Does microvascularization of the footprint play a role in rotator cuff healing of the shoulder?

Corticosteroid injection of the knee within one month prior to meniscus repair increases the risk of repair failure requiring meniscectomy

OBJECTIVE

Meniscal tears are common knee injuries with limited endogenous healing capacity. This study aimed to investigate the association between the timing and administration of preoperative intra-articular corticosteroid injections (CSIs) and the risk of subsequent meniscectomy following meniscus repair.

METHODS

Using a national insurance claims database, patients aged 18-40 years undergoing meniscus repair within six months of tear diagnosis were studied. Patients were categorized based on whether they received preoperative CSIs within three intervals prior to repair. Multivariable logistic regression was used to analyze the risk of follow-up meniscectomy while controlling for various patient-related variables.

RESULTS

Among 5,390 patients meeting inclusion criteria, 201 received preoperative CSIs. The CSI group was older and had higher rates of diabetes, obesity, and knee osteoarthritis. The overall rate of follow-up meniscectomy did not differ between groups. However, CSIs performed within one month prior to repair were associated with significantly higher odds of subsequent meniscectomy compared to CSIs performed between three and six months prior. Obesity, tobacco use, and knee osteoarthritis were also independently associated with higher risk, while increasing age was associated with lower risk.

CONCLUSION

The study highlights an increased risk of repair failure requiring follow-up meniscectomy for patients receiving intra-articular CSIs within one month prior to meniscus repair. These findings suggest caution when considering CSIs as a treatment option for patients scheduled for meniscus repair. Further research is needed to establish optimal timing guidelines for CSIs in relation to meniscus repair and to understand the underlying mechanisms.

Relationship between hematoma-like tissue on the footprint and structural outcome of arthroscopic rotator cuff repair with a transosseous technique

Background

We have tried to create hematoma over the footprint site at the end of arthroscopic rotator cuff repair (ARCR) surgery, expecting to apply biochemical effects of the platelet-related factors. The purpose of this study was to investigate the presence of hematoma-like tissue (HLT) on postoperative magnetic resonance imaging, and to evaluate the relationship between the HLT and the structural outcomes of ARCR.

Materials and methods

Twenty-five patients were reviewed with a mean age at surgery of 69.8 years (range, 52-85 years). Postoperative magnetic resonance imaging was performed at 1 week, 6-8 weeks, and >6 months postoperatively. Structural outcomes for the repaired cuff and thickness of HLT were evaluated on coronal T2-weighted images. Signal intensity of HLT was evaluated on coronal T2-weighted fat-suppressed images as the ratio compared to supraspinatus tendon intensity (HLT/SSP ratio).

Results

Structural outcomes showed Sugaya type 1 in 12 shoulders, type 2 in 4, and type 3 in 9. HLT thickness was significantly thicker at 1 week and 6-8 weeks postoperatively in Sugaya type 1 patients than in type 3 patients (1 week; P = .014, 6-8 weeks; P < .001). HLT/SSP ratio gradually decreased (at 1 week; 1.9 ± 0.7, 6-8 weeks; 1.6 ± 0.6, >6 months; 1.2 ± 0.5), and differed significantly between >6 months and both 1 week and 6-8 weeks (P < .001 each).

Functional and Structural Outcomes After Arthroscopic Rotator Cuff Repair With or Without Preoperative Corticosteroid Injections

BACKGROUND

Corticosteroid injections (CSIs) are effective in alleviating pain in patients with rotator cuff tears, but controversy still exists regarding their potential adverse effects on clinical outcomes after rotator cuff repair.

PURPOSE

To compare both the functional and the structural outcomes in patients who underwent arthroscopic rotator cuff repair with or without preoperative CSIs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective cohort study was carried out among patients who underwent arthroscopic rotator cuff repair for partial- and full-thickness tears between 2015 and 2019. The patients who received preoperative CSIs were included in the CSI group and compared with a group without preoperative CSIs (non-CSI group), matched at a ratio of 1:2 based on tear size, age, and follow-up time. Both functional evaluation and structural assessments using magnetic resonance imaging (MRI) were performed at the final follow-up. Clinical outcomes-including retear rate as the primary outcome; pain; functional scores including the Constant-Murley score, American Shoulder and Elbow Surgeons score, and Fudan University Shoulder Score; range of motion (ROM); tendon integrity; tendon healing type; and cartilage thickness-were compared between the 2 groups with a statistical significance of P < .05 and power of 0.9.

