Massive rotator cuff tears: pathomechanics, current treatment options, and clinical outcomes

Arthroscopic Mobilization Techniques for Retracted Immobile Rotator Cuff Tears

The treatment of massive, retracted rotator cuff tears remains a significant challenge to orthopaedic surgeons. While debridement and partial repair has been described as a viable option, surgeons seeking to perform a complete repair often must employ advanced mobilization techniques to lateralize retracted immobile rotator cuff tissue. Tears that appear irreparable often may be effectively mobilized with elements of capsular release, anterior interval slide, or posterior interval slide. When rotator cuff tissue is mobilized to the medial aspect of the anatomic footprint, a low-tension repair can be performed with good clinical outcomes.

Muscle and joint function in the rotator cuff deficient shoulder

Full-thickness rotator cuff tears can lead to poor coaptation of the humeral head to the glenoid, disrupting muscle forces required for glenohumeral joint stability, ultimately leading to joint subluxation. The aim of this study was to evaluate muscle forces and glenohumeral joint translations during elevation in the presence of isolated and combined full-thickness rotator cuff tears. Eight fresh-frozen upper limbs were mounted to a computer-controlled testing apparatus that simulated joint motion by simulated muscle force application. Scapular-plane abduction was performed, and glenohumeral joint translations were measured using an optoelectronic system. Testing was performed in the native shoulder, a following an isolated tear to the supraspinatus, as well as combined tears involving the supraspinatus and subscapularis, as well as supraspinatus, infraspinatus, and teres minor. Rotator cuff tears significantly increased middle deltoid force at 30°, 60°, and 90° of abduction relative to that in the native shoulder (p < 0.05). Significantly greater superior translations were observed relative to the intact shoulder due to combined tears to the supraspinatus and infraspinatus at 30° of abduction (mean increase: 1.6 mm, p = 0.020) and 60° of abduction (mean increase: 4.8 mm, p = 0.040). This study illustrates the infraspinatus-teres minor complex as a major humeral head depressor and contributor to glenohumeral joint stability. An increase in deltoid force during abduction occurs in the presence of rotator cuff tears, which exacerbates superior migration of the humeral head. The findings may help in the development of clinical tests in rotator cuff tear diagnostics, in surgical planning of rotator cuff repair, and in planning of targeted rehabilitation.

Patients With Graft Tears Leaving the Tuberosity Covered Have Similar Functional Outcomes to Those With an Intact Graft After Superior Capsular Reconstruction

BACKGROUND

Studies to date of superior capsular reconstruction (SCR) comparing outcomes of healed grafts versus torn grafts do not separate graft tears based on location of the tear, rather they combine and report all tears as a single group.

PURPOSE/HYPOTHESIS

The purpose of this study was to correlate functional outcome with graft integrity and graft tear location after SCR with a dermal allograft. It was hypothesized that the functional outcomes of patients with an intact graft would be equivalent to those with graft tears leaving the tuberosity covered.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent SCR with an acellular dermal allograft at a single institution were included. Pre- and postoperative American Shoulder and Elbow Surgeons (ASES), Oxford Shoulder Score, visual analog scale (VAS) for pain, and postoperative Single Assessment Numeric Evaluation (SANE) scores were recorded. A magnetic resonance imaging scan was performed postoperatively to assess graft integrity.

RESULTS

A total of 39 patients met inclusion criteria. Mean age of patients was 60.4 ± 8.7 years; mean follow-up was 53.3 ± 25 months (range, 14-98 months). Magnetic resonance imaging performed at a mean of 17.5 months (range, 6-66 months) demonstrated an intact graft in 14 (36%); tear from the glenoid in 11 (28%), from midsubstance in 4 (10%), and from the tuberosity in 8 (21%); and complete graft absence in 2 (5%). Patients were divided into group 1 (intact graft), group 2 (tuberosity covered: tears from glenoid and midsubstance tears), and group 3 (tuberosity bare: tears from the tuberosity and dissolved or absent grafts). In group 1, there was significant improvement in ASES (37.9 to 88.5; P < .001), Oxford (25.2 to 46.2; P < .001), and VAS (6.8 to 0.9; P < .001). In group 2, there was significant improvement in ASES (32.2 to 86.1; P < .001), Oxford (23.4 to 44.2; P < .001), and VAS (7.3 to 1.3; P < .001). In group 3, there was no significant improvement in ASES (40.3 to 45.8; P = .50) or Oxford (33.5 to 31.4; P = .81), but there was a significant reduction in VAS (7.1 to 5.4; P = .03). There was no significant difference between group 1 and 2 in postoperative ASES (88.5 vs 86.1; P = .59), Oxford (46.2 vs 44.2; P = .07), VAS (0.9 vs 1.3, P = .42) and SANE (85.4 vs 83.2; P = .92) scores. However, group 3 had significantly lower ASES (45.8; P < .001), lower Oxford (31.4; P < .001), lower SANE (45.4; P < .001), and higher VAS (5.4; P < .001) scores than groups 1 and 2. There were no differences in outcomes based on sex (P = .72), previous surgery (P = .06), preoperative acromiohumeral distance (P = .57), and preoperative Goutallier stage of the supraspinatus (P = .16).

CONCLUSION

Patients who underwent SCR with a dermal allograft and developed a graft tear leaving the tuberosity covered had equivalent functional outcomes to those with an intact graft.

Biological Patch in the Repair of Rotator Cuff Tears: Functional and Clinical Evaluation of Twenty-Three Cases with a Mean Follow-Up of Six Years

Background: Rotator cuff (RC) repair leads to less than optimal results when dealing with massive lesions, so the use of scaffolds as biological support has been proposed to improve RC repair site biology. The present study aims to evaluate the clinical and radiographical outcomes of a series of patients suffering from massive or irreparable RC tears treated with patch (porcine or human scaffolds) repair (augmentation or bridging). Methods: Twenty-three patients with a minimum follow-up of 24 months were subjectively, clinically, and radiographically assessed before and after surgery. Three different patient-related outcome measurements (PROMs) (American Shoulder and Elbow Surgeons score, Constant score, visual analog scale) were used for the subjective and clinical evaluation, while plain radiographs and magnetic resonance imaging where employed for radiographical follow-up. Results: Regardless of the technique (augmentation or bridging) or type of scaffold (porcine or human) employed, at follow-up, all patients experienced a statistically significant improvement in all PROMs and clinically. Conclusions: Patch repair represents a valid salvage procedure in massive or irreparable RC tears, improving the quality of life and eventually delaying the need for prosthetic replacement.

Tissue-engineered Bicipital Autologous Tendon Patch Enhances Massive Rotator Cuff Defect Repair in a Rabbit Infraspinatus Tendon Defect Model

BACKGROUND

Massive rotator cuff defects represent an important source of shoulder pain and functional debilitation, substantially diminishing patients' quality of life. The primary treatment of massive rotator cuff defects includes complete or partial repair and patch augmentation. However, because of the tendon's limited regenerative ability, the tendon retear risk after rotator cuff defect repair is still high. Thus, a new therapy is needed to promote tendon regeneration for repair of massive rotator cuff defects.

QUESTIONS/PURPOSES

Using an in vitro analysis, we first asked: (1) What is the biocompatibility and collagen synthesis ability of fibrin glue, and what is the cell growth of tissue-engineered bicipital tendon patches, which is comprised of fibrin glue and biceps tendon tissue particles? Then, using an in vivo animal model of full-thickness defects in the infraspinatus tendon in New Zealand White rabbits, we asked: (2) What is the potential of the tissue-engineered bicipital autologous tendon patch to promote tendon regeneration?

METHODS

In vitro experiments were conducted to assess the survival, proliferation, and collagen synthesis ability of tendon stem/progenitor cells cultured in fibrin glue. This was achieved through an assay of live/dead cell viability, cell counting kit-8 (CCK-8) assay, and Sirius red staining, respectively. The in vivo animal study was conducted using 8- to 12-week-old New Zealand White rabbits. The left shoulder of each animal was operated on, with equal numbers of males and females. There were 12 rabbits in the control group and 15 rabbits each in the gel and patch groups. Six rabbits were allocated to each of the three groups at the 1- and 3-month time points and three rabbits each were in the gel and patch groups at 2-month time point. Through an infraspinatus tendon defect model, the effectiveness of tissue-engineered bicipital autologous tendon patches (patch group) in tendon repair was assessed compared with untreated (control group) and fibrin glue (gel group) treatments in vivo. This assessment included histological evaluation of repaired tissue morphology, transmission electron microscopy (TEM) evaluation of regenerated collagen fibrils, and RNA sequencing to explore the potential mechanisms of tissue-engineered bicipital autologous tendon patches in tendon regeneration.

