Hyperlipidemia increases the risk of retear after arthroscopic rotator cuff repair

Fatty Infiltration, Tear Size, and Retraction Size Are Significant Risk Factors for Retear following Arthroscopic Rotator Cuff Repair: A Systematic Review

PURPOSE

To assess the consistency and quality of risk factor reporting for rotator cuff repair (RCR) retear and identify risk factors most frequently associated with retear.

METHODS

A systematic review with PRISMA guidelines was performed. Of the initial 3,158 titles, a total of 31 studies met the following inclusion criteria: (1) clinical studies regarding RCR failure, (2) arthroscopic procedures involving RCR, (3) reporting clinical outcomes (4) performed within 5 years (5) and studies investigating pre-operative risk factors for retear. After full-text review, 18 risk factors were analyzed.

RESULTS

The most consistently significant risk factors were acromiohumeral distance (AHD) (80%), critical shoulder angle (CSA) (67%), tear size (63%), anterior/posterior (AP) dimension (60%), fatty infiltration (FI, 58%), and retraction size (56%). FI was analyzed using different methods between studies with 63% finding significant results and 50% of all studies performing ordinal analysis. Tear size was inconsistently analyzed quantitatively or qualitatively, with 58% finding significant results and 63% of all studies analyzing quantitatively. Risk factors consistently found to be non-significant included age, sex, diabetes mellitus (DM), symptom duration, hand dominance, repair technique, smoking and body mass index (BMI).

CONCLUSIONS

Tear size, fatty infiltration, and retraction size were found to be significant risk factors in the majority of included studies evaluating rotator cuff retear. Risk factors less likely reported as predictive included repair technique, age, sex, DM, symptom duration, hand dominance, repair technique, smoking, and BMI. Risk factors that require further investigation include CSA, AHD, and AP tear dimension. Level III, systematic review of Level III-V studies.

A causal association between lipid-lowering medications and rotator cuff syndrome: a drug-targeted mendelian randomization study

Background: Previous research has suggested that dyslipidemia may be a risk factor for rotator cuff syndrome (RCS), and lipid-lowering drugs may aid in its treatment, though conclusions have not been definitive. Mendelian randomization is a statistical method that explores the causal relationships between exposure factors and diseases. It overcomes the confounding issues inherent in traditional observational studies, thereby providing more reliable causal inferences. We employed this method to investigate whether hyperlipidemia is a risk factor for rotator cuff syndrome and whether lipid-lowering drugs can effectively treat this condition. Methods: Genetic variations linked to lipid traits low-density lipoprotein cholesterol (LDL-C), triglyceride (TG), and total cholesterol (TC) were acquired from the UK Biobank and the Global Lipids Genetics Consortium (GLGC). Data on genetic variation in rotator cuff syndrome were obtained from FinnGen, including 24,061 patients and 275,212 controls. In the next step, we carried out two-sample Mendelian randomization analyses to determine whether lipid traits correlate with rotator cuff syndrome risk. Additionally, we performed drug-target Mendelian randomization (MR) analyses on 10 drug targets related to rotator cuff syndrome. For the drug targets that showed significant results, further analysis was done using Summary-data-based Mendelian Randomization (SMR) and colocalization techniques. We performed a mediation analysis to identify potential mediators between HMG-CoA reductase (HMGCR) and RCS. Results: No causative link was established between these lipid traits and rotator cuff syndrome. However, a significant association has been identified where HMGCR inhibition corresponds to a reduced risk of rotator cuff disease (OR = 0.68, [95% CI, 0.56-0.83], p = 1.510 × 10-4). Additionally, enhanced expression of HMGCR in muscle tissues is also linked to a decreased risk of rotator cuff syndrome (OR = 0.88, [95% CI, 0.76-0.99], p = 0.03). Body mass index (BMI) mediated 22.97% of the total effect of HMGCR on RCS. Conclusion: This study does not support low-density LDL-C, TG, and TC as risk factors for rotator cuff syndrome. HMGCR represents a potential pharmaceutical target for preventing and treating rotator cuff syndrome. The protective action of statins on the rotator cuff syndrome might not be associated with their lipid-lowering properties.

Socioeconomic and Other Risk Factors for Retear after Arthroscopic Surgery for Nontraumatic Rotator Cuff Tear

Background and Objectives: Few studies have investigated the socioeconomic factors associated with retear after rotator cuff repair. This study aimed to identify the risk factors, including socioeconomic factors, for rotator cuff retear in patients who underwent arthroscopic rotator cuff repair. Materials and Methods: This retrospective study included 723 patients diagnosed with full-thickness rotator cuff tears who underwent arthroscopic rotator cuff repair from March 2010 to March 2021. The outcome variable was rotator cuff retear observed on postoperative magnetic resonance imaging or ultrasonography. Sex, age, obesity, diabetes, symptom duration, and tear size were the independent variables. Socioeconomic variables included occupation, educational level, type of medical insurance, and area of residence. We compared patients with and without retear and estimated the effects of the independent factors on retear risk. Results: The mean age of the patients, symptom duration, and tear size were 62.4 ± 8.0 years, 1.8 ± 1.7 years, and 21.8 ± 12.5 mm, respectively. The age, type of medical insurance, diabetes, tear size, and symptom duration differed significantly between patients with and without retearing (p < 0.05). Age, occupation, type of medical insurance, diabetes, initial tear size, and symptom duration significantly affected the risk of retear. Patients who performed manual labor had a significantly higher retear rate (p = 0.005; OR, 1.95; 95% CI, 1.23-3.11). The highest retear risk was seen in patients with Medicaid insurance (p < 0.001; OR, 4.34; 95% CI, 2.09-9.02). Conclusions: Age, initial tear size, and symptom duration significantly affect retear risk after arthroscopic rotator cuff repair. Occupation and type of medical insurance were also risk factors for retear. Socioeconomically vulnerable patients may be at a greater risk of retear. Proactive efforts are required to expand early access to medical care.

Dyslipidemia may impact initial recovery following arthroscopic rotator cuff repair: a retrospective study

BACKGROUND

The current literature shows that dyslipidemia can lead to a higher incidence of rotator cuff tears (RCTs) and an increased retear rate after repair. We aimed to evaluate the influence of preoperative dyslipidemia on postoperative pain, patient-reported outcomes (PROs), active range of motion (ROM), and structural integrity.

METHODS

A cohort of 111 patients who underwent arthroscopic RCT repair between January 2021 and July 2022, and whose complete preoperative serum lipid data were available within one week prior to surgery was retrospectively reviewed. Dyslipidemia was defined as the presence of an increase or decrease in at least one blood lipid profile (triglycerides, total cholesterol, low-density lipoprotein, high-density lipoprotein, or non-high-density lipoprotein). There were 43 patients in the dyslipidemia group and 68 in the ortholiposis group. Patient evaluations, including pain score, PROs, and ROMs, were conducted preoperatively; at 3 and 6 months postoperatively; and at the last follow-up. Structural integrity was assessed by magnetic resonance imaging (MRI) 6 months after surgery if possible, and Sugaya type 4 or 5 was considered a retear. Propensity score matching (PSM) was used to reduce bias.

RESULTS

The RCT size, surgical technique, preoperative pain status, PROs, and active ROM were comparable between patients with dyslipidemia and those with ortholiposis. Three months after surgery, patients in the dyslipidemia group had worse average PROs (Constant score: P = 0.001; ASES score: P = 0.012; UCLA score: P = 0.015), forward flexion (P = 0.012), and internal rotation (P = 0.001) than patients in the ortholiposis group did. The difference between the two groups persisted after PSM but disappeared at the sixth month after surgery. No significant differences in pain score, PROs, or active ROMs were detected between the dyslipidemia and ortholiposis groups after a mean follow-up of 24 months. Of the 72 patients who underwent MRI, 4 retears (5.6%) were found, and all were in the ortholiposis group. There was no difference in the rate of retears between the two groups (P = 0.291) or with (P = 0.495) PSM.

CONCLUSIONS

In conclusion, we found that perioperative dyslipidemia may impact initial recovery within the first 3 months following arthroscopic rotator cuff repair but may have no effect on pain, PROs, or active ROMs at a mean 2-year follow-up or rotator cuff integrity at 6 months postoperatively. Trail registration Retrospectively registered.

Differences in Clinical Outcomes Between Patients With Retear After Supraspinatus Tendon Repair and Those With Intact Repair at 5-Year Follow-up

BACKGROUND

It is well known that rotator cuff repair is associated with an overall retear rate of 21% to 26%. However, a cuff retear may not necessarily be associated with poor clinical outcomes.

HYPOTHESIS

There would be no difference in clinical outcomes between patients with a cuff retear and those with an intact repair at a midterm follow-up of 5 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective study was conducted involving patients who received arthroscopic complete repair of the supraspinatus tendon between January 2009 and December 2017. Patients who did not have a postoperative magnetic resonance imaging (MRI) scan or who had a follow-up of <5 years were excluded. Clinical outcomes, including the visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, and active forward flexion (FF) of the involved shoulder were assessed at the 2-year and 5-year follow-up points.

RESULTS

The study group included 105 patients with a mean follow-up of 85 months. MRI scans were performed at a mean of 20 months. Fourteen full-thickness cuff retears and 91 intact repairs were identified using postoperative MRI scans. Significant improvement in VAS score, ASES score, and FF were found between the preoperative assessment and the 2 designated follow-up points (2 years and 5 years) in both the cuff retear and the intact repair groups (P < .001). The VAS and ASES scores at the 2-year follow-up for the intact repair group were 1.8 ± 2.0 and 80.7 ± 18.1, respectively. The corresponding values for the retear group were 2.3 ± 2.2 and 71.9 ± 19.5, respectively. No significant difference was found between the 2 groups in the VAS and ASES scores at the 2-year follow-up. However, patients with an intact repair had a better VAS score (1.4 ± 1.8; P = .049) and ASES score (81.7 ± 17; P = .019) than those with a cuff retear at the 5-year assessment (3.0 ± 2.8 and 67.1 ± 22.9, respectively). In the intact repair group, 91% of patients achieved the minimal clinically important difference for the 5-year VAS score, compared with 54% in the cuff retear group (P < .001). The corresponding values for the 5-year ASES score were 80% and 54%, respectively (P = .044). FF measurements at the 5-year follow-up in patients with intact repair and those with a cuff retear were 161°± 23° and 144°± 37°, respectively (P = .059). Continuous improvement in VAS score and FF between the 2-year and 5-year follow-up was observed in the intact repair group (P = .005 and P = .04, respectively).

