Arthroscopic Rotator Cuff Repair Results in Improved Clinical Outcomes and Low Revision Rates at 10-Year Follow-Up: A Systematic Review

Acromioplasty combined with arthroscopic rotator cuff repair can reduce the risk of reoperation: a systematic review and meta-analysis

BACKGROUND

Whether to perform acromioplasty in arthroscopic rotator cuff repair (ARCR) is controversial, and the optimal surgical approach for rotator cuff tear repair is unknown. The purpose of this study was to compare the reoperation rate, retear rate and patient-reported outcomes (PROs) of ARCR with those of ARCR combined with acromioplasty (ARCR-A).

METHODS

PubMed, Embase and Cochrane Library were searched for relevant literature dated between database inception and 4 December 2023. The primary outcomes of this study were the reoperation rate and the retear rate. The secondary outcomes were PROs, including the visual analogue scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, the University of California-Los Angeles (UCLA) score, the Constant score and the Western Ontario Rotator Cuff (WORC) score. The quality of the included studies was evaluated by using the risk of bias assessment tool. RevMan 5.3 software was used for meta-analysis. Fixed (I2 <50%) or random (I2 ≥50%) effects models were applied to calculate the effect size.

RESULTS

Meta-analysis revealed that ARCR-A had a lower reoperation rate (OR = 0.35, 95%CI: 0.15-0.85, p = 0.02), but the difference in the retear rate between ARCR-A and ARCR was not significant (p = 0.25). In type 2 acromion patients, the reoperation rate was not significantly different between ARCR and ARCR-A (p = 0.12), but, for type 3 acromion patients, the retear rate was lower for ARCR-A than for ARCR (OR = 0.12, 95%CI: 0.01-0.94, p = 0.04). There were statistically significant differences in the 6-month postoperative Constant scores (p < 0.001), VAS pain scores (p = 0.003) 12-month postoperative ASES scores (p = 0.02) and 24-month postoperative WORC scores (p = 0.04), but these differences were not clinically significant.

CONCLUSIONS

Combining ARCR with acromioplasty can reduce the rate of reoperation, especially in patients with type 3 acromion, but it provides no clinically important change in the retear rate and postoperative PRO compared with ARCR.

Effects of Quality of Integrity on Clinical and Structural Outcomes of Rotator Cuff Repair: A Retrospective Cohort Study of 504 Cases

BACKGROUND

The clinical implications of structural integrity have been a subject of long debate. The oversimplified binary categorization of structural integrity into either healing or retear, along with faulty preoperative baselines for comparison, may contribute to the controversy.

PURPOSE

To determine how the quality of structural integrity in a repaired cuff tendon affects both clinical and structural outcomes by dividing the patients into groups based on integrity and using the immediate postoperative baseline (time zero).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 504 patients with a full-thickness rotator cuff tear who underwent arthroscopic rotator cuff repair and were followed up for at least a year with magnetic resonance imaging (MRI) were included. The quality of structural integrity was graded using the Sugaya classification. To evaluate clinical outcomes, pain, range of motion, strength, functional scores, and overall satisfaction and function were used for within- and between-group analyses at the last follow-up. For the assessment of structural outcomes, the Goutallier classification for fatty infiltration (FI) and the tangent sign, occupation ratio, and normalized cross-sectional area for muscle atrophy (MA) were used. The baselines for these structural measurements were both the preoperative and the time-zero MRI scans.

RESULTS

The mean clinical follow-up period was 31.8 ± 27.5 months, and the MRI follow-up period was 10.9 ± 5.3 months. There were 178 (35.3%), 228 (45.2%), 58 (11.5%), 14 (2.8%), and 26 (5.2%) shoulders with Sugaya grades 1, 2, 3, 4, and 5, respectively. Regardless of structural integrity, all clinical outcomes at a mean follow-up of 31.8 months after repair significantly improved compared with those before repair. Only in shoulders with Sugaya grade 1 did the FI of the supraspinatus muscle improve significantly from baseline. FI of the infraspinatus muscle did not change significantly in those with grades 1 and 2 but worsened in those with grades 3 and 5. MA measured using the occupation ratio improved significantly in shoulders with Sugaya grades 1 and 2 but declined in those with grade 5.

CONCLUSION

This study established a correlation between improved structural integrity of the repaired cuff tendon and enhanced structural outcomes in rotator cuff muscles. Furthermore, the findings revealed that both FI and MA could be reversed in patients exhibiting high-quality structural integrity. However, these structural improvements were not mirrored in the clinical outcomes.

