Estimating optimal shoulder immobilization postures following surgical repair of massive rotator cuff tears

The Influence of Adherence to Orthosis and Physiotherapy Protocol on Functional Outcome after Proximal Humeral Fracture in the Elderly

In the treatment of proximal humeral fractures (PHF), patients are often recommended to wear a sling or orthosis and to perform physiotherapy. However, some patients, especially elderly ones, struggle to comply with these rehabilitation regimens. Therefore, the aim of the study was to evaluate whether these incompliant patients have a worse functional outcome than those who adhere to the rehabilitation protocol. After receiving a diagnosis of a PHF, patients were divided into four groups according to fracture morphology: conservative with sling, operative with sling, conservative with abduction orthosis, and operative with abduction orthosis. At the 6-week follow-up, compliance regarding brace use and physiotherapy performance were assessed, as well as the constant score (CS) and complications or revision surgeries. The CS as well as the complications and revision surgeries were also surveyed after one year. In 149 participants, with a mean age of 73.9 ± 7.2 years, only 37% terminated orthosis and only 49% underwent physiotherapy as recommended. The statistical analysis showed no significant difference in the CS, complications, and revision surgeries between the groups.

Rotator Cuff Healing

The present article broadly addresses the aspects that interfere with the healing process of the rotator cuff. Life habits, such as smoking and alcoholism, are considered, systemic factors such as diabetes mellitus, hypertension, and obesity, as well as local factors, among which are those related to the pre, peri, and postoperative periods. From an extensive literature review, with the citation of 60 scientific articles from both Western and Eastern literature, the authors intend to deepen the theme by bringing to medical practice conducts based on new established concepts.

Biomechanical and Clinical Evaluation of the Optimal Arm Position After Rotator Cuff Surgery With an Adjustable Abduction Brace

Abduction braces are used with the intention of relieving tension on the supraspinatus, thereby protecting an operative repair. It is not known, however, whether patients wearing a brace do deposit the weight of the arm on the brace effectively or actively stabilize the arm despite the brace. It is further unknown what position of the arm is most effective to relax the shoulder and is considered most comfortable. Twenty-two patients who had undergone an arthroscopic supraspinatus repair were postoperatively fitted with a standard abduction brace equipped with a torque sensor to measure the weight of the arm on the brace on the first and second postoperative days. The most comfortable arm position, tear size, and degenerative muscular changes on magnetic resonance imaging were assessed. Most patients (15 vs 5) preferred a low angle of abduction with the brace in the scapular rather than the true frontal plane irrespective of tear location or size. While loads applied to the brace were slightly higher at high abduction angles (70° and 90°) under regional anesthesia (day 1), they were significantly higher at low abduction angles (30° and 50°) with the arm fully awake (day 2). The most comfortable brace position-which is at low angles of abduction (30° to 50°) in the scapular plane-is associated with the highest load transfer to the brace in the unanesthetized arm. The authors therefore conclude that if an abduction brace is used, it should be fitted in the scapular plane with an abduction angle between 30° and 50°. [Orthopedics. 2021;44(1):e1-e6.].

Editorial Commentary: Optimizing Postoperative Care After Rotator Cuff Repair: What Do We Know and Understand?

Optimization of the management of rotator cuff tears is still needed. Preoperative patient selection, perioperative surgical techniques, and postoperative care are all important topics that are studied extensively. This commentary will examine the current situation and important fields of interest for future research. Postoperative pain management is scrutinized in relation to the level of abduction using an abduction brace.

Does The Type of Shoulder Brace Affect Postoperative Pain and Clinical Outcome After Arthroscopic Rotator Cuff Repair?

PURPOSE

To compare postoperative pain and clinical outcome after arthroscopic rotator cuff repair in patients immobilized with an abduction brace versus patients placed in an antirotation brace.

METHODS

One hundred twenty patients (72 women and 48 men) with symptomatic degenerative complete tear of the supraspinatus or infraspinatus tendons were included in the study. Exclusion criteria were history of trauma/traumatic tears, concomitant shoulder pathology, psychological illnesses, and previous shoulder surgery. The Constant-Murley score (CMS) was obtained before surgery and at 3 months, 6 months, and 1 year after surgery. The visual analogue scale (VAS) was done on the day of surgery and at 1 week, 3 weeks, 6 weeks, and 3 months after surgery. Postoperative isokinetic muscle strength evaluation was done for the shoulder external rotator at 1 year.