CONCLUSION

The patients with an intact repair had better VAS and ASES scores compared with those who had a cuff retear at a midterm follow-up of 5 years. Between the 2-year and the 5-year follow-up, some further improvement was observed in the VAS score and FF in the intact repair group.

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

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

Risk factors for symptomatic rotator cuff tears: a retrospective case-control study

Background

The incidence and diagnostic rate of rotator cuff tears (RCTs) have increased significantly. The purpose of this study was to investigate and analyze the risk factors for symptomatic RCTs to provide a basis for their prevention and treatment.

Methods

We retrospectively analyzed the relevant clinical indicators of 193 randomized clinical trial (RCT) patients and 161 non-RCT patients hospitalized with shoulder pain as the main complaint from January 1, 2017, to August 31, 2021. Univariate analysis and multivariate logistic regression analysis were used to analyze the differences in potential risk factors between the two groups.

Results

Univariate analysis revealed that age (p < 0.001), body mass index (BMI) (p = 0.036), hypertension (p < 0.001), coronary heart disease (p = 0.028), history of shoulder trauma (p < 0.001), hyperlipidemia (p = 0.025), type III acromion (p = 0.012) and critical shoulder angle (CSA) (p < 0.001) increased the risk of RCTs. Multivariate logistic regression analysis revealed that age ≥ 60 years (OR = 2.61, 95% CI = 1.23 to 5.12), CSA ≥ 35° (OR = 4.24, 95% CI = 1.60 to 11.22), hypertension (OR = 2.34, 95% CI = 1.33 to 4.11) and history of shoulder trauma (OR = 5.20, 95% CI = 2.87 to 9.45) were independent risk factors for symptomatic RCTs.

Conclusion

The results of this study showed that age ≥ 60 years, CSA ≥35°, hypertension and history of shoulder trauma are independent risk factors for symptomatic RCTs and can provide directions for further development of prevention and treatment strategies. Future studies need to clarify the mechanism underlying the association between these risk factors and symptomatic RCTs.

Current Research on the Influence of Statin Treatment on Rotator Cuff Healing

Rotator cuff tears are a condition characterized by damage to the muscles and tendons that connect the scapula and humerus, which are responsible for shoulder rotation and arm lifting. Metabolic factors such as diabetes, thyroid disease, high cholesterol, vitamin D deficiency, obesity, and smoking have been associated with an increased risk of rotator cuff tears. Interestingly, patients with hyperlipidemia, a condition characterized by high levels of cholesterol and other fats in the blood, have been found to have a higher incidence of rotator cuff tears and breakdown of tendon matrix. As a result, statin therapy, which is commonly used to lower cholesterol levels in hyperlipidemia, has been explored as a potential treatment to improve clinical outcomes in rotator cuff tears. However, the results of preclinical and clinical studies on the effects of statins on tendon healing in rotator cuff tears are limited and not well-defined. Moreover, since hyperlipidemia and rotator cuff tears are more prevalent in older individuals, a literature review on the efficacy and safety of statin therapy in this population is needed.

Progress in studying the impact of hyperlipidemia and statins on rotator cuff injury and repair

This review delves into the intersection of two prevalent conditions, hyperlipidemia and rotator cuff injuries, both of which bear substantial healthcare burdens. Our investigation begins with an exploration of rotator cuff injuries, common musculoskeletal disorders that severely impair shoulder functionality and quality of life. These injuries are notably pervasive among sports enthusiasts and the older adult, with an incidence rate estimated at 5-10% in the general population. Despite their widespread occurrence and the diverse, multifactorial etiological factors, effective treatment strategies remain elusive. We then examine hyperlipidemia, a metabolic disorder affecting approximately 40% of the global adult population. Characterized by elevated levels of cholesterol and triglycerides, hyperlipidemia can precipitate severe cardiovascular complications and presents a significant socioeconomic burden. Although current management strategies encompass lifestyle modifications and pharmacological interventions, the condition remains a formidable health challenge. Central to this review is the exploration of a potential association between hyperlipidemia and rotator cuff injuries. We aim to synthesize the current understanding of hyperlipidemia's role in the pathophysiology of rotator cuff injuries, thereby offering fresh insights into their common etiological underpinnings, potential therapeutic targets, and drugs, such as Statins. The influence of other lipid-lowering therapeutics on tendon health is also considered, and further research into the molecular pathways and potential therapeutic benefits of these drugs is required. This pursuit aligns with broader efforts to enhance patient outcomes, minimize healthcare burdens, and contribute to the global understanding of these prevalent conditions.

Factors associated with healing failure after early repair of acute, trauma-related rotator cuff tears

BACKGROUND

Healing failure after rotator cuff repair is a challenging problem. Acute, trauma-related tears are considered a separate entity and are often treated surgically. The aim of this study was to identify factors associated with healing failure in previously asymptomatic patients with trauma-related rotator cuff tears treated with early arthroscopic repair.

METHODS

This study included 62 consecutively recruited patients (23% women; median age, 61 years; age range, 42-75 years) with acute symptoms in a previously asymptomatic shoulder and a magnetic resonance imaging-verified full-thickness rotator cuff tear after shoulder trauma. All patients were offered, and underwent, early arthroscopic repair, during which a biopsy specimen was harvested from the supraspinatus tendon and analyzed for signs of degeneration. Of the patients, 57 (92%) completed 1-year follow-up and underwent assessment of repair integrity on magnetic resonance images according to the Sugaya classification. Risk factors for healing failure were investigated using a causal-relation diagram where age, body mass index, tendon degeneration (Bonar score), diabetes mellitus, fatty infiltration (FI), sex, smoking, tear location regarding integrity of the rotator cable, and tear size (number of ruptured tendons and tendon retraction) were included and analyzed.

RESULTS

Healing failure at 1 year was identified in 37% of patients (n = 21). A high degree of FI of the supraspinatus muscle (P = .01), a tear location including disruption of rotator cable integrity (P = .01), and old age (P = .03) were associated with healing failure. Tendon degeneration as determined by histopathology was not associated with healing failure at 1-year follow-up (P = .63).

CONCLUSION

Older age, increased FI of the supraspinatus muscle, and a tear including disruption of the rotator cable increased the risk of healing failure after early arthroscopic repair in patients with trauma-related full-thickness rotator cuff tears.

Biphasic Interpositional Allograft for Rotator Cuff Repair Augmentation Is Safe in an Ovine Model

PURPOSE

To perform a preclinical histologic assessment of a biphasic acellular interpositional cancellous allograft in an ovine model of rotator cuff repair (RCR) designed to better understand its safety profile and effects on tendon healing after RCR.

METHODS

Thirty skeletally mature sheep with clinically normal shoulders with an artificially created degenerative infraspinatus tendon tear were randomized to control and treatment groups. Animals were euthanized at 3 weeks, 6 weeks, and 12 weeks. After gross dissection, rotator cuff specimens were fixed with formalin and polymerized for sectioning and staining. Blinded histologic scores evaluated inflammatory cell infiltrates, signs of degradation, particulate debris, collagen arrangement, neovascularization, and enthesis qualitative measures.

RESULTS

There were no treatment specimens that exhibited histologic signs of a significant infection, inflammatory infiltrate, or foreign body reaction such as granuloma or fibrous capsule formation. Histologic scores in all categories were not significantly different at all time points, including the primary end point mean cumulative inflammatory score (control: 3.66 ± 1.21 vs treated: 4.33 ± 1.51, P = .42), when comparing the treatment and control RCR groups. In general, the degree of tendon healing and host tissue response was essentially equivalent between the 2 groups with observation of low overall levels of inflammation and progressive improvements in collagen organization, reduced tenocyte activity, and fibrocartilaginous enthesis reformation.

CONCLUSIONS

This histologic study demonstrated the use of a biphasic interpositional allograft for RCR augmentation in an ovine model does not generate an inflammatory response or foreign body reaction. Use of the biphasic interpositional allograft resulted in a histological profile that was essentially equivalent to that of a standard RCR at 3-, 6-, and 12-week postoperative timepoints. These findings suggest that a biphasic interpositional allograft is safe for further clinical investigation in humans before broader clinical application.

CLINICAL RELEVANCE

Patch augmentation of RCR is a popular technique that has shown clinical success in improving the likelihood of a successful repair in patients at elevated risk for retear. Newer augmentation technologies are being developed to address the biology at the interface between the bone and soft tissue where failure typically occurs.

Engineered Tissue Graft for Repair of Injured Infraspinatus Rotator Cuff Tendon

Rotator cuff tears constitute a vast majority of shoulder-related injuries, occurring in a wide population range and increasing in incidence with age. Current treatments for full thickness tears use suture to secure the ruptured tendon back to its native attachment site and often retear due to improper enthesis regeneration. To reduce the occurrence of retear, our laboratory developed an engineered tendon graft for rotator cuff repair (ETG-RC) to serve as an underlayment to traditional suture repair. We hypothesize the ETG-RC will aid in the repair of the torn rotator cuff tendon by promoting the regeneration of a functional enthesis. This devitalized graft fabricated from ovine-derived bone marrow stromal cells was evaluated for biomechanical and histomorphology properties in an ovine infraspinatus rotator cuff repair model. Compared with a current standard practice Suture-Only model, the ETG-RC repair showed comparable high strain-to-failure forces, greater fibrocartilage deposition, regeneration of zonal gradients, and Shapey's fibers formation, indicative of enthesis regeneration. Enthesis regeneration after rotator cuff repair should repair mechanical properties and alleviate the need for subsequent surgeries required due to retear. The ETG-RC could potentially be used for repairing other tendon injuries throughout the body.

Rotator cuff degeneration and healing after rotator cuff repair

Rotator cuff tear is a common shoulder injury that compromises both function and quality of life. Despite the prevalence of the injury and advancements in repair techniques, a significant percentage of these repairs fail. This review aims to explore the multifactorial reasons behind this failure, including the degenerative nature of the rotator cuff tendon, inherent and extrinsic factors, and the role of hypoxia in tissue degeneration. Additionally, it elucidates potential strategies for improving healing outcomes.