RESULTS

Thirty-one patients were included in the CSI group, and 62 were included in the non-CSI group. After a mean 3-year follow-up, the 2 groups demonstrated no significant differences in retear rate; visual analog scale for pain; shoulder functional scores; and active ROM including forward flexion, abduction, external rotation, and internal rotation. No significant differences were observed on postoperative MRI scans of the rotator cuff tendon (tendon integrity, healing type, residual tendon attachment area, etc), cartilage thickness, and muscle atrophy.

CONCLUSION

No significant differences were found at a mean 3-year follow-up in the retear rates, pain, ROM, and glenohumeral structure on postoperative MRI scans after arthroscopic rotator cuff repair with or without preoperative CSIs.

Better Short-Term Outcomes After Rotator Cuff Repair in Studies With Poorer Mean Shoulder Scores and Predominantly Small to Medium-Sized Tears at Baseline: A Systematic Review and Meta-analysis

PURPOSE

To perform a meta-analysis to explore factors associated with clinical and structural short-term outcomes in randomized and nonrandomized prospective studies of rotator cuff repair.

METHODS

Medline, clinicaltrials.gov, and Mendeley were searched for literature published from January 2000 to December 2020 to identify randomized controlled trials (RCT) and nonrandomized prospective cohort studies (PCS) describing the outcome of surgical repair of full-thickness rotator cuff tears. Study quality was assessed by two independent reviewers. We calculated standardized mean difference (SMD) from baseline to follow-up in each trial arm, preferably at 12 months follow-up. Between-study heterogeneity of outcomes, small-study effects and rates of retear were assessed. Meta-regression was performed to estimate associations between prespecified variables and clinical and structural outcomes.

RESULTS

Outcomes in 64 RCT and 19 PCS trial arms were analyzed. Median age was 59 years. There was substantial between-study heterogeneity in clinical outcomes (SMD range: .42 to 6.44; I² = 93% in RCT, 88% in PCS) and summary estimates were not calculated. On the basis of multivariate analysis, better clinical outcome was associated with lower (worse) mean outcome value at baseline, smaller tear size, and lower proportion of large-massive tears (R² = 56 and 44%, respectively). Overall retear rate at median 13-month follow-up was 19.9% (interquartile range: 10-30). Higher mean age together with larger tear size and higher proportion of large-massive tears were associated with increased retear rates (R² = 33% and 58%, respectively). Clinical outcome was not significantly related to rate of retear.

CONCLUSIONS

Studies with lower mean outcome values at baseline and predominantly small- to medium-sized tears reported better clinical outcomes. Studies with higher mean age and a predominance of large-massive tears had significantly increased retear rates, but retear rates were not associated with clinical outcome.

LEVEL OF EVIDENCE

Level II, meta-analysis of level I and II studies.

Dexamethasone decreases postoperative opioid and antiemetic use in shoulder arthroplasty patients: a prospective, randomized controlled trial

BACKGROUND

Multimodal pain control can be beneficial in relieving postoperative pain and limiting narcotic use following orthopedic procedures. Additionally, with increasing interest in outpatient arthroplasty procedures, providers have interest in adequate early postoperative pain control and complications. The purpose of this study was to investigate the effect of dexamethasone on pain, postoperative nausea and vomiting, and length of stay following total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

METHODS

One hundred twelve patients undergoing TSA or RTSA by a single surgeon were assessed for inclusion in this investigation. We performed a prospective randomized controlled trial to investigate the effect of 10 mg of dexamethasone administered within 90 minutes of surgery. Primary outcome assessed was the average morphine equivalent use over the first 24 hours postsurgery. Secondary outcomes included postoperative visual analog scale (VAS) scores, antiemetic use, postoperative nausea and vomiting, and complications.

RESULTS

A total of 75 patients were included in the final analysis, with 32 patients (42.7%) randomized to the control group and 43 (57.3%) randomized to the dexamethasone group. Body mass index was significantly greater in the control group (33.8 vs. 30.3, P = .014); otherwise, there were no significant demographic differences between groups. Average ondansetron use was significantly lower in the dexamethasone group compared with controls for the 0- to 4-hour interval (0.1 vs. 0.9 mg, respectively, P = .006) and was lower overall for the first 24 hours (0.3 vs. 1.0 mg, P = .025). Differences in VAS scores were significantly lower in the dexamethasone group at all time points (P < .05 for all). The average VAS score over the 24-hour period for the dexamethasone group was also significantly lower than the controls (3 vs. 6, P < .001). Morphine equivalent use was significantly lower in the dexamethasone group compared with controls at 12-16 hours (1.7 vs. 4.0 mg, respectively, P = .004) and at 16-20 hours (1.7 vs. 3.4 mg, respectively, P = .006). When averaged over the first 24 hours, morphine equivalent was also significantly lower in the dexamethasone group (16.1 vs. 25.4 mg, P = .007). There was no significant difference in glucose control or complications between groups.