Impact of surgeon volume, experience, and training on outcomes after arthroscopic rotator cuff repair: a nationwide analysis of 1489 surgeons

Background

Given the complexity of arthroscopic rotator cuff repair (ARCR) and increasing prevalence, there is a need for comprehensive, large-scale studies that investigate potential correlations between surgeon-specific factors and postoperative outcomes after ARCR. This study examines how surgeon-specific factors including case volume, career length, fellowship training, practice setting, and regional practice impact two-year reoperation rates, conversion to total shoulder arthroplasty (anatomic or reverse), and 90-day post-ARCR hospitalization.

Methods

The PearlDiver Mariner database was used to collect surgeon-specific variables and query patients who underwent ARCR from 2015 to 2018. Patient outcomes were tracked for two years, including reoperations, hospitalizations, and International Classification of Diseases, Tenth Revision codes for revision rotator cuff repair (RCR) laterality. Hospitalizations were defined as any emergency department (ED) visit or hospital readmission within 90 days after primary ARCR. Surgeon-specific factors including surgeon case volume, career length, fellowship training, practice setting, and regional practice were analyzed in relation to postoperative outcomes using both univariate and multivariate logistic regression.

Results

94,150 patients underwent ARCR by 1489 surgeons. On multivariate analysis, high-volume surgeons demonstrated a higher risk for two-year total reoperation (odds ratio [OR] = 1.06, 95% confidence interval [CI]: 1.01-1.12, P = .03) and revision RCR (OR = 1.06, 95% CI: 1.01-1.12, P = .02) compared to low-volume surgeons. Early-career surgeons showed higher rates of 90-day ED visits (mid-career surgeons: OR = 0.78, 95% CI: 0.73-0.83, P < .001; late-career surgeons: OR = 0.73, 95% CI: 0.68-0.78, P < .001) and hospital readmission (mid-career surgeons: OR = 0.74, 95% CI: 0.63-0.87, P < .001; late-career surgeons: OR = 0.73, 95% CI: 0.61-0.88, P = .006) compared to mid- and late-career surgeons. Sports medicine and/or shoulder and elbow fellowship-trained surgeons demonstrated lower two-year reoperation risk (OR = 0.95, CI: 0.91-0.99, P = .04) and fewer 90-day ED visits (OR = 0.93, 95% CI = 0.88-0.98, P = .002). Academic surgeons experienced higher readmission rates compared to community surgeons (OR = 1.16, 95% CI = 1.01-1.34, P = .03). Surgeons practicing in the Northeast demonstrated lower two-year reoperation (OR = 0.88, 95% CI: 0.83-0.93, P < .001) and revision (OR = 0.88, 95% CI: 0.83-0.94, P < .001) RCR risk compared to surgeons in the Southern United States.

Conclusion

High-volume surgeons exhibit higher two-year reoperation rates after ARCR compared to low-volume surgeons. Early-career surgeons demonstrate increased hospitalizations. Sports medicine or shoulder and elbow surgery fellowships correlate with reduced two-year reoperation rates and 90-day ED visits.

Magnetic Seeding of SPIO-BMSCs Into a Biphasic Scaffold Can Promote Tendon-Bone Healing After Rotator Cuff Repair

BACKGROUND

The tendon-bone interface (TBI) in the rotator cuff has a poor intrinsic capacity for healing, which increases the risk of retear after rotator cuff repair (RCR). However, facilitating regeneration of the TBI still remains a great clinical challenge. Herein, the authors established a novel strategy based on magnetic seeding to enhance the TBI regeneration.

HYPOTHESIS

Magnetic seeding bone marrow mesenchymal stem cells labeled with superparamagnetic iron oxide (SPIO-BMSCs) into a biphasic scaffold can promote tendon-bone healing after RCR.

STUDY DESIGN

Controlled laboratory study.

METHODS

BMSCs were labeled with SPIOs. Prussian blue staining, CCK-8 tests, Western blot, and quantitative reverse transcription polymerase chain reaction (PCR) were used to determine the optimal effect concentration of SPIOs on cell bioactivities and abilities. Then SPIO-BMSCs were magnetically seeded into a biphasic scaffold under a magnetic field. The seeding efficacy was assessed by a scanning electron microscope, and the potential mechanism in chondrogenic differentiation after seeding SPIO-BMSCs into the scaffold was evaluated by Western blot and PCR. Furthermore, the effect of SPIO-BMSC/biphasic scaffold on tendon-bone healing after RCR using a rat model was examined using histological analysis, enzyme-linked immunosorbent assay, and biomechanical evaluation.

