Patient-Reported Outcomes After Use of a Bioabsorbable Collagen Implant to Treat Partial and Full-Thickness Rotator Cuff Tears

Arthroscopic management of isolated partial-thickness rotator cuff tears

PURPOSE

The aim of the present study is to provide a comprehensive review on the surgical outcomes following arthroscopic treatments of partial-thickness rotator cuff tears (PT-RCTs) and to compare the postoperative American Shoulder and Elbow Surgeons (ASES) score following in situ transtendon repair and tear completion, followed by repair.

METHODS

Medline, EMBASE, Scopus, CINAHL and CENTRAL bibliographic databases were searched. Papers including patients with PT-RCTs of any grade who underwent treatment using debridement, in situ transtendon repair, tear completion and repair or bioinductive collagen implants were reviewed. Primary PT-RCTs were the sole indication for surgery. Primary postoperative outcomes assessed included the ASES score, the Absolute Constant-Murley score, the Simple Shoulder Test, the Visual Analogue Scale, the University of California-Los Angeles Shoulder Scale, the Western Ontario Rotator Cuff Score, range of motion, complications and revisions. A meta-analysis of comparative studies compared the postoperative ASES score between patients treated with in situ transtendon repair versus tear completion repair.

RESULTS

Twenty-eight studies were included. The ASES score was reported by four comparative studies with contrasting results. The heterogeneity was high (I2 = 86%), and effect sizes ranged from -0.49 in favour of the tear completion and repair technique to an effect size of +1.07 favouring in situ transtendon repair. The overall effect size of 0.02 suggests an equivalence between the two techniques in terms of the ASES score. Two studies with a total sample size of 111 patients reported on debridement, and four studies with a total sample size of 155 patients reported on bioinductive collagen implants.

CONCLUSION

Debridement alone is suitable for Ellman grades I-II PT-RCTs. In situ transtendon and tear completion repair techniques yield similar postoperative outcomes. Bioinductive collagen implants hold promise but lack long-term efficacy data. High-quality comparative studies are needed to determine the best treatment for PT-RCTs.

LEVEL OF EVIDENCE

Level IV.

Metaverse, virtual reality and augmented reality in total shoulder arthroplasty: a systematic review

PURPOSE

This systematic review aims to provide an overview of the current knowledge on the role of the metaverse, augmented reality, and virtual reality in reverse shoulder arthroplasty.

METHODS

A systematic review was performed using the PRISMA guidelines. A comprehensive review of the applications of the metaverse, augmented reality, and virtual reality in in-vivo intraoperative navigation, in the training of orthopedic residents, and in the latest innovations proposed in ex-vivo studies was conducted.

RESULTS

A total of 22 articles were included in the review. Data on navigated shoulder arthroplasty was extracted from 14 articles: seven hundred ninety-three patients treated with intraoperative navigated rTSA or aTSA were included. Also, three randomized control trials (RCTs) reported outcomes on a total of fifty-three orthopedics surgical residents and doctors receiving VR-based training for rTSA, which were also included in the review. Three studies reporting the latest VR and AR-based rTSA applications and two proof of concept studies were also included in the review.

CONCLUSIONS

The metaverse, augmented reality, and virtual reality present immense potential for the future of orthopedic surgery. As these technologies advance, it is crucial to conduct additional research, foster development, and seamlessly integrate them into surgical education to fully harness their capabilities and transform the field. This evolution promises enhanced accuracy, expanded training opportunities, and improved surgical planning capabilities.

Effect of Porcine-Derived Absorbable Patch-Type Atelocollagen for Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Trial

BACKGROUND

Even though arthroscopic rotator cuff repair is recognized as a standard treatment option, the risk of postoperative retear is a major concern.

PURPOSE

To evaluate the effect of porcine-derived absorbable patch-type atelocollagen during arthroscopic rotator cuff repair.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 64 patients with rotator cuff tears diagnosed on magnetic resonance imaging (MRI) were enrolled prospectively from November 2020 to December 2021. Both groups had repairs using the suture bridge technique. For the atelocollagen group, before securing the lateral anchors, we inserted porcine-derived absorbable patch-type atelocollagen between the footprint and the tendon. On postoperative day 2, the patients underwent MRI to confirm containment of the patch-type atelocollagen. At 6 months and 1 year postoperatively, the signal intensity of the repaired tendon was assessed using MRI. Patients were evaluated using the Constant score as the primary outcome, along with the visual analog scale for pain; range of motion; American Shoulder and Elbow Surgeons score; University of California, Los Angeles, score; and Korean Shoulder Score preoperatively and at 2, 3, 6, and 12 months postoperatively.

RESULTS

No significant changes in the Constant score as primary outcome, pain or other functional scores, and range of motion were observed between the groups at 1 year postoperatively. The patch-type atelocollagen was confirmed to be contained by the time-zero MRI scan taken 2 days postoperatively. Among the 55 patients included in final analysis, 12 retear cases were recorded (21.8% retear rate). A significantly lower retear rate was found in the atelocollagen group, as 3 cases were observed in this group (10.3%) and 9 cases were observed in the conventional repair group (34.6%) (P = .048).

CONCLUSION

The Constant score was not different between the groups. The retear rate after rotator cuff repair was significantly lower in the group that received porcine-derived absorbable patch-type atelocollagen compared with in the conventional group.

REGISTRATION

KCT0005184 (Clinical Research Information Service [CRIS]; https://cris.nih.go.kr).

Arthroscopic Repair of Retracted Large and Massive Rotator Cuff Tears With and Without Augmentation With a Bio-Inductive Collagen Implant Reveals Substantial and Comparable Clinical Improvement

PURPOSE

To compare clinical and imaging results after repair of retracted large and massive full-thickness rotator cuff tears, including revision repairs, with and without augmentation with a bio-inductive collagen implant.

METHODS

The study group comprised 24 patients (17 male subjects) with retracted 2 or 3 tendon rotator cuff tears undergoing arthroscopic repair followed by onlay augmentation with a bio-inductive collagen implant. The control group comprised 24 patients (19 male subjects) matched by tear size undergoing repair without augmentation. Mean patient age at repair in both groups was 61 years. Active range of motion and patient-reported outcomes were recorded before and after surgery. Noncontrast high-field magnetic resonance imaging was obtained in 20 of 24 collagen implant patients and 17 of 24 control patients at minimum 6 months' follow-up to assess tendon healing.

RESULTS

American Shoulder and Elbow Surgeons and Simple Shoulder Test scores improved from 35 to 86 and 3.6 to 9.3, respectively, in the collagen implant group and from 39 to 87 and 3.9 to 9.7 in the control group. The visual analog score-pain improved from 6.0 to 0.9 and from 5.9 to 0.9 in the collagen implant and control groups, respectively (P < .001 for all). Overall improvements in range of motion and patient-reported outcomes were similar in both groups. Magnetic resonance imaging revealed intact repairs in 11 of 20 (55%) patients in the patch group and 9 of 17 (53%) in the control group. Two patients in each group were revised to reverse shoulder arthroplasty.

