceleration, activity count, mean activity index, active time) and intensity (intensity gradient). Patients had significantly less volume (p ≤ .03) and intensity (p = .01) than controls. Time post-surgery was significantly associated with the volume (p ≤ .05 for mean acceleration, activity count, and mean activity index) and intensity (p = .03) of shoulder activity, but not active time (p = .08). These findings indicate this approach has the accuracy and precision necessary to continuously monitor shoulder activity with a wrist-worn sensor. The preliminary data demonstrate the ability to discriminate between healthy control subjects and patients recovering from rotator cuff repair and provide support for using a wearable sensor to monitor changes over time in shoulder activity.

Immunologic Contributions Following Rotator Cuff Injury and Development of Cuff Tear Arthropathy

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Rotator cuff tear arthropathy (RCTA) describes a pattern of glenohumeral degenerative changes following chronic rotator cuff tears that is characterized by superior humeral head migration, erosion of the greater tuberosity of the humeral head, contouring of the coracoacromial arch to create a socket for the humeral head, and eventual glenohumeral arthritis.

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Acute and chronic inflammatory changes following rotator cuff tears are thought to contribute to cartilage damage, muscle fibrosis, and fatty infiltration in the glenohumeral joint.

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In vitro animal studies targeting various inflammatory modulators, including macrophages, insulin-like growth factor-I, and transforming growth factor-beta pathways, provide promising therapeutic targets to improve healing after rotator cuff tears.

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The role of platelet-rich plasma in the treatment and prevention of RCTA has been investigated, with conflicting results.

Application of Platelet-Rich Plasma in Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis

Background:

It is unclear how and which factors affect the clinical efficacy of platelet-rich plasma (PRP) applied during arthroscopic rotator cuff repair.

Purpose:

To evaluate the clinical efficacy of PRP for arthroscopic repair of full-thickness rotator cuff tear and investigate the factors that affect its clinical efficacy.

Study Design:

Systematic review; Level of evidence, 1.

Methods:

We searched Cochrane Library, EMBASE, MEDLINE, and OVID to identify randomized controlled trials (RCTs) of patients who received PRP treatment and arthroscopic rotator cuff repair (PRP group) versus controls (no-PRP group). The primary outcomes included retear rate, Constant-Murley score, University of California Los Angeles (UCLA) score, short-term American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) score for pain, and adverse events.

Results:

A total of 14 RCTs were included in this systematic review. Significant improvement in Constant-Murley, UCLA, and VAS pain scores were found in the PRP group during short-term, midterm, and long-term follow-up. The PRP group had a significantly decreased retear rate (risk ratio [RR], 0.57 [95% CI, 0.42 to 0.78]; P = .0003), especially for long-term follow-up (RR, 0.38 [95% CI, 0.17 to 0.83]; P = .02), large to massive tears (RR, 0.58 [95% CI, 0.42 to 0.80]; P = .0008), use of leukocyte-poor PRP (RR, 0.50 [95% CI, 0.33 to 0.76]; P = .001), and intraoperative application of PRP (RR, 0.57 [95% CI, 0.42 to 0.79]; P = .0007). No significant difference between the 2 groups was found in the incidence of adverse events (RR, 1.34 [95% CI, 0.83 to 2.15]; P = .23) or in ASES scores at short-term follow-up (weighted mean difference, 1.04 [95% CI, –3.10 to 5.19]; P = .62).

Conclusion:

The results of this review indicated that arthroscopic rotator cuff repair with PRP significantly reduced the long-term retear rate and shoulder pain and provided improved long-term shoulder function in patients. Intraoperative application of PRP, use of leukocyte-poor plasma, and large to massive tear size contributed to a significantly decreased retear rate for rotator cuff repair combined with PRP.

Healing and Functional Results of Dermal Allograft Augmentation of Complex and Revision Rotator Cuff Repairs

BACKGROUND

Primary rotator cuff repairs in complex cases (older patient age, larger tear sizes, chronic tears) and revision repairs are at high risk for failure of healing.

PURPOSE

To examine clinical outcomes and healing rates in complex and revision rotator cuff repairs with dermal allograft augmentation.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective study was made of cases performed by 3 fellowship-trained surgeons via a uniform technique involving rotator cuff repairs with allograft augmentation. In all cases, a 1.5-mm, human, decellularized dermal graft was tied on top of the tendon at the medial row and compressed to the rotator cuff footprint using a double-row technique. Postoperative magnetic resonance imaging (MRI) was performed at a minimum of 6 months and American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and 12-Item Short Form Health Survey scores were collected at a minimum of 2 years postoperatively.

RESULTS

A total of 35 patients (23 revision repairs, 12 primary complex repairs) were included. The mean patient age was 57.9 years (range, 41.0-70.5 years). All shoulders had 2-tendon tears (supraspinatus and infraspinatus), and 8 included the upper 50% of the subscapularis. At a minimum of 2 years after surgery (mean, 3.2 years), mean ASES and SANE scores improved from 42.4 and 35.3 to 77.6 and 73.5, respectively (P < .001). In the 23 patients (66%) with postoperative MRI evaluation, 11 (48%) had images showing the tendons were retorn. ASES (89.7 vs 66.4; P = .04) and SANE (84.1 vs 50.5; P = .02) scores were higher in healed patients than those with retears. The retear group had a higher degree of preoperative fatty atrophy of the infraspinatus (P = .024).

CONCLUSION

Double-row arthroscopic repair with dermal allograft augmentation of complex and revision rotator cuff tears led to improved functional outcomes. Approximately half of patients experienced a failure of healing, which was associated with poorer functional results.

Arthroscopic knotless repair: an effective technique for small-sized supraspinatus tendon tears

PURPOSE

The purpose was to evaluate the clinical and radiological results of knotless repair with flat-braided suture in full small-sized supraspinatus tendon tears (< 1 cm).

METHODS

A consecutive series of 54 patients with isolated small supraspinatus tendon tear (< 1 cm and Goutallier index < 2) was evaluated in the study. Patients underwent a knotless arthroscopic repair using flat-braided suture (2 mm wide). Minimal follow-up required was 5 years. Changes in Murley-Constant score, ASES score, strength, and pain relief were assessed. The Sugaya score was used to confirm the tendon repair on MRI. Data were analyzed in two subgroups: technique with additional U point for dog ear deformity (group 1) and technique without additional U point (group 2). The immobilization period was 3 weeks long. Passive mobilization was immediate.

RESULTS

Fifty-four patients were included. Mean age was 57 ± 4 years. The average follow-up was 68 ± 10 months. Average preoperative score of Constant was 51.2 ± 8.5 and 83.1 ± 14.6 at the end of the follow-up (p < 0.001). Mean VAS went from 5.8 ± 1.8 to 1.9 ± 2.1 (p < 0.001). Average forward elevation of the shoulder went from 86.3° ± 9 preoperatively to 169.6° ± 15.9 at the end of the follow-up (p < 0.001). The strength score was significantly higher post-operatively (18.4 vs. 8.3, p < 0.001.). The ASES score was significantly improved 49.1 ± 13.1 vs. 88.6 ± 15.8, p < 0.001). The MRI assessment revealed 94% of Sugaya 1-2. No significant difference was observed between group 1 and 2 regarding all clinical outcomes. Two complex regional pain syndromes were described with a favorable evolution. Three patients presented a retear requiring an iterative arthroscopic repair.