RESULTS

In vitro experiments demonstrated that fibrin glue enhanced the collagen synthesis ability of tendon stem/progenitor cells (0.38 ± 0.02) compared with standard cell culture alone (0.27 ± 0.02, mean difference 0.11 [95% CI 0.07 to 0.14]; p < 0.001). With prolonged cultivation, the cell growth area of tissue-engineered bicipital tendon patches showed a notable increase after culturing for 14 days (78.13% ± 3.68%) compared with 11 days (13.05% ± 8.78%, mean difference -65.08% [95% CI -77.99% to -52.15%]; p＜0.001), 7 days (2.67% ± 2.62%, mean difference -75.46% [95% CI -88.37% to -62.53%]; p＜0.001), and 1 day (0.33% ± 0.30%, mean difference -77.80% [95% CI -90.71% to -64.87%]; p＜0.001). At 3 months after transplantation, in vivo experiments revealed that compared with the control and gel groups, the patch group displayed improved repair outcomes. This was evidenced by better histological scores in the patch group (3.83 ± 2.01) compared with the gel group (10.67 ± 0.58, mean difference 6.84 [95% CI 3.67 to 10.00]; p = 0.001) and control group (10.75 ± 0.66, mean difference 6.92 [95% CI 3.75 to 10.08]; p = 0.001), and by regular alignment and larger diameters of newly formed collagen fibrils in the patch group (77.52 ± 44.41 nm) compared with the control group (53.34 ± 6.64 nm, mean difference 24.18 [95% CI 22.24 to 26.11]; p < 0.001). RNA sequencing analysis revealed that a tissue-engineered bicipital autologous tendon patch facilitated tendon regeneration by modulating the immune response, promoting collagen fibril organization, and alleviating vasoconstriction.

CONCLUSION

This animal study demonstrates that the tissue-engineered bicipital autologous tendon patch effectively modulates an immune response and collagen fibril organization, leading to the promotion of tendon regeneration.

CLINICAL RELEVANCE

The tissue-engineered bicipital autologous tendon patch represents a promising strategy for tendon regeneration, offering potential in the repair of massive rotator cuff defects during clinical rotator cuff surgery. Subsequent research could focus on large animal experiments using a tissue-engineered bicipital autologous tendon patch to explore their feasibility for clinical translation.

Primary Arthroscopic Repair for Massive Rotator Cuff Tears Results in Good Shoulder Function, Low Pain, and Satisfactory Outcomes at 2-Year Minimum Follow-Up

PURPOSE

To evaluate outcomes of patients who underwent primary arthroscopic repair for massive rotator cuff tears (MRCTs).

METHODS

Patients with MRCTs (full-thickness tear of 2 or more tendons or full-thickness tear ≥5 cm) who underwent arthroscopic repair with a minimum follow-up of 2 years were retrospectively reviewed (n = 51). All patients had preoperative magnetic resonance imaging used to characterize pattern of tear, degree of fatty degeneration (Goutallier classification), and degree of rotator cuff arthropathy (Hamada classification). Outcomes were determined by American Shoulder and Elbow Surgeons (ASES) scores and Penn Shoulder Scores (PSS).

RESULTS

A total of 51 patients with a minimum 2.3-year follow-up (mean, 5.4 years; range, 2.3-9.7 years) were included in this study. Mean ASES score was 46.1 ± 7.8 (95% CI, 43.9-48.3) for pain and 39.4 ± 12.1 (95% CI, 36.0-42.8) for function. Total ASES score averaged 85.5 ± 18.4 (95% CI, 80.4-90.7). PSS had a mean pain score of 26.8 ± 4.4 (95% CI, 25.4-28.1), a mean satisfaction score of 7.9 ± 2.9 (95% CI, 7.0-8.2), and a mean function score of 48.5 ± 13.5 (95% CI, 44.7-52.3). Total PSS averaged 83.2 ± 19.6 (95% CI, 77.7-87.7). No correlation was found between Goutallier grade and ASES/PSS scores or between Hamada grade and ASES/PSS scores. Three patients underwent reoperation after primary arthroscopic repair of an MRCT (5.9%).

CONCLUSIONS

Patients with MRCTs who undergo primary arthroscopic repair have postoperative outcome scores indicative of good shoulder function, low pain, and high satisfaction. The rate of reoperation for individuals who underwent primary arthroscopic repair with MRCTs was low at 6%.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Bursal Tissue Harvested During Rotator Cuff Repair Contains Viable Mesenchymal Stem Cells

Purpose

To evaluate the effect of intraoperative ablation on the viability, distribution, phenotype, and potential for culture expansion of bursal cells harvested during arthroscopic rotator cuff surgery.

Methods

Tissue was collected during primary arthroscopic rotator cuff repair on 6 healthy, randomly selected patients from a fellowship-trained surgeon's practice between September 2020 and January 2021. There were 3 women (aged 60 ± 8 years) and 3 men (aged 61 ± 10 years). At the time of surgery, subacromial bursal tissue was subjected to no ablation, 1 second of ablation, or 3 seconds of ablation. Tissues were collected by an autograft harvesting system connected to an arthroscopic shaver and a pituitary grasper. Tissue fragments from each condition were sampled for viability testing or cell isolation. A viability kit with confocal microscopy was used to assess live and dead cells. Cell isolation consisted of collagenase digestion or placing tissue fragments onto tissue culture-treated plates that induced migration of cells out of the tissue. Cell proliferation rates were monitored and surface markers for mesenchymal stem cells (MSC) and pericytes were analyzed via multicolor flow cytometry.

Results

Increased ablation time significantly reduced cell viability. The mean percentage of live cells was 55.2% ± 27.2% (range, 26%-90% live) in the control group, 46.8% ± 23.8% (range, 9.6%-69.6%, P = .045) in the short-ablation group, and 35.5% ± 19% (range, 11%-54%, P = .03) in the long-ablation group. No significant differences in population doubling level (1.6 ± 0.5 days) and population doubling time (6.7 ± 2.4 days) were observed in cells from any treatment. The surface marker profile indicated an MSC phenotype with absence of a pericyte population. Ablation or cell isolation procedure had no significant effect on the surface marker profile of isolated cells.

Conclusions

Radiofrequency ablation significantly reduced the overall tissue viability but had no significant effect on cell proliferation or expression of surface markers on isolated subacromial bursal cells harvested arthroscopically.

Clinical Relevance

Analysis of the viability and performance of cells harvested after the use of ablation devices using mechanical surgical collection during rotator cuff repair surgery could further our understanding of subacromial bursal tissue and its potential role in augmenting rotator cuff repair healing.

Inlay Scaffold Augmentation of Rotator Cuff Repairs Enhances Histologic Resemblance to Native Enthesis in Animal Studies: A Systematic Review

PURPOSE

To investigate the outcomes of inlay positioned scaffolds for rotator cuff healing and regeneration of the native enthesis after augmentation of rotator cuff tendon repairs in preclinical studies.

METHODS

A literature search was performed using the PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature databases according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Preclinical studies reporting on outcomes after inlay tendon augmentation in rotator cuff repair were included. Preclinical study quality was assessed using an adapted version of the Gold Standard Publication Checklist for animal studies. The level of evidence was defined based on the inclusion of clinical analyses (grade A), biomechanical analyses (grade B), biochemical analyses (grade C), semiquantitative analyses (grade D), and qualitative histologic analyses (grade E).

RESULTS

Thirteen preclinical studies met the inclusion criteria. Quality assessment scores ranged from 4 to 8 points, and level-of-evidence grades ranged from B to E. Sheep/ewes were the main animal rotator cuff tear model used (n = 7). Demineralized bone matrix or demineralized cortical bone was the most commonly investigated scaffold (n = 6). Most of the preclinical evidence (n = 10) showed qualitative or quantitative differences regarding histologic, biomechanical, and biochemical outcomes in favor of interpositional scaffold augmentation of cuff repairs in comparison to controls.

CONCLUSIONS

Inlay scaffold positioning in preclinical studies has been shown to enhance the healing biology of the enthesis while providing histologic similarities to its native 4-zone configuration.

CLINICAL RELEVANCE

Although onlay positioned grafts and scaffolds have shown mixed results in preclinical and early clinical studies, inlay scaffolds may provide enhanced healing and structural support in comparison owing to the ability to integrate with the bone-tendon interface.

A scoping review of tendon transfer surgeries and postsurgical physical therapy interventions in individuals with massive rotator cuff tears

OBJECTIVE

To identify tendon transfer surgeries and postsurgical physical therapy interventions in people with massive rotator cuff (RC) tears.

METHODS

The literature search was conducted in the MEDLINE, Science Direct, Scopus, Web of Science, and PEDro databases from inception to September 2022. Studies with patients diagnosed with massive RC tears undergoing tendon transfers that reported physical therapy interventions after surgery were included. Two reviewers pooled the data into ad hoc summary tables with the following information: authors, year, study characteristics (sample size, tendon transfer surgical used, approach type, preoperative risk, deficit addressed, additional surgical interventions), and physical therapy interventions (early stage, intermediate stage, and advanced stage).

RESULTS

Forty-four articles (59.0% case series) were included, with a total sample of 1213 participants. The most frequently used surgery was the isolated tendon transfer of the latissimus dorsi (49.1%). Most of the studies reported three main stages of physical therapy interventions after tendon transfer surgery: early stage (lasting 5-6 weeks), intermediate stage (started at 7-12 weeks), and advanced stage (started at 12 weeks). Physical therapy interventions included passive, active-assisted, resisted therapeutic exercise, and hydrotherapy.