RESULTS

BMSCs labeled with 100 μg/mL SPIO had no effect on cell bioactivities and the ability of chondrogenic differentiation. SPIO-BMSCs were magnetically seeded into a biphasic scaffold, which offered a high seeding efficacy to enhance chondrogenic differentiation of SPIO-BMSCs via the CDR1as/miR-7/FGF2 pathway for TBI formation in vitro. Furthermore, in vivo application of the biphasic scaffold with magnetically seeded SPIO-BMSCs showed their regenerative potential, indicating that they could significantly accelerate and promote TBI healing with superior biomechanical properties after RCR in a rat rotator cuff tear model.

CONCLUSION

Magnetically seeding SPIO-BMSCs into a biphasic scaffold enhanced seeding efficacy to promote cell distribution and condensation. This construct enhanced the chondrogenesis process via the CDR1as/miR-7/FGF2 pathway and further promoted tendon-bone healing after RCR in a rat rotator cuff tear model.

CLINICAL RELEVANCE

This study provides an alternative strategy for improving TBI healing after RCR.

European Society for Surgery of the Shoulder and Elbow (SECEC) rotator cuff tear registry Delphi consensus

Background

The purpose of this study was to establish consensus statements via a Delphi process on the factors that should be included in a registry for those patients undergoing rotator cuff tear treatment.

Methods

A consensus process on the treatment of rotator cuff utilizing a modified Delphi technique was conducted. Fifty-seven surgeons completed these consensus statements and 9 surgeons declined. The participants were members of the European Society for Surgery of the Shoulder and Elbow committees representing 23 European countries. Thirteen questions were generated regarding the diagnosis and follow-up of rotator cuff tears were distributed, with 3 rounds of questionnaires and final voting occurring. Consensus was defined as achieving 80%-89% agreement, whereas strong consensus was defined as 90%-99% agreement, and unanimous consensus was defined by 100% agreement with a proposed statement.

Results

Of the 13 total questions and consensus statements on rotator cuff tears, 1 achieved unanimous consensus, 6 achieved strong consensus, 5 achieved consensus, and 1 did not achieve consensus. The statement that reached unanimous consensus was that the factors in the patient history that should be evaluated and recorded in the setting of suspected/known rotator cuff tear are age, gender, comorbidities, smoking, traumatic etiology, prior treatment including physical therapy/injections, pain, sleep disturbance, sports, occupation, workmen's compensation, hand dominance, and functional limitations. The statement that did not achieve consensus was related to the role of ultrasound in the initial diagnosis of patients with rotator cuff tears.

Conclusion

Nearly all questions reached consensus among 57 European Society for Surgery of the Shoulder and Elbow members representing 23 different European countries. We encourage surgeons to use this minimum set of variables to establish rotator cuff registries and multicenter studies. By adapting and using compatible variables, data can more easily be compared and eventually merged across countries.

Outcomes After Revision Arthroscopic Rotator Cuff Repair: A Systematic Review

BACKGROUND

Arthroscopic rotator cuff repair (ARCR) is one of the most commonly performed orthopaedic procedures; however, it is unclear how to manage patients with symptomatic retears.

PURPOSE

To perform a systematic review to evaluate the outcomes of revision ARCR in the literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic literature search based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed utilizing the Embase, MEDLINE, and Cochrane Library databases. Eligible for inclusion were clinical studies reporting on revision rotator cuff repair. Clinical outcomes were recorded.

RESULTS

The 17 included studies were composed of 888 shoulders in 885 patients. The mean age of the 885 patients was 58.6 ± 9.1 years, with a mean follow-up of 28.1 ± 22.1 months. The mean visual analog scale score was 2.1 ± 1.8, the mean American Shoulder and Elbow Surgeons score was 75.0 ± 18.3, and the mean Constant score was 67.4 ± 16.6. The overall rate of retears after revision was 25.3%, with an 8.0% reoperation rate including 2.7% undergoing reverse shoulder arthroplasty and 2.0% undergoing subsequent rotator cuff repair. Finally, the complication rate was 8.6%.

CONCLUSION

Revision ARCR improved patient-reported outcomes, with 92% of patients free from reoperations at a mean follow-up of 2 years. Overall, 78.4% of patients were satisfied at final follow-up; however, the rate of retears was found to be higher than after primary ARCR.

Preoperative handgrip strength can predict early postoperative shoulder function in patients undergoing arthroscopic rotator cuff repair

BACKGROUND

Rotator cuff tears (RCTs) are a common musculoskeletal disorder, and arthroscopic rotator cuff repair (ARCR) is widely performed for tendon repair. Handgrip strength correlates with rotator cuff function; however, whether preoperative grip strength can predict functional outcomes in patients undergoing ARCR remains unknown. This study aimed to investigate the correlation between preoperative grip strength and postoperative shoulder function following ARCR.