CONCLUSION

The use of a knotless arthroscopic construct with flat-braided suture for small supraspinatus repair achieved excellent structural and clinical results. This technique is fully adequate for the arthroscopic treatment of such tears, enabling early mobilization.

LEVEL OF EVIDENCE

Level III.

Predicting the surgical reparability of large-to-massive rotator cuff tears by B-mode ultrasonography: a cross-sectional study

PURPOSE

This study aimed to compare the ability of B-mode ultrasonography and magnetic resonance imaging (MRI) to predict the repairability of large-to-massive rotator cuff tears (RCTs).

METHODS

This cross-sectional study included participants with large-to-massive RCTs who underwent arthroscopic repair. B-mode ultrasonography and MRI were conducted prior to arthroscopic repair. B-mode ultrasonography was used to evaluate the echogenicity of the rotator cuff muscle using the Heckmatt scale. Intra-rater and inter-rater reliabilities were examined for two independent physicians. MRI was used to evaluate the degrees of tendon retraction, fatty infiltration of rotator cuff muscles, and muscle atrophy. Finally, two experienced orthopedic surgeons performed surgery and decided whether the torn stump could be completely repaired intraoperatively.

RESULTS

Fifty participants were included, and 32 complete repairs and 18 partial repairs were performed. B-mode ultrasonography showed good intra-rater reliability and inter-rater reliability for assessment of the muscle echogenicity of the supraspinatus and infraspinatus muscles. The correlation coefficients between B-mode ultrasound findings and MRI findings showed medium to large effect sizes (r=0.4-0.8). The Goutallier classification of the infraspinatus muscles was the MRI predictor with the best discriminative power for surgical reparability (area under the curve [AUC], 0.89; 95% confidence interval [CI], 0.81 to 0.98), while the Heckmatt scale for infraspinatus muscles was the most accurate ultrasound predictor (AUC, 0.85; 95% CI, 0.74 to 0.96). No significant differences in AUCs among the MRI and ultrasound predictors were found.

CONCLUSION

B-mode ultrasonography was a reliable examination tool and had a similar ability to predict surgical reparability to that of MRI among patients with large-to-massive RCTs.

Septuagenarians aged 75 years and older do benefit from arthroscopic rotator cuff repair: a propensity matched-pair analysis

Background

Numerous studies show that patients who failed conservative management, benefit from open, mini open and arthroscopic rotator cuff repair (ARCR). However, there is a paucity of literature addressing ARCR and outcomes in patients older than the age of 75 years. The purpose of our study was to compare the outcomes of ARCR in patients older than 75 years and younger than 75 years of age.

Methods

Between January 2010 and December 2016, 397 patients underwent unilateral ARCR; of which, 23 patients were 75 years of age and older. Outcome measures recorded include the Constant Shoulder Score (CSS), University of California, Los Angeles Shoulder Score (UCLASS), Oxford Shoulder Score (OSS), and visual analog scale (VAS) for pain assessment.

Results

There were no statistically significant differences in VAS, CSS, and UCLASS between the two groups at all time points of follow-up (all P > .05). At 2 years after surgery, the OSS was 2 ± 5 points better in the <75 group (P = .012). However, the improvement in OSS was comparable between both groups. The improvement in VAS, CSS, and UCLASS at 2 years after surgery compared with baseline was also similar between the two groups (all P < .05).

Conclusions

The improvement in VAS, CSS, and UCLASS was similar in both groups of patients. We conclude that septuagenarians with symptomatic cuff tears, who have failed conservative management, experience significant improvement in pain, and function after surgery and should not be excluded from the benefits of ARCR.

A new decellularized tendon scaffold for rotator cuff tears - evaluation in rabbits

Background

Scaffolds have considerably advanced in recent years. In orthopaedic surgery, scaffolds have been used as grafts in procedures involving tendon and ligament reconstruction. This paper aimed to produce and evaluate decellularized tendon scaffolds (DTSs) from biomechanical, microscopic, macroscopic and in vivo perspectives.

Methods

Bilateral gastrocnemius muscle tendons from 18 adult New Zealand rabbits were collected. Of these 36 tendons, 11 were used as controls (Group A - control), and 25 were used in the decellularization protocol (Group B - DTS). The groups were subjected to histological, biomechanical and macroscopic analyses, and Group B - DTS was subjected to an additional in vivo evaluation. In the decellularization protocol, we used a combination of aprotinin, ethylenediamine tetraacetic acid (EDTA), sodium dodecyl sulfate (SDS) and t-octyl-phenoxypolyethoxyethanol (Triton X-100) for six days. During this period, the scaffolds were kept at room temperature on an orbital shaker with constant motion.

Results

The DTSs showed an increased cross-sectional area and inter-fascicular distance and no change in parallelism or matrix organization. The nuclear material was not organized in the DTSs as it was in the control. In the biomechanical analysis, no significant differences were found between the groups after analysing the ultimate tensile load, stiffness, and elongation at the ultimate tensile load. During the in vivo evaluation, mononuclear cell infiltration was noted.

Conclusions

The evaluated decellularization protocol generated a tendon scaffold, maintained the most important biomechanical characteristics and permitted cell infiltration.

Arthroscopic isolated long head of biceps tenotomy in patients with degenerative rotator cuff tears: mid-term clinical results and prognostic factors

Introduction

The long head of biceps tendon is frequently involved in degenerative rotator cuff tears. Therefore, this study explored the clinical results of an isolated biceps tenotomy and identified prognostic factors for improvement in pain and function.

Materials and methods

Between 2008 and 2017, an arthroscopic isolated biceps tenotomy was performed on 64 patients with a degenerative rotator cuff tear (> 65 years). Primary outcome was patient-perceived improvement in pain and function. Potential prognostic factors for improvement in pain and function were identified.

Results

A perceived improvement in pain was reported in 78% of the patients at three months after surgery and in 75% at a mean follow-up of 4.2 years (1–7 years; n = 55). A perceived improvement in function was observed in 49% of patients at three months and in 76% of patients at follow-up. Patients with a preoperatively normal acromiohumeral distance (> 10 mm) reported an improvement in pain and function significantly more often. Retraction of the supraspinatus tendon Patte 3 was significantly associated with worse functional outcome.

Conclusions

A biceps tenotomy can be a reliable treatment option for patients with symptomatic degenerative cuff tears who fail conservative treatment and have a normal acromiohumeral distance (> 10 mm).

