Operative versus nonoperative treatment for the management of full-thickness rotator cuff tears: a systematic review and meta-analysis

The effect of platelet-rich fibrin, platelet-rich plasma, and concentrated growth factor in the repair of full thickness rotator cuff tears

BACKGROUND

Rotator cuff lesions rank among the prevalent causes of shoulder pain. Combining surgical interventions with growth factors, scaffolds, and stem cell therapies can effectively decrease the likelihood of rotator cuff repair recurrence. Platelet-rich plasma (PRP), platelet-rich fibrin (PRF), and concentrated growth factor (CGF), isolated from blood and rich in growth factors, have a critical role in cell migration, cell proliferation, and angiogenesis during the tissue regeneration process. Investigations have further substantiated the beneficial impact of PRP and PRF on the biomechanical and histologic attributes of the tendon-bone interface. We aimed to investigate the effectiveness of CGF compared with PRF and PRP in the repair of rotator cuff lesions as a new treatment strategy.

METHODS

Incision was performed on both shoulder regions of 21 adult rabbits. After 8 weeks, both shoulders of the rabbits were repaired by suturing. PRF and CGF were administered to 2 separate groups along with the repair. Tissues were collected for biomechanical measurements and histologic evaluations.

RESULTS

Histologically, CGF, PRF, and PRP showed similar results to the healthy control group. The level of improvement was significant in the PRF and PRP groups. In the PRF group, the distribution of Ki67 (+), CD31 (+), and CD34 (+) cells was determined intensely in the tendon-bone junction regions. Apoptotic cells increased significantly in the repair group compared with the healthy group, whereas fewer apoptotic cells were found in the PRF-, PRP-, and CGF-applied groups. In the biomechanical results, no statistical difference was recorded among the groups.

CONCLUSION

The use of PRF, PRP, and CGF in rotator cuff repair shows promise in shortening the treatment period and preventing the recurrence of rotator cuff lesions.

Optimizing Tissue Engineering for Clinical Relevance in Rotator Cuff Repair

Rotator cuff tear (RCT) is the most common cause of disability in the upper extremity. It results in 4.5 million physician visits in the United States every year and is the most common etiology of shoulder conditions evaluated by orthopedic surgeons. Over 460,000 RCT repair surgeries are performed in the United States annually. Rotator cuff (RC) retear and failure to heal remain significant postoperative complications. Literature suggests that the retear rates can range from 29.5% to as high as 94%. Weakened and irregular enthesis regeneration is a crucial factor in postsurgical failure. Although commercially available RC repair grafts have been introduced to augment RC enthesis repair, they have been associated with mixed clinical outcomes. These grafts lack appropriate biological cues such as stem cells and signaling molecules at the bone-tendon interface. In addition, they do little to prevent fibrovascular scar tissue formation, which causes the RC to be susceptible to retear. Advances in tissue engineering have demonstrated that mesenchymal stem cells (MSCs) and growth factors (GFs) enhance RC enthesis regeneration in animal models. These models show that delivering MSCs and GFs to the site of RCT enhances native enthesis repair and leads to greater mechanical strength. In addition, these models demonstrate that MSCs and GFs may be delivered through a variety of methods including direct injection, saturation of repair materials, and loaded microspheres. Grafts that incorporate MSCs and GFs enhance anti-inflammation, osteogenesis, angiogenesis, and chondrogenesis in the RC repair process. It is crucial that the techniques that have shown success in animal models are incorporated into the clinical setting. A gap currently exists between the promising biological factors that have been investigated in animal models and the RC repair grafts that can be used in the clinical setting. Future RC repair grafts must allow for stable implantation and fixation, be compatible with current arthroscopic techniques, and have the capability to deliver MSCs and/or GFs.

Atelocollagen Injection During Arthroscopic Rotator Cuff Repair for Small- to Medium-Sized Subacute or Chronic Rotator Cuff Tears Enhances Radiographic Tendon Integrity: A Propensity Score-Matched Comparative Study

PURPOSE

To evaluate the clinical and structural outcomes of using injectable atelocollagen during arthroscopic rotator cuff repair (ARCR) for small- to medium-sized rotator cuff tears.