CONCLUSION

Dexamethasone decreases opioid requirements in the first 24 hours following surgery, provides improved pain control, and decreases antiemetic use following shoulder arthroplasty. Dexamethasone is an important multimodal adjunct for controlling pain and postoperative nausea and vomiting following primary TSA.

How periarticular corticosteroid injections impact the integrity of arthroscopic rotator cuff repair

INTRODUCTION

Multimodal analgesic (MMA) injections combined with corticosteroids have recently been shown to be effective for managing pain after arthroscopic rotator cuff repair.

HYPOTHESIS

The goal of this study was to analyze the effects of corticosteroid injections on the integrity of tendon repairs using magnetic resonance imaging (MRI). The hypothesis was that MMA injections combined with corticosteroids have no deleterious effects on functional outcomes and tendon healing 1 year after surgical rotator cuff repair.

METHODS

This was a prospective, double-blind study of 50 patients undergoing arthroscopic rotator cuff repair who were randomized into two groups. The study group (n=25) received a periarticular injection of a mixture of ropivacaine, morphine and methylprednisolone at the end of the procedure. The control group (n=25) received a placebo injection. The clinical outcomes were the pain level and complications, while the functional outcomes consisted of the Constant-Murley Score (CMS), American Shoulder and Elbow Surgeons Shoulder (ASES) score and Simple Shoulder Test (SST). The structural integrity of the operated tendons was analyzed on MRI at a mean follow-up of 15.1±1.3 months for the study group and 15.2±1.1 for the control group (p=0.848).

RESULTS

Pain on a visual analog scale was significantly reduced in both groups after the surgery. Nevertheless, there was no significant difference between groups at the final follow-up visit (p=0.803). Compared to the preoperative values, the CMS, ASES and SST significantly improved in both groups after surgery but were not significantly different between groups at the final assessment (p=0.801, 0.869 and 0.769, respectively). MRI revealed supraspinatus tendon retears in 16% of patients in the study group and 36% in the control group (p=0.107). There were no infections in the study group as of the final assessment. Advanced age (p=0.049), diabetes (p<0.01) and posterior extension of the tear (p=0.039) negatively impact healing. Corticosteroid injection did not negatively impact healing (p=0.197).

CONCLUSION

This study shows that MMA injection combined with corticosteroids does not alter the tendon healing, clinical outcomes, or functional outcomes 1 year after arthroscopic rotator cuff repair. It remains a safe and effective analgesia method during rotator cuff repair surgery.

LEVEL OF EVIDENCE

II, low-powered placebo-controlled, randomized study.

Corticosteroid Injections May Increase Retear and Revision Rates of Rotator Cuff Repair: A Systematic Review

PURPOSE

To synthesize the clinical outcome data of preoperative and postoperative corticosteroid injections (CIs) and their effect on rotator cuff repairs (RCRs).

METHODS

A systematic review was performed to identify studies that reported the results or clinical outcomes of RCRs in patients receiving either preoperative or postoperative CIs. The searches were performed using MEDLINE, Google Scholar, and Embase, and studies were chosen following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.

RESULTS

A total of 11 studies were included with data for 176,352 shoulders: 6 studies involving 175,256 shoulders with data regarding preoperative CIs, 4 studies involving 1,096 shoulders with data regarding postoperative CIs, and 1 study with 212 shoulders containing preoperative and postoperative data. Preoperative CIs were found in 3 studies to increase the risk of revision surgery when administered within 6 months (odds ratio [OR], 1.38-1.82) and up to 1 year (OR, 1.12-1.52) prior to RCR, with revision rates in 2 studies being highest when patients received 2 or more injections (OR, 2.12-3.26) in the prior year. Postoperative CIs reduced pain and improved functional outcomes in 5 studies without increasing the retear rates (5.7%-19% for CI and 14%-18.4% for control) in most studies.

CONCLUSIONS

CIs provide benefit by relieving pain and improving functional outcome scores. However, repeated preoperative CIs may increase retear rates and the likelihood of revision surgery. A lower frequency of CI and longer preoperative waiting period after CI should be considered to decrease such risks. Postoperative CIs several weeks after RCR do not appear to increase retear rates.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Clinical and functional outcomes of a novel transosseous device to treat rotator cuff tears: A minimum 2-year follow-up

PURPOSE

Despite the improvements in the repair equipment techniques of rotator cuff, a gold standard method has not been defined yet and transosseous fixation through deltoid-splitting (mini-open) approach is still regarded as a good option. The primary purpose of this study is to present satisfactory clinical and functional outcomes with a novel transosseous device in full-thickness rotator cuff tear through deltoid-splitting.