Arthroscopic repair of posterosuperior rotator cuff tears with bioabsorbable patch augmentation: a magnetic resonance-controlled case series with 1-year follow-up

Background

Among many advances in the treatment of rotator cuff tears, arthroscopic augmentation techniques with patches of various biological and synthetic graft materials have been introduced to reinforce the repair. However, structural and functional outcomes after patch augmentation vary, and reinforcing the tendon healing remains a challenge. The aim of this study was to evaluate clinical and radiologic outcomes 1 year after arthroscopic posterosuperior (PS) rotator cuff repair with bioabsorbable patch augmentation.

Methods

From October 2014 to December 2017, all patients with PS rotator cuff tears undergoing arthroscopic repair with patch augmentation using a resorbable, biologically derived poly-4-hydroxybutyrate patch (Biofiber; Wright, Memphis, TN, USA) were enrolled in this study. Only full-thickness PS lesions with ≥1 of the following tear patterns were augmented with a patch and were the subject of this study: large U- and L-shaped tear, transtendinous tear, delamination, and fraying of the bursal layer. Patients were examined preoperatively and at 1 year postoperatively with a standardized examination protocol and magnetic resonance imaging (MRI).

Results

Sixteen patients were included in this study; 1 patient was lost to follow-up. One patient only underwent clinical follow-up. We detected 1 repair failure (6.7%) with dislocation of the lateral-row anchors on computed tomography scanning at 3 months postoperatively. MRI was performed in 14 patients after 1 year; in all of them, the cuff repair was intact. The Sugaya tendon integrity score was 1.7 ± 0.9. The Constant-Murley score improved from 44 to 89 points (P < .001). Muscular strength improved in the supraspinatus (from 2.6 to 4.8), infraspinatus (from 3.2 to 4.9), and subscapularis (from 4 to 4.9) (all P < .001). Overall, patient satisfaction was high (3.6 ± 0.6).

Discussion

This small-sized case series is the first to prospectively assess clinical and radiologic outcomes after patch augmentation of PS rotator cuff tears using bioabsorbable poly-4-hydroxybutyrate patches. Good to excellent structural and functional outcomes were observed with a low retear rate (6.7%) and good tendon integrity on 1-year postoperative MRI, and the graft did not cause any complications. The use of bioabsorbable patches could be beneficial when unfavorable PS tear patterns are encountered in which a stable repair of the full tendon thickness at its insertion is otherwise difficult to reach.

Autologous microfragmented adipose tissue reduces inflammatory and catabolic markers in supraspinatus tendon cells derived from patients affected by rotator cuff tears

PURPOSE

Rotator cuff tears are common musculoskeletal disorders, and surgical repair is characterized by a high rate of re-tear. Regenerative medicine strategies, in particular mesenchymal stem cell-based therapies, have been proposed to enhance tendon healing and reduce the re-tear rate. Autologous microfragmented adipose tissue (μFAT) allows for the clinical application of cell therapies and showed the ability to improve tenocyte proliferation and viability in previous in vitro assessments. The hypothesis of this study is that μFAT paracrine action would reduce the catabolic and inflammatory marker expression in tendon cells (TCs) derived from injured supraspinatus tendon (SST).

METHODS

TCs derived from injured SST were co-cultured with autologous μFAT in transwell for 48 h. Metabolic activity, DNA content, the content of soluble mediators in the media, and the gene expression of tendon-specific, inflammatory, and catabolic markers were analyzed.

RESULTS

μFAT-treated TCs showed a reduced expression of PTGS2 and MMP-3 with respect to untreated controls. Increased IL-1Ra, VEGF, and IL-6 content were observed in the media of μFAT-treated samples, in comparison with untreated TCs.

CONCLUSION

μFAT exerted an anti-inflammatory action on supraspinatus tendon cells in vitro through paracrine action, resulting in the reduction of catabolic and inflammatory marker expression. These observations potentially support the use of μFAT as adjuvant therapy in the treatment of rotator cuff disease.

Use sonoelastography to predict the reparability of large-to-massive rotator cuff tears

INTRODUCTION

Most symptomatic large-to-massive rotator cuff tears (RCTs) should be operated, but the surgical reparability depended on the degree of rotator cuff muscle atrophy or fatty infiltration. The orthopedic surgeons will decide whether the teared stump is reparable during the surgery, but preoperative evaluation can be done by some assessment tools. Magnetic resonance imaging (MRI) was used in recent studies to predict the reparability of large-to-massive RCTs, but the clinical availability was not as good as ultrasound. We hypothesize that the ultrasound elastography can predict the reparability of large-to-massive RCTs.

METHODS

This is a prospective observational study and participants with large-to-massive RCTs who are going to have surgeries will be included. Out investigators will evaluate the shoulder passive range of motion (ROM) and strength of all participants. Participants' degree of shoulder pain and activities of daily living (ADLs) will be assessed by American Shoulder and Elbow Surgeons (ASES) score. The ultrasound elastography will be used to evaluate the tissue quality of supraspinatus muscle and infraspinatus muscle. To test the reliability of the ultrasound elastography, two physicians will perform the ultrasound elastography independently and twenty participants will be selected for the reliability test. Besides, MRI will be used to evaluate the size of tear, the degree of tendon retraction, fatty infiltration of rotator cuff muscles, and muscle atrophy. Finally, the orthopedic surgeons will perform surgeries and decide whether the teared stump can be completely repaired intraoperatively. The primary analysis is the predictive validity of ultrasound elastography for the reparability of large-to-massive RCTs. Before the predictive validity of ultrasound elastography is measured, our investigators will assess the reliability of ultrasound elastography when administered to cases with large-to-massive RCTs, and we will check the correlations between the findings of ultrasound elastography and MRI.

DISCUSSION

The outcome will provide the evidence of ultrasound elastography for preoperative evaluation of large-to-massive RCTs. The relationships between the findings of ultrasound elastography and MRI will also be examined for further analysis.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03682679. Date of Registration: 25 September 2018, https://clinicaltrials.gov/ct2/show/NCT03682679?cond=rotator+cuff&cntry=TW&draw=2&rank=1.

Midterm outcomes of arthroscopic rotator cuff repair in patients aged 75 years and older

BACKGROUND

Full-thickness rotator cuff tears remain a significant cause of pain and dysfunction in the elderly. Substantial improvement in pain and functional outcomes with arthroscopic cuff repair is possible. Recent data has shown that patients older than 70-75 years still have clinical improvement with operative rotator cuff repair.

MATERIALS AND METHODS

This is a retrospective study of patients aged ≥75 years undergoing arthroscopic rotator cuff repair at a minimum of 24 months after surgery. Outcome measurements included range of motion (ROM), visual analog scale (VAS) pain scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores, Single Assessment Numeric Evaluation (SANE) scores, and Short Form Health Survey (SF-12) scores. Reoperation and rates of conversion to reverse shoulder arthroplasty (RSA) were determined.

RESULTS

Eighty-three patients were included with an average follow-up of 56.9 ± 25.9 months (range 24-127 months). Six (7.2%) patients had additional surgery, including 3 revision rotator cuff repairs for retear, 2 conversion to RSA, and 1 capsular release and loose anchor removal. There were statistically significant improvements in shoulder ROM, ASES, SANE, VAS, and SF-12 scores postoperatively.