Dietary ginger polysaccharides (Gps) improve symptoms in hyperlipidemia rats via alterations in gut microbiota

The aim of this research is to investigate lipid-lowering influence of dietary ginger (Zingier officinales Rocs) polysaccharides (GP_S) on hyperlipidemia rats. Rat models with hyperlipidemia was established by high-fat food diet (HFD). Comparing to GP-negative model group, GP_S attenuated several effects of HFD feeding, including the levels of blood lipid biochemistry, serum inflammatory markers (tumor necrosis factor TNF-a, interleukin IL-6), antioxidant capacity (superoxide dismutase SOD, glutathione peroxidase GSH-Px, total antioxidant capacity T-AOC, propylene dialdehyde MDA), uric acid and immune index. 16 S rDNA gene sequencing of fecal samples showed that GP_S increased the growth of Akkermansia muciniphila and decreased the proportion of Firmicutes to Bacteroidetes; This changes in microbial community structure can help prevent diet-induced metabolic disease. These results suggest that GPs may act on the gut, changing the structure of the gut microbial community, thereby reducing intestinal and systemic inflammation, thus improved metabolic outcomes.

Modifiable and Nonmodifiable Risk Factors Associated with the Development of Recurrent Rotator Cuff Tears

Nonoperative and operative strategies exist to manage rotator cuff pathology. Although surgical repair is successful for most patients, others may experience retear or nonhealing of the rotator cuff. Several modifiable and nonmodifiable risk factors are associated with an increased retear rate. The literature shows consistency and agreement regarding many of these risk factors, most notably, patient age, tear size, and rotator cuff muscular atrophy, whereas others remain controversial. It is important that shoulder surgeons are familiar with modifiable and nonmodifiable risk factors associated with retear, to better advise patients and optimize their chances of success following rotator cuff repair surgery.

Relationship of Missed Statin Therapy and 10-Year Atherosclerotic Cardiovascular Disease Risk Score to Retear Rate After Arthroscopic Rotator Cuff Repair

BACKGROUND

There is no practical consensus on managing cholesterol in patients with rotator cuff repair despite hyperlipidemia and statin therapy being well-known factors in rotator cuff healing. The 10-year atherosclerotic cardiovascular disease (ASCVD) risk score is a commonly used guideline to determine statin administration for hyperlipidemia.

PURPOSE

To identify the relationship between retear and preoperative factors, including 10-year ASCVD risk score and statin administration status, and to compare clinical outcomes and retear rates between patients who are taking and not taking statins.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This study enrolled 182 patients with a symptomatic full-thickness rotator cuff tear who underwent arthroscopic repair. Serum lipid profile, 10-year ASCVD risk score, statin eligibility, and statin administration status were assessed. Patients were categorized into 2 groups based on magnetic resonance imaging to evaluate cuff integrity at postoperative 6 months: a healed group and a retear group. Radiographic and intraoperative factors related to retear were analyzed. Multiple regression analysis was performed to evaluate factors related to rotator cuff retear. For the subgroup analysis, patients eligible for statin therapy were divided into 2 subgroups according to administration status.

RESULTS

There were 149 (81.9%) patients in the healed group and 33 (18.1%) in the retear group. In the multiple regression analysis, missed statin therapy, 10-year ASCVD risk score, and fatty infiltration of the infraspinatus muscle were the independent factors related to retear. The cutoff value for 10-year ASCVD risk score was 11.85%, with a sensitivity of 0.75 and a specificity of 0.62. In the subgroup analysis of 104 patients eligible for statin therapy, 66 (63.5%; group 1) received statin therapy and 38 (36.5%; group 2) missed it. Group 2 showed a significantly higher retear rate than group 1 (36.8% vs 13.6%; P = .006).

CONCLUSION

Missed statin therapy, 10-year ASCVD risk score, and fatty infiltration of the infraspinatus were the independent factors associated with rotator cuff retear. Patients who missed statin therapy showed a higher retear rate than patients receiving statin therapy. Optimal statin therapy for patients who undergo arthroscopic rotator cuff repair might improve repair integrity.

Impact of chronic hyperlipidemia on perioperative complications in patients undergoing lumbar fusion: a propensity score matching analysis

PURPOSE

Lumbar fusion is widely used to treat degenerative and traumatic conditions of the spine, with various perioperative complications. This study compared lumbar fusion complications in patients with and without chronic hyperlipidemia.

METHODS

Using the MSpine division of the PearlDiver database, patients with or without chronic hyperlipidemia who underwent lumbar fusions were identified. The appropriate Current Procedural Terminology (CPT) codes identified patients with single- or multi-level lumbar spinal fusion surgeries. International Classification of Diseases (ICD-9 and ICD-10) codes identified patients with chronic hyperlipidemia. The surgical and medical complications were obtained utilizing the appropriate ICD-9, ICD-10, and CPT codes. Propensity score matching analysis was used to control for confounding factors. Chi-square test was applied to compare the incidence of complications among different groups.

RESULTS

In single-level fusion group, patients with hyperlipidemia had a higher incidence of wound complications (P < 0.001), surgical site infection (P < 0.001), failed back syndrome (P < 0.001), hardware removal (P < 0.001), deep venous thrombosis/pulmonary embolism (P = 0.031), myocardial infarction (P < 0.001) cerebrovascular accident (P < 0.001), renal failure (P < 0.001), sepsis (P < 0.001), and urinary tract infection/incontinence (P < 0.001). In multi-level fusion group, patients with hyperlipidemia had a higher incidence of nerve root injury (P = 0.034), wound complications (P < 0.001), surgical site infection (P < 0.001), failed back syndrome (P < 0.001), hardware removal (P < 0.001), revision (P = 0.002), myocardial infarction (P < 0.001), renal failure (P < 0.001), and urinary tract infection/incontinence (P < 0.001).

CONCLUSION

Following lumbar fusion, patients with chronic hyperlipidemia have an increased risk of perioperative complications, including wound complications, surgical site infection, failed back surgery syndrome, hardware removal, myocardial infarction, renal failure, and urinary tract infection/incontinence.

A lipid metabolite lipidomics assay for prediction and severity evaluation of rotator cuff injury

Objective

Rotator cuff injury can be caused by local inflammation and fibrosis of musculotendinous cuff. Hypercholesterolemia can lead to physiological changes of rotator cuff that resemble rotator cuff injury. However, the relationship between lipid metabolism and rotator cuff injury and its potential pathological mechanism remain unclear. Herein, we aimed to investigate the correlation between the plasma lipidome, rotator cuff injury, and successive fatty infiltration pathology, and hoped to identify biomarkers for predicting higher risk or higher severity rotator cuff injury by assessing metabolic perturbations and dyslipidemia using lipidomics.

Methods

We quantitatively analyzed 60 lipids species of seven lipids classes and subclasses from 66 subjects using lipidomics. Subjects were divided into four groups: (1) normal rotator cuff with normal clinical routine serum lipid test results (NN group = 13); (2) normal rotator cuff with abnormal clinical routine serum lipid test results (NA group = 10); (3) rotator cuff tear with normal routine serum lipid test results (RN group = 30); (4) rotator cuff tear with abnormal routine serum lipid test results (RA group = 13). Independent-sample t-tests and Kruskal-Wallis tests were used to compare lipid metabolite levels in serum between different groups in patients with rotator cuff tears. The orthogonal partial least squares-discriminant analysis (OPLS-DA) model was used to verify the ability of five lysophosphatidylcholines (LPCs) to distinguish rotator cuff injuries. In the rotator cuff tear group, magnetic resonance imaging (MRI) was used to classify fatty infiltration according to Goutallier's classification. Kruskal-Wallis tests were used to analyze molecular differences between high-grade (grade 3–4) and low-grade (grade 0–2) fatty infiltration groups. Receiver operator characteristic (ROC) curves were drawn for each diagnostic method via different metabolites. The area under the curve (AUC), cutoff, specificity, sensitivity, and accuracy of each diagnostic criterion were calculated.

Results

Our results showed that some rotator cuff injury patients yielded unique lipidomic profiles. Based on Kruskal-Wallis tests, our results showed significant differences in three lipid molecules, 17:1 Lyso PI, 18:0–22:6 PE, and 18:3 (Cis) PC, among all four groups independent of clinical blood lipid levels. Also, independent of clinical blood lipid levels, two lipid molecules, 22:0 Lyso PC and 24:0 Lyso PC, were significantly different between the two groups based on Independent sample t-tests. Kruskal-Wallis test results showed that in the rotator cuff tear group, two metabolites (24:0 SM and 16:0 ceramide) differed between high-grade and low-grade fatty infiltration. The AUC values for 22:0 Lyso PC, 24:0 Lyso PC, 18:0–22:6 PE, 24:0 SM, and 16:0 ceramide were 0.6036, 0.6757, 0.6712, 0.8333, and 0.8981, respectively.

Conclusion

The results provide insight into how the metabolic mechanisms associated with dyslipidemia impact rotator cuff diseases. Five lipid molecules, 17:1 Lyso PI, 18:0–22:6 PE, 18:3 (Cis) PC, 22:0 Lyso PC, and 24:0 Lyso PC, were closely related to rotator cuff tear based on two statistical analysis methods, independent of clinical routine serum lipid test results, which indicates that lipidomics assays are more sensitive than conventional lipid tests, and more suitable for studying rotator cuff lipid metabolism. In addition, two lipid metabolites, 24:0 SM and 16:0 ceramide, are potentially useful for predicting fatty infiltration severity. Further research with a larger number of samples is needed to verify whether these two metabolites can serve as potential markers of severe fatty infiltration. The findings illuminate how metabolic mechanisms associated with dyslipidemia affect rotator cuff disease.

Dyslipidemia is associated with risk for rotator cuff repair failure: a systematic review and meta-analysis

Background

Lipid deposition secondary to dyslipidemia (DLD) is shown to have a significant impact on tendon pathology, including tendon elasticity, fatty infiltration, and healing properties. Rotator cuff repair is a common procedure, susceptible to influence from many tear-related and patient-related characteristics. The purpose of this study was to determine the relationship between DLD and rotator cuff repair outcomes with analysis of retear risk and function.

Methods

PubMed, Embase, and SPORTDiscus were searched for all English-language, peer-reviewed studies between 2000 and the present, which analyzed relationships between patient-related factors and outcomes of rotator cuff repair. Studies that explicitly examined the effect of DLD on rotator cuff repair outcomes were chosen for inclusion. Included studies were assessed for methodological quality, and data were extracted for meta-analysis.

Results

Of the 3087 titles, 424 were screened by abstract, and 67 were reviewed in full. Inclusion criteria were met by 11 studies. Of these studies, 5 studies assessed retear, 2 studies measured function, 3 studies reported both retear and function, and 1 study evaluated the risk of retear necessitating a revision surgery. The studies report no significant difference in functional outcomes. Meta-analysis revealed that DLD patients had a significantly higher risk of retear after primary rotator cuff repair (odds ratio 1.32, 95% confidence interval 1.06-1.64).

