Revision rotator cuff repair

Fatty degeneration and wnt10b expression in the supraspinatus muscle after surgical repair of torn rotator cuff tendon

PURPOSE

In the torn rotator cuff muscles, decreased expression of wnt10b prior to elevation of peroxisome proliferator-activated receptor γ (PPARγ) and CCAAT/enhancer-binding protein α (C/EBPα) has previously been reported. The purpose of this study is to elucidate the expression profiles of these adipogenesis-related genes after rotator cuff detachment and reattachment in a rabbit model.

METHODS

We investigated gene expression profiles of PPARγ, C/EBPα, and wnt10b in different parts of rabbit supraspinatus (SSP) muscle after tendon detachment (n = 6 for each time point). In addition, we assessed expression of the same genes after SSP reattachment with different intervals from initial detachment (n = 6). Fatty degeneration of the SSP muscle was examined by Oil red-O staining. Gene expression profiles were examined by quantitative real-time polymerase chain reaction.

RESULTS

After SSP detachment, Oil red-O-positive oil deposits increased after 3 weeks. In the SSP reattachment model, numerous Oil red-O-positive cells were present at 5-week reattachment, following 2- and 3-week detachment. PPARγ and C/EBPα messenger ribonucleic acid expression exhibited a significant increase at 2 and 3 weeks after SSP detachment and remained increased at 5-week reattachment after 2- and 3-week detachment. A decreased expression of wnt10b was observed from 1 week after SSP detachment. Expression of wnt10b was recovered not in the central area of the SSP muscle but in the periphery after reattachment. Adipogenic change was not observed when SSP tendon was reattached after 1-week detachment.

CONCLUSIONS

These results may suggest that once the adipogenic transcription factors, PPARγ and C/EBPα, were elevated, repair surgery after rotator cuff tear could not prevent the emergence of fat in the SSP muscle.

Clinical and Imaging Outcomes After Revision Open Rotator Cuff Repair: A Retrospective Review of a Midterm Follow-Up Study

BACKGROUND

Revision open rotator cuff repair (ORCR) has been associated with unpredictable functional outcome with concerns of deltoid detachment. The aim of this study was to evaluate the clinical and imaging outcomes of revision ORCR.

MATERIALS AND METHODS

The study retrospectively reviewed 30 consecutive patients (mean age 60.4 ± 7.2 years) who underwent revision ORCR after failed rotator cuff repair. Pain visual analog scale (VAS), Constant and American Shoulder Elbow Surgeon (ASES) score were assessed preoperatively and at mean 58-month follow-up (range 24-120 months). The acromio-humeral distance (AHD) was measured on pre- and postoperative radiograph. Tear size and fatty infiltration of rotator cuff were evaluated by preoperative magnetic resonance imaging (MRI) study. The retear rate, change of fatty infiltration and deltoid origin integrity were evaluated by postoperative MRI.

RESULTS

There was significant improvement of pain VAS and functional outcome scores (all p < 0.001). AHD showed no significant change after surgery. On postoperative MRI, the retear rate was 43% (13/30). However, the size of the tendon defect was smaller than that of pre-revision tear (p = 0.006). The patients who had intact tendon had significantly better functional outcomes than those with retear. The intact group had significantly higher AHD both pre- and postoperatively than the retear group. There was no change of fatty infiltration after surgery. Four patients (13%, 4/30) showed thinning of deltoid origin on postoperative MRI, but showed no weakness on clinical examination.

CONCLUSION

Revision ORCR resulted in improved outcomes in pain relief and shoulder function, with low rate of subclinical deltoid thinning.

Effectiveness of supervised early exercise program in patients with arthroscopic rotator cuff repair: Study protocol clinical trial

BACKGROUND

Based on the available evidence, it is difficult to make a clinical decision about the best exercise program and to establish the most favorable time to start postoperative treatment after rotator cuff (RC) repair. The aim of this trial is to evaluate the effects of adding a supervised early exercise program to standard treatment for functional improvement and pain relief compared with standard treatment alone in patients with arthroscopic RC repair.