MATERIALS AND METHODS

This retrospective study was performed on 70 consecutive patients who underwent surgery by a single surgeon from June 2014 to June 2016 for a full-thickness rotator cuff tear and was managed with a novel transosseous device. Total number of patients, mean age, percentage of male and female patients, mean duration of follow-up, percentage of involvement of the dominant extremity, affected shoulder, and tear size were recorded. Functional and clinical outcomes were assessed baseline and postoperatively at 3 and 6 months and final follow-up using Disabilities of the Arm, Shoulder and Hand (Q-DASH) and Constant-Murley scores.

RESULTS

A total of 70 (49 (70%) female, 21 (30%) male) patients whose mean age was 58.66 ± 9.19 (38-77) years were included. The mean surgery time was 35.33 ± 5.34 (28-55) min. The mean follow-up time was 28.31 ± 3.03 (24-36) months. According to the DeOrio and Cofield classification, 15 (21.43%) tears were small, 33 (47.14%) medium, 16 (22.86%) large, and 6 (8.57%) massive. By the final follow-up, the mean Constant-Murley score had significantly improved from 27.67 ± 7.46 (13-41) to 81.25 ± 3.77 (74-87; p = 0.0001) and the Q-DASH score had decreased from 82.34 ± 10.37 (65.91-100) to 10.28 ± 6.88 (0-23.45; p = 0.0001). There were no significant differences in the Constant-Murley or Q-DASH score at baseline-final follow-up between the small, medium, large, and massive tear groups (p > 0.05).

CONCLUSIONS

Treatment of full-thickness rotator cuff tear using this novel transosseous device significantly improved functional and clinical scores. However, further long-term prospective randomized multicenter trials involving comparative studies are necessary to confirm these findings.

Tendon Healing Progression Evaluated With Magnetic Resonance Imaging Signal Intensity and Its Correlation With Clinical Outcomes Within 1 Year After Rotator Cuff Repair With the Suture-Bridge Technique

BACKGROUND

After a rotator cuff (RC) is repaired, its signal intensity (SI) on magnetic resonance imaging (MRI) gradually changes to normal and could reflect the degree of RC healing. Nevertheless, it remains unclear how long it takes for SI to recover to normal and whether the SI progression correlates with clinical outcomes after RC repair (RCR).

PURPOSE

To serially evaluate the SIs of the repaired RC tendon on MRI and the postoperative clinical outcomes and then analyze the correlation between them.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This study prospectively included 25 patients who underwent arthroscopic RCR with the suture-bridge technique between June 2016 and July 2017. Twenty-three patients accepted full follow-ups at 1, 3, 6, 9, and 12 months. Before surgery and at each follow-up, visual analog scale (VAS) for pain and 4 functional scores were evaluated: Constant-Murley score, American Shoulder and Elbow Surgeons shoulder evaluation form, modified University of California at Los Angeles score, and Fudan University shoulder score. The patients underwent MRI examinations at every follow-up. The values of the signal/noise quotient at the distal (SNQd) and proximal (SNQp) areas were calculated to evaluate the SI of the repaired tendon. The correlations of clinical outcomes with SNQd and SNQp values were analyzed, and subgroup analyses were performed.

RESULTS

Overall, the mean postoperative VAS score significantly decreased at postoperative 1 month (P < .001), and the functional scores were all significantly higher than the preoperative values at 6 months (all P < .001). SNQd and SNQp values were both significantly higher than normal at 1 and 3 months (all P < .001) and reduced to normal after 9 and 6 months, respectively. Correlation analyses showed that the SNQp value significantly correlated with VAS score (positive) and all functional scores (negative) at 1 and 3 months postoperatively. Further comparison indicated that the patients with VAS score >3 had higher SNQp values than patients with VAS score ≤3 at 1 and 3 months postoperatively (both P = .01).

CONCLUSION

After RCR with the suture-bridge technique, it took longer for SI to become relatively normal than it did to have a significant clinical improvement. Early after surgery (1-3 months), worse clinical outcome correlated with higher SI on proximal cuff tendon.

No healing improvement after rotator cuff reconstruction augmented with an autologous periosteal flap

PURPOSE

To show descriptive clinical and magnetic resonance (MR) imaging results after an additional periosteal flap augmentation in mini-open rotator cuff reconstruction and to evaluate potential healing improvement at long-term follow-up.