CONCLUSIONS

Arthroscopic repair of retracted large and massive rotator cuff tears, including revision repairs, with and without augmentation using a bio-inductive collagen implant results in substantial and comparable early clinical improvement, although predictable healing remains elusive. Further work is needed to optimize patient selection for massive rotator cuff repair and define more precisely the indications for augmentation of these repairs using the collagen implant.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Editorial Commentary: Acellular Collagen Matrix Patch Augmentation of Large Rotator Cuff Tear Repair Results in Improved Healing

Despite a high retear rate, repair of large rotator cuff tendon tear repairs shows good clinical outcomes. Unfortunately, these results often deteriorate with time, and large tears, not to mention progressively symptomatic retears, especially in compromised rotator cuff tissue, remain a problem. The solution could include augmenting repair with a patch such as an acellular collagen matrix. Proper patient selection is needed to achieve a benefit justifying the added expense and operative time associated with adding a patch. Biomechanically, such patches are strong and increase suture retention, as well as repair construct strength and stiffness. Patches provide a significant healing effect. Recent research and meta-analysis support the use of patches on rotator cuff tendon tears 3 cm or larger, whereas smaller tears (1-2 cm in length) appear to heal without the need for a patch.

Rotator Cuff Augmentation: Its Role and Best Practices

Rotator cuff tears are a common source of pain and impairment in the shoulder. Healing of the rotator cuff tendons following repair has been associated with improved patient outcomes. While there have been many technical improvements in surgical techniques for rotator cuff repair, failure rates are still surprisingly high. Augmentation of these repairs has been shown to help with fixation biomechanics as well as healing rates. The described types of augments include autograft, allograft, xenograft, and synthetic options. This report reviews the commonly available types of augments and some of the outcomes associated with their use.

Economic Evaluation of a Bioinductive Implant for the Repair of Rotator Cuff Tears Compared with Standard Surgery in Italy

INTRODUCTION

Rotator cuff tear (RCT) is a painful, progressive condition resulting from damage to the rotator cuff tendons and is the leading cause of shoulder-related disability. Surgical repair of rotator cuff is an established standard of care (SOC); however, failure of the procedure can occur. In this context, the use of collagen-based bioinductive implant REGENETEN showed long-term improvements in clinical scores. The aim of the study was to assess the cost-effectiveness of REGENETEN combined with SOC (SOC + REGENETEN) compared to SOC alone from both National Healthcare Service (NHS) and societal perspectives in Italy.

METHODS

A decision analytic model was developed to estimate the number of tears healed and costs for the two considered treatment strategies over 1 year. Clinical data were retrieved from the literature, and the clinical pathways for the management of patients with RCTs were retrieved from four key opinion leaders in Italy.

RESULTS

Over a 1-year time horizon, healed lesions were 90.70% and 72.90% for surgical repair of RCTs with and without REGENETEN, respectively. Considering the NHS perspective, mean costs per patient were €7828 and €4650 for the two strategies, respectively, leading to an incremental cost-effectiveness ratio (ICER) of €17,857 per healed tear. From the societal perspective, the mean costs per patient were €12,659 for SOC and €11,784 for REGENETEN, thus showing savings of €4918 per healed tear when the bioinductive implant is used. The sensitivity analyses confirmed the robustness of the model results.

CONCLUSION

In the context of paucity of cost-effectiveness studies, our findings provide additional evidence for clinicians and payers regarding the value of a new treatment option that supports a tailored approach for the management of patients with RCTs.

Scaffold- and graft-based biological augmentation of rotator cuff repair: an updated systematic review and meta-analysis of preclinical and clinical studies for 2010-2022

BACKGROUND

Despite advancements in the surgical techniques of rotator cuff repair (RCR), there remains a high retear rate. Biological augmentation of repairs with overlaying grafts and scaffolds may enhance healing and strengthen the repair construct. This study aimed to investigate the efficacy and safety of scaffold-based (nonstructural) and overlay graft-based (structural) biological augmentation in RCR (excluding superior capsule reconstruction and bridging techniques) in both preclinical and clinical studies.

METHODS

This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, as well as guidelines outlined by The Cochrane Collaboration. A search of the PubMed, Embase, and Cochrane Library databases from 2010 until 2022 was conducted to identify studies reporting the clinical, functional, and/or patient-reported outcomes of ≥1 biological augmentation method in either animal models or humans. The methodologic quality of included primary studies was appraised using the Checklist to Evaluate a Report of a Non-pharmacological Trial (CLEAR-NPT) for randomized controlled trials and using the Methodological Index for Non-randomized Studies (MINORS) for nonrandomized studies.

RESULTS

A total of 62 studies (Level I-IV evidence) were included, comprising 47 studies reporting outcomes in animal models and 15 clinical studies. Of the 47 animal-model studies, 41 (87.2%) demonstrated biomechanical and histologic enhancement with improved RCR load to failure, stiffness, and strength. Of the 15 clinical studies, 10 (66.7%) illustrated improvement in postoperative clinical, functional, and patient-reported outcomes (eg, retear rate, radiographic thickness and footprint, and patient functional scores). No study reported a significant detriment to repair with augmentation, and all studies endorsed low complication rates. A meta-analysis of pooled retear rates demonstrated significantly lower odds of retear after treatment with biological augmentation of RCR compared with treatment with non-augmented RCR (odds ratio, 0.28; P < .00001), with low heterogeneity (I2 = 0.11).

CONCLUSIONS

Graft and scaffold augmentations have shown favorable results in both preclinical and clinical studies. Of the investigated clinical grafts and scaffolds, acellular human dermal allograft and bovine collagen demonstrate the most promising preliminary evidence in the graft and scaffold categories, respectively. With a low risk of bias, meta-analysis revealed that biological augmentation significantly lowered the odds of retear. Although further investigation is warranted, these findings suggest graft and scaffold biological augmentation of RCR to be safe.

Biphasic Interpositional Allograft for Rotator Cuff Repair Augmentation Is Safe in an Ovine Model

PURPOSE

To perform a preclinical histologic assessment of a biphasic acellular interpositional cancellous allograft in an ovine model of rotator cuff repair (RCR) designed to better understand its safety profile and effects on tendon healing after RCR.