METHOD/DESIGN

A total of 118 patients between the ages of 18 and 50 years with arthroscopic RC repair will be randomized to 2 treatment arms. The control group will receive a standard exercise program based on a consensus statement on shoulder rehabilitation developed by the American Society of Shoulder and Elbow Therapists. The intervention group will receive a supervised early exercise program in combination with standard treatment. This supervised exercise program will be based on electromyographic evidence. Three evaluations will be performed: before surgery, at 6 weeks, and at 12 weeks. The primary outcome measure will be the shoulder function by the Constant-Murley questionnaire, and the secondary outcome measures will be the upper limb function by the disabilities of the arm, shoulder, and hand questionnaire; pain by the visual analog scale; and the shoulder range of motion by a goniometer.

DISCUSSION

We hypothesize that patients who receive a supervised early exercise program in combination with standard treatment will benefit more in respect to shoulder function, pain reduction, and range of motion than those who receive a standard exercise program. If this is confirmed, our study can be used clinically to enhance the recovery of patients with arthroscopic RC repair.

TRIAL REGISTRATION

Brazilian registry of clinical trials UTN number U1111-1224-4143. Registered December 18, 2018.

Biomechanical Performance of Medial Row Suture Placement Relative to the Musculotendinous Junction in Transosseous Equivalent Suture Bridge Double-Row Rotator Cuff Repair

PURPOSE

To compare the biomechanical performance of medial row suture placement relative to the musculotendinous junction (MTJ) in a cadaveric transosseous equivalent suture bridge (TOE-SB) double-row (DR) rotator cuff repair (RCR) model.

METHODS

A TOE-SB DR technique was used to reattach experimentally created supraspinatus tendon tears in 9 pairs of human cadaveric shoulders. The medial row sutures were passed either near the MTJ (MTJ group) or 10 mm lateral to the MTJ (rotator cuff tendon [RCT] group). After the supraspinatus repair, the specimens underwent cyclic loading and load to failure tests. The localized displacement of the markers affixed to the tendon surface was measured with an optical tracking system.

RESULTS

The MTJ group showed a significantly higher (P = .03) medial row failure (5/9; 3 during cyclic testing and 2 during load to failure testing) compared with the RCT group (0/9). The mean number of cycles completed during cyclic testing was lower in the MTJ group (77) compared with the RCT group (100; P = .07) because 3 specimens failed in the MTJ group during cyclic loading. There were no significant differences between the 2 study groups with respect to biomechanical properties during the load to failure testing.

CONCLUSIONS

In a cadaveric TOE-SB DR RCR model, medial row sutures through the MTJ results in a significantly higher rate of medial row failure.

CLINICAL RELEVANCE

In rotator cuff tears with tendon tissue loss, passage of medial row sutures through the MTJ should be avoided in a TOE-SB RCR technique because of the risk of medial row failure.

Effectiveness of early compared with conservative rehabilitation for patients having rotator cuff repair surgery: an overview of systematic reviews

AIM/OBJECTIVE

The aim is to critically analyse and discuss the current literature and determine the effectiveness of rehabilitation for patients after surgical repair of rotator cuff tears for range of motion (ROM), pain, functional status and retear rates; in addition, an update of new literature is included.

DESIGN

Overview of systematic reviews.

DATA SOURCES

A search was performed with no restrictions to date of publication and language in the following databases: EBSCO, AMED, CINAHL, SPORTDiscus, EMBASE, Cochrane, LILACS, MEDLINE, PEDro, Scielo, SCOPUS and Web of Knowledge. The PRISMA guideline was followed to develop this review and the R-AMSTAR tool was used for critical appraisal of included reviews.

ELIGIBILITY CRITERIA

Only systematic reviews and randomised controlled trials (RCTs) comparing the effectiveness of early with conservative rehabilitation, after surgical repair of the rotator cuff, were included. Moreover, the studies should report ROM, pain, functional status and/or retears rates before and after 3-24 months of the surgery.