Conclusion

DLD leads to an increased risk of retear after rotator cuff repair, although function appears to be unimpaired. DLD should be considered among other risk factors when counseling patients regarding expected rotator cuff repair outcomes.

Progression of Symptomatic Partial-Thickness Rotator Cuff Tears: Association With Initial Tear Involvement and Work Level

Background

Partial-thickness rotator cuff tears (PTRCTs) often progress to full-thickness rotator cuff tears (FTRCTs). Thus, it is important to analyze the risk factors for tear progression to determine the proper timing of repair.

Purpose

To identify the risk factors associated with progression of PTRCT.

Study Design

Case-control study; Level of evidence, 3.

Methods

Included were 89 patients diagnosed with PTRCT on magnetic resonance imaging (MRI) scans who underwent nonoperative treatment at the authors' institution between August 2012 and August 2019. Patient characteristics, shoulder stiffness (compared with the contralateral shoulder); work level (classified as high [heavy manual labor], medium [manual labor with less activity], and low [sedentary activity]); and radiological factors including initial tear size, acromion type (flat, curved, hooked, or heel-shaped), and initial tear involvement (as a percentage of the rotator cuff tendon footprint length) were analyzed to assess their association with tear progression, defined as >20% increase in tear involvement.

Results

The mean MRI follow-up period was 22.3 ± 17.2 months (median, 16.1 months; range, 6.4-89.5 months), and tear progression was observed in 12 patients (13.5%). In these 12 patients, tear involvement increased by 60% of the rotator cuff footprint, while mediolateral (ML) and anteroposterior (AP) tear sizes progressed by 1.1 and 1.8 mm, respectively. Univariate regression analysis showed that shoulder stiffness (P = .031), work level (P = .001), initial tear involvement (P < .001), ML and AP tear sizes (P < .001 and P = .005, respectively), and acromion type (P = .003) were significantly associated with tear progression. Multivariate regression analysis showed that initial tear involvement (odds ratio [OR], 1.053; 95% CI, 1.006-1.102; P = .026) and high work level (OR, 15.831; 95% CI, 1.150-217.856; P = .039) were independent risk factors for tear progression. The cutoff value for initial tear involvement was 47.5% (sensitivity, 81.8%; specificity, 85.7%).

Conclusion

Tear progression was observed in 14% of patients with PTRCT in this study. To predict tear progression, evaluating the tear involvement during initial MRI is essential. The risk of tear progression increased with initial tear involvement >47.5% and a heavy work level.

Biochemical Markers of Aging (Advanced Glycation End Products) and Degeneration Are Increased in Type 3 Rotator Cuff Tendon Stumps With Increased Signal Intensity Changes on MRI

BACKGROUND

Advanced glycation end products (AGEs) are end products of protein glycation that bind to the receptor for AGEs (RAGE) and activate nicotinamide adenine dinucleotide phosphate oxidase (NOX), resulting in increased oxidative stress and rotator cuff fragility. Stump classification using the signal intensity ratio of the tendon rupture site to the deltoid muscle in the coronal view of T2-weighted fat-suppressed magnetic resonance imaging (MRI) scans is an indicator of clinical outcomes after rotator cuff repair surgery. Comparing the signal intensities of the deltoid (D) and rotator cuff tears (C), Ishitani et al. classified C/D <0.8 as type 1, 0.8 to 1.3 as type 2, and >1.3 as type 3.

HYPOTHESIS/PURPOSE

It was hypothesized that the oxidative stress and collagen degeneration that occur in the rotator cuff due to accumulation of AGEs can be assessed on MRI scans (stump classification). Therefore, this study aimed to compare AGE-related factors in the rotator cuff tear site tissues based on stump classification.

STUDY DESIGN

Descriptive laboratory study.

METHODS

The authors included 30 patients (11 with type 1, 9 with type 2, and 10 with type 3; mean age, 62.3 years) who underwent surgery for complete rotator cuff tears at our hospital. Tendon tissue was harvested from the torn rotator cuff site during surgery for tissue and cell evaluation.

RESULTS

There was no significant difference in the mean age according to stump classification. The number of patients with diabetes was significantly larger in type 3 than in the other types (P < .05). Tissue evaluation showed significantly higher expression of AGE and RAGE staining in type 3 than in the other types (~6.7-fold; P < .01). Cell evaluation showed that the expression rates of reactive oxygen species and apoptosis were significantly higher in type 3 than in the other types (~4.3-fold; P < .01). Gene expression by real-time polymerase chain reaction showed significantly higher RAGE (~5.1-fold), NOX (~5.3-fold), and IL (~3.0-fold) in type 3 than in the other types (P < .05).

CONCLUSION

Stump classification type 3 exhibited the highest accumulation of AGEs and the highest oxidative stress and apoptosis, suggesting a high degree of degeneration and inflammation. Imaging based on stump classification reflects the degeneration and fragility of the torn rotator cuff site.

CLINICAL RELEVANCE

This study provides evidence of a relationship between stump classification, which reflects rotator cuff fragility on MRI, and pathologies related to advanced glycation end products.

Is there a relation between plantar fasciitis and total cholesterol levels?

BACKGROUND

The main objective of this study is to investigate the relationship between hypercholesterolemia and Plantar Fasciitis (PF).

METHODS

The study includes patients who presented to the orthopedics outpatient clinic with heel pain and were diagnosed with PF. The control group was composed of patients who came to the orthopedics outpatient clinic, with complaints other than heel pain. The two groups were compared in terms of epidemiological data, total cholesterol (TC) levels, and hypercholesterolemia prevalence. We also performed an in-group analysis of PF patients in terms of age, sex, body mass index, and duration of symptoms.

RESULTS

There were 238 patients (mean age, 46.7) in the PF group and 240 patients (mean age, 47.9) in the control group. There was a significant difference between the PF group and the control group in TC levels (207.6 ± 47.5 versus 195.1 ± 30.1, p = 0.001). Hypercholesterolemia (TC level > 240 mg/dL) was found in 22.7% (n = 54) of the patients in the PF group whereas in the control group this rate was 10.8% (n = 26) (p < 0.001). It was seen that the TC levels were significantly higher in patients over the age of 45 in the PF group (p = 0.038). We also found that TC levels were higher in PF patients with symptoms for longer than a year (p = 0.026).

CONCLUSION

Significantly higher TC levels were found in PF patients in comparison with other orthopedic outpatients. Besides, being over the age of 45 and having a duration of symptoms longer than a year is associated with higher cholesterol levels for PF patients.

LEVEL OF CLINICAL EVIDENCE

4.

Retear bigger than preoperative tear size would lead to treatment failure after rotator cuff repair

BACKGROUND

This study aimed to (1) define treatment failure using the referred patient acceptable symptomatic state (PASS) values for pain visual analog scale (PVAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numeric Evaluation (SANE) clinical scores and (2) identify the factors that lead to patient dissatisfaction after arthroscopic rotator cuff repair (ARCR).

METHODS

We analyzed the arthroscopic rotator cuff surgery registry data from January 2015 to December 2016. Patients were followed for ≥2 years and categorized as dissatisfied or satisfied based on our own definition of treatment failure at 2 years postoperatively. For defining treatment failure, the referred PASS values for the PVAS, ASES, and SANE scores were used. Patients who failed to attain the PASS value for the PVAS, ASES, or SANE score were categorized into the dissatisfied group. Pre- and postoperative imaging and basic demographic data were compared between groups. Univariable and multivariable logistic regression analyses were performed to identify the factors affecting patient satisfaction at 2 years after rotator cuff repair.

RESULTS

Of 117 patients, 30 (25.6%) were defined as the dissatisfied group (mean follow-up period, 37.5 months). Seventeen patients (14.5%) had confirmed retear on follow-up magnetic resonance imaging. In the univariate analysis, sex significantly differed between the groups (female, satisfied vs. dissatisfied groups: 39 [44.8%] vs. 22 [73.3%]; P = .010). Retear alone did not affect patient satisfaction in the univariate analysis (P = .11). Progressed retear size featured a significantly higher risk of patient dissatisfaction (P = .024; odds ratio 6.430, 95% confidence interval 1.270-32.541) in the multivariable analysis using symptom duration, sex, preoperative ASES score, preoperative tear size, retear, and progressed retear size as variables. Moreover, female sex had an increased odds for dissatisfaction (odds ratio 4.646, 95% confidence interval 1.590-13.578; P = .005).

CONCLUSION

Two years after ARCR, most patients (74.4%) reported satisfaction with their outcomes. However, satisfaction levels can be altered by female sex or progressed retear size compared with the preoperative state.

Effect of Abduction Brace Wearing Compliance on the Results of Arthroscopic Rotator Cuff Repair

The benefit of protective bracing after rotator cuff reconstruction has been debated for many years, although immobilization compliance has never been assessed objectively to date. In a previous study, compliance with the wearing of an abduction brace was measured for the first time with use of temperature-sensitive sensors. The purpose of the present follow-up study was to assess the effect of immobilization compliance on tendon-healing after rotator cuff repair.

Clinical differences between patients with early and late revision surgery for symptomatic failed arthroscopic rotator cuff repair

PURPOSE

Time ranges of revision rotator cuff surgeries after arthroscopic repair are highly variable. However, the cause and clinical relevance of the different timings of revision surgeries have not been analyzed. The purpose of this study was to evaluate the clinical manifestations of patients who required revision surgeries at early and late periods after failed arthroscopic rotator cuff repair, and to identify clinical and radiological differences related to the timing of revision surgery.

METHODS

Sixty patients who underwent revision surgery due to symptomatic failed rotator cuff repair after arthroscopic repair were included. Patients were divided into two groups: patients who underwent revision surgeries within 1 year postoperatively (21 patients, group I) and patients who underwent revision surgeries more than 1 year postoperatively (39 patients, group II). Clinical and radiological characteristics were compared between the two groups before primary and revision surgery.