CONCLUSIONS

The evidence regarding physical therapy interventions after RC tendon transfer surgery is limited to the number and duration of the stages and general characteristics without specifying the type and dose of the interventions. Future research with high methodological quality should integrate more detailed rehabilitation protocols to better guide therapeutic decisions after RC transfer surgery.

Clinical application of tranexamic acid in arthroscopic rotator cuff repair surgery: A randomized controlled trial

BACKGROUND

To investigate whether intravenous administration of tranexamic acid (TXA) prior to arthroscopic rotator cuff repair improves operative blood loss, postoperative fibrinolytic index, inflammatory response, and postoperative pain.

METHODS

This was a prospective, double-blind, randomized controlled study. From January 2023 to February 2024, 64 patients who required arthroscopic rotator cuff repair were included and divided into tranexamic acid group (T group) group and control group (C group) according to the random number table method. In T group, 1000 mg TXA was administered intravenously 10 minutes before surgery, and an equivalent dose of normal saline was administered intravenously 10 minutes before surgery in C group. Intraoperative bleeding, postoperative fibrinolytic indexes, inflammatory indexes, pain scores, and occurrence of adverse effects were compared between the 2 groups.

RESULTS

Intraoperative bleeding in T group was lower than that in C group (P < .05); D-D and FDP in T group were significantly lower than those in C group (P < .05); postoperative TNF-α and IL-6 in 2 groups was higher than that before operation and T group was lower than C group (P < .05); The pain scores of the 2 groups after operation were lower than those before operation (P < .05), and there was no difference between the 2 groups (P > .05).

CONCLUSION SUBSECTIONS

TXA is able to reduce blood loss and inflammatory reactions, modulate fibrinolytic function, and promote postoperative recovery in patients undergoing arthroscopic rotator cuff repair, with no elevated risk of complications.

Balloon Spacer Implant Is an "Intermediate Value" Innovation Relative to Partial Repair for Full-Thickness Massive Rotator Cuff Repairs: A Cost-Utility Analysis

PURPOSE

To evaluate the cost-utility of a balloon spacer implant relative to partial repair (PR) for the surgical treatment of full-thickness massive rotator cuff tears (MRCTs).

METHODS

A decision-analytic model comparing balloon spacer with PR was developed using data from a prospective, randomized, single-blinded, multicenter-controlled trial of 184 randomized patients. Our model was constructed on the basis of the various event pathways a patient could have after the procedure. The probability that each patient progressed to a given outcome and the quality-adjusted life years (QALY) associated with each outcome were derived from the clinical trial data. Incremental cost utility ratio (ICUR) and incremental net monetary benefit were calculated on the basis of a probabilistic sensitivity analysis using Monte Carlo simulations of 1,000 hypothetical patients progressing through the decision-analytic model. One-way sensitivity and threshold analyses were performed by varying cost, event probability, and QALY estimates.

RESULTS

The balloon spacer had an ICUR of $106,851 (95% confidence interval $96,317-$119,143) relative to PR for surgical treatment of MRCT. Across all patients, the balloon spacer was associated with greater 2-year QALY gain compared with PR (0.20 ± 0.02 for balloon spacer vs 0.18 ± 0.02 for PR), but with substantially greater total 2-year cost ($9,701 ± $939 for balloon spacer vs $6,315 ± $627 for PR). PR was associated with a positive incremental net monetary benefit of $1,802 (95% confidence interval $1,653-$1,951) over balloon spacer at the $50,000/QALY willingness-to-pay threshold.

CONCLUSIONS

Compared with PR, the balloon spacer is an "intermediate-value" innovation for treatment of MRCT over a 2-year postoperative period with an ICUR value that falls within the $50,000 to $150,000 willingness-to-pay threshold.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Reverse shoulder arthroplasty for massive rotator cuff tears without glenohumeral arthritis can improve clinical outcomes despite history of prior rotator cuff repair: A systematic review

IMPORTANCE

Reverse shoulder arthroplasty (RSA) is often used to surgically address massive irreparable rotator cuff tears (MIRCT) without arthritis. The impact of prior attempted rotator cuff repair (RCR) on outcomes is unclear.

OBJECTIVE

The purpose of this systematic review was to compare functional outcomes, range of motion, and complications in patients with a MIRCT without arthritis who underwent RSA as a primary procedure versus after prior RCR.

EVIDENCE REVIEW

A systematic review was performed on RSA for a MIRCT. The search was conducted from February to March of 2022 using the MEDLINE database. Patient-reported outcome measures (PROs), range of motion (ROM), and complications were extracted. These outcomes were weighted and analysed based on whether the reverse was performed as the primary procedure or following a prior RCR.

FINDINGS

Seven studies were included in the analysis, consisting of 343 cases in the primary RSA group and 95 cases in the prior RCR group, with a mean follow-up of 40.8 months. There were no demographic differences between cohorts. Postoperative PROs and ROM were comparable between groups, although the prior RCR group had a higher maximal percentage of improvement (MPI%) for the Constant-Murley Score and Simple Shoulder Test. There was a higher risk for complications (relative risk [RR] 6.26) and revisions (RR 3.91) in the prior RCR group. The most common complications were acromial stress fractures and prosthetic dislocation.

CONCLUSION AND RELEVANCE

Patients undergoing RSA for MIRCT following a prior RCR have functional outcomes that are largely comparable to those who have a primary RSA, but they may be at higher risk of complications and revision.

LEVEL OF EVIDENCE

IV.

Influence of the rotator cuff tear pattern in shoulder stability after arthroscopic superior capsule reconstruction: a computational analysis

OBJECTIVES

To assess the ability of the arthroscopic superior capsule reconstruction (SCR) in restoring glenohumeral stability in the presence of different preoperative patterns of irreparable rotator cuff tears (RCTs).

METHODS

A computational musculoskeletal (MSK) model of the upper limb was used to simulate isolated SCR and to estimate the stability of the shoulder. Four patterns of preoperative irreparable RCTs were modeled: Supraspinatus (SSP); SSP ​+ ​Subscapularis (SSC); SSP ​+ ​Infraspinatus (ISP); and SSP ​+ ​SSC ​+ ​ISP. The muscles involved in the irreparable RCT were removed from the MSK model to simulate an irreparable full-thickness tear. In the MSK model, the muscle and joint forces were estimated for a set of upper limb positions, from four types of motions (abduction in the frontal plane, forward flexion in the sagittal plane, reaching behind the back, and combing the hair) collected in a biomechanics laboratory, through inverse dynamic analysis. The stability of the shoulder was estimated based on the tangential and compressive components of the glenohumeral joint reaction force. The comparison of pre- and post-operative conditions, for the four patterns of irreparable RCTs, with the healthy condition, was performed using ANOVA and Tukey's tests (statistical level of p ​< ​0.05).

RESULTS

In the setting of an isolated irreparable SSP tear, SCR statistically significantly improved stability compared with the preoperative condition (p ​< ​0.001). For the irreparable SSP ​+ ​SSC pattern, a statistically significant loss in stability was observed (p ​< ​0.001) when SCR was applied. For the irreparable SSP ​+ ​ISP and SSP ​+ ​SSC ​+ ​ISP patterns, the postoperative condition increased shoulder stability, compared to the preoperative condition; however, the improvement was not statistically significantly different.

CONCLUSION

Isolated SCR for irreparable RCTs extending beyond the SSP does not statistically significantly improve the stability of the glenohumeral joint.

LEVEL OF EVIDENCE

Level IV.

Rotator cuff tear patterns: MRI appearance and its surgical relevance

A new perspective on rotator cuff anatomy has allowed a better understanding of the patterns of the different rotator cuff tears. It is essential for radiologists to be aware of these different patterns of tears and to understand how they might influence treatment and surgical approach. Our objective is to review the arthroscopy correlated magnetic resonance imaging appearance of the different types of rotator cuff tears based on current anatomical concepts.Critical relevance statement Knowledge of the characteristics of rotator cuff tears improves our communication with the surgeon and can also make it easier for the radiologist to prepare a report that guides therapeutic conduct and serves as a prognosis for the patient.Key points• There is no universally accepted classification for RC tears.• New patterns such as delamination or myotendinous junction tears have been defined.• The most difficult feature to assess in full thickness tears on MRI is the pattern.• Fatty infiltration of the RC tendons is crucial in the prognosis and outcome.• The radiological report is an effective way of communication with the surgeon.

Top 50 most impactful publications on massive rotator cuff tears

Background

Bibliometric analysis is a useful tool for measuring the scholarly impact of a topic and its more and less heavily studied aspects. The purpose of this study is to use bibliometric analysis to comprehensively analyze the 50 articles with the highest citation indices in studies evaluating the treatment and outcomes of massive rotator cuff tears (mRCTs).

Methods

This cross-sectional study identified articles within the Scopus database published through December 2022. Keywords used were "massive rotator cuff tear." Articles were sorted in chronological order. The year published and number of citations were recorded. A citation index (CI) was calculated for each article by dividing the number of citations by number of years published [1 citation/1 year published (2021) = CI of 1]. Of these, the 50 articles with the highest CIs were carried forward for evaluation. Frequencies and distributions were assessed for data of each variable collected.