METHODS

A total of 52 patients with full-thickness repairable RCTs were prospectively enrolled. Baseline parameters, namely patient characteristics and intraoperative findings, were included for analysis. Postoperative shoulder functional outcomes were assessed using the Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) questionnaire and Constant-Murley scores (CMSs). Patients were followed up and evaluated at three and six months after ARCR. The effects of baseline parameters on postoperative outcomes were measured using generalized estimating equations.

RESULTS

At three and six months postoperatively, all clinical outcomes evaluated exhibited significant improvement from baseline following ARCR. Within 6 months postoperatively, higher preoperative grip strength was significantly correlated with higher CMSs (β = 0.470, p = 0.022), whereas increased numbers of total suture anchors were significantly correlated with decreased CMSs (β =  - 4.361, p = 0.03). Higher body mass index was significantly correlated with higher postoperative QDASH scores (β = 1.561, p = 0.03) during follow-up.

CONCLUSIONS

Higher baseline grip strength predicts more favorable postoperative shoulder function following ARCR. A preoperative grip strength test in orthopedic clinics may serve as a predictor for postoperative shoulder functional recovery in patients undergoing ARCR.

Factors associated with reparability of rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

To identify and quantify the factors associated with the reparability of rotator cuff tears (RCTs).

METHODS

PubMed, Scopus, and Web of Science databases were searched for clinical studies published in English focusing on RCT reparability by using the keywords "rotator cuff tear" and "reparability". A meta-analysis was conducted if ≥3 studies examined the same factor and provided enough data to assess RCT reparability. Quality assessment was completed using the quality assessment of diagnostic accuracy studies tool.

RESULTS

Eighteen studies (2700 patients) were enrolled and 26 factors were included in the meta-analysis. The dichotomous variables associated with irreparability were Patte stage 3 (odds ratio (OR): 8.0, 95% confidence interval [CI]: 4.3-14.9), massive tear vs. large tear (OR: 3.1, 95% CI: 1.3-7.2), Goutallier stage for each tendon, and tangent sign (OR: 11.1, 95% CI: 4.3-28.4). The continuous variables associated with irreparability were age (mean difference (MD): 3.25, 95% CI: 1.4-5.1), mediolateral tear size (MD: 12.3, 95% CI: 5.8-18.9), anteroposterior tear size (MD: 10.4, 95% CI: 5.2-15.6), acromiohumeral distance on X-ray (MD: -2.3, 95% CI: -3.0 to -1.6) and magnetic resonance imaging (MD: -1.8, 95% CI: -2.8 to -0.9), and inferior glenohumeral distance on magnetic resonance imaging (MD: 2.2, 95% CI: 1.4-3.0).

CONCLUSION

This study revealed that older age, larger tear size, severe fatty infiltration, muscle atrophy, and advanced superior migration of the humeral head were strongly associated with irreparable RCTs. Conversely, clinical symptoms provided limited information for predicting reparability. Additionally, the tangent sign emerged as a powerful and simple tool for individual prediction, and several quantitative scoring systems also proved useful.

Outcomes of arthroscopic single-row repair alone vs. repair with human dermal allograft patch augmentation in patients with large to massive, posterosuperior rotator cuff tears: a retrospective comparative study

BACKGROUND

Large to massive rotator cuff tears (RCTs) affect shoulder functions profoundly with unmanageable disability without intervention. The retear rates with arthroscopic rotator cuff repair (ARCR) in these patients are abysmal. Patch augmentation has been credited for preventing retears, improving functions by increasing the strength, and acting as a bioconductive scaffold. This study aimed to assess the retear rates and compare the clinical and radiological outcomes between the ARCR with and without acellular human dermal allograft (HDA) augmentation.

METHODS

This is a retrospective comparative study among patients diagnosed with large to massive, posterosuperior RCTs, operated between January 2020 and December 2021, including 36 patients (group I) with and 131 patients (group II) without HDA augmentation, with a mean follow-up of 20 (range, 12-35) months. The average age was 64 (range, 49-80) and 66 (range, 41-81) years in groups I and II, respectively. In group I, there were 16 male and 20 female patients, whereas in group II, there were 58 male and 73 female patients.