RESULTS

Mean age was 50.4 years for the abduction brace group (ABG) and 50.8 years for the open pouch arm sling group (PASG). The mean level of the VAS score ranged from 75.6 for the ABG and 74.9 for the PASG on the day of the operation to 17.7 and 18.5 at 3 months after surgery. In both groups, the repeated measure analysis of variance showed that there were highly significant changes (P < .001) in the VAS from the day of operation to 3 months after surgery. A significant improvement was detected in both groups in the mean level of the CMS, from 40.9 for the ABG and 41.2 for the PASG before surgery to 84.7 and 84.5 at 1 year after the operation. There was no statistically significant difference between the 2 groups regarding the isokinetic muscle strength, VAS, or the CMS.

CONCLUSIONS

Our study did not find a significant difference between abduction brace and antirotation sling in patient-oriented outcome measures or postoperative pain after rotator cuff repair.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Abduction Brace Versus Antirotation Sling After Arthroscopic Cuff Repair: The Effects on Pain and Function

PURPOSE

To study the effects on pain as the main outcome parameter and on function and cuff integrity as the secondary outcome parameters after arthroscopic rotator cuff repair in the short term comparing the abduction brace with an antirotation sling for postoperative shoulder immobilization.

METHODS

Eligible patients were between the ages of 18 and 75 years who were diagnosed with a traumatic or degenerative tear of the supraspinatus and/or infraspinatus tendon, confirmed by magnetic resonance imaging, for which an arthroscopic footprint repair was indicated and performed. Patients were randomly allocated to the antirotation sling or abduction brace group. Postoperative pain and use of analgesics were accurately registered up to 3 months after surgery using a patient diary. Follow-up examinations including the Constant-Murley score, Western Ontario Rotator Cuff index, and glenohumeral range of motion were scheduled 6 weeks, 3 and 6 months, and 1 year after surgery.

RESULTS

The average level of pain measured directly postoperation up to 1 year after surgery was not significant different between groups. Postoperatively, function scores and glenohumeral range of motion improved significantly for both groups; however, no differences were observed between groups. No retears were observed on ultrasonograph 3 months after surgery.

CONCLUSIONS

In the short term, the level of pain, function, and quality of life were not significantly different between the use of an abduction brace and that of an antirotation sling after arthroscopic rotator cuff repair. Based on these findings, the abduction brace used in this study does not seem to be the solution for decreasing the pain experienced in the first postoperative weeks after arthroscopic rotator cuff repair, and both are recommendable.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

The Rotator Cuff Organ: Integrating Developmental Biology, Tissue Engineering, and Surgical Considerations to Treat Chronic Massive Rotator Cuff Tears

The torn rotator cuff remains a persistent orthopedic challenge, with poor outcomes disproportionately associated with chronic, massive tears. Degenerative changes in the tissues that comprise the rotator cuff organ, including muscle, tendon, and bone, contribute to the poor healing capacity of chronic tears, resulting in poor function and an increased risk for repair failure. Tissue engineering strategies to augment rotator cuff repair have been developed in an effort to improve rotator cuff healing and have focused on three principal aims: (1) immediate mechanical augmentation of the surgical repair, (2) restoration of muscle quality and contractility, and (3) regeneration of native enthesis structure. Work in these areas will be reviewed in sequence, highlighting the relevant pathophysiology, developmental biology, and biomechanics, which must be considered when designing therapeutic applications. While the independent use of these strategies has shown promise, synergistic benefits may emerge from their combined application given the interdependence of the tissues that constitute the rotator cuff organ. Furthermore, controlled mobilization of augmented rotator cuff repairs during postoperative rehabilitation may provide mechanotransductive cues capable of guiding tissue regeneration and restoration of rotator cuff function. Present challenges and future possibilities will be identified, which if realized, may provide solutions to the vexing condition of chronic massive rotator cuff tears.