METHODS

Thirty skeletally mature sheep with clinically normal shoulders with an artificially created degenerative infraspinatus tendon tear were randomized to control and treatment groups. Animals were euthanized at 3 weeks, 6 weeks, and 12 weeks. After gross dissection, rotator cuff specimens were fixed with formalin and polymerized for sectioning and staining. Blinded histologic scores evaluated inflammatory cell infiltrates, signs of degradation, particulate debris, collagen arrangement, neovascularization, and enthesis qualitative measures.

RESULTS

There were no treatment specimens that exhibited histologic signs of a significant infection, inflammatory infiltrate, or foreign body reaction such as granuloma or fibrous capsule formation. Histologic scores in all categories were not significantly different at all time points, including the primary end point mean cumulative inflammatory score (control: 3.66 ± 1.21 vs treated: 4.33 ± 1.51, P = .42), when comparing the treatment and control RCR groups. In general, the degree of tendon healing and host tissue response was essentially equivalent between the 2 groups with observation of low overall levels of inflammation and progressive improvements in collagen organization, reduced tenocyte activity, and fibrocartilaginous enthesis reformation.

CONCLUSIONS

This histologic study demonstrated the use of a biphasic interpositional allograft for RCR augmentation in an ovine model does not generate an inflammatory response or foreign body reaction. Use of the biphasic interpositional allograft resulted in a histological profile that was essentially equivalent to that of a standard RCR at 3-, 6-, and 12-week postoperative timepoints. These findings suggest that a biphasic interpositional allograft is safe for further clinical investigation in humans before broader clinical application.

CLINICAL RELEVANCE

Patch augmentation of RCR is a popular technique that has shown clinical success in improving the likelihood of a successful repair in patients at elevated risk for retear. Newer augmentation technologies are being developed to address the biology at the interface between the bone and soft tissue where failure typically occurs.

Arthroscopic Autologous Coracoacromial Ligament Augment Technique for Particle Thickness of Rotator Cuff with at Least Two Years Follow-Up

OBJECTIVE

Patch technology has been the new technique in the treatment of partial thickness of the rotator cuff tear (PTRCTs) to address the limitation of traditional techniques. Compared with allogeneic patches and artificial materials, coracoacromial ligament is obviously closer to their own biology. The purpose of the study was to evaluate the functional and radiographic outcomes following arthroscopic autologous coracoacromial ligament augment technique for treatment of PTRCTs.

METHOD

This study included three female patients with PTRCTs who underwent arthroscopy operation in 2017 with an average age of 51 years (range from 50 to 52 years). The coracoacromial ligament implant was attached to the bursal side surface of the tendon. The clinical results were evaluated by American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), acromiohumeral distance (AHD) and muscle strength before and 12 months after operation. Magnetic resonance imaging (MRI) was performed 24 months after operation to assess the integrity of the anatomical structure of the original tear site.

RESULT

The average ASES score improved significantly from 57.3 preoperatively to 95.0 at 1-year follow-up. The strength improved significantly from grade 3 preoperatively to grade 5 at 1 year. Two of three patients underwent the MRI at 2-year follow-up. Radiographic released the complete healing of rotator cuff tear. No implant-related serious adverse events were reported.

CONCLUSION

The new technique of using autogenous coracoacromial ligament patch augment provides good clinical results on patients with PTRCTs.

Resorbable Bioinductive Collagen Implant Is Cost Effective in the Treatment of Rotator Cuff Tears

Purpose

This study was conducted to investigate whether the use of resorbable bioinductive collagen implant (RBI) in addition to conventional rotator cuff repair (conventional RCR) is cost-effective when compared to conventional RCR alone, in the treatment of full-thickness rotator cuff tears (FT RCT).

Methods

We developed a decision analytic model to compare the expected incremental cost and clinical consequences for a cohort of patients with FT RCT. The probabilities for healing or failure to heal (retear) were estimated from the published literature. Implant and healthcare costs were estimated from a payor's perspective in 2021 U.S. prices. An additional analysis included indirect cost estimations (e.g., productivity losses). Sensitivity analyses explored the effect of tear size, as well as the impact of risk factors.

Results

The base case analysis demonstrated that resorbable bioinductive collagen implant + conventional rotator cuff repair results in incremental costs of $232,468 and an additional 18 healed RCTs per 100 treated patients over 1 year. The estimated incremental cost-effectiveness ratio (ICER) is $13,061/healed RCT compared to conventional RCR alone. When return to work was included in the model, RBI + conventional RCR was found to be cost saving. Cost-effectiveness improved with tear size with the largest benefit seen in massive tears compared to large tears, as well as patients at higher risk of retearing.

Conclusions

This economic analysis demonstrated that RBI + conventional RCR delivered improved healing rates at a marginal increase in costs when compared to conventional RCR alone and is, therefore, cost-effective in this patient population. Considering indirect costs, RBI + conventional RCR resulted in lower costs compared to conventional RCR alone and is, therefore, deemed to be cost saving.

Level of Evidence

Level IV, economic analysis.

Rotator Cuff Repair Augmented With Interpositional Nanofiber Scaffold

Despite advances in arthroscopic rotator cuff repair, failure rates up to 94% have been reported in the literature for large tears, with rates as high as 36% for small and medium tears. One strategy for improving outcomes is augmentation with a patch, which has typically been incorporated onto the bursal portion of the repaired tendon and been made up of either dermal or bovine collagen tissue. The Rotium wick (Atreon Orthopedics, Columbus, OH)-an interpositional augmentation-is a nanofiber scaffold that is meant to be sandwiched between the rotator cuff and humerus at the bone-tendon interface and is currently the only implant approved by the US Food and Drug Administration to be used in this manner. The scaffold works to improve the cellular organization of the basement membrane during tendon healing at the enthesis and, in a recent sheep study, has been shown to better replicate the natural Sharpey-like fibers similar to the native tendon and increase the strength of the repair more rapidly. The purpose of this Technical Note is to describe the means for use of an interpositional nanofiber scaffold for arthroscopic rotator cuff repair.

Intrasubstance Patellar Tendon Repair with the Addition of a Bio-inductive Implant

Intrasubstance patellar tendon ruptures are an uncommon injury that can have devastating long-term effects for patients. Operative intervention to repair the ruptured tendon is the gold standard treatment for these injuries and can be performed using a variety of techniques. Unlike the more common patellar tendon ruptures at the level of the patella, repairs of intrasubstance ruptures are often challenging because of the poor quality of the remaining tendon fibers. Tendon repair with augmentation via bio-inductive implants has gained popularity in upper extremity literature, as it has demonstrated improved tendon strength and patient outcomes. However, there remains a sparsity of reports regarding tendon augmentation in the lower extremity literature. Here, we describe repair of an intrasubstance patellar tendon rupture using a modified SpeedBridge repair and augmentation with a bio-inductive implant.