METHODS

This retrospective study reviewed patients with small- to medium-sized full-thickness tears who underwent ARCR from 2016 to 2022 with a minimum 1-year follow-up. Propensity score (PS) matching was used to reduce bias. Tendon integrity was evaluated using magnetic resonance imaging (MRI) at postoperative 6 months. Clinical and structural outcomes were compared between the 2 groups.

RESULTS

After PS matching, this study included 181 pairs of patients comparing ARCR with atelocollagen injection and without atelocollagen injection. Range of motion, muscle strength, and functional outcomes were significantly improved in both the atelocollagen group and the control group. Forward elevation and external rotation were significantly worse in the atelocollagen group compared with the control group at 2, 6, and 12 months postoperatively and at the final follow-up. In total, 125 patients (69.1%) in the atelocollagen group and 130 patients (71.8%) in the control group exceeded the minimal clinically important difference in the American Shoulder and Elbow Surgeons score without a significant difference between the 2 groups (P = .509). The mean value of Sugaya grade on postoperative MRI evaluation was 2.03 ± 0.81 for the atelocollagen group and 2.24 ± 0.97 for the control group, with a significant difference between the 2 groups (P = .027). Tendon healing failure was observed in 12 patients (6.6%) in the atelocollagen group and 19 patients (10.5%) in the control group, with no statistical difference between the 2 groups (P = .189).

CONCLUSIONS

Atelocollagen injection during ARCR for small- to medium-sized subacute or chronic rotator cuff tears did not show a benefit in clinical outcomes. However, postoperative MRI showed significantly lower Sugaya grade compared with the control group, with no significant difference in retear rate.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Comparing Telerehabilitation and Home-based Exercise for Shoulder Disorders: A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to quantitatively compare the effects of telerehabilitation and home-based exercise for shoulder disorders.

DATA SOURCES

We conducted a search for eligible studies in PubMed, EMBASE, Web of Science, Cochrane Library, and MEDLINE databases following Preferred Reporting Items for Systematic Review and Meta-analyses guidelines.

STUDY SELECTION

Independent reviewers selected randomized controlled trials that compared the effects of telerehabilitation and home-based exercise in individuals with shoulder disorders.

DATA EXTRACTION

Two reviewers independently conducted data extraction and assessed the risk of bias using the Cochrane Risk of Bias tool.

DATA SYNTHESIS

A total of 7 studies with 508 participants were included. Compared with home-based exercise, telerehabilitation showed superior improvements in range of motion (flexion: standardized mean difference [SMD] 0.35, 95% confidence interval [CI] 0.14 to 0.56; abduction: SMD 0.37, 95% CI 0.16 to 0.58; external rotation: SMD 0.43, 95% CI 0.22 to 0.64; internal rotation: SMD 0.33, 95% CI 0.08 to 0.58), functional outcomes (Shoulder Pain and Disability Index: SMD -0.37, 95% CI -0.61 to -0.12; shortened Disabilities of the Arm, Shoulder and Hand questionnaire: mean difference [MD] -4.51, 95% CI -8.70 to -0.32), and quality of life (EuroQol Five Dimensions Questionnaire: MD 0.04, 95% CI 0.01 to 0.07). Telerehabilitation was not different from home-based exercise in terms of pain relief (SMD -0.19, 95% CI -0.60 to 0.23). Subgroup analysis demonstrated that telerehabilitation provided significant pain relief when sustained for over 12 weeks (SMD -0.46, 95% CI -0.81 to -0.11).

CONCLUSIONS

Telerehabilitation is more effective than home-based exercise in improving range of motion, functional outcomes, and quality of life for patients with shoulder disorders. Telerehabilitation significantly outperforms home-based exercise in relieving pain when continued for over 12 weeks.

Assessment of description and implementation fidelity of clinical trials involving exercise-based treatment in individuals with rotator cuff tears: a scoping review

BACKGROUND

For evidence-based practice, clinicians and researchers can rely on well-conducted randomized clinical trials that exhibit good methodological quality, provide adequate intervention descriptions, and implementation fidelity.