Mechanical risk of rotator cuff repair failure during passive movements: A simulation-based study

BACKGROUND

Despite improvements in rotator cuff surgery techniques, re-tear rate remains above 20% and increases with tear severity. Mechanical stresses to failure of repaired tendons have been reported. While optimal immobilization postures were proposed to minimize this stress, post-operative rehabilitation protocols have never been assessed with respect to these values. Purpose was to use musculoskeletal simulation to predict when the stress in repaired tendons exceeds safety limits during passive movements. Hence, guidelines could be provided towards safer post-operative exercises.

METHODS

Sixteen healthy participants volunteered in passive three-dimensional shoulder range-of-motion and passive rehabilitation exercises assessment. Stress in all rotator cuff tendons was predicted during each movement by means of a musculoskeletal model using simulations with different type and size of tears. Safety stress thresholds were defined based on repaired tendon loads to failure reported in the literature and used to discriminate safe from unsafe ranges-of-motion.

FINDINGS

Increased tear size and multiple tendons tear decreased safe range-of-motion. Mostly, glenohumeral elevations below 38°, above 65°, or performed with the arm held in internal rotation cause excessive stresses in most types and sizes of injury during abduction, scaption or flexion. Larger safe amplitudes of elevation are found in scapular plane for supraspinatus alone, supraspinatus plus infraspinatus, and supraspinatus plus subscapularis tears.

INTERPRETATION

This study reinforces that passive early rehabilitation exercises could contribute to re-tear due to excessive stresses. Recommendations arising from this study, for instance to keep the arm externally rotated during elevation in case of supraspinatus or supraspinatus plus infraspinatus tear, could help prevent re-tear.

Suture anchor fixation strength with or without augmentation in osteopenic and severely osteoporotic bones in rotator cuff repair: a biomechanical study on polyurethane foam model

BACKGROUND

The purpose of the present study was to compare the results of various types of anchor applications with or without augmentation in both osteopenic and severely osteoporotic bone models.

METHODS

Two different types of suture anchors were tested in severely osteoporotic (SOP) and osteopenic polyurethane (PU) foam blocks using an established protocol. An Instron machine applied static loading parallel to the axis of insertion until failure, and the mean anchor failure strengths were calculated. The mode of failure (anchor pullout, suture tear) was recorded. The anchors tested included the Corkscrew (CS) (Arthrex Inc., Naples, FL, USA) (without augmentation, polymethylmethacrylate (PMMA)-augmented, and bioabsorbable tricalcium phosphate (TCP) cement-augmented) and Corkscrew FT II (CS FT II) 5.5 mm (without augmentation as used routinely).

RESULTS

The mean failure loads for both SOP and osteopenic PU foam blocks, respectively, were as follows: CS, 16.2 and 212.4 N; CS with TCP, 75.2 and 396 N; CS with PMMA, 101.2 and 528.8 N; CS FT II, 13.8 and 339.8 N.

CONCLUSIONS

Augmentation of CS with TCP or PMMA would be essential to SOP bones. In the osteopenic bone model, although anchor fixation augmented with PMMA is the best fixation method, CS augmented with TCP cement or CS FT II without any need for augmentation may also be used as an alternative.

Optimal shoulder immobilization postures following surgical repair of rotator cuff tears: a simulation analysis

BACKGROUND

There is a high incidence of retear following surgical repair of rotator cuff tears. Postoperative shoulder immobilization is commonly prescribed to protect the repair; but there is no consensus on the best immobilization postures.

METHODS

A generic musculoskeletal model of the shoulder was used to simulate postoperative immobilization of full thickness rotator cuff tears involving the supraspinatus only and the supraspinatus concomitantly with the infraspinatus or subscapularis. Optimal immobilization postures, which simultaneously minimized the stresses in the repaired tendons and the angle of humerus elevation, were obtained.

RESULTS

For isolated supraspinatus tears, elevation of the humerus in planes close to the scapular plane was suggested. When the infraspinatus was also involved, planes posterior to the scapular plane were suggested; while, if the subscapularis was also involved, planes anterior to the scapular plane and internal rotation were suggested. The required thoracohumeral elevation angles ranged from 58° to 109°, depending on the tear length and the muscles involved. The optimal postures reduced the stresses in the repaired tendons by between 29% and 90%.

CONCLUSION

Prescription of immobilization posture for a patient should be based on the conditions of the tear repaired. Appropriate choice of immobilization posture will reduce the stress in the repair, and as such has the potential to reduce retear rates.