Two-year outcomes with a bioinductive collagen implant used in augmentation of arthroscopic repair of full-thickness rotator cuff tears: final results of a prospective multicenter study

BACKGROUND

Full-thickness rotator cuff tears (FTRCTs) represent a common shoulder injury that, if untreated, can progress in size, become increasingly painful, and inhibit function. These lesions are often surgically repaired, with double-row arthroscopic repair often preferred for larger tears. Biological augmentation technologies have been developed to improve rates of postoperative radiographic retear and enhance patient-reported outcomes after surgical FTRCT repair. This study sought to confirm that augmented repair with a bioinductive bovine collagen implant results in favorable retear rates and patient outcomes with follow-up to 2 years.

METHODS

A prospective multicenter cohort study was undertaken to determine the efficacy and safety of augmenting single- or double-row arthroscopic repair of FTRCTs with a bioinductive bovine collagen implant. Of 115 adult patients participating, 66 (57.4%) had medium (1-3-cm) tears and 49 (42.6%) had large (3-5-cm) tears. Magnetic resonance imaging and patient-reported outcomes (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Constant-Murley Score [CMS]) were performed and recorded at baseline, 3 months, 1 year, and 2 years.

RESULTS

Mean duration of follow-up was 2.1 years (range, 1.5-2.9 years). Between baseline and 2-year follow-up, mean total thickness of the supraspinatus tendon increased by 12.5% for medium tears and by 17.1% for large tears. Radiographic retear was noted in 7 of 61 available patients (11.5%) with medium tears, and in 14 of 40 patients (35.0%) with large tears. In both groups, these tears primarily occurred before the 3-month follow-up visit (13 of 21 [61.9%]). Radiographic retear with the supplemented double-row (DR) repair technique was 13.2% overall (12 of 91 DR patients; 11.3% for medium tears and 15.8% for large tears). The minimal clinically important difference was achieved by >90% of patients with both medium and large tears for both ASES and CMS. There were 2 serious adverse events classified by the treating surgeon as being possibly related to the device and/or procedure (1 case of swelling/drainage and 1 case of intermittent pain). Nine patients (7.8%; 4 medium tears and 5 large tears) required reoperation of the index rotator cuff surgery.

CONCLUSION

Final 2-year data from this study confirm that using this implant in augmentation of arthroscopic double-row repair of FTRCTs provides favorable rates of radiographic retear and substantial functional recovery. The relative safety of the device is also further supported.

Can the Single Assessment Numeric Evaluation be used as a stand-alone subjective outcome instrument in patients undergoing rotator cuff repair?

BACKGROUND/HYPOTHESIS

There is no consensus to which patient-determined shoulder outcome scores should be considered when analyzing patient outcomes. Use of multiple patient-determined outcomes may be redundant and cause increased responder burden. The Single Assessment Numeric (SANE) has not been widely accepted as a stand-alone shoulder-specific outcome measure. The hypothesis was that SANE will correlate with and be comparable in responsiveness to other subjective outcome measures that have been used in a stand-alone fashion in patients undergoing rotator cuff repair (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], Western Ontario Rotator Cuff Index [WORC], and the Simple Shoulder Test [SST]). In addition, the SANE will be more relevant to each patient compared to the ASES, further supporting its use as a stand-alone shoulder-specific outcomes measure.

METHODS

A retrospective review of a database of patients undergoing rotator cuff repair was reviewed where the SANE was recorded with the ASES, WORC, and/or SST. Correlations were determined using the Pearson coefficient. Subgroup analysis was performed to determine if correlations differed in (1) preoperative and (2) postoperative outcome determinations. Responsiveness was determined by calculating the standardized response mean (SRM) and the effect size (ES) of all scores. Relevance and precision of the SANE and ASES were examined using 150 consecutive patients to determine the number of questions in each score that were not answered.

RESULTS

Correlation was excellent for the SANE and the ASES (n = 1838, r = 0.81, P < .0001), the WORC (n = 1793, r = 0.82, P < .0001), and the SST (n = 1836, r = 0.76, P < .0001). Correlation of preoperative scores was moderate and postoperative scores were excellent when comparing the SANE with all 3 scores. All scores were highly responsive, with the SRM of the SANE = 2.1, ASES = 2.2, WORC = 2.4, and the SST = 1.8. The ES of the SANE = 2.4, ASES = 2.7, WORC = 3.0, and the SST = 2.1. One hundred percent of the SANE scores were answered completely compared with 57% (P < .0001) of the ASES, with significant variability found in the answers to the "work" and "score" questions.

CONCLUSION

In patients undergoing rotator cuff repair, the SANE highly correlated and has equivalent responsiveness with the WORC, ASES, and SST, which have been used as stand-alone shoulder-specific outcomes measures. The SANE may provide the same information as the WORC, ASES, and SST regarding outcome with significant reduction in responder burden. This study supports that the SANE can be used as a subjective, stand-alone instrument for patients undergoing rotator cuff repair.

Venothromboembolism following shoulder arthroscopy: a systematic review

Background

Venous thromboembolic events (VTEs) following orthopedic surgery may lead to serious morbidity and mortality. Fortunately, VTEs following upper extremity procedures are uncommon. However, the true incidence is likely underreported. The aim of this study is to provide a systematic review, excluding large database studies, to report on the incidence of VTEs following shoulder arthroscopic procedures.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review of multiple databases was performed. A comprehensive search of several databases from inception to September 1, 2021, limited to English language and excluding animal studies, was designed and conducted. Studies were screened by 2 independent reviewers. A decision to exclude studies from large surgical or insurance claim databases was made to minimize the risk of including overlapping data points in this systematic review.

Results

Thirteen studies met inclusion and exclusion criteria and form part of this systematic review. A total of 32,407 patients were included in this study. Among these patients, the deep vein thrombosis, pulmonary embolism, and overall VTE rates were 0.15%, 0.08%, and 0.21%, respectively. Among the patients specified to have undergone arthroscopic rotator cuff repair, the rate of deep vein thrombosis, pulmonary embolism, and overall VTE was 0.71%, 0.37%, and 1.04%, respectively.

Conclusion

While symptomatic VTEs are rare following shoulder arthroscopic procedures, surgeons must be aware that they still account for a certain number of postoperative complications. Factors such as operative time, open procedures, obesity, and altitude may increase the risk of postoperative VTE although conflicting data exist. Current literature supports the idea that chemical antithrombotic prophylaxis likely provides no significant advantage over early mobilization in reducing VTEs following shoulder arthroscopy in low-risk patients.

Traumatic Midsubstance Patellar Tendon Ruptures: A Unique Surgical Repair Technique in the Setting of Poor Tissue Quality

In the setting of traumatic midsubstance patellar tendon ruptures in which the tissue is unable to be repaired end to end, surgical options are limited. We offer a technique using suture anchors for the native tendon reconstruction, allograft augmentation, and a bioinductive implant.