RESULTS

The visual analog scale score improved to 1.1 ± 1.7 in group I and 2.1 ± 1.7 in group II (P = .005). There was a greater improvement in the University of California, Los Angeles shoulder score to 30.1 ± 4.2 in group I compared with 23.2 ± 3.9 in group II (P = .046). Forward flexion (degrees) improved from a mean of 103.2 ± 18.6 to 138.9 ± 23.5 in group I and from 106.4 ± 21.3 to 127.0 ± 19.5 in group II (P = .004). The acromiohumeral interval (mm) measured in anteroposterior radiographs increased to 8.4 ± 1.8 in group I and 8.2 ± 2.0 in group II (P = .006). The satisfaction after the procedure was 4.4 ± 0.6 in group I and 3.1 ± 1.1 in group II (P = .044). The retear rate in the HDA-augmented group was 5.6% as compared with 29.1% in the nonaugmented group, which was statistically significant (P = .007). There were no complications or adverse tissue reactions against HDA seen in any patients.

CONCLUSION

In patients with large to massive, posterosuperior RCTs, patch augmentation with acellular HDA significantly averted the retears after ARCR without any graft-related complications. The augmentation also resulted in improved shoulder function and greater range of motion compared with the nonaugmented group.

The Influence of Obesity on Outcomes Following Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-Analysis of 118,331 Patients Internationally

Background

Given the rising prevalence of obesity, the number of patients with obesity undergoing arthroscopic rotator cuff repair (RCR) will likely increase; however, there have been mixed results in the existing literature with regard to the effect of elevated body mass index (BMI) on functional outcomes and complications.

Methods

The patient-reported outcome measures included the visual analog scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, range of motion, and adverse events.

Results

Fourteen studies (118,331 patients) were included. There were significant decreases in VAS pain scores for both patients with obesity (mean difference, -3.8 [95% confidence interval (CI), -3.9 to -3.7]; p < 0.001) and patients without obesity (mean difference, -3.2 [95% CI, -3.3 to -3.1]; p < 0.001). There were also significant increases in ASES scores for both patients with obesity (mean difference, 24.3 [95% CI, 22.5 to 26.1]; p < 0.001) and patients without obesity (mean difference, 24.3 [95% CI, 21.4 to 26.0]; p < 0.001). There were also significant increases in ASES scores for both patients with obesity (mean difference, 24.3 [95% CI, 22.5 to 26.1]; p < 0.001) and patients without obesity (mean difference, 24.3 [95% CI, 21.4 to 26.0]; p < 0.001). However, there were no significant differences in final VAS pain scores, ASES scores, or range of motion between the groups. The mean rates of complications were higher among patients with obesity (1.2% ± 1.7%) than among patients without obesity (0.59% ± 0.11%) (p < 0.0001), and the mean rates of postoperative admissions were also higher among patients with obesity (5.9%) than patients without obesity (3.7%) (p < 0.0001). Although the mean rates of reoperation were similar between groups (5.2% ± 2.8% compared with 5.2% ± 4.2%), the meta-analysis revealed lower odds of reoperation in patients without obesity (odds ratio [OR], 0.76 [95% CI, 0.71 to 0.82]).

Conclusions

No significant or clinically important differences in postoperative pain, ASES scores, or range of motion were found between patients with and without obesity following arthroscopic RCR. However, populations with obesity had higher rates of complications, postoperative admissions, and reoperation following arthroscopic RCR.

Level of Evidence

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Long-term clinical outcomes of arthroscopic supraspinatus tendon repair using the single anchor tension band technique - Minimum 5-years follow-up

Background

The primary aim of this study was to assess the long-term patient reported outcomes of arthroscopic rotator cuff tear (ARCR) using a single anchor tension band (TB) technique for small and medium supraspinatus tears at minimum 5-years follow-up.

Methods

A retrospective cohort study of consecutive ARCRs of small and medium supraspinatus tears using a knotless single anchor TB technique with minimum 5-year follow-up was carried out. Outcomes of interest included: range of motion (ROM) on examination under anaesthesia (EUA), visual analogue scale (VAS), American Shoulder and Elbow Surgeons (ASES) scores, Oxford Shoulder Score (OSS) and Short-Form (SF-12).

Results

From 243 consecutive ARCR procedures, 82 patients with a mean age of 55 ± 9.5 years met the inclusion criteria at 6.7 ± 1.5 years follow-up. There were significant improvements in VAS (5.5 ± 2.2 vs. 0.7 ± 1.5), ASES (47.6 ± 16.8 vs. 92.8 ± 13.0), OSS (31.3 ± 7.2 vs. 45.3 ± 3.5) and SF-12 (37.6 ± 7.6 vs. 50.3 ± 7.7) post-operatively (all p < 0.001).

Conclusions

The single anchor TB ARCR technique has excellent patient reported outcomes at a minimum of 5 years and is suitable for supraspinatus tears smaller than 20 mm in the sagittal plane.