OBJECTIVE

To assess the description and implementation fidelity of exercise-based interventions in clinical trials for individuals with rotator cuff tears.

METHODS

A systematic search was conducted in PubMed, Embase, CINAHL, LILACS, Cochrane Library, Web of Science, SCOPUS and SciELO. Randomized clinical trials that assessed individuals with rotator cuff tears confirmed by imaging exam were included. All individuals must have received an exercise-based treatment. The methodological quality was scored with the Physiotherapy Evidence Database (PEDro) scale. The Template for Intervention Description and Replication (TIDieR) checklist and the National Institutes of Health Behaviour Change Consortium (NIHBCC) were used to assess intervention description and implementation fidelity, respectively.

RESULTS

A total of 13 studies were included. Despite their adequate methodological quality, the description of the intervention was poor with TIDieR scores ranging from 6 to 15 out of 24 total points. The TIDieR highest-scoring item was item 1 (brief name) that was reported in all studies. Considering fidelity, only one of the five domains of NIHBCC (i.e., treatment design) reached just over 50%.

CONCLUSION

Exercise-based interventions used in studies for individuals with rotator cuff tears are poorly reported. The description and fidelity of the intervention need to be better reported to assist clinical decision-making and support evidence-based practice.

Bone channeling in arthroscopic rotator cuff repair: a systematic review and meta-analysis of level I studies

BACKGROUND

There is ongoing controversy regarding the effect of bone channeling in arthroscopic rotator cuff repair. Since the most recent systematic reviews in 2019, several large high-level trials have been completed. This study assessed all available level I randomized controlled trials (RCTs) that compared arthroscopic rotator cuff repair with and without bone marrow channeling.

METHODS

A systematic search of the Ovid MEDLINE, Embase, and Cochrane Library databases was conducted through mid January 2023. Two reviewers performed screening of studies meeting the eligibility criteria: English-language RCTs in patients aged ≥18 years comparing arthroscopic rotator cuff repair of full-thickness tears with and without bone marrow channeling (channeling group and control group, respectively). Functional scores, pain, healing rates, and reoperations were reviewed using pooled analysis where appropriate. The methodologic quality of included studies was assessed using the Cochrane risk-of-bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

A total of 6 randomized studies (N = 593) met the inclusion criteria. Pooled analysis of all 6 studies showed no significant mean difference in function (1.32; 95% confidence interval [CI], -0.63 to 3.26), as measured by the Constant-Murley score. Retear rates were also not statistically different between groups (risk ratio, 0.99; 95% CI, 0.57 to 1.71), with pooled retear rates of 19.6% (48 of 245) with channeling and 19.8% (51 of 257) without. The other outcomes of interest were only available for analysis in a subset of studies. There were no standardized mean differences in pain (0.09; 95% CI, -0.18 to 0.36), and there were similar reoperation rates (risk ratio, 1.19; 95% CI, 0.43 to 3.34) in the channeling and control groups. For the included studies, the overall quality of evidence by outcome was judged to be moderate (function, pain, and reoperations) or low (retear rates), mainly owing to risk of bias (all outcomes) and inconsistency (retear rates).

CONCLUSION

The results of this study refute the findings of prior systematic reviews that showed that channeling reduces the retear rate when combined with arthroscopic rotator cuff repair. This meta-analysis of level I evidence, including recent larger RCTs, demonstrates that bone marrow stimulation in the setting of primary arthroscopic rotator cuff repair has no significant effect on functional outcomes, healing, pain, or reoperation rates.

Many patients fail to achieve MCID for PROMIS upper extremity and pain interference following nonoperative management of rotator cuff tears

Background

Efficacy of nonoperative treatment for rotator cuff tears has been debated, especially for full-thickness tears. The purpose of this study was to a) define the minimal clinically important difference (MCID) of nonoperative treatment with regard to Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) and upper extremity (UE), and b) determine the proportion of patients with both partial and full-thickness tears (PTRCT, FTRCT) who achieve this improvement following initial nonoperative treatment. We hypothesized that >75% of PTRCT and FTRTC patients would achieve MCID for PROMIS PI and UE.