METHODS

Twenty-three patients with degenerative rotator cuff tears were followed after receiving a mini-open single-row repair with a subtendinous periosteal flap augmentation. Data were collected preoperatively, after 12 months and after 11 years. Clinical examination, simple shoulder test (SST), Constant-Murley Score (CS), ultrasonography examination and 3T MR imaging were performed.

RESULTS

Out of 23 patients, 20 were available for short-term and 19 for final follow-up at a median of 11.5 years (range 10.4-13.0). Questions answered with "yes" in SST improved from baseline 5.0 (range 1.0-8.0) to short 10.5 (range 8.0-12.0) and final follow-up 12.0 (range 7.0-12.0). CS improved from 53.5 (range 25.0-66.0) to 80.8 (range 75.9-89.3) and finally to 79.8 points (range 42.3-95.4). Improvement was highly significant (p < 0.05). Severe retears were found in 9/19 patients. Ossifications along the refixed tendon were noticed in 8/19 cases. Ossifications did not correlate with clinical outcome. At final follow-up, patients with retears seemed likely to have lower strength values in CS (mean ± SD) than patients without retears (7.3 ± 4.1 vs. 12.8 ± 5.3; p < 0.05).

CONCLUSION

No positive effect on improving healing response in rotator cuff refixation with a periosteal flap augmentation could be found. Retear rate is comparable to that of conventional rotator cuff refixation in the published literature. Ossifications along the tendon, without negatively affecting the clinical outcome, were seen. This invasive technique cannot be advised and should not be used anymore.

LEVEL OF EVIDENCE

IV.

Substantial Biomechanical Improvement by Extracorporeal Shockwave Therapy After Surgical Repair of Rodent Chronic Rotator Cuff Tears

BACKGROUND

Characteristics of chronic rotator cuff tears include continuous loss of tendon structure as well as tendon elasticity, followed by a high failure rate after surgical reconstruction. Several studies have already shown the beneficial effect of extracorporeal shockwave therapy (ESWT) on tissue regeneration in tendon pathologies.

HYPOTHESIS

ESWT improves biomechanical tendon properties as well as functional shoulder outcomes in chronic rotator cuff reconstruction in rodents.

STUDY DESIGN

Controlled laboratory study.

METHODS

After tendon detachment and 3 weeks of degeneration, a subsequent transosseous reattachment of the supraspinatus tendon was performed in 48 adult male Sprague-Dawley rats (n = 16 per group). Rodents were randomly assigned to 3 study groups: no ESWT/control group, intraoperative ESWT (IntraESWT), and intra- and postoperative ESWT (IntraPostESWT). Shoulder joint function, as determined by gait analysis, was assessed repeatedly during the observation period. Eight weeks after tendon reconstruction, the rats were euthanized, and biomechanical and gene expression analyses were performed.

RESULTS

Macroscopically, all repairs were intact at the time of euthanasia, with no ruptures detectable. Biomechanical analyses showed significantly improved load-to-failure testing results in both ESWT groups in comparison with the control group (control, 0.629; IntraESWT, 1.102; IntraPostESWT, 0.924; IntraESWT vs control, P≤ .001; IntraPostESWT vs control, P≤ .05). Furthermore, functional gait analyses showed a significant enhancement in intensity measurements for the IntraPostESWT group in comparison with the control group (P≤ .05). Gene expression analysis revealed no significant differences among the 3 groups.

CONCLUSION

Clearly improved biomechanical results were shown in the single-application and repetitive ESWT groups. Furthermore, functional evaluation showed significantly improved intensity measurements for the repetitive ESWT group.

CLINICAL RELEVANCE

This study underpins a new additional treatment possibility to prevent healing failure. Improved biomechanical stability and functionality may enable faster remobilization as well as an accelerated return to work and sports activities. Furthermore, as shockwave therapy is a noninvasive, easy-to-perform, cost-effective treatment tool with no undesired side effects, this study is of high clinical relevance in orthopaedic surgery. Based on these study results, a clinical study has already been initiated to clinically confirm the improved functionality by ESWT.

The Timing of Corticosteroid Injections After Arthroscopic Shoulder Procedures Affects Postoperative Infection Risk

BACKGROUND

Corticosteroid injections are sometimes used in the postoperative period after shoulder arthroscopy; however, a well-defined safety profile has not been established.