CONCLUSION

Rotator cuff repair in select patients aged ≥75 years results in reliable improvements in pain and function. There was a low reoperation rate or conversion to RSA (7.2%) at midterm follow-up. This study indicates a role for rotator cuff repair in an elderly population and argues against the routine use of reverse arthroplasty for repairable rotator cuff tears in this population.

Repair of Rotator Cuff Tears in the Elderly: Does It Make Sense? A Systematic Review

BACKGROUND

The indications and outcomes for rotator cuff repair (RCR) among patients ≥70 years old are not widely reported. Many active patients in this age range desire a joint-preserving option, and several small series reported successful clinical outcomes after RCR among patients aged ≥70 years.

PURPOSE

To systematically review the literature on the outcomes of RCR among patients ≥70 years old.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The electronic databases of PubMed and Cochrane were used for the literature search. The quality of the included studies was evaluated according to the Coleman Methodology Score. Studies in English evaluating repair of full-thickness rotator cuff tears among patients aged ≥70 years were included.

RESULTS

Eleven studies were reviewed, including 680 patients (694 shoulders) who were treated with arthroscopic and/or open RCR with a mean follow-up of 24.2 months (range, 12-40.8 months). Forty patients were lost to follow-up, leaving 654 shoulders with outcome data. This age group demonstrated a significant increase in clinical and functional outcomes after RCR with high satisfaction. American Shoulder and Elbow Surgeons scores showed an improvement from 44.2 (range, 35.4-56) preoperatively to 87.9 (range, 84-90.3) postoperatively, while Constant scores improved from 41.7 (range, 22.6-53.6) to 70.8 (range, 58.6-76). Postoperative imaging evaluation was performed on 513 shoulders, revealing a retear rate of 27.1% (139 shoulders). There were 45 retears after open repair and 94 after arthroscopic repair. The difference in retear rate among patients receiving arthroscopic repairs was not significantly different than open repairs (P = .831). Pain according to a visual analog scale improved from 5.5 (range, 4.6-6.4) preoperatively to 1.3 (range, 0.5-2.3) postoperatively.

CONCLUSION

RCR among patients ≥70 years old shows high clinical success rates with good outcomes and overall excellent pain relief. Although patients in this age group have a high potential for retear or persistent defects on imaging studies, RCR offers a joint-preserving option with significant functional and clinical improvement for the appropriately indicated patient.

Targeting the NF-κB signaling pathway in chronic tendon disease

Tendon disorders represent the most common musculoskeletal complaint for which patients seek medical attention; inflammation drives tendon degeneration before tearing and impairs healing after repair. Clinical evidence has implicated the nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) pathway as a correlate of pain-free return to function after surgical repair. However, it is currently unknown whether this response is a reaction to or a driver of pathology. Therefore, we aimed to understand the clinically relevant involvement of the NF-κB pathway in tendinopathy, to determine its potential causative roles in tendon degeneration, and to test its potential as a therapeutic candidate. Transcriptional profiling of early rotator cuff tendinopathy identified increases in NF-κB signaling, including increased expression of the regulatory serine kinase subunit IKKβ, which plays an essential role in inflammation. Using cre-mediated overexpression of IKKβ in tendon fibroblasts, we observed degeneration of mouse rotator cuff tendons and the adjacent humeral head. These changes were associated with increases in proinflammatory cytokines and innate immune cells within the joint. Conversely, genetic deletion of IKKβ in tendon fibroblasts partially protected mice from chronic overuse-induced tendinopathy. Furthermore, conditional knockout of IKKβ improved outcomes after surgical repair, whereas overexpression impaired tendon healing. Accordingly, targeting of the IKKβ/NF-κB pathway in tendon stromal cells may offer previously unidentified therapeutic approaches in the management of human tendon disorders.

Outcomes after rotator cuff repair in the elderly as assessed by the American Shoulder and Elbow Surgeons shoulder score

Rotator cuff tears are common among the elderly, and studies on the outcomes after rotator cuff repair in the elderly are limited. We carried out this meta-analysis with systematic literature search, aiming to clarify the outcomes after rotator cuff repair in the elderly as assessed by the American Shoulder and Elbow Surgeons (ASES) shoulder score. We conducted a literature search through October 2019 in PubMed and EMBASE databases and performed meta-analysis to calculate the summary mean difference comparing the post- and pre-operation ASES scores under both fixed-effect and random-effect models. Among 4978 studies identified through literature search, four studies (two in the United States, one in France, and one in Republic of Korea) were eligible for the meta-analysis, including 282 patients who were aged over 70 years. These studies had low heterogeneity as measured by Cochran's Q test (p=0.88) and I2 statistic (0%). The ASES scores on average increased by 39.7 (95% confidence interval 28.3-51.1, p<0.001) after rotator cuff repair, in both fixed-effect and random-effect models. No substantial publication bias was indicated. Our findings suggest improved outcomes after rotator cuff repair in the elderly population as measured by the ASES score, and such improvements have been consistent in previous studies.

Retears of the Rotator Cuff: An Ultrasonographic Assessment During the First Postoperative Year

Background

Surgical repair of rotator cuff (RC) tears is an effective treatment option. However, the prevalence of recurrent ruptures is high.

Hypothesis

Recurrent tears are a frequent complication of surgical repair of RC tears. Their incidence might be influenced by factors such as the patient's age and size of the initial tear.

Study Design

Case series; Level of evidence, 4.

Methods

Data from 90 adult patients who underwent arthroscopic RC repair between 2014 and 2017 and underwent an ultrasound examination 6 to 12 months after surgery were analyzed retrospectively. Massive tears were repaired using a double-row technique, and nonmassive tears were repaired with a single-row technique. Clinical records were reviewed for demographic information.

Results

All patients (57.8% women; 42.2% men) were older than 18 years (mean, 58.9 years). Of these patients, 30.0% (27/90) had massive tears, which were primarily found in patients ≥60 years (74.1%; 20/27). Complete healing was seen in 74.5% of all repairs during follow-up. A total of 23 patients (25.5%) had retears (13 complete; 10 partial), which were diagnosed by ultrasound imaging 6 to 12 months after the initial surgery. The occurrence of retears was more prevalent in patients with massive tears than in patients with nonmassive tears (40.7% vs 19.0%, respectively); the difference was statistically significant (P = .03). Reruptures occurred in 50.0% of patients older than 60 years with massive tears. Although patients older than 60 years had more recurrent tears (32.6%) compared with younger patients (18.2%), the difference was not statistically significant (P = .12).

Conclusion

One-quarter of the patients who had undergone surgical repair of an RC tear had recurrent ruptures. There was a statistically significant association between the initial massive tear and a retear. Patients older than 60 years showed a higher recurrence rate, but this difference lacked statistical significance. Reruptures occurred in 50.0% of patients older than 60 years with massive tears.

Cost-effectiveness and satisfaction following arthroscopic rotator cuff repair: does age matter?

AIMS

The aim of this study was to investigate the influence of age on the cost-effectiveness of arthroscopic rotator cuff repair.