Level of evidence

Level IV; Consecutive Case Series.

One- and 2-Year American Shoulder and Elbow Surgeons Scores Do Not Vary Significantly After Arthroscopic Rotator Cuff Repair: A Prospective Multicenter Analysis of 1,567 Patients

PURPOSE

To evaluate whether there are clinically significant changes in patient-reported outcomes between 1 and 2 years' postoperatively after arthroscopic rotator cuff repair (RCR).

METHODS

A retrospective analysis of prospective, multicenter registry was queried for all patients who underwent RCR. Patients with preoperative, 6-month, 1-year, and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) scores were included. We evaluated mean postoperative ASES scores, Δ (change from preoperative) ASES, and the %MOI (% maximum outcome improvement). We also evaluated achievement of clinically significant outcomes (CSOs) for the ASES score, including the minimal clinically important difference (MCID), substantial clinical benefit, and patient-acceptable symptom state.

RESULTS

There were 1,567 patients with complete data through 2-year follow-up. There were small differences in achievement of CSOs from 1 to 2 years: 88% to 91% for MCID, 81% to 83% for substantial clinical benefit, and 65% to 71% for patient-acceptable symptom state. There were statistically significant differences from 1 to 2 years in mean ASES (87 to 88, P < .001), Δ ASES (37 to 39, P < .001), and %MOI (72% to 76%, P < .001); however, these changes were well below the MCID of 11.1. From 1 to 2 years, the mean ASES improved only 1.7 points (P < .001). At 1 year, patients achieved, on average, 97% of their 2-year ASES.

CONCLUSIONS

Both patient-reported outcomes and achievement of CSOs show small differences at 1 and 2 years after RCR. Given the large sample size, there were statistical differences, but these are unlikely to be clinically relevant.

LEVEL OF EVIDENCE

Level IV, case series.

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.

Editorial Commentary: Improved Suture Configurations Can Enhance Shoulder Rotator Cuff Healing: The Cuff Doesn't Always Heal-But We Can Nudge It in the Right Direction

The success of rotator cuff repair is often measured by patient-reported outcomes or structural healing on magnetic resonance imaging. Ideally, we can achieve both a satisfied patient and a healed tendon. Various technical modifications and stitch patterns have been presented in an effort to achieve the perfect rotator cuff repair. It appears the independently popular suture bridge technique and Mason-Allen stitch may do their best work when combined together. First, double-row repair "anchors down" the tendon to its footprint, and suture bridge adds to this concept with double-row compressive interlinking suture. Second, the Mason-Allen stitch, combining a horizontal stich and a simple stitch that passes around the horizontal, leverages the rip-stop concept where an "anchor suture" is included as a suture is passed around friable tendon like steel rebar rods strengthening concrete. In the midst of many factors out of the surgeon's control during the healing process, we are compelled to listen when a change in our technique might actually make a difference.

Acellular Collagen Matrix Patch Augmentation of Arthroscopic Rotator Cuff Repair Reduces Re-Tear Rates: A Meta-analysis of Randomized Control Trials

PURPOSE

To perform a meta-analysis of randomized controlled trials (RCTs) to compare the outcomes of arthroscopic rotator cuff repair (ARCR) with and without acellular collagen matrix patch (ACMP) augmentation.

METHODS

A literature search of 3 databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RCTs comparing ACMP augmentation and a control for ARCR were included. Clinical outcomes were compared using Revman, and a P value < .05 was considered to be statistically significant.

RESULTS

Five RCTs with 307 patients were included. Overall, 11% of patients treated with ACMP augmentation and 34% of patients in the control group had a re-tear (P = .0006). The mean Constant score was 90.1 with ACMP augmentation, and 87.3 in controls (P = .02). Additionally, there was a significant higher American Shoulder and Elbow Surgeons score with ACMP augmentation (87.7 vs 82.1, P = .01).

CONCLUSIONS

The RCTs in the literature support the use of ACMP augment as a modality to reduce re-tear rates and improve outcomes after ARCR.

LEVEL OF EVIDENCE

Level II, Meta-Analysis of Level II Studies meta-analysis of Level II studies.