RESULTS

VAS for pain (5.9 ± 1.9 in group I, 3.9 ± 1.4 in group II, P < 0.001) and Constant score (50.7 ± 9.9 in group I, 60.4 ± 8.9 in group II, P < 0.001) at the time of revision surgery were significantly different between the two groups. In group II, isometric muscle strength of forward flexion (74.1 ± 21.1 to 63.9 ± 15.1, P = 0.020) and external rotation (73.0 ± 23.5 to 61.2 ± 15.0, P = 0.032) were significantly deteriorated after primary surgery, even with significant improvement of pain and shoulder function (VAS: 5.7 ± 1.9 to 3.9 ± 1.4, P < 0.001; Constant score: 50.3 ± 11.0 to 60.4 ± 8.9, P < 0.001). On postoperative MRI, re-tear at the tendon-bone interface on the greater tuberosity occurred significantly more in group I (81.0%) than group II (51.3%, P = 0.024). Incidence of full-thickness tear of the subscapularis tendon was significantly different between the two groups (42.9% in group I, 12.8% in group II, P = 0.012).

CONCLUSION

Patients who had early revision surgeries had significantly worse clinical outcomes after primary surgery than patients who had late revision surgeries. Healing failure at the tendon-bone interface on the greater tuberosity and re-tear combined with full-thickness tear of subscapularis tendon were related to early revision. Conversely, patients of the late revision group had muscle weakness that considerably impacted daily activities, even with improved pain and shoulder function.

LEVEL OF EVIDENCE

III.

Trends in rotator cuff repair rates and comorbidity burden among commercially insured patients younger than the age of 65 years, United States 2007-2016

Background

Prior US studies have shown increasing rotator cuff repair rates through 2009. We hypothesize that rotator cuff repair rates are continuing to increase and the comorbidity profiles of patients are becoming more complex over time.

Methods

We identified rotator cuff repairs in a large US cohort of people 18-64 years of age with ≥1 year of commercial insurance coverage. Repair rate trends across time were standardized by age, sex, and geographic region. Procedures were categorized as inpatient vs. outpatient and as arthroscopic vs. open. Prevalent comorbidities were defined as 1 inpatient diagnosis claim or 2 outpatient diagnosis claims during the year before rotator cuff repair. General population comorbidity prevalence was determined based on a random 5% sample of the commercially insured population and compared with patients with rotator cuff repair using standardized morbidity ratios.

Results

From 2007 to 2016, 314,239 rotator cuff repairs were identified (165 repairs per 100,000 person-years). Rotator cuff repairs were performed more frequently in men, older people, and in the Midwest. Across time, cuff repair rates increased by 1.6% per year (95% confidence interval [CI] = +1.4%-1.7%) adjusting for demographics. The highest increases in repair rates were observed among patients aged 50-64 years (+2.0%, 95% CI = +1.8%-2.2%). Rotator cuff repairs were more frequently performed using an arthroscopic approach and in an outpatient setting in later calendar years. In 2016, 83% of rotator cuff repairs were arthroscopic procedures and 99% were performed as outpatient procedures. Comorbidity prevalence in rotator cuff repair patients increased across calendar time by 4.5% per year for hypertension (95% CI = +4.2%-4.7%), 2.3% per year for diabetes (+1.9%-2.7%), 0.9% per year for hypercholesterolemia (+0.3%-1.5%), 2.9% for congestive heart failure (+0.8%-4.9%), 4.2% for peripheral vascular disease (+2.4%-6.0%), and 4.2% for chronic pulmonary disease (+3.6%-4.8%). Comorbidity prevalence in repair patients was higher than prevalence in the general population, and prevalence relative to the general population was most heightened during later calendar years. For example, hypertension prevalence was 1.58 times higher in repair patients than the general population in 2007 (95% CI = 1.53-1.62), and 2.06 times higher in 2016 (95% CI = 2.02-2.11).

Conclusion

Rotator cuff repair is becoming more frequent in the US commercially insured population, particularly in those 50-64 years of age. More rotator cuff repairs are being performed using an arthroscopic approach and in an outpatient setting. Over time, the comorbidity profile of patients undergoing rotator cuff repair is becoming more complex with greater prevalence of numerous conditions, including hypertension, peripheral vascular disease, and chronic pulmonary disease.

Risk factors affecting rotator cuff retear after arthroscopic repair: a meta-analysis and systematic review

BACKGROUND

Retear after arthroscopic rotator cuff repair (ARCR) consistently challenges medical staff and patients, and the incidence of retear after surgery is 10%-94%. The purpose of this study was to identify the risk factors that cause retear after ARCR and provide theoretical guidance for clinical intervention to reduce the occurrence of postoperative rotator cuff retear.

METHODS

The protocol for this meta-analysis was registered with PROSPERO (CRD42021225088). PubMed, Web of Science, and Embase were searched for observational studies on risk factors for rotator cuff retear after arthroscopic repair. Meta-analytical methods were used to determine the odds ratio or weighted mean difference of potential risk factors related to postoperative rotator cuff retear. Stata 15.1 was used to quantitatively evaluate the publication bias of the statistical results.

RESULTS

Fourteen studies from 6 countries with a total of 5693 patients were included. The meta-analysis revealed that the risk factors for retear after rotator cuff repair were age, body mass index, diabetes, subscapularis and infraspinatus fatty infiltration, symptom duration, bone mineral density, tear length, tear width, tear size area, amount of retraction, critical shoulder angle, acromiohumeral interval, distance from the musculotendinous junction to the glenoid, operative duration, biceps procedure, and postoperative University of California Los Angeles shoulder score.

CONCLUSION

These findings can help clinical medical staff identify patients who are prone to retear early after arthroscopic repair and develop targeted prevention and treatment strategies for modifiable risk factors, which are of great significance for reducing the occurrence of rotator cuff retear after ARCR.

Does statin-treated hyperlipidemia affect rotator cuff healing or muscle fatty infiltration after rotator cuff repair?

BACKGROUND

Hyperlipidemia is linked to poor tendon-to-bone healing and progression of fatty infiltration after rotator cuff repair. Statins effectively treat hyperlipidemia, but it is unknown if they have any potential detrimental effects following rotator cuff repair. The aim of this study was to evaluate the effect of statins on rotator cuff healing and fatty infiltration following repair.

METHODS

A total of 77 patients undergoing arthroscopic rotator cuff repair were recruited prospectively, 38 patients who were prescribed a statin for hyperlipidemia (statin group) and 39 patients who were not taking a statin (control group). Patients who did not have both preoperative and 1-year postoperative magnetic resonance imaging (MRI) scans were excluded from the study. Patient-reported outcome measures, namely the Western Ontario Rotator Cuff (WORC) index, Constant-Murley score, American Shoulder and Elbow Surgeons (ASES) score, and Disabilities of the Arm, Shoulder and Hand (DASH) score, were collected preoperatively and at 1 year. Fatty infiltration was assessed on MRI according to the Goutallier grade preoperatively and at 12 months; rotator cuff healing was assessed at 12 months according to the Sugaya classification. Following propensity score weighting to adjust for baseline imbalances, 12-month outcomes were compared between the 2 groups.

RESULTS

At 12 months, all patient-reported outcome measures had improved significantly compared with baseline (WORC score, 85.9 vs. 32.5, P < .001; ASES score, 87.3 vs. 37.5, P < .001; Constant-Murley score, 77 vs. 31, P < .001; and DASH score, 13.6 vs. 61.4, P < .001). There was no significant difference in postoperative scores in the statin group vs. the control group (WORC score, 84.9 vs. 89.6, P = .94; ASES score, 87.5 vs. 86.6, P = .40; Constant-Murley score, 77 vs. 81, P = .90; and DASH score, 14.4 vs. 11.4, P = .14), and for 3 of these scores, the 95% confidence intervals excluded a clinically meaningful difference. Similarly, rotator cuff healing at 12 months and Goutallier fatty infiltration grades were comparable between the 2 groups. Retears were seen in 6 patients (15.8%) in the statin group and 8 (20.5%) in the control group. Progression of fatty infiltration was seen in 4 patients (10.5%) in the statin and 4 (10.3%) in the control group. Statin use did not demonstrate a significant association with either retear risk (P = .41) or progression of fatty atrophy (P = .69).

CONCLUSION

Patient-reported outcomes, rotator cuff retear rate, and fatty infiltration on MRI at 12 months after rotator cuff repair in patients with hyperlipidemia treated with statins are similar to those in a control group.

Analysis of Patient Factors Affecting In Vitro Characteristics of Subacromial Bursal Connective Tissue Progenitor Cells during Rotator Cuff Repair

Unsatisfactory failure rates following rotator cuff (RC) repair have led orthopaedic surgeons to explore biological augmentation of the healing enthesis. The subacromial bursa (SB) contains abundant connective tissue progenitor cells (CTPs) that may aid in this process. The purpose of the study was to investigate the influence of patient demographics and tear characteristics on the number of colony-forming units (CFUs) and nucleated cell count (NCC) of SB-derived CTPs. In this study, we harvested SB tissue over the supraspinatus tendon and muscle in 19 patients during arthroscopic RC repair. NCC of each sample was analyzed on the day of the procedure. After 14 days, CFUs were evaluated under a microscope. Spearman’s rank correlation coefficient was then used to determine the relationship between CFUs or NCC and patient demographics or tear characteristics. The study found no significant correlation between patient demographics and the number of CFUs or NCC of CTPs derived from the SB (p > 0.05). The study did significantly observe that increased tear size was negatively correlated with the number of CFUs (p < 0.05). These results indicated that increased tear size, but not patient demographics, may influence the viability of CTPs and should be considered when augmenting RCrepairs with SB.

Re-tears after rotator cuff repair: Current concepts review

Re-tear following rotator cuff repair is common and has been reported to range from between 13 and 94% despite satisfactory clinical outcomes following rotator cuff surgery. Various risk factors have been associated with an increased tear rate, including patient factors, tear and shoulder morphology, repair technique, and rehabilitation regimes. Different modes of rotator cuff failure have been described. The management of re-tear in patients following rotator cuff repair is challenging and depends on the age, functional status and requirements of the patient, and re-tear size and residual tendon length. This article aims to review the factors associated with rotator cuff re-tear. It describes which of these are associated with poor clinical outcomes, and discusses the long-term outcomes of re-tear and treatment options.

Does diabetes mellitus predispose to both rotator cuff surgery and subsequent failure?

Background

Diabetes mellitus (DM) may be associated with the etiology of rotator cuff disease; however, its effect on healing after surgical rotator cuff repair (RCR) is not well characterized. The purposes of this study are to analyze the association between DM and surgical RCR, the association between DM and revision RCR after RCR, and the association between DM and the cost of RCR.