Methods

We performed a retrospective cohort study evaluating nonoperatively managed patients with image-confirmed PTRCT and FTRCT. Treatment modalities and follow-up PROMIS scores at least 6 months after their initial visit were recorded. Using a distribution technique, MCID was calculated.

Results

A total of 111 FTRCT and 68 PTRCT patients were included with at least 6 months of follow-up. At 6 months from initial presentation, the MCID for PROMIS UE was 3.75 and 3.95 for FTRCT and PTRCT patients, respectively. For PROMIS PI, the MCID was 3.35 and 3.90 for FTRCT and PTRCT, respectively. In total, 41% of FTRCT and 41% of PTRCT achieved MCID for PROMIS UE. Thirty-four percent of FTRCT and 35% of PTRCT achieved MCID for PROMIS PI.

Conclusion

The majority of patients undergoing nonoperative treatment for supraspinatus/infraspinatus rotator cuff tears did not achieve MCID at 6 months for PROMIS PI (34% for FTRCT and 35% for PTRCT) or UE (41% for FTRCT and 41% for PTRCT).

Postoperative psychological factors and quality of life but not shoulder brace adherence affect clinical outcomes after arthroscopic rotator cuff repair

BACKGROUND

Despite the high prevalence, there is no consensus for postsurgical management after rotator cuff repair. We aimed to assess the impact of psychological well-being on patients who underwent rotator cuff repair. We also investigated correlations and possible predictors between patient demographics and adherence to the use of the shoulder brace and outcomes in terms of shoulder functionality and quality of life.

METHODS

We conducted a retrospective study with prospective data collection enrolling 120 consecutive patients who underwent shoulder arthroscopy for rotator cuff tear repair. Each patient was clinically evaluated after a mean follow-up of 24.2 (±9.8) months using (1) the Disability of the Arm, Shoulder and Hand (DASH) scale, (2) the Hospital Anxiety and Depression Scale (HADS), (3) the Rotator Cuff Quality of Life (RC-QoL), (4) the visual analog scale, and (5) the Medical Adherence Measure.

RESULTS

The final sample consisted of 100 patients (45 females, 45%) averaging 60.9 (±8.5) years. The average brace wearing time was 3.4 (±0.6) weeks, with an adherence superior to 80% in 84% of cases, and 96% of patients were living with family members. The mean postoperative DASH scores were 20.1 (±16.7), 23.4 (±25), and 18.9 (±21.5) for the general, work, and sport sections, respectively. The mean Medical Adherence Measure score reached 72.5 (±14.2) points, and the RC-QoL mean score was 30.4% (±20.5). The Hospital Anxiety and Depression Scale-Anxiety and Hospital Anxiety and Depression Scale-Depression scores' continuous mean values were 5.1 (±3.4) and 3.9 (±3.6), respectively. The DASH, Hospital Anxiety and Depression Scale-Anxiety, Hospital Anxiety and Depression Scale-Depression, and RC-QoL scores directly correlated with each other, and all these questionnaires directly correlated with the visual analog scale scores. Moreover, we found a direct correlation (r = 0.204, P = .033) between the female sex and adherence to the brace and a direct correlation (r = 0.242, P = .015) between adherence to the brace and the number of weeks it was worn according to the medical recommendation. A correlation between lower educational qualifications and poorer outcomes was found. No correlation emerged between adherence to the brace and functional results. According to the regression analysis, diabetes was found to be a predictor of worse postoperative DASH scores (β = 0.245, P = 0.28).

CONCLUSION

A lower perceived quality of life was associated with worse functional results, anxiety and depression symptoms, and pain after rotator cuff repair surgery. The adherence to the use of the shoulder brace was associated with the female sex and a longer prognosis, but no correlation emerged between adherence to the brace and functional outcomes.