PURPOSE

To examine the association between the timing of postoperative corticosteroid injections and rates of infection after shoulder arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Private payer and Medicare national insurance databases were queried for patients who underwent arthroscopic rotator cuff repair, debridement, or subacromial decompression. Patients who underwent corticosteroid injections within 1, 2, 3, or 4 months postoperatively were identified and compared with a matched control group that underwent the same procedures without a postoperative steroid injection. International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes were used to identify rates of postoperative infection within 90 days after injection for the study groups and controls. Multivariate binomial logistic regression analysis was used to compare groups, and adjusted odds ratios (ORs) and 95% CIs were calculated, with P < .05 considered significant.

RESULTS

A total of 3946 patients were identified, including 264 patients who received an injection within 1 month after surgery, 471 within 2 months, 1037 within 3 months, 1874 within 4 months, and 2640 matched controls. When compared with controls, patients who underwent a corticosteroid injection within 1 month postoperatively had a significantly higher rate of infection (private payer: OR, 2.63; P = .014; Medicare: OR, 11.2; P < .0001). There were no differences in infection rates at all other time points ( P = .264-.835).

CONCLUSION

This study adds to the evidence suggesting caution when administering injections in the immediate postoperative period after shoulder arthroscopy. Although causality cannot be determined on the basis of this database review, the authors found a significant association between intra-articular corticosteroid injections administered 1 month postoperatively and an increased rate of postoperative infection in Medicare and private payer patient cohorts as compared with a control group.

Preoperative Injections May Be an Iatrogenic Cause of Reoperation After Arthroscopic Rotator Cuff Repair

PURPOSE

To determine whether an association exists between preoperative shoulder injections and reoperations in patients undergoing arthroscopic rotator cuff repair (aRCR).

METHODS

The PearlDiver Patient Records Database was reviewed for Humana-insured patients undergoing aRCR after a shoulder injection. Two matched groups were created: aRCR within 1 year of injection (n = 12,054) and aRCR without prior injection within 1 year of surgery (n = 12,054). Reoperation rates within 3 months, at 3 to 6 months, and at 6 to 12 months postoperatively were assessed. Statistical analysis was performed with the χ-square test.

RESULTS

The rate of reoperation within 3 months of the index procedure was higher in the control group (3.7% vs 3.1%, P = .01); however, 3 to 6 months after the index procedure, the rate of reoperation was higher in patients who received an injection within 1 year of the index procedure (1.8% vs 1.4%, P = .03). During the same intervals, the rate of revision rotator cuff repair (RCR) within 3 months of the index procedure was higher in the control group (2.9% vs 2.6%) and the rate of revision RCR 3 to 6 months after the index procedure was higher in patients who received an injection within 1 year of the index procedure (1.1% vs 0.9%); however, these results were not statistically significant (P = .3 and P = .8, respectively). The incidence of revision RCR (1.6% vs 1.1%; odds ratio, 1.4; P = .003) and incidence of subacromial decompression (1.5% vs 1.1%; odds ratio, 1.3; P = .01) 6 to 12 months after the index procedure were significantly higher in patients receiving an injection within 1 year before surgery.

CONCLUSIONS

Preoperative shoulder injections may increase the risk of revision RCR and subacromial decompression by up to 150% in patients 6 to 12 months after index surgery compared with patients who did not receive a preoperative injection. However, the absolute increase in these revision procedures is only 0.5%.

LEVEL OF EVIDENCE

Level III, comparative study.

Enhancement of rotator cuff tendon-bone healing using bone marrow-stimulating technique along with hyaluronic acid

Objective

The purpose of this study was to investigate the effect of hyaluronic acid (HA) in the tendon–bone healing process after rotator cuff repair in a rabbit model.

Methods

In vitro, rat bone marrow stromal cells (rBMSCs) were cultured in media for cartilage-related and inflammation-related gene expression levels examination at 1.0 mg/mL of HA. In vivo, 48 New Zealand white rabbits underwent rotator cuff repair surgery, and they were randomly divided into three groups: (1) control group (n = 16), (2) microfracture (MF) group accepting MF treatment (n = 16) and (3) MF/HA group accepting MF with HA treatment (n = 16). Four rabbits from each group were sacrificed at 6 and 12 weeks postoperatively for histological evaluation and biomechanical testing.

Results

In vitro experiments reveal that HA significantly decreased inflammation-related mRNA expression (IL-1, TNFα) compared with the control group. At 6 weeks after surgery, there was no significant difference of load-to-failure between groups. At 12 weeks after surgery, the mean failure load of the MF/HA group was significantly higher than that of the control group (100.5 ± 10.1 N vs. 68.0 ± 6.2 N; p = 0.0115). The mean failure load of the MF group appeared higher than that of the control group, whereas there was no significant difference (p > 0.05). Histologically, more chondrocytes were clustered at the tendon–bone interface, and more extracellular matrixes were produced in the MF/HA group. The interface of the MF/HA group appeared similar with the normal tendon–bone interface.