Methods

A retrospective analysis of claims data of privately and publicly insured subjects from the Truven Health MarketScan database from 2008 to 2017 was conducted, collecting RCR cases and controls matched for age, sex, year of RCR, and first and last year in the database. Multivariable logistic regression models were used to compare DM incidence within the RCR and control groups after adjusting for all matching variables plus region, insurance plan type, tobacco use, and Charlson comorbidity index (CCI). Cox proportional hazard models were used to compare rates of revision RCR between DM and non-DM groups after adjusting for patient age, sex, year of RCR, plan type, and CCI. Generalized estimating equations were used to analyze RCR cost, and exponentiated regression coefficients were reported to represent cost ratios.

Results

The full analysis cohort consisted of 292,666 RCR cases and matched controls. The adjusted odds of having RCR surgery in diabetic patients was 48% higher (odds ratio = 1.48 [95% confidence interval {CI} 1.46 to 1.51], P < .001) than nondiabetics. DM was not significantly associated with revision RCR after RCR when adjusting for age, sex, region, plan type, tobacco use, year of RCR, and CCI (hazard ratio = 1.03, 95% CI 0.99 to 1.07, P = .17). Diabetes was associated with a higher cost of RCR by 3% (ratio = 1.03, 95% CI 1.02 to 1.03, P < .001).

Conclusions

Diabetic patients are at a higher risk of undergoing RCR surgery; however, there is no association between DM and subsequent rotator cuff revision surgery.

Revision Rotator Cuff Repair Versus Primary Repair for Large to Massive Tears Involving the Posterosuperior Cuff: Comparison of Clinical and Radiological Outcomes

Background:

The retear rate after revision rotator cuff repair (rRCR) ranges from 50% to 90%. Patients who undergo primary RCR (pRCR) for large to massive rotator cuff tear (mRCT) also have unpredictable outcomes.

Purpose:

To compare the clinical outcomes after rRCR for a posterosuperior rotator cuff tear of any size with those after pRCR for mRCT and to identify the risk factors for poor outcomes and retear after rRCR.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Among patients with posterosuperior cuff tear treated between 2010 and 2017, the clinical outcomes of 46 patients who underwent rRCR were compared with 106 patients who underwent pRCR for mRCT. Between-group differences in patient-reported outcomes (visual analog scale [VAS] for pain, VAS for satisfaction and American Shoulder and Elbow Surgeons [ASES] and Constant scores) at final follow-up were evaluated and compared with previously published minimal clinically important difference (MCID) values. Radiological outcomes were evaluated using magnetic resonance imaging or ultrasonography at a minimum 1-year follow-up. Multivariate linear regression analysis was performed to identify the risk factors for poor ASES score, and multivariate logistic regression analysis was used to assess the risk factors for retear after rRCR.

Results:

The mean follow-up was 26.4 months (range, 24-81 months). Although final VAS for pain, VAS for satisfaction, and ASES scores in the rRCR group were significantly worse than those in the pRCR group, the Constant score was similar between the groups. These differences in outcomes did not exceed the MCID threshold. The retear rate in the rRCR group was 50% compared with 39% for the pRCR group (P = .194). In the rRCR group, risk factors for worse ASES score were retear (P = .043; r = –11.3), lower body mass index (P = .032; r = 1.9), and lower preoperative VAS for pain (P = .038; r = 2.3), and risk factors for retear were preoperative high-grade fatty degeneration (Goutallier grades 3 and 4) of the supraspinatus muscle (P = .026; odds ratio, 5.2) and serum hyperlipidemia (P = .035; odds ratio, 11.8).

Conclusion:

Both study groups had similar clinical and radiological outcomes. Patients with symptomatic failed rotator cuff repairs having high-grade fatty degeneration of the supraspinatus muscle and/or serum hyperlipidemia had a greater likelihood of retear after rRCR.

Poor Prognostic Factors in Patients With Rotator Cuff Retear

Background:

The treatment for retears after arthroscopic rotator cuff repair (ARCR) has long been a challenge.

Purpose:

This study aimed to (1) summarize the characteristics of patients with a retear after primary ARCR and (2) determine the risk factors for poor clinical outcomes after a retear.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

We collected the data of patients with a retear after primary ARCR between January 2011 and December 2016. There were 45 patients with retears included (19 men [42.2%] and 26 women [57.8%]; mean ± SD age, 63.11 ± 8.87 years). Initially, the demographic and outcome data of patients with a retear were analyzed. Patients were classified into good and poor outcome groups according to their overall satisfaction at final follow-up. Univariable and multivariable logistic regression analyses were performed to determine the factors for poor clinical outcomes after a retear.

Results:

A total of 31 patients were classified into the good outcome group, and 14 patients were classified into the poor outcome group. Both the good and the poor outcome groups showed that clinical scores significantly improved at the time of the retear diagnosis, but the final scores were maintained or worse compared with scores at the time of the retear diagnosis. Final range of motion (ROM), except external rotation in the good outcome group, was worse or had no significant change compared with ROM at the time of the retear diagnosis. On multivariable logistic regression analysis, current smoking (odds ratio [OR], 45.580 [95% CI, 3.014-689.274]; P = .006), female sex (OR, 32.774 [95% CI, 2.433-441.575]; P = .009), and retears of the same or larger size than the initial tear (OR, 10.261 [95% CI, 1.544-68.202]; P = .016) showed a higher OR for poor clinical outcomes after a retear.

Conclusion:

Smoking, female sex, and retears of the same or larger size than the initial tear were independent risk factors for poor clinical outcomes after a rotator cuff retear. Final clinical scores and ROM were similar or worse compared with the scores and ROM at the time of the retear diagnosis. Therefore, revision surgery should be actively considered in female patients or those who smoke with poor clinical outcomes and a larger retear size than the preoperative tear size at the time of the retear diagnosis.

Rotator Cuff Retears

» Regardless of recent advances in rotator cuff repair techniques, the rate of unhealed or recurrent rotator cuff tears remains high, with most recurrent rotator cuff tears occurring within the first 6 months after surgery. » Factors that can negatively affect tendon healing include older age, greater tear size, tendon retraction, and fatty infiltration. However, several clinical features that are often underestimated, including osteoporosis, diabetes, smoking, and hyperlipidemia, have proven to have an important influence on rotator cuff healing. » Recent meta-analyses that evaluated studies with Level-I and Level-II evidence have shown an overall increase in retear rates after single-row repair compared with double-row repair. However, to our knowledge, there are no Level-I clinical studies comparing different double-row configurations and, to date, no double-row repair technique has proven to be superior to the others. » The influence of postoperative rotator cuff healing on clinical outcomes is controversial. Although clinical differences may not be apparent in the short term, healed tendons have had better functional outcomes and greater strength in the midterm. » In general, a period of immobilization for 2 to 4 weeks, depending on tear size, is recommended. Graded supervised rehabilitation has proven to facilitate tendon healing without associated stiffness compared with early unprotected range of motion.

Combination of risk factors affecting retear after arthroscopic rotator cuff repair: a decision tree analysis

BACKGROUND

Several risk factors for postoperative retear after arthroscopic rotator cuff repair (ARCR) have been cited in a large number of reports; various combinations of these seem to be present in the clinical setting.

PURPOSE

Using a combination model for decision tree analysis, we aimed to investigate the combination of risk factors that affect postoperative retear the most.

METHODS

A total of 286 patients who underwent magnetic resonance (MR) imaging at 6 months after surgery were included in this study. Based on the structural integrity of the MR images taken 6 months after surgery, the patients were divided into a healed group (intact tendon, 254 patients) and a retear group (ruptured tendon, 32 patients). Using univariate and decision tree analyses, we selected a combination of 11 risk factors that drastically affected postoperative retear.

RESULTS

The mean age was 64.9 ± 7.1 years, and the mean symptom duration was 9.7 ± 11.6 months. The tear was small/medium in 177 patients and large/massive in 109 patients. The technique for surgical repair was single row in 42 patients, double row in 60 patients, and suture bridging in 216 patients. On univariate analysis, both groups had significant differences in the anteroposterior (AP) tear size (P < .0001), mediolateral tear size (P < .0001), hyperlipidemia (P = .0178), global fatty degeneration index (P < .0001), supraspinatus fatty degeneration stage (P < .0001), and critical shoulder angle (CSA) (P = .0015). All of these 5 risk factors, except for mediolateral tear size, were selected as candidates for the decision tree analysis. Eight combination patterns were determined to have prediction probabilities that ranged from 4.3% to 86.1%. In particular, the combination of an AP tear size of ≥40 mm, hyperlipidemia, and a CSA of ≥37° affected retear after ARCR the most.

CONCLUSIONS

Decision tree analysis lead to the extraction of different retear factor combinations, which were divided into 5 retear groups. The worst combination was of AP tear size ≥40 mm, hyperlipidemia, and CSA ≥37°, and the prediction probability of this combination was 86.2%. Therefore, our data may offer a new index for the prediction of retear after ARCR.

Morphological characteristics of the acromion in Fosbury flop tears and their clinical outcomes after arthroscopic rotator cuff repair

Background

Rotator cuff tears that have flipped upon itself and adhered medially have been recently described as Fosbury flop tears (FFT). However, there are no reports on the cause and clinical outcomes of FFT. We investigated the preoperative anatomical factors and clinical outcomes related to the occurrence of FFT.

Methods

Among patients with more than two years of follow-up, 33 patients with FFT who underwent arthroscopic rotator cuff repair (ARCR) for a small-to-medium sized tear of the supraspinatus tendon alone (Group F: mean age, 63.4 ± 8.9 years) and 52 patients without FFT who underwent ARCR (Group C: mean age, 62.1 ± 7.0 years) were included. Presence of diabetes mellitus, critical shoulder angle (CSA), lateral acromial angle (LAA), acromiohumeral distance (AHD), sagittal and coronal morphologies of the acromion, JOA score, and rate of rotator cuff re-tear were evaluated.

Results

There were significantly more males in Group F (P = 0.017). There were no significant differences in age or rate of diabetic complications. The mean CSA, LAA, and AHD in the Groups F and C were respectively as follows: CSA, 33.7 ± 4.0° and 34.5 ± 3.4°; LAA, 82.1 ± 9.9° and 82.1 ± 6.9°; AHD, 10.2 ± 1.4 mm and 9.8 ± 1.4 mm. There were no significant differences between groups. The acromial morphology showed no significant difference in the sagittal plane; however, significantly more double-floor type acromia were found in the coronal plane (P < 0.001). Although the JOA score significantly improved in both groups, there was no significant difference between groups. The re-rupture rate was significantly higher in Group F than Group C (15.2% versus 1.9%; P = 0.02).