RESULTS

10 systematic reviews and 11 RCTs were included for the final analysis. Conflicting results and conclusions were presented by the systematic reviews, the use of primary studies varied; also the methodological quality of the reviews was diverse. This updated review, with new meta-analysis, showed no difference for function, pain, ROM or retears ratio between early and conservative rehabilitation.

SUMMARY/CONCLUSIONS

Early mobilisation may be beneficial, particularly for small and medium tears; however, more studies with higher quality are required, especially for patients with large tears who have been given less attention.

Management of failed rotator cuff repair: a systematic review

Importance

Recurrent tear after rotator cuff repair (RCR) is common. Conservative, and open and arthroscopic revisions, have been advocated to treat these failures.

Aim or objective

The purpose of this systematic review was to evaluate the different options for managing recurrent rotator cuff tears.

Evidence review

A search was conducted of level I through 4 studies from January 2000 to October 2015, to identify studies reporting on failed RCR. 10 articles were identified. The overall quality of evidence was very low.

Findings

Mid-term to long-term follow-up of patients treated conservatively revealed acceptable results; a persistent defect is a well-tolerated condition that only occasionally requires subsequent surgery. Conservative treatment might be indicated in most patients, particularly in case of posterosuperior involvement and poor preoperative range of motion. Revision surgery might be indicated in a young patient with a repairable lesion, a 3 tendon tear, and in those with involvement of the subscapularis.

Conclusions and relevance

The current review indicates that arthroscopic revision RCR can lead to improvement in functional outcome despite a high retear rate. Further studies are needed to develop specific rehabilitation in the case of primary rotator cuff failure, to better understand the place of each treatment option, and, in case of repair, to optimise tendon healing.

Revision versus primary arthroscopic rotator cuff repair: a 2-year analysis of outcomes in 360 patients

BACKGROUND

Symptomatic rotator cuff tears are often treated surgically. However, there is a paucity of information regarding the outcomes of revision arthroscopic rotator cuff repairs.

PURPOSE

To evaluate the outcome of revision arthroscopic rotator cuff surgery when compared with primary arthroscopic rotator cuff surgery in a large cohort of patients.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHOD

A consecutive series of 50 revision arthroscopic rotator cuff repairs performed by a single surgeon, with minimum 2-year follow-up, were retrospectively reviewed using prospectively collected data. As a comparison, 3 primary arthroscopic rotator cuff repair cases (primary group; n = 310) were chosen immediately before each revision case, and 3 were chosen after. Standardized patient-ranked outcomes, examiner-determined assessments, and ultrasound-determined rotator cuff integrity were assessed preoperatively at 6 months and at a minimum of 2 years after surgery.

RESULTS

The revision group was older (mean age, 63 years; range, 43-80 years) compared with the primary group (mean age, 60 years; range, 18-88 years) (P < .05) and had larger tear size (mean ± SEM) (4.1 ± 0.5 cm(2)) compared with the primary group (3.0 ± 0.2 cm(2)) (P < .05). Two years after surgery, the primary group reported less pain at rest (P < .02), during sleep (P < .05), and with overhead activity (P < .01) compared with the revision group. The primary group had better passive forward flexion (+13°; P < .05), abduction (+18°; P < .01), internal rotation (+2 vertebral levels; P < .001) and also significantly greater supraspinatus strength (+15 N; P < .001), lift-off strength (+9.3 N; P < .05), and adduction strength (+20 N; P < .01) compared with the revision group at 2 years. When compared with the primary group, the revision group was more satisfied with the overall shoulder function before surgery but was less satisfied with their shoulder function than the primary group at 2 years (P < .005). The retear rate for primary rotator cuff repair was 16% at 6 months and 21% at 2 years, while the retear rate for revision rotator cuff repair was 28% at 6 months and deteriorated to 40% at 2 years (P < .05).

CONCLUSION

The short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to those after primary rotator cuff repair. However, these results did not persist, and by 2 years patients who had revision rotator cuff repair were twice as likely to have retorn compared with those undergoing primary repair. The increase in retear rate in the revision group at 2 years was associated with increased pain, impaired overhead function, less passive motion, weaker strength, and less overall satisfaction with shoulder function.