Re-tear after arthroscopic rotator cuff repair can be predicted using deep learning algorithm

The application of artificial intelligence technology in the medical field has become increasingly prevalent, yet there remains significant room for exploration in its deep implementation. Within the field of orthopedics, which integrates closely with AI due to its extensive data requirements, rotator cuff injuries are a commonly encountered condition in joint motion. One of the most severe complications following rotator cuff repair surgery is the recurrence of tears, which has a significant impact on both patients and healthcare professionals. To address this issue, we utilized the innovative EV-GCN algorithm to train a predictive model. We collected medical records of 1,631 patients who underwent rotator cuff repair surgery at a single center over a span of 5 years. In the end, our model successfully predicted postoperative re-tear before the surgery using 62 preoperative variables with an accuracy of 96.93%, and achieved an accuracy of 79.55% on an independent external dataset of 518 cases from other centers. This model outperforms human doctors in predicting outcomes with high accuracy. Through this methodology and research, our aim is to utilize preoperative prediction models to assist in making informed medical decisions during and after surgery, leading to improved treatment effectiveness. This research method and strategy can be applied to other medical fields, and the research findings can assist in making healthcare decisions.

Rotator cuff tears

Rotator cuff tears are the most common upper extremity condition seen by primary care and orthopaedic surgeons, with a spectrum ranging from tendinopathy to full-thickness tears with arthritic change. Some tears are traumatic, but most rotator cuff problems are degenerative. Not all tears are symptomatic and not all progress, and many patients in whom tears become more extensive do not experience symptom worsening. Hence, a standard algorithm for managing patients is challenging. The pathophysiology of rotator cuff tears is complex and encompasses an interplay between the tendon, bone and muscle. Rotator cuff tears begin as degenerative changes within the tendon, with matrix disorganization and inflammatory changes. Subsequently, tears progress to partial-thickness and then full-thickness tears. Muscle quality, as evidenced by the overall size of the muscle and intramuscular fatty infiltration, also influences symptoms, tear progression and the outcomes of surgery. Treatment depends primarily on symptoms, with non-operative management sufficient for most patients with rotator cuff problems. Modern arthroscopic repair techniques have improved recovery, but outcomes are still limited by a lack of understanding of how to improve tendon to bone healing in many patients.

Editorial Commentary: Subacromial Balloon Spacer for Management of Massive Irreparable Posterosuperior Rotator Cuff Tears Improves Shoulder Range of Motion and Patient-Reported Outcome Measures

Considerable controversy exists regarding the management of massive posterosuperior rotator cuff tears. This conversation has been invigorated further by the emergence of the subacromial balloon spacer for management of patients with tear patterns deemed irreparable. Most data lend support to the balloon spacer improving shoulder range of motion and patient-reported outcome measures, with a simplified technique and accelerated patient recovery. Biomechanical data support both decreased contact pressure in the subacromial space and humeral re-centering. Patient indications are increasingly being defined and include lower-demand patients who prioritize pain relief over strength recovery and have maintained active elevation, absence of glenohumeral arthritis, and an intact subscapularis. The subacromial balloon spacer has shown largely positive results at mid-term follow-up. Further data are still needed to determine long-term outcomes and the impact on future revision surgery or conversion to reverse arthroplasty, as well as expanded indications such as large tears that are mechanically repairable but carry a substantial risk of failure of healing. For now, so far, so good.

Human Rotator Cuff Tears Reveal an Age-Dependent Increase in Markers of Cellular Senescence and Selective Removal of Senescent Cells With Dasatinib + Quercetin Increases Genetic Expression of COL1A1 In Vitro

PURPOSE

To quantify cellular senescence in supraspinatus tendon and subacromial bursa of humans with rotator cuff tears and to investigate the in vitro efficacy of the senolytic dasatinib + quercetin (D+Q) to eliminate senescent cells and alter tenogenic differentiation.

METHODS

Tissue was harvested from 41 patients (mean age, 62 years) undergoing arthroscopic rotator cuff repairs. In part 1 (n = 35), senescence was quantified using immunohistochemistry and gene expression for senescent cell markers (p16 and p21) and the senescence-associated secretory phenotype (SASP) (interleukin [IL] 6, IL-8, matrix metalloproteinase [MMP] 3, monocyte chemoattractant protein [MCP] 1). Senescence was compared between patients <60 and ≥60 years old. In part 2 (n = 6) , an in vitro model of rotator cuff tears was treated with D+Q or control. D+Q, a chemotherapeutic and plant flavanol, respectively, kill senescent cells. Gene expression analysis assessed the ability of D+Q to kill senescent cells and alter markers of tenogenic differentiation.