PATIENTS AND METHODS

A total of 112 patients were prospectively monitored for two years after arthroscopic rotator cuff repair using the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), the Oxford Shoulder Score (OSS), and the EuroQol five-dimension questionnaire (EQ-5D). Complications and use of healthcare resources were recorded. The incremental cost-effectiveness ratio (ICER) was used to express the cost per quality-adjusted life-year (QALY). Propensity score-matching was used to compare those aged below and above 65 years of age. Satisfaction was determined using the Net Promoter Score (NPS). Linear regression was used to identify variables that influenced the outcome at two years postoperatively.

RESULTS

A total of 92 patients (82.1%) completed the follow-up. Their mean age was 59.5 years (sd 9.7, 41 to 78). There were significant improvements in the mean DASH (preoperative 47.6 vs one-year 15.3; p < 0.001) and OSS scores (26.5 vs 40.5; p < 0.001). Functional improvements were maintained with no significant change between one and two years postoperatively. The mean preoperative EQ-5D was 0.54 increasing to 0.81 at one year (p < 0.001) and maintained at 0.86, two years postoperatively. There was no significant difference between those aged below or above 65 years of age with regards to postoperative shoulder function or EQ-5D gains. Smoking was the only characteristic that significantly adversely influenced the EQ-5D at two years postoperatively (p = 0.005). A total of 87 were promoters and five were passive, giving a mean NPS of 95 (87/92). The total mean cost per patient was £3646.94 and the mean EQ-5D difference at one year was 0.2691, giving a mean ICER of £13 552.36/QALY. At two years, this decreased further to £5694.78/QALY. This was comparable for those aged below or above 65 years of age (£5209.91 vs £5525.67). Smokers had an ICER that was four times more expensive.

CONCLUSION

Arthroscopic rotator cuff repair results in excellent patient satisfaction and cost-effectiveness, regardless of age. Cite this article: Bone Joint J 2019;101-B:860-866.

Rotator cuff muscles fatty infiltration increases with age: retrospective review of 210 patients with intact cuff on computed tomography arthrography

HYPOTHESIS

We aimed to demonstrate that rotator cuff fatty infiltration (FI) increases physiologically with age and that a FI degree of 2 might be encountered in patients with an intact cuff.

METHODS

We retrospectively evaluated the FI of 210 patients (classified in 7 age groups: <20, 20-30, 30-40, 40-50, 50-60, 60-70, and >70 years) who had an intact cuff on computed tomography (CT) arthrography. The Goutallier grading system was used to assess FI of rotator cuff muscles and of the deltoid muscle. FI was then compared between groups for each muscle, and determinants (age, sex, and body mass index) of FI were assessed.

RESULTS

FI of all evaluated muscles progressively increased with age, but a statistically significant increase between 2 consecutive age groups was observed for all muscles only after age 40 years. For each group, intermuscle comparison showed that the FI distribution was not significantly different between each rotator cuff muscle at any age. Age was a determinant for FI for all muscles, but sex and body mass index also influenced deltoid FI. A median FI value of 2 was found in the "over 70 group" for the supraspinatus, but in the 60 to 70 group for infraspinatus and subscapularis and in the 50 to 60 group for the deltoid.

CONCLUSION

FI of rotator cuff muscles increased with age, with a significant acceleration after 40 years. Moreover, a FI graded 2, a common threshold for management decision, was commonly found in those aging patients with intact cuff on CT arthrography.

Tear characteristics and surgeon influence repair technique and suture anchor use in repair of superior-posterior rotator cuff tendon tears

BACKGROUND

The factors that associate with surgical decisions about repair technique and the number of suture anchors used in rotator cuff repair have not been previously investigated. This study investigated the extent to which patient, surgeon, and surgical factors associate with performing single-row vs. double-row repair technique and ultimately with the number of suture anchors used.

METHODS

Our institution's prospective surgical cohort was queried for patients undergoing suture anchor repair of superior-posterior rotator cuff tendon tears between February 2015 and August 2017. Exclusion criteria were patients with isolated subscapularis tears, tears that were not repaired, repairs without suture anchors, repairs involving graft augmentation, and repairs by surgeons with fewer than 10 cases. Multivariable statistical modeling was used to investigate associations between patient and surgical factors and the choice of repair technique and number of suture anchors used.

RESULTS

A total of 925 cases performed by 13 surgeons met inclusion criteria. Tear type (full thickness), tear size (medium, large, and massive), a greater number of torn tendons, repair type (arthroscopic), and surgeon were significantly associated with performing a double-row over a single-row repair. Tear size, a greater number of torn tendons, double-row repair technique, and surgeon were significantly associated with a greater number of anchors used for repair.

CONCLUSIONS

Our findings suggest that in the absence of data to conclusively support a clinical benefit of one repair technique over another, surgeons' training, experience, and inherent practice patterns become the primary factors that define their surgical methods.

Graft use in the treatment of large and massive rotator cuff tears: an overview of techniques and modes of failure with MRI correlation

Despite technical advances, repair of large or massive rotator cuff tears continues to demonstrate a relatively high rate of failure. Rotator cuff repair or superior capsular reconstruction (SCR) using a variety of commercially available grafts provides a promising option in patients with tears that may be at high risk for failure or otherwise considered irreparable. There are three major graft constructs that exist when utilizing graft in rotator cuff repair or reconstruction: augmentation at the rotator cuff footprint, bridging, and SCR. Each construct has a unique appearance when evaluated using postoperative magnetic resonance imaging (MRI), and each construct has unique sites that are predisposed to failure. Understanding the basic principles of these constructs can help the radiologist better evaluate the postoperative MRI appearance of these increasingly utilized procedures.

The use of suture-tape and suture-wire in arthroscopic rotator cuff repair: A comparative biomechanics study

BACKGROUND

Rotator cuff repair surgery aims to create a secure, pressurized tendon-bone footprint to permit re-establishment of the fibrovascular interface and tendon healing. Flat-braided suture-tape is an alternative suture material to traditional suture-wire that has potential to reproduce a larger repair construct contact area. The objective of this study was to compare contact pressure, area as well as the mechanical fatigue strength between suture-wire and suture-tape Suture-bridge repair constructs in an ovine model.

METHODS

Sixty lamb infraspinatus tendons were harvested and randomly allocated to three- and four-anchor Suture-bridge repairs performed using either suture-wire or suture-tape. Thirty-two specimens were cyclically loaded for 200 cycles in an Instron testing machine, while tendon gap formation was recorded using a high speed digital motion analysis system. Loading to failure was then performed to evaluate construct ultimate tensile strength and stiffness. The remaining 28 specimens were assessed for repair contact pressure and area using pressure-sensitive film.

RESULTS

There was a significantly greater average tendon contact pressure (mean difference: 0.064 MPa, p = 0.04) and area (mean difference: 2.71 mm², p = 0.03) in fiber-tape repair constructs compared to those in fiber-wire constructs for the three-anchor Suture-bridge configuration. The four-anchor suture-tape constructs had a significantly larger ultimate tensile strength than that of the four-anchor suture-wire constructs (mean difference: 56.4 N, p = 0.04). There were no significant differences in gap formation or stiffness between suture-tape and suture-wire constructs (p > 0.05).