Results

These search methods produced 625 articles regarding mRCT research (ranging from January 1986 to December 2022). Four of the top 10 most impactful articles were published in the 2010s. The level of evidence (LOE) published with the greatest frequency was level of evidence 4 (41%). The journal Arthroscopy published the highest number within the top 50 (26%) followed by the Journal of Bone and Joint Surgery and the American Journal of Sports Medicine (20% each). Clinical studies composed 88% of the top 50. Case series (38%) predominated, while systematic reviews (20%) and randomized control trials (8%) were less prevalent. The majority of studies concentrated on the clinical outcomes of certain interventions (62%), mainly comparing multiple interventions.

Conclusion

Despite the relatively high prevalence of mRCTs (40% of all tears), this topic comprises only a small proportion of all rotator cuff research. This analysis has identified gaps within and limitations of the findings concerning mRCTs for researchers to propose research questions targeting understudied topics and influence the future treatment and outcomes of this clinically difficult diagnosis.

Editorial Commentary: Bridging Graft Techniques Improve Short-Term Outcomes for Irreparable Rotator Cuff Tear Repair

There is a growing need for nonarthroplasty treatment options for irreparable rotator cuff tears. Options include superior capsular reconstruction (SCR), tendon transfers, subacromial balloon spacer, bridge grafting, biological tuberoplasty, and partial rotator cuff repair with or without augmentation. In our experience, repair with marginal convergence techniques is superior to SCR; if there is enough tissue, repair is the preferred strategy. In an effort to improve outcomes after repair, there has been increased interest in the use of interposition or bridging graft (BG) techniques, in which an allograft or autograft is secured on the humerus laterally and to the remnant tendon medially. Interposition or bridging grafts can be used to supplement partial repair in an effort to replace the patient's own missing tissues, and restore the biomechanical force couple of the rotator cuff and create a humeral head-depressing spacer effect in the subacromial space. These techniques show promising results compared to superior capsular reconstruction. Various graft options for BG are available, including human dermal allograft, fascia lata autograft, and tenotomized biceps autograft. Multiple animal studies have demonstrated that interposition grafts can improve the biomechanical properties of the repair construct, and histological studies in animal models have shown evidence of tissue in-growth into the BG, which could lead to increased repair strength over time. Finally, recent studies suggest that a bridging graft may improve short-term outcomes compared to partial repair alone. It remains to be seen whether this difference is clinically meaningful and durable.

Management of partial-thickness rotator cuff tears with autologous adipose-derived regenerative cells is safe and more effective than injection of corticosteroid

Symptomatic, partial-thickness rotator cuff tears (sPTRCT) are problematic. This study tested the hypothesis that management of sPTRCT with injection of fresh, uncultured, unmodified, autologous, adipose-derived regenerative cells (UA-ADRCs) is safe and more effective than injection of corticosteroid even in the long run. To this end, subjects who had completed a former randomized controlled trial were enrolled in the present study. At baseline these subjects had not responded to physical therapy treatments for at least 6 weeks, and were randomly assigned to receive respectively a single injection of UA-ADRCs (n = 11) or a single injection of methylprednisolone (n = 5). Efficacy was assessed using the ASES Total score, pain visual analogue scale (VAS), RAND Short Form-36 Health Survey and range of motion at 33.2 ± 1.0 (mean ± SD) and 40.6 ± 1.9 months post-treatment. Proton density, fat-saturated, T2-weighted MRI of the index shoulder was performed at both study visits. There were no greater risks connected with injection of UA-ADRCs than those connected with injection of corticosteroid. The subjects in the UA-ADRCs group showed statistically significantly higher mean ASES Total scores than the subjects in the corticosteroid group. The MRI scans at 6 months post-treatment allowed to "watch the UA-ADRCs at work".

Salvaging the 'irreparable' tear: Superior Capsular Reconstruction augmented with partial cuff repair

Introduction

Massive rotator cuff tears (MRCTs) have long posed a complex problem for both patients and surgeons. If not treated promptly, tendon retraction, fatty infiltration and muscle atrophy of the rotator cuff muscles occur. These lead to irreparable RCTs with poor functional outcomes. We describe our technique of superior capsular reconstruction (SCR) augmented with partial cuff repair and report on our short term outcomes.

Method

Seven consecutive patients who underwent the procedure were recruited at our institution from January 2019 to December 2019. Medical records of these patients were reviewed looking at pre-operative symptoms and examination findings, imaging studies, intra-operative findings, the surgical technique employed, post-operative progress in terms of pain, affected shoulder range of movement and outcome scores.

Results

All patients showed complete tears of at least two tendons and were deemed irreparable intra-operatively. All patients exhibited Goutalier grade 2-4 wasting of the affected tendons on MRI and Patte grade 3 intra-operatively. At 12 months, the mean improvement shown in Constant score is 12.1 points, in University of California Los Angeles (UCLA) score is 9.4 points and in Oxford Shoulder Score is 17 points. Active forward flexion improved in all patients with a mean improvement of 40 degrees. Numerical Pain Rating Scale improved in all patients with a mean of 5.1 points.

Conclusion

Our case series shows good short-term outcomes can be achieved with SCR augmented with partial cuff repair. Notably, our SCR results showed encouraging results even for challenging revision rotator cuff repairs.

Superior capsular reconstruction using the long head of the biceps to treat massive rotator cuff tears improves patients shoulder pain, mobility and function

PURPOSE

Arthroscopic superior capsule reconstruction (SCR) with the long head of the biceps (LHBT) was performed to restore structural stability, force couple balance, and shoulder joint function. This study aimed to evaluate the functional outcomes of SCR using the LHBT over at least 24 months of follow-up.

METHOD

This retrospective study included 89 patients with massive rotator cuff tears who underwent SCR using the LHBT, met the inclusion criteria and underwent follow up for at least 24 months. The preoperative and postoperative shoulder range of motion (forward flexion, external rotation, and abduction), acromiohumeral interval (AHI), visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score and Constant-Murley score were obtained, and the tear size, and Goutallier and Hamada grades were also investigated.

RESULTS

Compared with those measured preoperatively, the range of motion, AHI, and VAS, Constant-Murley, and ASES scores were significantly improved immediately postoperatively (P < 0.001) and at the 6-month, 12-month, and final follow-ups (P < 0.001). At the last follow-up, the postoperative ASES score and Constant-Murley score increased from 42.8 ± 7.6 to 87.4 ± 6.1, and 42.3 ± 8.9 to 84.9 ± 10.7, respectively; with improvements of 51 ± 21.7 in forward flexion, 21.0 ± 8.1 in external rotation, and 58.5 ± 22.5 in abduction. The AHI increased 2.1 ± 0.8 mm and the VAS score significantly changed from 6.0 (5.0, 7.0) to 1.0 (0.0, 1.0), at the final follow-up. Eleven of the 89 patients experienced retears, and one patient needed reoperation.

CONCLUSION

In this study with at least 24-months of follow-up, SCR using the LHBT for massive rotator cuff tears could effectively relieve shoulder pain, restore shoulder function and increase shoulder mobility to some extent.

LEVEL OF EVIDENCE

IV.

Simultaneous Arthroscopic Rotator Cuff Repair and Glenoid Microfracture in Active-Duty Military Patients Younger Than 50 Years: Outcomes at Midterm Follow-up

Background

While concomitant full-thickness rotator cuff tears and glenoid osteochondral defects are relatively uncommon in younger patients, military patients represent a unique opportunity to study this challenging injury pattern.

Purpose/Hypothesis

To compare the outcomes of young, active-duty military patients who underwent isolated arthroscopic rotator cuff repair (ARCR) with those who underwent ARCR plus concurrent glenoid microfracture (ARCR+Mfx). It was hypothesized that ARCR+Mfx would produce significant improvements in patient-reported outcome measures.

Study Design

Cohort study; Level of evidence, 3.

Methods

This was a retrospective analysis of consecutive active-duty military patients from a single base who underwent ARCR for full-thickness rotator cuff tears between January 2012 and December 2020. All patients were <50 years and had minimum 2-year follow-up data. Patients who underwent ARCR+Mfx were compared with those who underwent isolated ARCR based on the visual analog scale (VAS) for pain, Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) shoulder score, and range of motion.

Results

A total of 88 patients met the inclusion criteria for this study: 28 underwent ARCR+Mfx and 60 underwent isolated ARCR. The mean final follow-up was 74.11 ± 33.57 months for the ARCR+Mfx group and 72.87 ± 11.46 months for the ARCR group (P = .80). There were no differences in baseline patient characteristics or preoperative outcome scores between groups. Postoperatively, both groups experienced statistically significant improvements in all outcome scores (P < .0001 for all). However, the ARCR+Mfx group had significantly worse VAS pain (1.89 ± 2.22 vs 1.03 ± 1.70; P = .05), SANE (85.46 ± 12.99 vs 91.93 ± 12.26; P = .03), and ASES (86.25 ± 14.14 vs 92.85 ± 12.57; P = .03) scores. At the final follow-up, 20 (71.43%) patients in the ARCR+Mfx group and 53 (88.33%) patients in the ARCR group were able to remain on unrestricted active-duty military service (P = .05).