Increased stiffness and reoperation rate in partial rotator cuff repairs treated with a bovine patch: a propensity-matched trial

BACKGROUND

Treating high-grade (grade 2 and 3) partial-thickness rotator cuff tears after failed conservative care remains challenging. Arthroscopic repair techniques are often considered with or without subacromial decompression and biological injections. More recently, a bioinductive bovine collagen patch (Regeneten; Smith & Nephew, Memphis, TN, USA) has been proposed to create a healing response and thicken the injured tendon. Although promising early results have been shown, previous studies lacked control subjects or comparison to other surgical treatments. The purpose of this study was to compare the reoperation rates of arthroscopic débridement and repair without a bioinductive collagen patch vs. arthroscopic débridement and repair with a bioinductive collagen patch in patients with high-grade partial-thickness rotator cuff tears in whom a minimum of 6 months of nonoperative treatment failed.

METHODS

Thirty-two patients with high-grade partial-thickness supraspinatus tears were treated with surgical repair with a bioinductive patch. A control group of 32 patients with high-grade partial-thickness supraspinatus tears treated with débridement or tear completion and repair without a bioinductive patch was selected and matched for age, sex, and tear size. Patients were followed up at regular intervals of 6 weeks, 12 weeks, and 6 months postoperatively, and range of motion was assessed at respective clinic visits. Stiffness and reoperations were compared between groups.

RESULTS

Postoperative stiffness was observed in the first 12 weeks in 8 of 32 patients in the patch group compared with 1 of 32 patients in the control group. Six patients in the patch group underwent reoperations compared with no patients in the control group (P < .001). All 6 reoperations in the patch group were performed to address stiffness. There were no differences in race, smoking status, or diabetes between groups (P > .05).

CONCLUSION

Patients in the patch group had a significantly higher rate of postoperative stiffness. In the majority of patients in whom shoulder stiffness developed, reoperation was required.

Optimal Management of Partial Thickness Rotator Cuff Tears: Clinical Considerations and Practical Management

Partial thickness rotator cuff tears have been diagnosed with increased frequency due to heightened awareness and an improvement in diagnostic modalities. When >50% of the tendon thickness has ruptured, intra-tendinous strain of the residual tendon increases. Surgery is generally confined to patients who have failed non-operative measures and have persistent symptoms. The rationale for repairing partial thickness tears lies in their limited self-healing capacity, and propensity to enlarge over time and progress to a full thickness defect. Although tear debridement and acromioplasty can improve pain and function, tear progression can occur, in addition to worse results being noted in bursal-sided defects. Several surgical strategies have been recommended but there is a lack of evidence to advocate one form of treatment over another. The aim of this narrative review is to discuss the treatment options for partial thickness tears of the rotator cuff.

Biceps Augmentation Outperforms Tear Completion Repair or In Situ Repair for Bursal-Sided Partial-Thickness Rotator Cuff Tears in a Rabbit Model

BACKGROUND

There is an ongoing debate on the treatment of bursal-sided partial-thickness rotator cuff tears (PTRCTs), including ideal repair techniques. Augmentation using a collagen patch has been introduced as a new surgical approach to treat PTRCTs, while the effect of autogenous biceps augmentation (BA) has not been investigated.

PURPOSE

To analyze the effects of BA on bursal-sided PTRCTs and compare its histological and biomechanical results with those of tear completion followed by repair and in situ repair (ISR).

STUDY DESIGN

Controlled laboratory study.

METHODS

Unilateral chronic PTRCTs were created in 96 mature New Zealand White rabbits, which were randomly divided into 4 groups: no repair, tear completion repair (TCR), ISR, and BA. A new bicipital groove was fabricated in BA for the biceps tendon that was transferred to augment the bursal-sided PTRCT repair. In each group, we sacrificed 6 rabbits for biomechanical testing of the whole tendon-to-bone complex (WTBC) and 6 for histological evaluation of bursal- and articular-sided layers at 6 and 12 weeks postoperatively. Healing responses between the biceps and new bicipital groove in the BA group were determined using histological analysis, and final groove morphologies were evaluated using micro-computed tomography.

RESULTS

The remaining tendon and enthesis in bursal-sided PTRCTs progressively degenerated over time. WTBCs of ISR exhibited a larger failure load than those of TCR, although better healing properties in the bursal-sided repaired site were achieved using TCR based on histological scores and superior articular-sided histological scores were observed using ISR. However, WTBCs of BA displayed the best biomechanical results and superior histological scores for bursal- and articular-sided regions. The new bicipital groove in BA remodeled over time and formed similar morphologies to a native groove, which provided a mature bone bed for transferred biceps tendon healing to augment bursal-sided PTRCTs.

CONCLUSION

BA achieved better biomechanical and histological results for repairing bursal-sided PTRCTs as compared with TCR and ISR. When compared with that of TCR, the WTBC of ISR exhibited a higher failure load, showing histological superiority in the articular-sided repair and inferiority in the bursal-sided repair.

CLINICAL RELEVANCE

BA may be an approach to improve bursal-sided PTRCT repair in humans, which warrants further clinical investigation.

The Evolution of Arthroscopic Rotator Cuff Repair

Over the past 30 years, arthroscopic rotator cuff repair (ARCR) has evolved to become the gold standard in treating rotator cuff pathology. As procedural concepts of ARCR continue to improve, it is also continually compared with the open rotator cuff repair as the historical standard of care. This review highlights the evolution of ARCR, including a historical perspective; the anatomic, clinical, and surgical implications of the development of an arthroscopic approach; how arthroscopy improved some of the problems of the open approach; adaptations in techniques and technologies associated with ARCR; future perspectives in orthobiologics as they pertain to ARCR; and lastly, the clinical improvements, or lack of improvements, with all of these adaptations.

Tips and Tricks for Augmenting Rotator Cuff Repair With a Bio-inductive Collagen Implant

The contemporary literature suggests that a primary feature of recurrence of rotator cuff tear after arthroscopic repair is failure of tendon healing, which can occur for multiple reasons, including compromised tissue quality. Recently, the use of augmentation implants, grafts, or scaffolds has emerged as a strategy to address the issue of deficient rotator cuff tissue. A resorbable bio-inductive collagen implant (REGENETEN; Smith & Nephew, Andover, MA) has been shown to increase tendon thickness when applied in rotator cuff repair. This article presents an experienced surgeon's tips for implanting this device. In addition, we review the current literature about this bio-inductive implant.