CONCLUSION

Suture-tape offers greater pressurised tendon-bone contact than suture-wire in three-anchor Suture-bridge repairs, while greater mechanical strength is achieved with the use of suture-tape in four-anchor Suture-bridge constructs.

Bridging Repair of Large Rotator Cuff Tears Using a Multilayer Decellularized Tendon Slices Graft in a Rabbit Model

PURPOSE

The purpose of this study was to evaluate the efficacy of an extracellular matrix scaffold with multilayer decellularized tendon slices (MDTSs) for reconstructing large rotator cuff tears in a rabbit model.

METHODS

Large defects in the infraspinatus tendons were created bilaterally in 36 rabbits. The graft group underwent bridging repair of the defects with the MDTSs grafts from Achilles tendons of adult beagle dogs, and the control group underwent repair with the autologous excised tendon. Specimens underwent histologic observation, biomechanical testing, and microcomputed tomography analysis at 2, 4, and 8 weeks after surgery.

RESULTS

Histologic analysis confirmed that the MDTSs graft promoted cell ingrowth and tissue integration, and fibrocartilage and Sharpey fibers formed at the enthesis at 8 weeks. Accordingly, the MDTSs graft generated a histologic appearance similar to that of the autogenous tendon graft. Mechanical testing revealed a significant increase of the regenerated tendons in ultimate load and stiffness from 4 to 8 weeks postoperatively, which was similar to autologous tendon repair. Microcomputed tomography analysis demonstrated that the MDTSs graft promoted bone formation at the tendon-bone insertion, thus improving the mechanical properties of the repair tendon.

CONCLUSIONS

The MDTSs graft used to bridge large rotator cuff defects in a rabbit model promoted host cell ingrowth, enhanced the remodeling of regenerated tendon, and promoted fibrocartilage formation, thus improving the biomechanical properties of the repaired tendon. This study thereby provides fundamental information for rotator cuff regeneration with the MDTSs graft.

CLINICAL RELEVANCE

Rotator cuff regeneration using MDTSs grafts is a promising procedure for large rotator cuff tears.

An Intra-articular Steroid Injection at 6 Weeks Postoperatively for Shoulder Stiffness After Arthroscopic Rotator Cuff Repair Does Not Affect Repair Integrity

BACKGROUND

Shoulder stiffness is a common complication after arthroscopic rotator cuff repair. However, there is no consensus on the treatment of stiffness after repair. Although one treatment option is an intra-articular steroid injection, it may negatively affect repair integrity, and there is a paucity of literature regarding the timing of intra-articular injections for stiffness after repair and its effect on repair integrity.

PURPOSE

To compare repair integrity and clinical outcomes after an intra-articular steroid injection administered at 6 weeks and 12 weeks postoperatively for shoulder stiffness after arthroscopic rotator cuff repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who developed stiffness after arthroscopic rotator cuff repair were given a series of 3 intra-articular steroid injections every 4 weeks from 6 (6-week group) and 12 weeks (12-week group) postoperatively. The control group had rotator cuff tears but neither stiffness nor injections. Shoulder range of motion (ROM), the Korean Shoulder Scoring System (KSS) score, and the University of California, Los Angeles (UCLA) shoulder score were assessed preoperatively with a minimum of 2-year follow-up. Repair integrity was assessed using magnetic resonance imaging at 6 months postoperatively.

RESULTS

Seventy-four of 209 patients (35.4%) who underwent arthroscopic rotator cuff repair developed stiffness. There were no significant differences in retear rates among the 6-week (5.7%, 2/35 patients), 12-week (10.3%, 4/39 patients), and control groups (14.1%, 19/135 patients) ( P = .374). Both the 6- and 12-week groups showed significant improvement in ROM (both P < .001), KSS scores (both P < .001), and UCLA scores (both P < .001) at the final follow-up. The 6-week group showed significantly better ROM ( P < .001), KSS scores ( P < .001), and UCLA scores ( P < .001) than the 12-week group at 3 months postoperatively. However, both the 6- and 12-week groups showed significantly lower KSS (81.3 ± 12.0 [ P = .004] and 83.4 ± 8.6 [ P = .035], respectively) and UCLA (29.3 ± 4.6 [ P = .006] and 30.0 ± 3.3 [ P = .042], respectively) scores than the control group (90.4 ± 13.6 and 32.3 ± 4.7, respectively) at the last follow-up.

CONCLUSION

An intra-articular steroid injection administered at 6 weeks postoperatively for shoulder stiffness after arthroscopic rotator cuff repair may be effective for reducing patients' pain and improving shoulder ROM at 3 months postoperatively without compromising repair integrity.

Outcomes of Arthroscopic Rotator Cuff Repair in Patients Who Are 70 Years of Age or Older Versus Under 70 Years of Age: A Sex- and Tear Size-Matched Case-Control Study

PURPOSE

To compare the structural and clinical outcomes after arthroscopic rotator cuff repair (ARCR) of a case group aged 70 and above with those of a control group younger than 70, with the 2 groups matched for sex and tear size.

METHODS

The case group, comprising 53 patients 70 or older, and the control group, comprising 159 patients younger than 70, all received ARCR to 1 shoulder with symptomatic full-thickness rotator cuff tear. The case and the control subjects, who were matched for sex and tear size to minimize bias related to tendon healing, received ARCR during the same period. The mean age was 71.8 ± 2.6 years in the case group and 59.3 ± 7.1 years in the control group. The minimum follow-up period was 1 year in both groups. Cuff integrity was evaluated using ultrasonography. Structural and clinical outcomes of the 2 groups were compared.

RESULTS

Regarding structural outcomes, the complete healing, partial-thickness retear, and full-thickness retear rates were 66% (35/53), 15% (8/53), and 19% (10/53) in the case group, and 68% (108/159), 19% (30/159), and 13% (21/159), respectively, in the control group. The 2 groups had no significantly different retear rates (P = .52). Regarding clinical outcomes, the mean improvements in range of motion, pain, muscle strength, and age- and sex-matched Constant scores were not significantly different between the 2 groups (P > .37). The preoperative tear size was significantly associated with retear in both studied groups (P = .02).

CONCLUSIONS

The clinical and structural outcomes of ARCR in patients 70 or older with symptomatic full-thickness rotator cuff tear are comparable with those in patients younger than 70 with at least 1-year follow-up. Preoperative tear size, a biological factor, is a strong predictor for retear.

LEVEL OF EVIDENCE

Level III, a retrospective comparative (case-control) study.