Conclusion

HA may play a crucial role in the acceleration of tendon-to-bone healing which might be through inhibiting inflammation. Rotator cuff repair using MF along with HA led to better tendon–bone healing and a subsequent increase of biomechanical strength at the repair site.

The translational potential of this article

HA injection is very common for patients with rotator cuff disease because of its antiinflammatory action and adhesion prevention preoperatively. The HA injection during surgery provides an antiinflammatory effect during tendon–bone healing process and leads to better tendon–bone healing postoperatively.

Editorial Commentary: "Doctor, Are You Sure the Steroid Injection Won't Harm My Shoulder?" Perhaps We Should Stop Injecting Corticosteroids and Just Repair Those Rotator Cuffs

Analysis of insurance records indicates that 2 or more corticosteroid injections before rotator cuff repair could triple the odds of revision. The cause-and-effect relationship cannot be ascertained because it remains unclear whether steroids worsen outcomes or are injected in shoulders that are worse to start with. Registry studies cannot adjust for lesional determinants of prognosis and should be interpreted with caution to avoid depriving patients from safe and simple treatments to delay or circumvent surgery. The risks of corticosteroids could be mitigated using radiographically guided infiltration and, ultimately, by rapid surgical repair in young patients before the advent of fatty infiltration and tendon retraction.

Greater Tuberosity Decortication Decreases Load to Failure of All-Suture Anchor Constructs in Rotator Cuff Repair

PURPOSE

To evaluate the effect of greater tuberosity decortication on ultimate load to failure and displacement after cyclic loading with an all-suture anchor.

METHODS

A 2.9-mm all-suture anchor was evaluated in decorticated and nondecorticated greater tuberosities of 10 matched pairs of human cadaveric shoulders. Greater tuberosity decortication was performed to a mean depth of 1.7 mm. Anchors were placed in the anterior, middle, and posterior tuberosity. Anchors were tested under cyclic loads followed by load-to-failure testing. Displacement after 20, 100, and 200 cycles and ultimate failure strength were determined. Clinical failure was defined as displacement greater than 5 mm during cyclic loading.

RESULTS

After 20 and 100 cycles, there was no difference in mean displacement between the decorticated and nondecorticated cohorts (P = .139 and P = .127, respectively). The mean displacement after 200 cycles was greater in the decorticated cohort, although not significantly (3.4 vs 2.7 mm; P = .05). The mean ultimate load to failure was significantly lower in the decorticated cohort (314 vs 386 N, P = .049). There were 2 clinical failures in the decorticated specimens and 1 in the nondecorticated specimens.

CONCLUSIONS

A minimal greater tuberosity decortication significantly decreases the ultimate load to failure of an all-suture anchor. However, decreased biomechanical strength may not necessitate actual clinical failure.

CLINICAL RELEVANCE

A decrease in ultimate load to failure could increase the risk of catastrophic postoperative anchor failure. However, while this decrease in strength is statistically significant, the overall decrease in strength may not be sufficient in magnitude to translate to clinical failure.

Rotator cuff tear characteristics: how comparable are the pre-operative MRI findings with intra-operative measurements following debridement during arthroscopic repair?

PURPOSE

Magnetic resonance (MRI) is a valuable imaging method which can detect pre-operative rotator cuff tear characteristics accurately. However, tendon degeneration almost always necessitates a certain amount of debridement during arthroscopic repair, which alters tear size and shape. The aim of this study is to question the accuracy of the pre-operative tear size and classification in MRI and its relation to the tear size and type of the debrided tendon during arthroscopic repair.

METHODS

A retrospective survey was performed to identify shoulders that underwent arthroscopic rotator cuff repair. Rotator cuff tears with an adequate history, a standard pre-operative MRI, and available surgical video records with appropriate measurements were included. Traumatic tears, calcifying tendonitis, isolated subscapularis tears, and revisions were excluded. In total, 60 shoulders' (30 males, 27 females; age 55.2 [35-73]) preoperative MRIs and intra-operative measurements were analyzed by orthopaedic surgeons and radiologists. Tear width and type were recorded. Interdisciplinary and intradisciplinary consistency of measurements and classifications were analyzed. Tear width measured on pre-operative MRI and after debridement were compared.