A randomized controlled trial of postoperative rehabilitation using digital healthcare system after rotator cuff repair

A digital healthcare system based on augmented reality (AR) has promising uses for postoperative rehabilitation. We compare effectiveness of AR-based and conventional rehabilitation in patients after rotator cuff repair (RCR). This study randomly allocates 115 participants who underwent RCR to digital healthcare rehabilitation group (DR group) and conventional rehabilitation group (CR group). The DR group performs AR-based home exercises using UINCARE Home+, whereas the CR group performs brochure-based home exercises. The primary outcome is a change in the Simple Shoulder Test (SST) score between baseline and 12 weeks postoperatively. The secondary outcomes are the Disabilities of the Arm, Shoulder and Hand (DASH) score; Shoulder Pain And Disability Index (SPADI) score; EuroQoL 5-Dimension 5-Level (EQ5D5L) questionnaire score; pain; range of motion (ROM); muscle strength; and handgrip strength. The outcomes are measured at baseline, and at 6, 12, and 24 weeks postoperatively. The change in SST score between baseline and 12 weeks postoperatively is significantly greater in the DR group than in the CR group (p = 0.025). The SPADI, DASH, and EQ5D5L scores demonstrate group×time interactions (p = 0.001, = 0.04, and = 0.016, respectively). However, no significant differences over time are observed between the groups in terms of pain, ROM, muscle strength, and handgrip strength. The outcomes show significant improvement in both groups (all p < 0.001). No adverse events are reported during the interventions. AR-based rehabilitation shows better improvement in terms of shoulder function after RCR compared to conventional rehabilitation. Therefore, as an alternative to the conventional rehabilitation, the digital healthcare system is effective for postoperative rehabilitation.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Synthetic polytetrafluoroethylene patches for irreparable rotator cuff tears-how are they doing at 5 years?

BACKGROUND

Treating massive and irreparable rotator cuff tears are problematic. Several studies have reported that polytetrafluoroethylene (PTFE) patches demonstrated excellent construct integrity and positive clinical and patient outcomes. However, these studies either had small sample sizes or short follow-up periods.

PURPOSE

To determine the survivorship, efficacy, and medium-term (2-19 years) outcomes of PTFE patch repairs.

METHODS

This retrospective study used prospectively collected data to establish the medium-term outcomes of PTFE interposition patch repairs for massive rotator cuff tears that could not be repaired by the standard technique. Patients included those who met the ≥2-year follow-up criteria post repair. Standardized assessments of patient-ranked shoulder pain and function and shoulder strength and passive range of motion (ROM) were performed preoperatively and at follow-up visits. Radiographs and ultrasonography were used to evaluate repair integrity, measure proximal humeral head migration, and determine glenohumeral arthritis scores.

RESULTS

Forty-one shoulders formed the study cohort at a mean follow-up period of 5 years (range: 2-19 years). The mean age of this group was 72 (standard deviation: 10; range: 50-88) and had 14 cm² tears at surgery. Twenty-five of 41 (61%) PTFE interposition patch repairs remained intact at an average of 5 years postrepair. Thirteen patches failed at the patch-tendon junction, 1 was removed, and 2 patients underwent reverse total shoulder replacement. Patient-ranked shoulder stiffness (P < .05), frequency of pain during activity and sleep (P < .001), pain levels during overhead activity and rest (P < .001), and overall shoulder function significantly improved from bad preoperatively to fair at the mean 5-year postoperative visit (P < .001). No significant improvements were demonstrated in dynamometer-measured shoulder strength maneuvers and passive ROM. All patients demonstrated proximal humeral head migration on shoulder radiographs regardless of repair integrity (mean Upper Migration Index = 1.2). Failed repairs were associated with higher mean preoperative glenohumeral arthritis grades compared with intact repairs (grade 2 in failed repairs compared with grade 1 in intact repairs) (P < .01).

CONCLUSION

PTFE interposition patch repairs for massive and irreparable tears had good construct integrity and clinical outcomes at 2 years. These outcomes were not maintained. PTFE patch repairs often failed at the patch-tendon junction at 4 years and beyond and were ineffective in (1) preventing proximal humeral head migration, (2) stopping progression of glenohumeral arthritis, and (3) improving shoulder strength and ROM.