Tendon midsubstance trauma as a means for the development of translatable chronic rotator cuff degeneration in an ovine model

BACKGROUND

Chronic degeneration of rotator cuff tendons is a major contributing factor to the unacceptably high prevalence of rotator cuff repair surgery failures. The etiology of chronic rotator cuff degeneration is not well understood, and current therapies are not effective, necessitating preclinical research to fill this knowledge gap. Unfortunately, current large animal models rely on enthesis disruption as a means of model generation, which is not representative of human patients with chronic rotator cuff degeneration prior to full-thickness tears. Following, the goal of this study was to develop and characterize a translational large-animal model of chronic rotator cuff degeneration without enthesis release.

METHODS

A midsubstance damage model [i.e., "combed fenestration" (CF)] in adult sheep was generated by creating 16 longitudinal cuts within the top third of the infraspinatus tendon thickness. Tendon integrity was characterized through exhaustive non-destructive biomechanical stress relaxation testing [peak stress, peak load, percent relaxation, and cross-sectional area (CSA)], followed by histopathological degeneration scoring and analysis (Bonar score), histomorphological analysis of collagen organization and fatty atrophy (percent adipose area), and gene expression analyses.

RESULTS

The CF model tendons exhibited significantly decreased mechanical properties as evidenced by decreased peak stress (P<0.025) and increased percent relaxation (18-week vs. Control, P<0.035) at multiple strain magnitudes and across all timepoints. At all timepoints, the CF tendons exhibited pathological changes aligned with tendon degeneration, as evidenced by increased Bonar scoring (P<0.001) and decreased collagen organization (6-week vs. Control, P=0.013). Increases in intramuscular adipose content were also documented through histomorphology analysis (6- and 18-week vs. Control, P<0.077). Significant changes in gene expression were noted at all timepoints.

CONCLUSIONS

These data reveal that this new ovine CF model of chronic rotator cuff degeneration results in tendons with decreased mechanical properties, degenerative pathology characteristics, and gene expression profiles that aligned with the degenerative changes that have been noted in humans with tendinopathy. For these reasons, we believe this novel large animal model of chronic rotator cuff degeneration is a translational platform in which to test devices, therapies, and/or technologies aimed at repairing damage to the shoulder.

Full-Thickness Rotator Cuff Tears Can Be Safely Treated With a Resorbable Bioinductive Bovine Collagen Implant: One-Year Results of a Prospective, Multicenter Registry

Purpose

The purpose of this study was to prospectively collect safety and efficacy data in a large group of patients undergoing arthroscopic repair of full-thickness rotator cuff tears augmented with a resorbable bioinductive bovine collagen implant designed to promote healing.

Methods

Seventeen centers across the United States enrolled patients in an institutional review board-approved registry to collect outcomes data on the implant. Patients undergoing surgical management of full-thickness rotator cuff tears augmented with the implant were enrolled. Inclusion criteria were age of ≥21 years, willingness to participate and the ability to read and speak English. Exclusion criteria included hypersensitivity to bovine-derived products. Patients were assessed before and after surgery at up to 1 year with outcomes including the single-assessment numeric evaluation (SANE), Veterans RAND 12-Item (VR-12) mental components and physical components (VR-12 PCS), American Shoulder and Elbow Surgeons (ASES), and Western Ontario Rotator Cuff (WORC) outcome measures. Ad hoc analyses were performed to compare these outcomes at all time points depending on tear size (small/medium vs large/massive). Serious complications were collected.

Results

Of 210 patients enrolled, 192 had 1-year follow-up data available. The patients experienced statistically significant improvement between baseline and 1 year for mean SANE, VR-12 PCS, ASES, and WORC scores (40.0-82.0, 33.5-47.3, 46.2-87.8, and 36.2-81.0, respectively; P < .001 for all results). Ad-hoc analysis demonstrated that similar results were obtained at 1 year regardless of tear size. Twenty patients (10.4%) experienced serious complications (10.4%), including revision surgery (n = 18), proximal humerus fracture/partial subscapularis tear resulting from multiple falls (n = 1), and adhesive capsulitis (n = 1).

Conclusions

The safety and efficacy of a bioinductive implant in the surgical management of full-thickness rotator cuff tears at 1 year was shown in this study. Implant efficacy appears to be comparable regardless of the underlying tear size.

Level of Evidence

Level IV, therapeutic case series.

Treatment of Partial-Thickness Rotator Cuff Tears With a Resorbable Bioinductive Bovine Collagen Implant: 1-Year Results From a Prospective Multicenter Registry

Background:

Surgical treatment of partial-thickness rotator cuff tears remains challenging and controversial, with several traditional options including debridement with acromioplasty, transtendon or in situ repair, and take-down and repair. A resorbable bioinductive bovine collagen implant has shown promise as an alternative treatment option for partial-thickness tears.

Purpose:

Data from a registry were analyzed to further establish that the implant contributes to improved patient-reported outcome (PRO) scores across a large number of patients treated for partial-thickness rotator cuff tears.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 19 centers in the United States enrolled patients >21 years old with partial-thickness tears of the rotator cuff in a comprehensive prospective multicenter registry. PRO scores were recorded preoperatively and postoperatively at 2 and 6 weeks, 3 and 6 months, and 1 year: American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, Veterans RAND 12-Item Health Survey (physical and mental component scores), and Western Ontario Rotator Cuff scores. Revisions were reported throughout the study.

Results:

The registry included 272 patients with partial-thickness tears (49 grade 1 tears, 101 grade 2 tears, and 122 grade 3 tears), 241 who underwent isolated bioinductive repair (IBR; collagen implant placed after bursectomy without a traditional rotator cuff repair), and 31 who had take-down and repair with bioinductive augmentation. Patients experienced statistically significant and sustained improvement from baseline for all PRO scores beginning at 3 months. Among patients with grade ≥2 tears, those with take-down and repair had significantly inferior scores at 2 and 6 weeks for most PRO scores as compared with those who underwent IBR, but the difference was no longer significant at 1 year for all but the physical component score of the Veterans RAND 12-Item Health Survey. There were 11 revisions, which occurred at a mean ± SD of 188.7 ± 88.0 days after the index surgery. There were no infections.

Conclusion:

This registry analysis further establishes across a large data set that this resorbable bioinductive bovine collagen implant improves PROs in all grades of partial-thickness tears, whether used as IBR or in conjunction with take-down and repair. IBR may offer improved early clinical outcomes (≤6 weeks) and comparable outcomes at 1 year when compared with a more invasive “take-down and repair” approach.

Isolated bioinductive repair of partial-thickness rotator cuff tears using a resorbable bovine collagen implant: two-year radiologic and clinical outcomes from a prospective multicenter study

BACKGROUND

Current surgical treatment options for partial-thickness tears (eg, takedown and repair, in situ repair) are limited by the degenerative nature of the underlying tendon and may require extensive intervention that can alter the anatomic footprint. The complexity of available techniques to address these issues led to the development of a resorbable collagen implant, which can be used to create a bioinductive repair of partial-thickness tears.