Conclusion

Concomitant ARCR+Mfx led to statistically and clinically significant improvements in patient-reported outcome measures at the midterm follow-up. However, patients who underwent ARCR+Mfx had significantly worse outcomes and were less likely to return to active-duty military service than those who underwent isolated ARCR. The study findings suggest that ARCR+Mfx may be a reasonable option for young, active patients who are not candidates for arthroplasty.

Graft Augmentation of Rotator Cuff Repair Improves Load to Failure But Does Not Affect Stiffness or Gap Formation: A Meta-analysis of Biomechanical Studies

PURPOSE

To examine the biomechanical properties of rotator cuff repair with graft augmentation (RCR-G) with regard to ultimate load to failure, gap displacement, and stiffness.

METHODS

A systematic review was performed by searching PubMed, the Cochrane library, and Embase using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies that analyzed the biomechanical properties of RCR-G. The search string implemented used the concepts "rotator cuff" and "graft," and "biomechanical" OR "cadaver." Meta-analysis was performed to provide a quantitative comparison of the 2 techniques. Primary outcome measures were ultimate load to failure (N), gap displacement (mm), and stiffness (N/mm).

RESULTS

Our initial search yielded 1,493 articles for review. Following screening for inclusion criteria, 8 studies were included in the meta-analysis, including a total of 191 cadaveric specimens (106 RCR-G, 85 RCR). The pooled analysis from 6 studies reporting on ultimate load to failure revealed a statistically significant difference in favor of RCR-G compared with RCR (P < .001). Pooled analysis from 6 studies reporting on gap displacement failed to reveal a difference between RCR-G and RCR (P = .719). Pooled analysis from 4 studies reporting on stiffness failed to reveal a difference between RCR-G and RCR (P = .842).

CONCLUSIONS

Graft augmentation of RCR in vitro resulted in significantly increased ultimate load to failure, with no influence on gap formation or stiffness.

CLINICAL RELEVANCE

The biomechanical advantage of RCR with graft augmentation demonstrated via increased ultimate load to failure in cadaveric studies may provide an explanation for the decreased RCR retear rates and improved patient reported outcomes reported in the clinical literature regarding graft augmentation.

Anatomic characteristics of shoulder based on MRI accurately predict incomplete rotator cuff injuries in patients: relevance for predictive, preventive, and personalized healthcare strategies

Background and PPPM-related working hypothesis

In the diagnosis of incomplete rotator cuff injuries (IRCI), magnetic resonance imaging (MRI) and ultrasound examination often have false-positive and false-negative results, while arthroscopy is expensive, invasive, and complex. From the strategy of predictive, preventive, and personalized medicine (PPPM), shoulder anatomical characteristics based on MRI have been demonstrated to accurately predict IRCI and their clinical applicability for personalized prediction of IRCI.

Aims

This study aimed to develop and validate a nomogram based on anatomical features of the shoulder on MRI to identify IRCI for PPPM healthcare strategies.

Methods

The medical information of 257 patients undergoing preoperative MRI examination was retrospectively reviewed and served as the primary cohort. Partial-thickness rotator cuff tears (RCTs) and tendinopathy observed under arthroscopy were considered IRCI. Using logistic regression analyses and least absolute shrinkage and selection operator (LASSO), IRCI was identified among various preoperative factors containing shoulder MRI and clinical features. A nomogram was constructed and subjected to internal and external validations (80 patients).

Results

The following eight independent risk factors for IRCI were identified:AgeThe left injured sidesThe Goutallier classification of supraspinatus in oblique coronal positionThe Goutallier classification of supraspinatus in the axial positionAcromial thicknessAcromiohumeral distanceCoracohumeral distanceAbnormal acromioclavicular joint signalsThe nomogram accurately predicted IRCI in the development (C-index, 0.932 (95% CI, 0.891, 0.973)) and validation (C-index, 0.955 (95% CI, 0.918, 0.992)) cohorts. The calibration curve was consistent between the predicted IRCI probability and the actual IRCI ratio of the nomogram. The decision curve analysis and clinical impact curves demonstrated that the model had high clinical applicability.

Conclusions

Eight independent factors that accurately predicted IRCI were determined using MRI anatomical findings. These personalized factors can prevent unnecessary diagnostic interventions (e.g., arthroscopy) and can assist surgeons in implementing individualized clinical decisions in medical practice, thus addressing the goals of PPPM.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-023-00333-5.

Effect of Anterior Acromial Coverage on Functional and Radiological Outcomes After Arthroscopic Repair of Anteroposterior Massive Rotator Cuff Tears

BACKGROUND

Rotator cuff tear size, fatty infiltration, and scapular morphology are correlated with tendon healing and functional outcomes after arthroscopic repair; however, the association between anteroposterior acromial coverage and the clinical outcomes of anteroposterior massive rotator cuff tears (AP-MRCTs; involving all 3 tendons) remains unclear.

PURPOSE

To identify the association between AP acromial coverage and functional and radiological outcomes after arthroscopic repair of AP-MRCTs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 98 patients who underwent arthroscopic repair of AP-MRCTs between January 2015 and December 2020 were included in the study and classified according to whether anterior acromial coverage (AAC) was anterior (46 patients; positive AAC group) or posterior (52 patients; negative AAC group) to the scapular line on true lateral shoulder radiographs. Demographic characteristics, surgical details, and functional outcomes were prospectively collected. Acromial morphological features, global tear extension (GTE), the global fatty infiltration index (GFII), tendon integrity after repair, proximal humeral migration, and glenohumeral abduction were measured and calculated on radiographs or magnetic resonance imaging scans preoperatively and at 2 years postoperatively. Multivariate logistic regression was performed to identify the independent risk factors of a rotator cuff retear.

RESULTS

The positive AAC group showed larger AAC, posterior acromial tilt, and anterior acromial slope as well as smaller posterior acromial coverage compared with the negative AAC group. Postoperatively, the American Shoulder and Elbow Surgeons score (82.5 ± 8.3 vs 77.2 ± 11.5, respectively; P = .013), active abduction (157.8°± 27.1° vs 142.7°± 39.6°, respectively; P = .048), and glenohumeral abduction (45.6°± 10.4° vs 39.7°± 14.9°, respectively; P = .041) in the positive AAC group were significantly higher than those in the negative AAC group, while the retear rate (23.9% vs 44.2%, respectively; P = .035) and proximal humeral migration (1.7 ± 1.0 vs 2.3 ± 1.2 mm, respectively; P = .006) were significantly lower in the positive AAC group than in the negative AAC group. Smaller AAC (odds ratio [OR], 0.93 [95% CI, 0.87-1.00]; P = .040), larger GTE (OR, 1.03 [95% CI, 1.01-1.06]; P = .017), and a higher GFII (OR, 3.49 [95% CI, 1.09-11.19]; P = .036) were associated with an increased risk of a rotator cuff retear.

CONCLUSION

Increased AAC was associated with a lower retear rate and better functional outcomes after arthroscopic repair of AP-MRCTs. A preliminary risk evaluation integrating GTE, the GFII, and AAC is recommended to consider the necessity of additional procedures for patients in need of arthroscopic rotator cuff repair.

Subacromial balloon spacers for the treatment of irreparable rotator cuff tears: a review

Massive irreparable rotator cuff tears (RCTs) are a commonly encountered orthopedic condition that can be difficult to treat. Several techniques have been described to manage these tears, with the implantable subacromial balloon spacer being one of the most recent. The device, which has only been approved for clinical use in the United States since 2021, functions by resisting the superior humeral head migration seen in the setting of massive RCTs and restoring normal shoulder biomechanics, as corroborated by cadaveric studies. However, results regarding clinical outcomes have been mixed to date, and further high-quality studies are needed to define the optimal use of the subacromial balloon spacer in the treatment of massive irreparable RCTs.

Comparison of Outcomes After Arthroscopic Superior Capsule Reconstruction Versus Arthroscopic Partial Repair or Arthroscopic Debridement for Irreparable Rotator Cuff Tears

Background

Arthroscopic superior capsule reconstruction (SCR), arthroscopic partial repair (PR), and arthroscopic debridement (DB) are valid treatment options for irreparable rotator cuff (RC) tears.

Purpose/Hypothesis

The purpose of this study was to compare clinical, functional, and radiological outcomes of arthroscopic SCR with arthroscopic PR and arthroscopic DB in patients with irreparable posterosuperior RC tears. It was hypothesized that SCR would lead to superior clinical and functional outcomes compared with PR or DB.

Study Design

Cohort study; Level of evidence, 3.

Methods

Clinical and functional outcomes of this single-center retrospective study included range of motion, strength, and the age- and sex-adjusted Constant-Murley score. Patient-reported outcome measures (PROMs) involved the quick Disabilities of the Arm, Shoulder and Hand score, the Subjective Shoulder Value, and the visual analog scale for pain. Graft and repaired tendon integrity was evaluated by magnetic resonance imaging (MRI) at 12 months of follow-up.