RESULTS

Average measured tear width was 9 ± 5.3 mm on MRI. Surgeons (9.98 ± 4.6 mm) measured tears significantly wider than radiologists (7.71 ± 6.6 mm). Radiologists (ICC, 0.930; CI, 0.883-0.959) showed superior consistency on MRI than surgeons (CI, 0.502; CI, 0.105-0.726). Average tear width measured after debridement (29.3 ± 9.6 mm) was significantly higher than tear width measured on pre-operative MRI (p < 0.0001). None of the researchers assessing tear type on pre-operative MRI showed agreement with surgeons assessing intra-operative data.

CONCLUSIONS

There were significant differences between the pre-operative tear characteristics on MRI and the debrided tendon characteristics during surgery, which were extensive enough to classify the tear in a different category.

Do corticosteroid injections compromise rotator cuff tendon healing after arthroscopic repair?

Background

Rotator cuff tears are associated with capsular contraction and stiffness that should be restored before surgical repair. Corticosteroid injections (CSIs) are frequently used as conservative treatments before surgical repair. This study aimed to determine the influence of preoperative and postoperative CSIs on clinical and anatomic outcomes after rotator cuff repair.

Methods

The authors analyzed the records of 257 patients who had arthroscopic rotator cuff repair, of whom 212 were evaluated at 3.1 ± 1.0 years (median, 2.9 years; range, 1.4-7.1 years) by clinical (Constant score) and ultrasound (Sugaya classification) examinations. Univariable and multivariable regressions were performed to determine associations between outcomes and administration of preoperative and postoperative CSIs, patient characteristics, and tendon characteristics.

Results

The Constant scores improved from 56.4 ± 15.1 to 80.8 ± 12.5. Multivariable regression confirmed that postoperative scores were associated with postoperative CSIs (P < .001), preoperative scores (P < .001), gender (P < .001), and fatty infiltration (P < .005). Retears (Sugaya types IV-V) were observed in 27 shoulders (13%). Multivariable regression clarified that retear rates were associated only with postoperative CSIs (P = .007) and stage 3 fatty infiltration (P = .001). Adjusting for confounders, an additional postoperative CSI would decrease scores by 4.7 points and double retear risks.

Discussion

Preoperative CSIs had no influence on clinical scores and retear rates, whereas postoperative CSIs were associated with lower scores and more retears. Although we can infer that preoperative CSIs do not affect outcomes, we cannot determine whether postoperative CSIs compromised outcomes or were administered in patients who had already poor outcomes. Our findings may resolve controversies about the administration of preoperative CSIs.

Efficacy of bone marrow-stimulating technique in rotator cuff repair

BACKGROUND

This study used a chronic rotator cuff (RC) tear model to investigate the effect of microfracture as a bone marrow-stimulating (BMS) technique for RC healing.

METHODS

A chronic retracted RC tendon tear model was created bilaterally in the subscapularis tendons of 20 New Zealand rabbits. The tendons were repaired after 8 weeks using a single-row configuration. Tendons in the right shoulder were repaired in standard fashion (control group). Microfractures were performed in the left shoulders before repair (microfracture group). The animals were euthanized 8 and 16 weeks after repair. The repaired tendons were tested biomechanically for their ultimate failure load, linear stiffness, and elongation at failure. Gross and histologic evaluations of the tendon-to-bone healing were evaluated.

RESULTS

Macroscopically, subscapularis tendons were attached on the lesser tuberosity. In the microfracture group, collagen fibers were organized in relatively thicker bundles. The mean ultimate failure load of the microfracture group was significantly greater at 8 weeks (148.4 ± 31 N vs. 101.4 ± 26 N, respectively; P = .011) and 16 weeks (155 ± 30 N vs. 114.9 ± 25 N, respectively; P = .017) after repair. There were no significant differences between the groups for linear stiffness at 8 weeks (15.9 ± 2.7 N/mm vs. 15.8 ± 1.3 N/mm, respectively; P = .798) and 16 weeks (16.9 ± 4.3 N/mm vs. 17.1 ± 3.6 N/mm, respectively, P = .848) and elongation at failure at 8 weeks (4.7 ± 1.1 mm vs. 4.7 ± 1.3 mm, respectively; P = .848) and 16 weels (4.8 ± 1.5 mm vs. 4.9 ± 0.9 mm, respectively; P = .749).

CONCLUSION

The microfracture on the tuberosity of the repaired chronic rotator cuff tear promoted dynamic tendon healing with significantly increased ultimate force to failure and with thicker collagen bundles and more fibrocartilage histologically at 8 weeks.