Current Understanding and New Advances in the Surgical Management of Reparable Rotator Cuff Tears: A Scoping Review

Rotator cuff (RC) tears are among the most common musculoskeletal disorders and can be associated with pain, weakness, and shoulder dysfunction. In recent years, there have been significant advances with regard to the understanding of rotator cuff disease and its management. With technological improvements and advanced diagnostic modalities, there has been much progress as to improved understanding of the pathology. Similarly, with advanced implant designs and instrumentation, operative techniques have evolved. Furthermore, refinements in postoperative rehabilitation protocols have improved patient outcomes. In this scoping review, we aim to provide an overview of the current knowledge on the treatment of rotator cuff disorders and to highlight recent advances in its management.

Effect of Quality of Repair on Clinical and Structural Outcomes of Rotator Cuff Repair

BACKGROUND

Anatomic repair of a torn rotator cuff tendon on the greater tuberosity (GT) is an important surgical goal in rotator cuff repair. However, few studies have investigated whether the efforts made to maximize coverage of the GT are associated with the clinical and structural outcomes after rotator cuff repair surgery.

PURPOSE

To investigate whether the quality of repair at the time of surgery is associated with clinical and structural outcomes after surgery and to identify factors influencing the quality of repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were retrospectively collected from 141 patients who underwent arthroscopic rotator cuff repair between 2008 and 2016. All repairs were classified according to the amount of postoperative GT coverage: A, complete coverage of the GT (n = 96); B, incomplete coverage, comprising more than half of GT (n = 27); C, incomplete coverage, comprising less than half of the GT (n = 16); and D, exposure of the glenohumeral joint (n = 2). All patients underwent magnetic resonance imaging 1 year after surgery. Clinical outcomes and structural integrity based on Sugaya classification were assessed 2 years and 1 year after surgery, respectively. Preoperative factors associated with the postoperative GT coverage (measured at the close of surgery) were identified using a multivariable proportional odds cumulative logit model.

RESULTS

The forward flexion strength in group A (10.3 ± 4.6 lb) was significantly greater than that in group C (6.5 ± 3.7 lb) (P = .003) 2 years after surgery. The postoperative Constant score in group A (76.6 ± 11.5) was greater than that in group C (66.7 ± 15.6) (P = .018). The number of cases that showed retearing of the repaired tendon was as follows: group A (5/96; 5.2%), group B (7/27; 25.9%), and group C (10/16; 62.5%). There was no significant difference in the changes of pain visual analog scale scores among groups 2 years after surgery (all P > .05). Also, there was no significant difference in the changes of range of motion in all directions among groups 2 years after surgery (all P > .05). Patients with preoperative GT coverage B included in the postoperative GT coverage groups through surgery were as follows: group A (23/45; 51.1%), group B (17/45; 37.8%), and group C (5/45; 11.1%). Preoperative GT coverage was the only independent factor that was associated with GT coverage in multivariable analysis.

CONCLUSION

Quality of repair, measured as the extent of postoperative GT coverage at the time of surgery, was associated with clinical and structural outcomes after rotator cuff repair surgery.