Conclusions

Double-floor type acromia in the coronal plane was common in Group F. The location of osteophytes on the inferior surface of the acromion was believed to be associated with the occurrence of FFT. Furthermore, a high re-tear rate was observed in group F.

The Effect of Patient Characteristics and Comorbidities on the Rate of Revision Rotator Cuff Repair

PURPOSE

To describe the national rates of failed primary rotator cuff repair (RCR) requiring revision repair, using numerous patient characteristics previously defined in orthopaedic literature, including smoking history, diabetes mellitus (DM), hyperlipidemia (HLD), vitamin D deficiency, and osteoporosis to determine which factors independently affect the success of primary RCR.

METHODS

A combined public and private national insurance database was searched from 2007 to 2016 for all patients who underwent RCR. Current Procedural Terminology codes were used to identify RCRs. Laterality modifiers for the primary surgery were used to identify subsequent revision RCRs. All patients who did not have a linked laterality modifier for the RCR Current Procedural Terminology code were excluded from the study. Basic demographics were recorded. International Classification of Diseases Ninth Revision codes were used to identify patient characteristics including Charlson Comorbidity Index, smoking status, DM, obesity, HLD, vitamin D deficiency, and osteoporosis. Patient age categorized as <60, 60-69, 70-74, or 75+ years old. Dichotomous data were analyzed with χ² testing. Multivariable logistic regression was used to characterize independent associations with revision RCR.

RESULTS

Included in the study were 41,467 patients (41,844 shoulders, 52.7% male patients) who underwent primary arthroscopic RCR. Of all arthroscopic RCRs, 3072 patients (3463 shoulders, 53.5% male patients) underwent revision RCR (8.38%). In both primary and revision RCR, patients age 60 to 69 years were most prevalent, accounting for 38.4% and 37.6% of the cohorts, respectively. The average time from primary RCR to revision was 414.9 days (median 214.0 days). Increasing age and male sex (odds ratio [OR] 1.10, P = .019, 95% confidence interval [CI] 1.02-1.19) were significantly predictive of revision RCR. Of the remaining patient characteristics, smoking most strongly predicted revision RCR (OR 1.36, P < .001, CI 1.23-1.49). Obesity (OR 1.32, P < .001, CI 1.21-1.43), hyperlipidemia (OR 1.09, P = .032, CI 1.01-1.18), and vitamin D deficiency (OR 1.18, P < .001, CI 1.08-1.28) also increased risk of revision RCR significantly. DM was found to be protective against revision surgery (OR 0.84, P < .001, CI 0.76-0.92). Overall comorbidity burden as measured by the Charlson Comorbidity Index was not predictive of revision RCR.

CONCLUSIONS

Smoking, obesity, vitamin D deficiency, and HLD are shown to be independent risk factors for failure of primary RCR requiring revision RCR. However, despite the suggestions of previous studies, DM, osteoporosis, and overall comorbidity burden did not demonstrate independent associations in this study.

LEVEL OF EVIDENCE

IV, Case Series.

Dyslipidemia With Perioperative Statin Usage Is Not Associated With Poorer 24-Month Functional Outcomes After Arthroscopic Rotator Cuff Surgery

BACKGROUND

Current literature suggests a higher rate of rotator cuff disease development in patients with dyslipidemia (DL). Moderate to high levels of DL are associated with higher rates of retear and revision surgery after arthroscopic rotator cuff repair. Statins protect against development of rotator cuff disease and mitigate the need for rotator cuff repair.

PURPOSE

We aimed to investigate the influence of DL and statin use on postoperative functional outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between 2010 and 2016, 266 patients underwent arthroscopic double-row rotator cuff repair for atraumatic full-thickness tears. Evaluation was conducted preoperatively and at 3, 6, 12, and 24 months postoperatively. Three functional outcome measures were used (Constant Shoulder Score [CSS], Oxford Shoulder Score [OXF], and University of California, Los Angeles, Shoulder Rating Scale [UCLASS]), as well as a visual analog scale (VAS) for pain. DL and non-DL were classified through screening of health and assessment of lipid levels within 6 months of surgery (triglycerides, total cholesterol, low-density lipoprotein, and high-density lipoprotein). Patients with DL were divided into statin users and nonusers. Types and dosages of statins were recorded, and intensity and equivalency charts were employed for standardization. Mann-Whitney U test and Pearson chi-square test were used for analysis. Generalized estimating equations and linear mixed models were used to examine the influence of DL and statin dosage, respectively on percentage change of postoperative outcome scores.

RESULTS

Increased age was associated with a higher incidence of DL (P < .001), and 86% of the DL group was taking statins. The DL group also exhibited poorer scores preoperatively (CSS, P = .001; OXF, P = .032). No significant difference in scores was elicited between the DL and non-DL groups at 24 months. However, patients with DL experienced greater percentage improvement of CSS and OXF from preoperative baseline than did patients without DL (P = .008 and P = .034, respectively) at 24 months. There was no significant difference in 24-month functional outcomes between statin users and nonusers. No statistically significant change of CSS; OXF; UCLASS; or VAS was noted with increasing statin doses at 24 months.

CONCLUSION

Patients with DL with perioperative statin usage did not have poorer 24-month functional outcomes after arthroscopic rotator cuff surgery compared with those in patients without DL.

Hypo-High-Density Lipoproteinemia Is Associated With Preoperative Tear Size and With Postoperative Retear in Large to Massive Rotator Cuff Tears

PURPOSE

To evaluate any association of specific subtypes of dyslipidemia with increments of preoperative tear size and with structural integrity after arthroscopic rotator cuff repair (ARCR).

METHODS

One surgeon's consecutive patients who underwent ARCR from January 2011 to June 2018 were reviewed. The inclusion criteria were minimum 1-year follow-up ultrasonography, blood tests, physical examination, and provision of informed consent. The exclusion criteria were incomplete laboratory tests, history of acute trauma, previous shoulder surgery, isolated subscapularis tendon tear, inappropriate radiographs, no 1-year follow-up ultrasonography, and medication with lipid-lowering drugs. Associated preoperative factors for the increments of tear size and for retear after ARCR were determined using logistic regression analysis. Statistical significance was set at P < .05.

RESULTS

Of the 502 ARCR patients from the study period, 195 patients (195 shoulders), with a mean age of 60.5 ± 7.5 years, met the inclusion and exclusion criteria. Age (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.1-1.3), diabetes (OR, 3.6; 95% CI, 1.7-7.5), and hypo-high-density lipoproteinemia (hypo-HDLemia) (OR, 2.9; 95% CI, 1.5-5.6) were significantly associated with increments of preoperative tear size (P ≤ .01). Diabetes (OR, 3.0; 95% CI, 1.3-6.6), critical shoulder angle (OR, 2.0; 95% CI, 1.4-3.0), and tear size (OR, 2.1; 95% CI, 1.3-3.4) were significantly associated with retear after ARCR in overall study subjects (P = .01). Diabetes (OR, 3.8; 95% CI, 1.3-11.4), hypo-HDLemia (OR, 3.0; 95% CI, 1.1-8.8), and critical shoulder angle (OR, 1.5; 95% CI, 1.1-2.3) had significant associations with retear after ARCR in patients with a large to massive preoperative tear size (P ≤ .04).

CONCLUSIONS

Preoperative hypo-HDLemia (high-density lipoprotein level < 40 mg/dL in male patients and < 50 mg/dL in female patients) has a significant association with the increments of preoperative tear size and with retear after ARCR in large- to massive-sized rotator cuff tears.

LEVEL OF EVIDENCE

Level IV, case series.

Editorial Commentary: Revision Surgery After Symptomatic Failed Arthroscopic Rotator Cuff Repair: What Factors Affect Primary Surgery?

Anteroposterior tear length, hyperlipidemia, and muscle fatty degeneration lead to retear after arthroscopic rotator cuff repair and to subsequent revision surgery. The challenge is to develop methods to prevent these adverse effects after surgery.

Factors Related to Symptomatic Failed Rotator Cuff Repair Leading to Revision Surgeries After Primary Arthroscopic Surgery

PURPOSE

To evaluate the clinical characteristics of patients with symptomatic failed rotator cuff repair who required revision surgeries and to identify clinical and radiologic factors related to the need for revision surgery.

METHODS

Ninety-eight patients who were diagnosed with rotator cuff retear within 2 years after primary arthroscopic surgery were included. Patients were divided into 2 groups: patients who underwent revision surgery within 2 years postoperatively (44 patients, group I) and patients who did not require additional treatment due to minimal discomfort during the same period (54 patients, group II). Demographic and radiographic factors related to cuff healing were analyzed. Univariate and multivariate analyses were performed to evaluate factors related to revision surgery.

RESULTS

Group I showed significantly inferior clinical outcomes at the time of revision compared to group II (American Shoulder and Elbow Surgeons score; 54.0 ± 12.1 vs 86.5 ± 12.2, Constant score; 65.2 ± 10.8 vs 84.0 ± 11.4, P < .001). Total cholesterol level (210.2 ± 40.0 vs 189.7 ± 39.1, P = .012), low-density lipoprotein level (130.7 ± 28.7 vs 115.5 ± 26.9, P = .008), and fatty infiltration of the infraspinatus (20.5% vs 3.7%, P = .011) were significantly greater in group I than in group II. On postoperative magnetic resonance imaging, retear of the infraspinatus tendon occurred significantly more frequently in group I (81.8%) than in group II (37.0%, P < .001). In group I, relative changes in anteroposterior (AP) (19.2 ± 37.8) and mediolateral retear size (29.6 ± 90.7) were significantly greater than in group II (AP; -39.5 ± 19.2, mediolateral; -29.2 ± 26.8, P < .001). Relative change in AP retear size was the most powerful independent predictor of symptomatic failed rotator cuff repair (odds ratio 1.19, confidence interval 1.08-1.31, P < .001).

CONCLUSIONS

Preoperative serum total cholesterol level, low-density lipoprotein levels, and fatty infiltration of the infraspinatus were significantly related to symptomatic failed rotator cuff repair. Relative change in AP retear size was the most powerful independent predictor of symptomatic failed rotator cuff repair.

LEVEL OF EVIDENCE

Level III, Case-control study.

Factors Influencing the Reparability and Healing Rates of Rotator Cuff Tears

PURPOSE OF THE REVIEW

To discuss tear- and patient-related factors that influence the healing potential of rotator cuff tears and to clarify the terminology surrounding this topic.