Results

In total, 57 patients treated with SCR (n = 20), PR (n = 17), and DB (n = 20) were included. The mean clinical follow-up was 33.8 ± 17.9 months. Preoperative clinical and functional characteristics were comparable among the 3 groups. The range of motion and clinical and functional scores of all 3 groups significantly improved from pre- to postoperatively. Postoperative PROMs showed no differences among all 3 study groups. SCR revealed significantly higher postoperative strength compared with PR (P = .001) and DB (P = .004). Postoperative MRI revealed a rerupture in 4 patients with SCR (20%). Postoperative MRI showed a rerupture in 9 patients with PR ( 53%). Fatty muscle infiltration of the supraspinatus and infraspinatus significantly progressed within all 3 study groups in postoperative MRI scans. No clinical and functional differences were observed between intact and reruptured PR.

Conclusion

Patients who underwent SCR had better postoperative strength recovery than patients who underwent PR or DB.

Minimum 5-Year Clinical Outcomes of Arthroscopically Repaired Massive Rotator Cuff Tears: Effect of Age on Clinical Outcomes

BACKGROUND

Massive rotator cuff tears (MRCTs) can be challenging to treat, and the efficacy of repair of MRCTs in older patients has been debated.

PURPOSE

To report minimum 5-year outcomes after primary arthroscopic rotator cuff repair of MRCT and determine whether age affects outcomes.

STUDY DESIGN

Case series; Level of evidence 4.

METHODS

The study included consecutive patients with MRCTs who were treated with arthroscopic rotator cuff repair by a single surgeon between February 2006 and October 2016. MRCTs were defined as ≥2 affected tendons with tendon retraction to the glenoid rim and/or a minimum exposed greater tuberosity of ≥67. Patient-reported outcome (PRO) data collected preoperatively and at a minimum of 5 years included the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numeric Evaluation (SANE) score; the shortened version of the Disabilities of the Arm, Shoulder and Hand score (QuickDASH); the 12-Item Short Form Health Survey (SF-12) Physical Component Summary (PCS); and patient satisfaction. Surgical failure was defined as subsequent revision rotator cuff surgery or conversion to reverse total shoulder arthroplasty. Regression analysis was performed to determine whether age had an effect on clinical outcomes.

RESULTS

A total of 53 shoulders in 51 patients (mean age, 59.7 years; range, 39.6-73.8 years; 34 male, 19 female) met inclusion criteria with a mean follow-up of 8.1 years (range, 5.0-12.1 years). Three shoulders (5.7%) failed at 2.4, 6.0, and 7.1 years. Minimum 5-year follow-up was obtained in 45 of the remaining 50 shoulders (90%). Mean PROs improved as follows: ASES from 58.8 to 96.9 (P < .001), SANE from 60.5 to 88.5 (P < .001), QuickDASH from 34.2 to 6.8 (P < .001), and SF-12 PCS from 41.1 to 52.2 (P < .001). Patient satisfaction was a median of 10 (on a scale of 1-10). Age was not associated with any PRO measures postoperatively (P > .05).

CONCLUSION

This study demonstrated significantly improved clinical scores, decreased pain, and increased return to activity for patients with MRCT at midterm follow-up (mean, 8.1 years; range, 5.0-12.1 years). In this patient cohort, no association was found between age and clinical outcomes.

Poly-l-lactide-co-ε-caprolactone (PLCL) and poly-l-lactic acid (PLLA)/gelatin electrospun subacromial spacer improves extracellular matrix (ECM) deposition for the potential treatment of irreparable rotator cuff tears

Biodegradable subacromial spacer implantation has become practicable for the treatment of irreparable rotator cuff tears (IRCT). However, the relative high degradation rate and inferior tissue regeneration properties of current subacromial spacer may lead to failure regards to long-term survival. It is reported that satisfactory clinical results lie in the surrounding extracellular matrix (ECM) deposition after implantation. This study aims to develop a biological subacromial spacer that would enhance tissue regeneration properties and results in better ECM deposition. Physicochemical properties were characterized on both poly-l-lactide-co-ε-caprolactone (PLCL) dip-coating spacer (monolayer spacer, MS) and PLCL dip-coating + Poly-l-Lactic Acid (PLLA)/Gelatin electrospun spacer (Bilayer Spacer, BS). Cytocompatibility, angiogenesis, and collagen inducibility were evaluated with tendon fibroblasts and endothelial cells. Ultrasonography and histomorphology were used to analyze biodegradability and surrounding ECM deposition after the implantation in vivo. BS was successfully fabricated with the dip-coating and electrospinning technique, based on the human humeral head data. In vitro studies demonstrated that BS showed a greater cytocompatibility, and increased secretion of ECM proteins comparing to MS. In vivo studies indicated that BS promoted ECM deposition and angiogenesis in the surrounding tissue. Our research highlights that BS exhibits better ECM deposition and reveals a potential candidate for the treatment of IRCT in future.

Rotator cuff repair with an interposition polypropylene mesh: A biomechanical ovine study

BACKGROUND

Chronic large to massive rotator cuff tears are difficult to treat and re-tears are common even after surgical repair. We propose using a synthetic polypropylene mesh to increase the tensile strength of rotator cuff repairs. We hypothesize that using a polypropylene mesh to bridge the repair of large rotator cuff tears will increase the ultimate failure load of the repair.

AIM

To investigate the mechanical properties of rotator cuff tears repaired with a polypropylene interposition graft in an ovine ex-vivo model.

METHODS

A 20 mm length of infraspinatus tendon was resected from fifteen fresh sheep shoulders to simulate a large tear. We used a polypropylene mesh as an interposition graft between the ends of the tendon for repair. In seven specimens, the mesh was secured to remnant tendon by continuous stitching while mattress stitches were used for eight specimens. Five specimens with an intact tendon were tested. The specimens underwent cyclic loading to determine the ultimate failure load and gap formation.

RESULTS

The mean gap formation after 3000 cycles was 1.67 mm in the continuous group, and 4.16 mm in the mattress group (P = 0.001). The mean ultimate failure load was significantly higher at 549.2 N in the continuous group, 426.4 N in the mattress group and 370 N in the intact group (P = 0.003).

CONCLUSION

The use of a polypropylene mesh is biomechanically suitable as an interposition graft for large irreparable rotator cuff tears.

Outcomes and Survivorship 5 Years After Arthroscopic Rotator Cuff Repair in Active Patients 70 Years and Older

Background

Rotator cuff tears are common in the elderly population and are associated with increased pain, decreased function, and decreased enjoyment of recreational activities.

Purpose

To evaluate clinical outcomes at a minimum of 5 years after arthroscopic repair of full-thickness rotator cuff tears in recreational athletes aged ≥70 years at the time of surgery.

Study Design

Case series; Level of evidence, 4.

Methods

Included were recreational athletes aged ≥70 years who underwent arthroscopic rotator cuff repair (RCR) from December 2005 to January 2016. Patient and surgery characteristics were collected prospectively and retrospectively reviewed. Patient-reported outcome (PRO) scores utilized were the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), the shortened version of Disabilities of the Arm, Shoulder and Hand score (QuickDASH), 12-Item Short Form Health survey (SF-12) questionnaire (Physical Component Summary and Mental Component Summary), and patient satisfaction. Kaplan Meier survivorship analysis was performed, with failure defined as revision RCR or retear on magnetic resonance imaging (MRI).

Results

Overall, 71 shoulders (n = 67 patients [44 men, 23 women]; mean age, 73.4 years [range, 70.1-81.3 years]) were included in this study. Follow-up data was obtained for 65 of the 69 available shoulders (94%) at a mean of 7.8 years (range, 5-15.3 years). Mean age at follow-up was 81.2 years (range, 75.7-91.0). One RCR was revised after a traumatic accident, and another had a symptomatic, MRI-confirmed retear. One patient had lysis of adhesions for stiffness 3 months postoperatively. All PRO scores improved from pre- to postoperatively-ASES, from 55.3 to 93.6; SANE, from 62 to 89.6; QuickDASH, from 32.9 to 7.3; and SF-12 Physical Component Summary, from 43.3 to 53 (P < .001 for all)-and the median satisfaction score was 10 out of 10. Postoperatively, 63% of the patients returned to their original fitness program and 33% of patients modified their recreational activity. Survivorship analysis showed a 98% survival rate at 5 years and a 92% rate at 10 years.

Conclusion

Sustained improvement in function, reduced pain, and return to activities was seen after arthroscopic RCR in active patients ≥70 years old. Despite one-third of patients modifying their recreational activity, the cohort reported high levels of satisfaction and general health.

Effectiveness of Exercises With Electromyographic Biofeedback in Conservative Treatment of Massive Rotator Cuff Tears: A Randomized Controlled Study

OBJECTIVE

The aim of the study is to investigate the effectiveness of a rehabilitation program with electromyographic biofeedback compared with the control group on patients with massive rotator cuff tear.