Assembly, maturation, and degradation of the supraspinatus enthesis

The development of the rotator cuff enthesis is still poorly understood. The processes in the early and late developmental steps are gradually elucidated, but it is still unclear how cell activities are coordinated during development and maturation of the structured enthesis. This review summarizes current knowledge about development and age-related degradation of the supraspinatus enthesis. Healing and repair of an injured and degenerated supraspinatus enthesis also remain a challenge, as the original graded transitional tissue of the fibrocartilaginous insertion is not re-created after the tendon is surgically reattached to bone. Instead, mechanically inferior and disorganized tissue forms at the healing site because of scar tissue formation. Consequently, the enthesis never reaches mechanical properties comparable to those of the native enthesis. So far, no novel biologic healing approach has been successful in enhancing healing of the injured enthesis. The results revealed in this review imply the need for further research to pave the way for better treatment of patients with rotator cuff disorder.

Biomechanic and histologic analysis of fibroblastic effects of tendon-to-bone healing by transforming growth factor β1 (TGF-β1) in rotator cuff tears

PURPOSE

To evaluate the effect of transforming growth factor β1 (TGF-β1) on tendon-to-bone reconstruction of rotator cuff tears.

METHODS

Seventy-two rat supraspinatus tendons were transected and reconstructed in situ. At 8 and 16 weeks, specimens of three groups; that is control, L-dose (low dose), and H-dose (high dose) were harvested and underwent a biomechanical test to evaluate the maximum load and stiffness values. Histology sections of the tendon-to-bone interface were identified by hematoxylin-eosin or Masson trichrome stain. Collagen type III was observed by picric acid sirius red staining under polarized light. The level of insulin-like growth factor 1 (IGF-1) and vascular endothelial growth factor (VEGF) was measured by the enzyme-linked immunosorbent assay (ELISA) method.

RESULTS

Collagen type III of the H-dose group had a significant difference in histology structure compared with the L-dose group (P<0.05). The maximum load and stiffness decreased significantly in the control group compared with the values of the L-dose and H-dose groups. The stiffness among the three groups differed significantly at the same postoperative time (P<0.05). Interestingly, progressive reestablishment of collagen type III affected tendon-to-bone healing significantly in the later stages.

CONCLUSION

The H-dose was associated with an increased collagen type III morphology stimulated by TGF-β1.

Massive Rotator Cuff Tear: When to Consider Reverse Shoulder Arthroplasty

PURPOSE OF REVIEW

The purpose of this review is to discuss the indications for reverse shoulder arthroplasty (RSA) in the treatment of massive rotator cuff tear (MCT), review the reported outcomes in the literature, and outline our approach and surgical technique for treating these patients.

RECENT FINDINGS

While RSA remains a successful and well-accepted treatment for cuff tear arthropathy (CTA), management of MCT in the absence of arthritis is controversial. In this particular setting, patients best suited for RSA are elderly, lower-demand individuals with chronic, irreparable MCT, and pseudoparalysis. Age < 60, better pre-operative function and upper extremity neurologic dysfunction are potential risk factors for poor outcome with RSA in this population. Long-term follow-up studies of RSA for CTA and MCT show good functional outcomes and implant survival > 90% at 10 years. Treatment of MCT must be individualized for each patient. When patient selection is optimized, RSA is a reliable means of relieving pain and improving function with excellent success. Further investigation is necessary to better define its indications and assess the role of alternative, joint-salvaging procedures.

Are Outcomes After Meniscal Repair Age Dependent? A Systematic Review

PURPOSE

To determine if the failure rate and functional outcome after arthroscopic meniscus suture repair are age dependent.

METHODS

A systematic review was conducted using a computerized search of the electronic databases MEDLINE and ScienceDirect in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Extracted data from each included study were recorded on a standardized form. Studies were included if they (1) were English-language studies in peer-reviewed journals, (2) used a distinct age cut-off to evaluate outcome of meniscal surgery for those above and below the specified cut-off, and (3) used meniscal repairs using suture based technique with inside-out, outside-in, or all-inside techniques. Review papers, case reports, technique papers, non-English language publications, abstracts, and data on meniscal repairs using meniscal screws, arrows, or darts were excluded.

RESULTS

15 of 305 identified articles met the inclusion/exclusion criteria. There were 1,141 menisci treated in 1,063 patients. Seven and 8 studies met the inclusion/exclusion criteria for analysis for the age thresholds of 25 years and 30 years, respectively, demonstrating no difference in failure rates relative to age threshold. Four of 6 studies that met analysis criteria found no difference in failure rates above or below an age threshold of 35 years. No significant difference in failure in patients younger than 40 than patients older than 40 was found for 4 of the 5 studies in that arm of the review.

CONCLUSIONS

Analysis of the composite data in this systematic review reveals that no significant difference exists when evaluating meniscal repair failure rate as a function of age above or below the given age thresholds.

LEVEL OF EVIDENCE

Level IV, systematic review of level III and IV studies.

[Arthroscopic rotator cuff surgery : New and established methods]

This present article summarizes established and current developments and aspects of rotator cuff surgery. Achieved milestones as well as current approaches are presented and assessed with respect to their clinical and radiographic impact. Despite biomechanical and technical improvements in modern rotator cuff repair techniques, re-defect and re-tearing rates could not be fully eliminated. Meanwhile, the importance of biological processes around successful tendon-bone reintegration has been increasingly recognized. Hence, this article presents the current scientific standing regarding biological growth factors, platelet-rich plasma and rotator cuff augmentation techniques (with allogenic/autologous grafts). In summary, there are clear biomechanical advantages as well as many promising approaches to biological augmentation; however, the latter have not yet been transferred into regular clinical application.

How to Use a Graft in Irreparable Rotator Cuff Tears: A Literature Review Update of Interposition and Superior Capsule Reconstruction Techniques

PURPOSE OF REVIEW

To introduce the challenges in addressing irreparable rotator cuff tears and examine the surgical options, specifically interposition grafting and superior capsule reconstruction.

RECENT FINDINGS

Interposition grafting of rotator cuff tears shows promising results in reducing pain and improving function postoperatively and one study demonstrated that it performs significantly better than partial repair alone. Superior capsule reconstruction has become popular rapidly, but given the novelty of the procedure, there is currently a paucity of outcomes data to review. Irreparable rotator cuff tears are a challenging condition with a variety of surgical options available. Two such options-interposition and superior capsule reconstruction-both employ grafts in an attempt to restore joint stability and function. In the past 3 years, literature discussing interposition grafting has explored the different types of grafts, and mostly employed pre-post analysis. The recent superior capsule reconstruction articles strictly used human dermal allograft and offer a variety of surgical techniques without quantitative data.