RECENT FINDINGS

Over the last few years, further insight has been gained regarding rotator cuff tear features that are associated with poor healing rates after rotator cuff repair. Some of these features have been incorporated in prediction models developed to accurately predict rotator cuff healing rates utilizing preoperative risk factors weighted by importance. Rotator cuff tears may be considered functionally irreparable based on their size, chronicity, absence of adequate tendon length, atrophy, and fatty infiltration. Furthermore, advanced age, use of tobacco products, diabetes, and other patient-related factors may impair tendon healing. Careful analysis and discussion of all these factors with patients is essential to determine if surgical repair of a rotator cuff tear should be recommended, or if it is best to proceed with one of the several salvage procedures reviewed in this topical collection, including augmentation of the repair, superior capsular reconstruction, tendon transfers, and other.

Zoledronic Acid Substantially Improves Bone Microarchitecture and Biomechanical Properties After Rotator Cuff Repair in a Rodent Chronic Defect Model

BACKGROUND

Bone mineral density at the humeral head is reduced in patients with chronic rotator cuff tears. Bone loss in the humeral head is associated with repair failure after rotator cuff reconstruction. Bisphosphonates (eg, zoledronic acid) increase bone mineral density.

HYPOTHESIS

Zoledronic acid improves bone mineral density of the humeral head and biomechanical properties of the enthesis after reconstruction of chronic rotator cuff tears in rats.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 32 male Sprague-Dawley rats underwent unilateral (left) supraspinatus tenotomy with delayed transosseous rotator cuff reconstruction after 3 weeks. All rats were sacrificed 8 weeks after rotator cuff repair. Animals were randomly assigned to 1 of 2 groups. At 1 day after rotator cuff reconstruction, the intervention group was treated with a single subcutaneous dose of zoledronic acid at 100 µg/kg bodyweight, and the control group received 1 mL of subcutaneous saline solution. In 12 animals of each group, micro-computed tomography scans of both shoulders were performed as well as biomechanical testing of the supraspinatus enthesis of both sides. In 4 animals of each group, histological analyses were conducted.

RESULTS

In the intervention group, bone volume fraction (bone volume/total volume [BV/TV]) of the operated side was higher at the lateral humeral head (P = .005) and the medial humeral head (P = .010) compared with the control group. Trabecular number on the operated side was higher at the lateral humeral head (P = .004) and the medial humeral head (P = .001) in the intervention group. Maximum load to failure rates on the operated side were higher in the intervention group (P < .001). Cortical thickness positively correlated with higher maximum load to failure rates in the intervention group (r = 0.69; P = .026). Histological assessment revealed increased bone formation in the intervention group.

CONCLUSION

Single-dose therapy of zoledronic acid provided an improvement of bone microarchitecture at the humeral head as well as an increase of maximum load to failure rates after transosseous reconstruction of chronic rotator cuff lesions in rats.

CLINICAL RELEVANCE

Zoledronic acid improves bone microarchitecture as well as biomechanical properties after reconstruction of chronic rotator cuff tears in rodents. These results need to be verified in clinical investigations.

Is there an association between metabolic syndrome and rotator cuff-related shoulder pain? A systematic review

Objectives

Rotator cuff-related shoulder pain (RCRSP) is a common upper limb complaint. It has been suggested that this condition is more common among people with cardiometabolic risk factors. This systematic review has synthesised evidence from case–control, cross-sectional and cohort studies on the association between metabolic syndrome (MetS) and RCRSP.

Design and data sources

Five medical databases (MEDLINE, EMBASE, SCOPUS, CINAHL and AMED) and reference checking methods were used to identify all relevant English articles that considered MetS and RCRSP. Studies were appraised using the Newcastle-Ottawa Scale (NOS). Two reviewers performed critical appraisal and data extraction. Narrative synthesis was performed via content analysis of statistically significant associations.

Results

Three cross-sectional, two case–control and one cohort study met the inclusion criteria, providing a total of 1187 individuals with RCRSP. Heterogeneity in methodology and RCRSP or MetS definition precluded a meaningful meta-analysis. Four of the included studies identified associations between the prevalence of MetS and RCRSP. Studies consistently identified independent cardiometabolic risk factors associated with RCRSP. All studies were level III evidence.

Summary and conclusion

The low-moderate quality evidence included in this review suggests an association between MetS and RCRSP. Most studies demonstrated moderate quality on appraisal. The direction of association and cardiometabolic factors influencing should be investigated by longitudinal and treatment studies. These preliminary conclusions and clinical utility should be treated with caution due to limitations of the evidence base.

An automatic diagnostic system based on deep learning, to diagnose hyperlipidemia

Background: Using artificial intelligence to assist in diagnosing diseases has become a contemporary research hotspot. Conventional automatic diagnostic method uses a conventional machine learning algorithm to distinguish features from which a professional doctor manually extracts features in diagnostic reports. But it can be difficult to collect large amounts of necessary medical data. Therefore, these methods face challenges with efficiency and accuracy. Method: Here, we proposed an automatic diagnostic system based on a deep learning algorithm to diagnose hyperlipidemia by using human physiological parameters. This model is a neural network which uses technologies of data extension and data correction. Firstly, we corrected and supplemented the original data by the method mentioned previously to solve the problem of lacking data. Secondly, the processed data were used to train a deep learning model. Deep learning model can automatically extract all the available information instead of artificially reducing the raw data. Therefore, it can reduce labor costs. The classifiers classify the data by using features previously mentioned. Finally, the system was evaluated with data from a test dataset. Result: It achieved 91.49% accuracy, 87.50% sensitivity, 93.33% specificity, and 87.50% precision with data from the test dataset. Conclusion: The proposed diagnostic method has a highly robust and accurate performance, and can be used for tentative diagnosis. It can automatically diagnose diseases by using human physiological parameters, thereby reducing labor cost, which results in effective improvement of clinical diagnostic efficiency.

The Diagnostic Value of Subscapularis Clinical Tests in the Postoperative Diagnosis of Subscapularis Retears: An Ultrasound-Comparative Trial

Background:

Different physical examination tests have been used to preoperatively determine both the presence and size of a primary subscapularis tear. On the contrary, no clinical trial has yet been published to assess the diagnostic validity of the aforementioned tests in diagnosing subscapularis retears after arthroscopic subscapularis repair.

Objective:

To investigate the diagnostic value of the most commonly used clinical tests in the diagnosis of subscapularis tendon retears after arthroscopic repair.

Methods:

A retrospective (prospectively collected data) case series involving 37 patients who were suffering from symptomatic complete subscapularis tendon tear was conducted. All patients underwent an all-arthroscopic subscapularis repair with the same operative technique. They were postoperatively evaluated (final end point of follow-up: 12 months) with the use of ultrasound, Constant-Murlay score (CS), bear hug test, internal rotation lag sign, Napoleon test and lift-off test. Sensitivity, specificity, accuracy, positive and negative prognostic values were calculated for each test.

Results:

Shoulder function was significantly improved according to the final CS. The internal rotation lag sign was the most sensitive for the diagnosis of postoperative subscapularis retears, while the Napoleon sign had the highest specificity. Although postoperative clinical tests yielded no false negative findings, they were poorly predictive as for new ruptures. Ten patients (27%), who were found with a positive (for re-rupture), postoperative, clinical test, had a sonographically intact subscapularis tendon repair.

Conclusion:

We strongly support the use of subscapularis-specific clinical tests as a composite, in combination with a specific interpretation of their results. If all tests are found negative for retear, then we could assume that the arthroscopic repair remains intact and no further diagnostic examination might be necessary. On the contrary, if at least one subscapularis-specific clinical test is positive for retear, then the patient will likely require additional imaging control for definite diagnosis.

The effects of hyperlipidemia on rotator cuff diseases: a systematic review

BACKGROUND

Rotator cuff disease is a common condition that causes shoulder pain and functional disability. Recent studies suggested that hyperlipidemia might be associated with the development of rotator cuff disease. The objective of this study was to explore the relationship of hyperlipidemia and rotator cuff diseases.

METHODS

A computerized search using relevant search terms was performed in the PubMed, EMBASE, and Cochrane Library databases, as well as a manual search of reference and citation lists of the included studies. Searches were limited to studies that explored the association of hyperlipidemia and rotator cuff diseases.

RESULTS

Sixteen studies were included in this systematic review. Ten of sixteen included studies suggested an association between dyslipidemia and rotator cuff diseases, while the other six studies did not find an association. Two studies demonstrated there were an association between statins and reduced risk of developing rotator cuff diseases or decreased incidence of revision after rotator cuff repair.

CONCLUSION

The current study suggested that there was an association between hyperlipidemia and rotator cuff diseases. Furthermore, current evidence suggested that use of statins could decrease the risk of developing rotator cuff diseases and the incidence of revision after rotator cuff repair. Future high-quality studies are highly needed to confirm these findings.

Effects of mulberry leaf on experimental hyperlipidemia rats induced by high-fat diet

Hypercholesterolemia is a major risk factor for cardiovascular disease. Mulberry leaf (ML) is a Traditional Chinese Medicine used to treat hyperlipidemia in clinical settings. The aim of the present study was to identify the potential effect and possible target of ML in anti-hypercholesterolemia. Male Sprague-Dawley rats were fed with a high-fat diet and treated with ML for 5 weeks. Blood lipid levels, total cholesterol (TC) and total bile acid (TBA) in the liver and feces were measured to assess the effects of ML on hypercholesterolemia. Harris's hematoxylin staining and oil red O staining was applied to observe the pathological change and lipid accumulation in the liver. Immunohistochemical assay was performed to observe the location of expressions of scavenger receptor class B type I and low-density lipoprotein (LDL) receptor (-R), and western blotting was applied to determine the protein expression of ATP-binding cassette transporter G5/G8 (ABCG5/8), nuclear transcription factor peroxisome proliferator-activated receptor-α (PPARα), farnesoid-X receptor (FXR) and cholesterol 7α-hydroxylase 1 (CYP7A1). The results demonstrated that ML treatment reduced serum TC and LDL-cholesterol levels, and liver TC and TBA contents; increased serum HDL-C levels, and fecal TC and TBA contents; and alleviated hepatocyte lipid degeneration. In addition, ML treatment inhibited liver LDL-R, PPARα and FXR protein expression, promoted protein expression of CYP7A1, and maintained the ratio of ABCG5/ABCG8. The findings of the present study provide a positive role of ML on cholesterol clearance via promoting cholesterol and TBA execration via FXR- and CYP7A1-mediated pathways; RCT regulation may be a potential mechanism of ML on anti-hypercholesterolemia.