DESIGN

Forty-six adults with massive rotator cuff tears, randomly assigned to 2 groups (23 electromyographic biofeedback group vs. 23 control group). The electromyographic biofeedback group (experimental group) performed the exercises under the guidance of electromyographic biofeedback, unlike the control group. All patients underwent a 45-minute training session a day, 3 times a week over a 6-wk duration, and followed up until 1-year. The outcome measures were American Shoulder and Elbow score, shoulder flexion strength, shoulder range of motion, Numeric Pain Rating Scale, and Global Rating of Change Scale.

RESULTS

Compared with the control group, the electromyographic biofeedback group demonstrated a significant change in shoulder flexion strength and patient satisfaction from baseline to 6 wks (posttraining) and from baseline to 12-mo follow-up ( F = 4.671, P = 0.005). There were significant improvements in within groups statistics for American Shoulder and Elbow score, shoulder flexion strength, shoulder range of motion, and Numeric Pain Rating Scale in both groups ( P < 0.05).

CONCLUSIONS

The results demonstrate that deltoid-focused structured rehabilitation program combined with electromyographic biofeedback can be used to increase shoulder flexion strength and patient satisfaction in conservative treatment of massive rotator cuff tear.

The statistical fragility of studies on rotator cuff repair with graft augmentation

BACKGROUND

Clinical decision-making often relies on evidence-based medicine. Our purpose was to determine the fragility index (FI) and fragility quotient (FQ) for studies evaluating rotator cuff repair (RCR) with graft augmentation. A lost to follow-up (LTF) value greater than the FI indicates statistical instability for the reported outcomes and conclusions.

METHODS

We performed a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines by searching PubMed, the Cochrane library, and Embase in June 2022 to identify studies of RCR with graft augmentation. Comparative studies with at least 1 statistically analyzed dichotomous outcome were included. Seventeen studies published in seven peer-reviewed journals from 2003 to 2019 were subsequently evaluated. The FI was determined by changing each reported outcome event within 2 × 2 contingency tables until statistical significance or nonsignificance was reversed. The associated FQ was determined by dividing the FI by the sample size. LTF values were also extracted from each included study.

RESULTS

The included studies had a total of 1098 patients with 36 dichotomous outcomes. The associated median FI was 4 (interquartile range 2-5), indicating that the reversal of 4 patients' outcomes would have reversed the finding of significant difference. The median FQ was 0.08 (interquartile range 0.04-0.15), indicating that in a sample of 100 patients, reversal of 8 patients' outcomes would reverse statistical significance. The median number of patients LTF was 3 (range 0-25), with 56% of reported outcomes having LTF greater than their respective FI.

CONCLUSION

Studies of RCR with graft augmentation lack statistical stability, with few altered outcome events required to reverse statistical significance. Larger comparative studies with better follow-up will strengthen the statistical stability of the evidence for RCR with graft augmentation. For future investigations and reports, we recommend including FI and FQ along with traditional statistical significance analyses to provide better context on the strength of conclusions.

Superior Capsule Reconstruction Using Acellular Dermal Allograft Secured at 45° of Glenohumeral Abduction Improves the Superior Stability of the Glenohumeral Joint in Irreparable Massive Posterosuperior Rotator Cuff Tears

PURPOSE

The purpose of the current study was to create a dynamic cadaveric shoulder model to determine the effect of graft fixation angle on shoulder biomechanics following SCR and to assess which commonly used fixation angle (30° vs 45° of abduction) results in superior glenohumeral biomechanics.

METHODS

Twelve fresh-frozen cadaveric shoulders were evaluated using a dynamic shoulder testing system. Humeral head translation, subacromial and glenohumeral contact pressures were compared among 4 conditions: 1) Intact, 2) Irreparable supra- and infraspinatus tendon tear, 3) SCR using acellular dermal allograft (ADA) fixation at 30° of abduction, and 4) SCR with ADA fixation at 45° of abduction.

RESULTS

SCR at both 30° (0.287 mm, CI: -0.480 - 1.05 mm; P < .0001) and 45° (0.528 mm, CI: -0.239-1.305 mm; P = .0006) significantly decreased superior translation compared to the irreparably torn state. No significant changes in subacromial peak contact pressure were observed between any states. The average glenohumeral contact pressure increased significantly following creation of an irreparable RCT (373 kPa, CI: 304-443 vs 283 kPa, CI 214-352; P = .0147). The SCR performed at 45° (295 kPa, CI: 226-365, P = .0394) of abduction significantly decreased the average glenohumeral contact pressure compared to the RCT state. There was no statistically significant difference between the average glenohumeral contact pressure of the intact state and SCR at 30° and 45°.

CONCLUSION

SCR improved the superior stability of the glenohumeral joint when the graft was secured at 30° or 45° of glenohumeral abduction. Fixation at 45° of glenohumeral abduction provided more stability than did fixation at 30°.

CLINICAL RELEVANCE

Grafts attached at 45° of glenohumeral abduction biomechanically restore the glenohumeral stability after SCR using ADA better than fixation at 30° of glenohumeral abduction.

Design and bioprinting for tissue interfaces

Tissue interfaces include complex gradient structures formed by transitioning of biochemical and mechanical properties in micro-scale. This characteristic allows the communication and synchronistic functioning of two adjacent but distinct tissues. It is particularly challenging to restore the function of these complex structures by transplantation of scaffolds exclusively produced by conventional tissue engineering methods. Three-dimensional (3D) bioprinting technology has opened an unprecedented approach for precise and graded patterning of chemical, biological and mechanical cues in a single construct mimicking natural tissue interfaces. This paper reviews and highlights biochemical and biomechanical design for 3D bioprinting of various tissue interfaces, including cartilage-bone, muscle-tendon, tendon/ligament-bone, skin, and neuro-vascular/muscular interfaces. Future directions and translational challenges are also provided at the end of the paper.

Irreparable Massive Rotator Cuff Tears: Subacromial Balloon Surgical Technique

Massive irreparable rotator cuff tears pose a significant challenge for both the treating orthopedic surgeon and patient. Surgical treatment options for massive rotator cuff tears include arthroscopic debridement, biceps tenotomy or tenodesis, arthroscopic rotator cuff repair, partial rotator cuff repair, cuff augmentation, tendon transfers, superior capsular reconstruction, subacromial balloon spacer, and ultimately reverse shoulder arthroplasty. The present study will provide a brief overview of these treatment options along with a description of the surgical technique for subacromial balloon spacer placement.

Rotator Cuff Injury and Repair

Rotator cuff pathology is a commonly encountered clinical and radiologic entity that can manifest as tendinopathy or tearing. Magnetic resonance imaging (MRI) and ultrasonography offer similar sensitivity and specificity for the evaluation of the native rotator cuff, and the chosen modality may vary, depending on local practice and accessibility. MR arthrography is frequently used in the postoperative setting as a problem-solving tool. Key findings to include in the preoperative MRI report include the size and location of the tear, thickness of the tendon involved (partial versus full thickness), and overall tendon quality. The report should also address features associated with poor surgical outcomes, such as fatty atrophy, a decreased acromiohumeral interval, and evidence of rotator cuff arthropathy. Musculoskeletal radiologists should be familiar with the various surgical techniques and expected postoperative imaging appearance of rotator cuff repairs. Imaging also plays a role in identifying recurrent tearing, graft failure, hardware loosening, infection, and other complications.

Posterior Shoulder Pain and Muscle Wasting in an Older Adult

Musculoskeletal injuries are among the most common chief complaints in the geriatric population. Shoulder pain with associated deformity should be evaluated for possible joint dislocations, fractures, and musculotendinous tears. A comprehensive evaluation beginning with history and physical examination is important. Typical imaging utilized for the diagnosis of shoulder injuries includes plain radiography, ultrasound, and magnetic resonance imaging (MRI). We present a case of a 75-year-old male with massive rotator cuff tears and subsequent shoulder deformity. Management with non-surgical or surgical approaches should begin as soon as possible to delay the development of rotator cuff arthropathy.

InSpace Implant Compared with Partial Repair for the Treatment of Full-Thickness Massive Rotator Cuff Tears: A Multicenter, Single-Blinded, Randomized Controlled Trial

BACKGROUND

The purpose of this study was to prospectively evaluate the efficacy and safety of a subacromial balloon spacer (InSpace implant; Stryker) compared with arthroscopic partial repair in patients with irreparable, posterosuperior massive rotator cuff tears.

METHODS

Patients ≥40 years of age with symptomatic, irreparable, posterosuperior, massive rotator cuff tears and an intact subscapularis who underwent failed nonoperative management were included in this randomized controlled trial comparing the InSpace implant with partial repair. Clinical outcome data were collected at baseline through a 24-month follow-up. The primary outcome was improvement in the American Shoulder and Elbow Surgeons (ASES) scores. The secondary outcomes included change from baseline in the Western Ontario Rotator Cuff (WORC) score, the visual analog scale (VAS) pain score, the Constant-Murley shoulder score, the EuroQol-5 Dimensions-5-Level (EQ-5D-5L) score, active range of motion, and operative time. Complications and reoperations for each group were also recorded.