Increasing age and tear size reduce rotator cuff repair healing rate at 1 year

Background and purpose - There is a need to understand the reasons why a high proportion of rotator cuff repairs fail to heal. Using data from a large randomized clinical trial, we evaluated age and tear size as risk factors for failure of rotator cuff repair. Patients and methods - Between 2007 and 2014, 65 surgeons from 47 hospitals in the National Health Service (NHS) recruited 447 patients with atraumatic rotator cuff tendon tears to the United Kingdom Rotator Cuff Trial (UKUFF) and 256 underwent rotator cuff repair. Cuff integrity was assessed by imaging in 217 patients, at 12 months post-operation. Logistic regression analysis was used to determine the influence of age and intra-operative tear size on healing. Hand dominance, sex, and previous steroid injections were controlled for. Results - The overall healing rate was 122/217 (56%) at 12 months. Healing rate decreased with increasing tear size (small tears 66%, medium tears 68%, large tears 47%, and massive tears 27% healed). The mean age of patients with a healed repair was 61 years compared with 64 years for those with a non-healed repair. Mean age increased with larger tear sizes (small tears 59 years, medium tears 62 years, large tears 64 years, and massive tears 66 years). Increasing age was an independent factor that negatively influenced healing, even after controlling for tear size. Only massive tears were an independent predictor of non-healing, after controlling for age. Interpretation - Although increasing age and larger tear size are both risks for failure of rotator cuff repair healing, age is the dominant risk factor.

Targeting Inflammation in Rotator Cuff Tendon Degeneration and Repair

Rotator cuff degeneration is a common affliction that results in pain and disability. Tendinopathy was historically classified with or without the involvement of the immune system. However, technological advancements in screening have shown that the immune system is both present and active in all forms of tendinopathy. During injury and healing, the coordinated effort of numerous immune cell populations work with the resident stromal cells to break down damaged tissues and stimulate remodeling. These cells deploy a wide array of tools, including phagocytosis, enzyme secretion, and chemotactic gradients to direct these processes. Yet, there remains a knowledge gap in our understanding of the sequence of critical events and regulatory factors that mediate this is process in injury and healing. Furthermore, current treatments do not specifically target inflammation at the molecular level. Typical regimens include non-steroidal anti-inflammatory drugs or corticosteroids; however, researchers have found irrevocable functional deficits following treatment, and have disputed their long-term efficacy. Therefore, developing therapeutics that specifically consider the nuances of the immune system are necessary to improve patient outcomes.

Preoperative NSAIDs, non-acute onset and long-standing symptoms predict inferior outcome at long-term follow-up after rotator cuff repair

PURPOSE

To evaluate mid- to long-term results after arthroscopic rotator cuff repair and to explore possible predictors of inferior outcome.

METHODS

Patients treated for full-thickness supraspinatus and/or infraspinatus tears from 2004 to 2008, using a uniform single-row arthroscopic technique, were included in the study. Pre- and post-operative QuickDASH were used as the primary outcome measure, and VAS of pain, function and satisfaction were also collected. An additional questionnaire explored demographic and preoperative factors like onset and duration of symptoms, preoperative treatment and smoking habits.

RESULTS

One hundred and forty-seven patients (82 %) were available at 6-9 years after surgery. All outcomes improved significantly from the preoperative values. A total of 8 % of patients had undergone additional surgery to the same shoulder during the follow-up period. Long-standing symptoms (>12 months) (P < 0.01), non-acute onset of symptoms (P < 0.01) and preoperative use of NSAIDs (P = 0.01) were correlated with inferior outcome at follow-up. No other factors investigated (i.e. gender, age, smoking and steroid injections) were found to affect the primary outcome (QuickDASH).

CONCLUSION

The current study is one of few reports of mid- to long-term outcomes after arthroscopic single-row repair of full-thickness rotator cuff tears. Global improvement in symptoms and function was found between the preoperative and the 6-9 years evaluation, and the technique therefore seems like a viable approach for treating tears of the supra- and the infraspinatus tendon. Several predictors of inferior long-term outcome after rotator cuff repair were, however, identified: preoperative use of NSAIDs, long-standing symptoms before surgery and non-acute onset of shoulder symptoms. In light of the current findings, accurate diagnosis and prompt treatment seem important in optimizing outcomes after rotator cuff surgery.

LEVEL OF EVIDENCE

IV.

Can Preoperative Magnetic Resonance Imaging Predict the Reparability of Massive Rotator Cuff Tears?

BACKGROUND

Numerous studies have shown preoperative fatty infiltration of rotator cuff muscles to be strongly negatively correlated with the successful repair of massive rotator cuff tears (RCTs).

PURPOSE

To assess the association between factors identified on preoperative magnetic resonance imaging (MRI), especially infraspinatus fatty infiltration, and the reparability of massive RCTs.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

We analyzed a total of 105 patients with massive RCTs for whom MRI was performed ≤6 months before arthroscopic procedures. The mean age of the patients was 62.7 years (range, 46-83 years), and 46 were men. Among them, complete repair was possible in 50 patients (48%) and not possible in 55 patients (52%). The tangent sign, fatty infiltration of the rotator cuff, and Patte classification were evaluated as predictors of reparability. Using the receiver operating characteristic curve and the area under the curve (AUC), the prediction accuracy of each variable and combinations of variables were measured.

RESULTS

Reparability was associated with fatty infiltration of the supraspinatus ( P = .0045) and infraspinatus ( P < .001) muscles, the tangent sign ( P = .0033), and the Patte classification ( P < .001) but not with fatty infiltration of the subscapularis and teres minor ( P = .425 and .132, respectively). The cut-off values for supraspinatus and infraspinatus fatty infiltration were grade >3 and grade >2, respectively. The examination of single variables revealed that infraspinatus fatty infiltration showed the highest AUC value (0.812; sensitivity: 0.86; specificity: 0.76), while the tangent sign showed the lowest AUC value (0.626; sensitivity: 0.38; specificity: 0.87). Among 2-variable combinations, the combination of infraspinatus fatty infiltration and the Patte classification showed the highest AUC value (0.874; sensitivity: 0.54; specificity: 0.96). The combination of 4 variables, that is, infraspinatus and supraspinatus fatty infiltration, the tangent sign, and the Patte classification, had an AUC of 0.866 (sensitivity: 0.28; specificity: 0.98), which was lower than the highest AUC value (0.874; sensitivity: 0.54; specificity: 0.96) among the 2-variable combinations.

CONCLUSION

The tangent sign or Patte classification alone was not a predictive indicator of the reparability of massive RCTs. Among single variables, infraspinatus fatty infiltration was the most effective in predicting reparability, while the combination of Goutallier classification <3 of the infraspinatus and Patte classification ≤2 of the rotator cuff muscles was the most predictive among the combinations of variables. This information may help predict the reparability of massive RCTs.

The Impact of Re-tear on the Clinical Outcome after Rotator Cuff Repair Using Open or Arthroscopic Techniques - A Systematic Review

Background:

It is generally accepted that rotator cuff repair gives satisfactory results in the long term, although most studies have so far shown a fairly high rate of structural failure or re-tear. The purpose of this review study is to assess whether failure of the repaired cuff to heal could negatively affect the functional outcome.

Methods:

This article includes an extensive Internet PubMed based research in the current English-language literature including level I to level V studies as well as systematic reviews.

Results:

According to this extended study research, the results are mixed; certain reports show that patients with a healed rotator cuff repair have improved function and strength compared to those with structural failure, whereas other studies support the generally perceived concept that tendon re-tear does not lead to inferior clinical outcome.

Conclusion:

Further high-level prospective studies with larger numbers of patients and longer follow up are needed to overcome the current debate over function between healed and failed rotator cuff repairs.