METHODS

We prospectively enrolled 33 patients with chronic, degenerative, intermediate-grade (n = 12), or high-grade (n = 21) partial-thickness tears (11 articular, 10 bursal, 4 intrasubstance, and 8 hybrid) of the supraspinatus tendon in a multicenter study. After arthroscopic subacromial decompression without a traditional rotator cuff repair, a bioinductive implant was secured over the bursal surface of the tendon. Clinical outcomes were assessed using American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores (CMS) preoperatively and at 3 months, 1 year, and 2 years postoperatively. Magnetic resonance imaging was performed to assess postoperative tendon healing and thickness at the original tear site.

RESULTS

At 2-year follow-up, mean ASES and CMS scores improved both clinically and statistically at 1 and 2 years, compared with baseline, for intermediate- and high-grade tears. There was magnetic resonance imaging evidence of new tissue fill-in within the original baseline tear in 100% of the intermediate-grade tears and 95% of the high-grade tears. In 90.9% of the intermediate-grade tears and 84.2% of the high-grade tears, this new tissue fill-in represented at least an additional 50% of the volume of the initial lesion. From baseline to 2-year follow-up, the mean tendon thickness increased by 1.2 mm (standard deviation, 1.3; P = .012) and 1.8 mm (standard deviation, 2.2; P = .003) in the intermediate- and high-grade tears, respectively. The analysis of tear grade and location revealed no statistically significant difference in the change in mean tendon thickness at any time point. One patient with a high-grade articular lesion demonstrated progression to a full-thickness tear; however, the patient was noncompliant and the injury occurred while shoveling snow 1 month after surgery. Neither tear location nor treatment of bicep pathology affected the ASES or CMS scores at any follow-up point. No serious adverse events related to the implant were reported.

CONCLUSION

Final results from this 2-year prospective study indicate that the use of this resorbable bovine collagen implant for isolated bioinductive repair of intermediate- and high-grade partial-thickness rotator cuff tears of the supraspinatus is safe and effective, regardless of tear grade and location.

Use of biologics in rotator cuff disorders: Current concept review

Poor tendon to bone healing following rotator cuff repair has led to the continued interest and investigation into biological augmentation. The biology of tendinopathy is not fully understood and consequently the availability of disease modifying therapeutic targets is limited. A ceiling of benefit has been reached by mechanical optimisation of rotator cuff repair and thus, in order to improve healing rates, a biological solution is required. This review focuses on the strategies to biologically augment rotator cuff disorders with an emphasis on rotator cuff repair. Leucocyte rich platelet rich plasma has been shown to improve healing rates without clinically relevant improvements in outcome scores. Similarly, improved healing rates have also been reported with bone marrow stimulation and in long-term follow-up with bone marrow concentrate. Extracellular matrix (ECM) and synthetic scaffolds can increase healing through mechanical and or biological augmentation. A potential third category of scaffold is bio-inductive and has no mechanical support. Studies involving various scaffolds have shown promising results for augmentation of large to massive tears and is likely to be most beneficial when tendon quality is poor, however level I evidence is limited.

Bioinductive Collagen Implant Augmentation for the Repair of Chronic Lower Extremity Tendinopathies: A Report of Two Cases

In this report, we present two cases of refractory chronic lower extremity tendinopathies treated with collagen bioinductive implant augmentation: a 20-year-old male football player with chronic patellar tendinopathy and a 40-year-old active female with chronic proximal hamstring tendinopathy. We demonstrate that bioaugmentation may represent an effective strategy in the surgical treatment of chronic tendinopathies. Both patients were able to return to their pre-injury activity levels at an accelerated rate.

Enthesis trauma as a means for the development of translatable chronic rotator cuff degeneration in an ovine model

BACKGROUND

Untreated rotator cuff tears lead to irreversible tendon degeneration, resulting in unacceptable repair prognosis. The inability of current animal models of degenerated rotator cuff tendons to more fully emulate the manifestation and degree of pathology seen in humans with a previously torn rotator cuff tendon (s) significantly impairs the development of novel therapeutics. Therefore, the objective of this study was to develop a large-animal translational model of enthesis damage to the rotator cuff tendons to mimic the chronic degenerative changes that occur in patients that demonstrate clinical manifestations of tendinopathy.

METHODS

A partial enthesis tear model (i.e., sharp transection) in adult sheep was created by cutting the tendon fibers perpendicularly through the enthesis midpoint, while leaving the other portion of the tendon in-tact. To assess tendon integrity, non-destructive biomechanical tests were performed, followed by histopathological, histomorphological, and gene expression analysis. Samples of degenerated human rotator cuff tendons obtained from patients undergoing reverse total shoulder arthroplasty to use for comparative pathological analysis.

RESULTS

In the sheep model, transected tendons at all timepoints had significantly decreased mechanical properties. Histopathologic evaluation and Bonar scoring revealed that the tendons in sheep underwent degenerative changes similar in magnitude and manifestation as the degenerated human tendon samples. Furthermore, similar levels of collagen disorganization were noted between the 6 and 12-week ovine samples and the degenerated human samples.

CONCLUSIONS

These findings indicate that the new sheep model of rotator cuff injury reliably recapitulates the structural and cellular changes that occur clinically in humans with chronic rotator cuff tendon injuries and suggest that this new model is well suited to evaluation of new therapeutic interventions.

Cost of Arthroscopic Rotator Cuff Repairs Is Primarily Driven by Procedure-Level Factors: A Single-Institution Analysis of an Ambulatory Surgery Center

PURPOSE

To identify intraoperative drivers of cost associated with arthroscopic rotator cuff repairs (RCRs) through analysis of an institutional database.

METHODS

This was a single-institution retrospective review of arthroscopic RCRs performed at an ambulatory surgical center between November 2016 and July 2019. Patient-level factors analyzed included age, sex, insurance type (private, Medicare, Medicaid, self-pay, and other government), American Society of Anesthesiologists grade (I, II, III, and missing), and Charlson comorbidity index (0, 1, 2, and ≥3). Procedure-level factors included use of biologics (decellularized dermal allograft or bioinductive healing implant), anesthesia type (regional block, monitored anesthesia care, or general), number of anchors and sutures, additional procedures (biceps tenodesis, distal clavicle resection, subacromial decompression), and operative time. Multivariate linear regression analysis was used to identify factors significantly associated with higher or lower charges.

RESULTS

A total of 712 arthroscopic RCRs were included. The risk-adjusted operative charges were $19,728 (95% confidence interval $16,543 to $22,913). The above factors predicted nearly 65% of the variability in operative charges. The only patient-level factor significantly associated with lower charges was female sex (- $1,339; P = .002). Procedure-level factors significantly associated with higher charges were use of biologics (+ $17,791; P < .001), concurrent open biceps tenodesis (+ $4,027; P < .001), distal clavicle resection (+ $2,266; P = .039), use of regional block (+ $1,256; P = .004), number of anchors (+ $2,245/anchor; P < .001), and increasing operative time ($26/min). Other factors had no significant association.