RESULTS

Twenty sites randomized 184 patients: 93 in the InSpace group and 91 in the partial repair group. Significant and clinically relevant improvements in the ASES score from baseline were noted in both groups at Month 12 and were maintained at Month 24. Overall, 83% of patients in the InSpace group and 81% of patients in the partial repair group achieved the ASES minimally clinically important difference threshold, and 82% of patients in the InSpace group and 79% of patients in the partial repair group achieved the substantial clinical benefit threshold. Forward elevation was significantly greater in the InSpace group compared with the partial repair group at Day 10 (p = 0.04), Week 6 (p = 0.0001), Month 12 (p = 0.005), and Month 24 (p = 0.003). The operative time was significantly shorter in the InSpace group (p < 0.0001). No device-related surgical complications were noted, and 4 reoperations after InSpace implantation and 3 reoperations after partial repair were required.

CONCLUSIONS

The InSpace implant is an appropriate alternative to partial repair in patients with irreparable posterosuperior massive rotator cuff tears and an intact subscapularis. Notable benefits include early functional recovery and pain relief combined with a shorter operative time.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Early-stage inflammation changes in supraspinatus muscle after rotator cuff tear

BACKGROUND

Rotator cuff (RC) tendon tear leads to impaired shoulder function and pain. The supraspinatus (SS) tendon is most often affected, but the biological response of the SS muscle to SS tendon tear is largely unknown. This study aimed to investigate time-dependent muscle inflammation, degeneration, fatty infiltration, and regeneration in experimental SS tear conditions.

METHODS

Forty-five C57BL/6 mice were subjected to SS tendon tear and allowed to recover for 1, 3, 5, 7, 14, or 28 days. The extent of muscle damage was examined using histologic, flow cytometric, proteomic, and chemiluminescence analyses.

RESULTS

We found that muscle inflammation peaked around day 5 with increased monocyte infiltration and increased cytokine levels in the ipsilateral compared to the contralateral SS muscle. Bioinformatics analysis of proteomics on mice that survived 5 days after RC tendon tear revealed upregulated proteins involved in "neutrophil activation involved in immune response" and "extracellular matrix organization," whereas "skeletal muscle tissue development and contraction" and "respiratory electron transport chain" were among the most downregulated. Histologic analysis of collagen showed increased collagen accumulation and fatty infiltration of the ipsilateral SS over time. Finally, we observed time- and lesion-dependent changes in satellite cell and fibro-adipogenic progenitor populations.

CONCLUSION

Altogether, we demonstrate that the SS muscle shows severe signs of acute inflammation, early degeneration, and fatty infiltration, as well as reduced regenerative potential following SS tendon tear.

Functional outcome following arthroscopic repair of massive rotator cuff tears is equal to smaller rotator cuff tears: a retrospective case-control study

BACKGROUND

There is a paucity of studies comparing patient-reported outcomes of arthroscopic massive rotator cuff repairs against non-massive rotator cuff repairs. The aim of this study is to assess the Quick Disabilities of the Arm, Shoulder and Hand questionnaire and Oxford Shoulder Score at a minimum of one-year follow-up according to the size of the rotator cuff tear.

METHODS

A retrospective case-control study was undertaken. All patients underwent rotator cuff repairs using the same technique by a single surgeon. Quick Disabilities of the Arm, Shoulder and Hand questionnaire and Oxford Shoulder Score were collected pre-operatively and at final review with a minimum follow-up of one year. Patients with massive rotator cuff repairs were compared to patients who had non-massive rotator cuff repairs.

RESULTS

Eighty-two patients were included in the study of which 42 (51%) underwent massive rotator cuff repair. The mean follow-up period was 17.5 months. Quick Disabilities of the Arm, Shoulder and Hand questionnaire improved significantly (p < 0.001) from 46.1 pre-operatively to 15.6 at final follow-up for massive rotator cuff repairs. Oxford Shoulder Score improved significantly (p < 0.001) from 26.9 pre-operatively to 41.4 at final follow-up for massive rotator cuff repairs. There was no significant difference in the final Quick Disabilities of the Arm, Shoulder and Hand questionnaire (p = 0.35) or Oxford Shoulder Score (p = 0.45) between the groups. No revision surgery was required within the follow-up period.

CONCLUSION

Arthroscopic massive rotator cuff repairs have comparable functional outcome to smaller rotator cuff repair in the short-term and should be considered in a selected group of patients.

Reverse Total Shoulder Arthroplasty for Treatment of Massive, Irreparable Rotator Cuff Tear

Massive tears of the rotator cuff can result in severe functional deficits due to loss of the axial force couple and effective fulcrum that the intact cuff normally provides. For massive, irreparable rotator cuff tears, especially in the setting of early to moderate degenerative changes, reverse total shoulder arthroplasty functions to modify the center of joint rotation, allowing the deltoid and intact components of the cuff to carry out shoulder function more effectively. Our preferred technique uses a standard open deltopectoral shoulder approach with a 3-dimensional glenoid baseplate model and a 135° prosthesis in an onlay configuration to reduce the risk of scapular notching and increase lateralization of the humerus.

Outcome Comparison of Latissimus Dorsi Transfer and Pectoralis Major Transfer for Irreparable Subscapularis Tendon Tear: A Systematic Review

BACKGROUND

Latissimus dorsi transfer (LDT) and pectoralis major transfer (PMT) were developed to treat an irreparable subscapularis tendon tear (ISScT); however, the difference in their outcomes remains unclear.

PURPOSE

To systematically review and compare the outcomes of LDT and PMT for ISScT.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was performed through a comprehensive search of Embase, PubMed, and the Cochrane Library. Studies of LDT or PMT were included according to the inclusion and exclusion criteria. The primary outcome was the Constant-Murley score (CMS) at the final follow-up. Secondary outcomes included the subjective shoulder value (SSV), visual analog scale (VAS) score for pain, active shoulder range of motion, and the belly-press and lift-off tests. Postoperative failure and complication rates were the safety outcome measures. Outcomes were summarized into the LDT and PMT groups, and results were compared statistically (P < .05).

RESULTS

Twelve studies were included in this review: 184 shoulders from 9 studies for the PMT group and 85 shoulders from 3 studies for the LDT group. For the PMT and LDT groups, the mean ages were 58.9 and 55.1 years, respectively, and the mean follow-up was 66.9 and 17.4 months, respectively. Overall, the LDT and PMT groups improved in the primary outcome (CMS) and secondary outcomes (SSV, VAS, ROM, and belly-press and lift-off tests), with low rates of failure and complication. When compared with the PMT group, the LDT group showed more significant improvements in CMS (35.2 vs 24.7; P < .001), active forward flexion (44.3° vs 14.7°; P < .001), abduction (35.0° vs 17.6°; P < .002), and positive belly-press test rate (45% vs 27%; P < .001). No statistically significant difference was seen between the groups in postoperative failure rate, complication rate, mean improvement of active internal rotation, VAS, or SSV.

CONCLUSION

In general, LDT showed significantly better clinical outcomes postoperatively than did PMT. The available fair-quality evidence suggested that LDT might be a better choice for ISScT. Further evaluations on the relative benefits of the 2 surgical approaches are required, with more high-quality randomized controlled studies.

Biceps-incorporating rotator cuff repair with footprint medialization in large-to-massive rotator cuff tears

PURPOSE

In large-to-massive rotator cuff tears (MRCTs), incorporating the long head of the biceps tendon (LHBT) with arthroscopic partial rotator cuff and margin convergence can improve clinical outcomes and preserve the acromio-humeral interval (AHI) during mid-term follow-up. The purpose of this study was to evaluate mid-term clinical and radiological outcomes of arthroscopic biceps-incorporating rotator cuff repair with partial release of the LHBT and footprint medialization through the Neviaser portal in MRCTs.

METHODS

This study enrolled 107 patients (38 males and 69 females, mean age: 64.9 ± 8.6 years) with MRCTs. A novel arthroscopic biceps-incorporating repair was performed by footprint medialization, with a partially released biceps tendon covering central defects. Clinical outcomes such as pain VAS, KSS, ASES, UCLA, SST and CS scores and ROM were evaluated at a mean follow-up time of 35 months (range 12-132 months). Serial radiographs with a mean postoperative MRI follow-up duration of 33 months were used to evaluate AHI, tendon integrity, fatty infiltration (FI) and muscle hypotrophy.

RESULTS

Postoperative pain VAS, KSS, ASES, UCLA, SST, and CS scores and ROM (except external rotation) were improved significantly. AHI also improved significantly from 8.6 to 9.3 mm. According to Sugaya's classification, type I, II, III, IV, or V healing status was found in 30 (28.0%), 29 (27.1%), 26 (24.3%), 14 (13.1%), and 8 (7.5%) patients, respectively. The retear rate was 22 (20.6%).

CONCLUSIONS

Novel biceps-incorporating cuff repair with footprint medialization yielded satisfactory outcomes in MRCT patients at the 3-year follow-up. A partially released, repaired biceps tendon provided superior stability with preserved AHI similar to that of anterior cable reconstruction.

LEVEL OF EVIDENCE

IV.