RESULTS

Part 1 revealed an age-dependent significant increase in the relative expression of p21, IL-6, and IL-8 in tendon and p21, p16, IL-6, IL-8, and MMP-3 in bursa (P < .05). A significant increase was seen in immunohistochemical staining of bursa p21 (P = .028). In part 2, D+Q significantly decreased expression of p21, IL-6, and IL-8 in tendon and p21 and IL-8 in bursa (P < .05). Enzyme-linked immunosorbent assay analysis showed decreased release of the SASP (IL-6, MMP-3, MCP-1; P = .002, P = .024, P < .001, respectively). Tendon (P = .022) and bursa (P = .027) treated with D+Q increased the expression of COL1A1.

CONCLUSIONS

While there was an age-dependent increase in markers of cellular senescence, this relationship was not consistently seen across all markers and tissues. Dasatinib + quercetin had moderate efficacy in decreasing senescence in these tissues and increasing COL1A1 expression.

CLINICAL RELEVANCE

This study reveals that cellular senescence may be a therapeutic target to alter the biological aging of rotator cuffs and identifies D+Q as a potential therapy.

Gender and degree of tendon healing are independent predictive factors for clinical outcome in successfully healed rotator cuff tears

PURPOSE

Arthroscopic rotator cuff repair (aRCR) is a commonly performed procedure and has been reported to be a successful treatment. Successful healing has traditionally been considered to be associated with good outcome; however, knowledge on predictive factors affecting final outcome other than tendon healing is limited. This study aims to investigate predictive factors influencing clinical outcome following aRCR in patients with successfully healed tears.

METHODS

This retrospective case-control study was conducted in a single center with 135 patients who had successfully healed tendons based on Sugaya classification (grades I-III) on postoperative magnetic resonance imaging (MRI) scans following aRCR. Clinical outcome measures included Constant-Murley score (CMS), range of motion (ROM), pain score. Various preoperative, intraoperative factors and degree of postoperative tendon healing were assessed to identify independent predictive factors for final clinical outcome.

RESULTS

Mean age of patients was 55.9 ± 9.0 years and mean follow-up duration was 46.8 ± 14.9 months. There were 50 (37%) male and 85 (63.0%) female patients. At final follow-up, mean CMS was 85.7 ± 12.0. Considering mean postoperative CMS and the minimal clinically important difference (MCID) of 10 points for CMS, a cutoff level of 75 points for CMS was set (85-10 = 75) and study population was divided into two study groups (group I, poor outcome, CMS ≤ ;75, and group II, good outcome, CMS > 75). There were 24 (17.8%) patients in group I and 111 (82.2%) patients in group II. Univariate analysis revealed that gender, body mass index (BMI) and degree of tendon healing (Sugaya classification) differed significantly between two groups (p < 0.05). Multivariate logistic regression analysis which was conducted with these variables showed that female gender (odds ratio 3.65) and Sugaya grade III (odds ratio 8.19) were independent predictive factors which were significantly associated with poor outcome (p < 0.05).

CONCLUSIONS

This study showed that despite achieving a successful healing, considerable amount of patients (17.8%) have ended up with poor outcome. Female gender and degree of tendon healing were identified as independent predictive factors for poor outcome. These data would help surgeons during decision-making, risk assessment and patient counseling.

LEVEL OF EVIDENCE

III.

Nanofibrous scaffolds for the healing of the fibrocartilaginous enthesis: advances and prospects

With the current developmental advancements in nanotechnology, nanofibrous scaffolds are being widely used. The healing of fibrocartilaginous enthesis is a slow and complex process, and while existing treatments have a certain effect on promoting their healing, these are associated with some limitations. The nanofibrous scaffold has the advantages of easy preparation, wide source of raw materials, easy adjustment, easy modification, can mimic the natural structure and morphology of the fibrocartilaginous enthesis, and has good biocompatibility, which can compensate for existing treatments and be combined with them to promote the repair of fibrocartilaginous enthesis. The nanofibrous scaffold can promote the healing of fibrocartilaginous enthesis by controlling the morphology and ensuring controlled drug release. Hence, the use of nanofibrous scaffold with stimulative response features in the musculoskeletal system has led us to imagine its potential application in fibrocartilaginous enthesis. Therefore, the healing of fibrocartilaginous enthesis based on a nanofibrous scaffold may be a novel therapeutic approach.

Arthroscopic Superior Capsular Reconstruction With the Long Head of the Biceps Tendon to Reinforce the Repair of a Supraspinatus Tear and Increase Healing

Rotator cuff tears continue to be a challenge for the shoulder surgeon since there is still a high rate of retears. To increase the rate of repair and decrease the number of retears, we present a technique, in which we reinforce a tension-free double-row repair of the supraspinatus with reconstruction of the superior capsule with the long head of the biceps (LHB). With this reinforcement of the cuff suture using the LHB, we increase both the biomechanics and biology of the repair and decrease the rate of reruptures.