CONCLUSIONS

Procedural factors are the most significant drivers of operative cost in arthroscopic RCRs, such as quantity and type of implants; additional procedures such as biceps tenodesis and distal clavicle resection; and perioperative conditions such as type of anesthesia and total operating room time. Overall, patient-level factors were not shown to correlate well with operative costs, other than lower charges with female sex.

LEVEL OF EVIDENCE

IV, economic study.

Bio-inductive implant for rotator cuff repair: our experience and technical notes

The treatment of chonic large and partial rotator cuff tears represents a common challenge for orthopedic surgeons. Numerous treatments were suggested but the best is still controversial. Into this field the use of an augment for rotator cuff repair aims to protect the tension of the suture in the postoperative phase and to facilitate the biological healing process. In our institution we treated 4 patients (3 males and 1 female) with rotator cuff tear with bio-inductive implant. All patients presented with a postero-superior rotator cuff tear: 3 patients with a type C-III tear according to Snyder classification and 1 patient with partial articular tear with significant degeneration and poor tendon quality (type A-III tear according to Snyder classification). The final outcome is highly satisfying intraoperatively and the postoperative protocol reflects our normal postoperative protocol following to rotator cuff repair. No complications occurred at 6 months follow-up. The use of the bio-inductive implant in the arthroscopic rotator cuff repair resulted easy, rapid and reproducible. Although no current scientific evidences regarding such implants exist, in selected cases and with the correct indications, the use of bio-inductive implant could represent an effective aid and an option in case of complex rotator cuff tears. (www.actabiomedica.it)

Retear rates and clinical outcomes at 1 year after repair of full-thickness rotator cuff tears augmented with a bioinductive collagen implant: a prospective multicenter study

Background

Biologic technologies can potentially augment existing arthroscopic rotator cuff repair to improve retear rates and postoperative outcomes. The purpose of this study was to evaluate healing rates and clinical outcomes of full-thickness rotator cuff repairs augmented with a bioinductive bovine collagen implant.

Methods

In this prospective multicenter study, investigators enrolled 115 patients (mean age, 60.4 years) with full-thickness rotator cuff tears. There were 66 (57.4%) medium (1-3 cm) tears and 49 (42.6%) large (3-5 cm) tears. Eligible patients consisted of those ≥21 years of age with chronic shoulder pain lasting longer than 3 months and unresponsive to conservative therapy. Patients underwent single- or double-row repair augmented with a bioinductive bovine collagen implant. At the baseline, 3 months, and 1 year, magnetic resonance imaging was performed and patients were assessed for American Shoulder and Elbow Surgeons (ASES) Shoulder Score and Constant-Murley Score (CMS). The primary failure end point was retear, classified as any new full-thickness defect observed on magnetic resonance imaging.

Results

There were 13 retears (11.3%) at 3 months, with an additional 6 (19 total [16.5%]) found at 1 year. In large tears, double-row repair had a significantly lower rate of retear at 3 months (P = .0004) and 1 year (P = .0001) compared with single-row repair. ASES and CMS scores significantly improved between the baseline and 1 year for medium and large tears. At 1 year, the minimally clinically important difference for ASES and CMS was met by 91.7% (95% CI: 84.9-96.1) and 86.4% (95% CI: 78.2-92.4) of patients, respectively. Patients without retear and those <65 years of age had significantly better CMS scores at 1 year when compared with those with retear and those ≥65 years (P < .05). There was no statistically significant difference in outcomes based on treatment of the biceps tendon. Of 9 reported reoperations in the operative shoulder, only 2 were considered potentially related to the collagen implant.

Conclusion

Interim results from this prospective study indicate a favorable rate of retear relative to the literature and improvement in clinical function at 1 year after adjunctive treatment with the study implant augmenting standard arthroscopic repair techniques.

Use of Computerized Adaptive Testing to Develop More Concise Patient-Reported Outcome Measures

Background

Patient-reported outcome measures (PROMs) are essential tools that are used to assess health status and treatment outcomes in orthopaedic care. Use of PROMs can burden patients with lengthy and cumbersome questionnaires. Predictive models using machine learning known as computerized adaptive testing (CAT) offer a potential solution. The purpose of this study was to evaluate the ability of CAT to improve efficiency of the Veterans RAND 12 Item Health Survey (VR-12) by decreasing the question burden while maintaining the accuracy of the outcome score.

Methods

A previously developed CAT model was applied to the responses of 19,523 patients who had completed a full VR-12 survey while presenting to 1 of 5 subspecialty orthopaedic clinics. This resulted in the calculation of both a full-survey and CAT-model physical component summary score (PCS) and mental component summary score (MCS). Several analyses compared the accuracy of the CAT model scores with that of the full scores by comparing the means and standard deviations, calculating a Pearson correlation coefficient and intraclass correlation coefficient, plotting the frequency distributions of the 2 score sets and the score differences, and performing a Bland-Altman assessment of scoring patterns.

Results

The CAT model required 4 fewer questions to be answered by each subject (33% decrease in question burden). The mean PCS was 1.3 points lower in the CAT model than with the full VR-12 (41.5 ± 11.0 versus 42.8 ± 10.4), and the mean MCS was 0.3 point higher (57.3 ± 9.4 versus 57.0 ± 9.6). The Pearson correlation coefficients were 0.97 for PCS and 0.98 for MCS, and the intraclass correlation coefficients were 0.96 and 0.97, respectively. The frequency distribution of the CAT and full scores showed significant overlap for both the PCS and the MCS. The difference between the CAT and full scores was less than the minimum clinically important difference (MCID) in >95% of cases for the PCS and MCS.

Conclusions

The application of CAT to the VR-12 survey demonstrated an ability to lessen the response burden for patients with a negligible effect on score integrity.

Editorial Commentary: New Kid on the Block: Rotator Cuff Patch Augmentation Requires Rigorous Scrutiny

There is still plenty of room for improvement in surgical rotator cuff repair healing as well as in nonsurgical cases. Adding an implant or patch to improve results has been a subject of much discussion for a couple of decades. The main problem has been that the surgical procedures are so difficult, with added time and its effect, and therefore are controversial. Many surgeons are reluctant to go the surgical route. As we have advanced technically, we are at a turning point, with newer implants that can be easily augmented. Therefore, recently many surgeons have been using implants, and preliminary reports seem promising. New implants must withstand vigorous challenges, and future extensive and long-term studies can enable improved implants using human tissue.