Aktuelle Aspekte der Behandlung der Rotatorenmanschette

Rotatorenmanschettenrupturen gehören zu den häufigsten muskuloskeletalen Erkrankungen und können mit ausgeprägten Schmerzen und Funktionseinschränkungen einhergehen. Für ihre Entstehung ist eine Vielzahl von Faktoren relevant, u. a. die individuelle Anatomie des Akromions. Mit Hilfe der heutigen technischen Möglichkeiten wurde nun festgestellt, dass zusätzlich zu seiner lateralen Ausdehnung auch die sagittale Ausdehnung des Akromions eine Rolle zu spielen scheint. Die bildgebende Darstellung der Rotatorenmanschette (RM) hat von den technischen Fortschritten der letzten Jahrzehnte ebenfalls profitiert. Magnetresonanztomographie (MRT) und MR-Arthrographie werden heute flächendeckend eingesetzt. Letztere bietet die höchste Sensitivität für die Entdeckung selbst kleiner Partialläsionen. Neue Sequenzen und Nachbearbeitungsmöglichkeiten können als hilfreiche tools für die operative Planung eingesetzt werden. Grundsätzlich richtet sich die Behandlung der RM neben der Symptomatik nach der Rupturgenese und -morphologie sowie der erwarteten Gewebequalität des Muskel-Sehnen-Kontinuums. Auch das Gesamtprofil, die Erwartungshaltung und die Rehabilitationsmöglichkeiten des Patienten sind wichtig. Die heutigen operativen Techniken werden durch spannende Entwicklungen der Industrie mitbestimmt, die in den letzten Jahren immer bessere Fadenankersysteme, aber auch Augmentationsmaterialien auf den Markt gebracht hat. Letztere zielen nicht nur auf die mechanische Verstärkung der Sehnenrekonstruktion, sondern auch auf die Optimierung der biologischen Eigenschaften des Konstrukts ab. Hinsichtlich Fixation konnte die biomechanische Forschung zeigen, dass zweireihige oder Suture-Bridge-Fixationen einreihigen oder transossären Fixationen überlegen sind. Diese Überlegenheit im Labor spiegelt sich noch nicht klar in den klinischen Ergebnissen wider, dennoch sind die meisten Chirurgen heute auf diese Technik übergegangen. Was die postoperative Nachbehandlung angeht, stellen jüngste randomisiert-kontrollierte Untersuchungen das Konzept der postoperativen Immobilisation in Abduktion in Frage. Hier scheint das letzte Wort noch nicht gesprochen zu sein.

Supraspinatus pathology on MRI is associated with degree of weakness on dynamic clinical strength testing

OBJECTIVE

To analyze shoulder strength and function in patients presenting with possible supraspinatus pathology and to ascertain if these clinical findings are associated with severity of supraspinatus pathology on MRI.

MATERIALS AND METHODS

In total, 171 patients with presumptive rotator cuff pathology and with preserved strength on standard rotator cuff examination were prospectively recruited. Patients were subjected to bilateral shoulder strength testing employing dynamometry; this included isometric strength testing at 90° of abduction, followed by eccentric assessment of isotonic strength from full abduction through the full range of motion until the arm rested at the patient's side. We calculated absolute strength and symptomatic-to-asymptomatic arm (S/A) strength ratios. On subsequent shoulder MRI, supraspinatus pathology was designated into one of seven categories. The association between strength measurements and MRI findings was analyzed.

RESULTS

Increasing lesion severity on MRI was associated with both decreasing absolute strength (no tear [59.9 N] to full-thickness tear [44.2 N]; P = 0.036) and decreasing S/A strength ratios during isotonic testing (no tear [91.9%] to full-thickness tear [65.3%]; P = 0.022). In contrast, there were no significant relationships between imaging severity and absolute strength or S/A strength ratios on isometric testing.

CONCLUSION

Severity of supraspinatus pathology on MRI was associated with dynamic clinical function. These results validate the clinical correlation between MRI designations of supraspinatus pathology and function and suggest the need for future work to investigate utility of dynamic (versus isometric) rotator cuff physical examination maneuvers.

Exercise as effective as surgery in improving quality of life, disability, and pain for large to massive rotator cuff tears: A systematic review & meta-analysis

QUESTIONS

To report the characteristics of exercise interventions and ascertain their effectiveness compared to surgery on quality of life, disability, and pain for people with large to massive rotator cuff tendon tears (L-MRCTTs).

DESIGN

Systematic review with meta-analysis of randomised controlled trials (RCTs).

PARTICIPANTS

Adults with L-MRCTTs defined as; >5 cm, 2 or more tendons.

INTERVENTION

Exercise as an intervention for L-MRCTTs.

OUTCOME MEASURES

Primary: quality of life, disability, and pain. Secondary: range of motion (ROM). The Consensus on Exercise Reporting Template (CERT) was used to extract data on the individual characteristics of each exercise intervention. The Cochrane Risk of Bias Tool V2 was used to assess study quality with the certainty of evidence assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

RESULTS

Five trials (n = 297 participants, average age 66.7 years, 55% male) were included in analysis. Three trials compared exercise to another non-surgical intervention and 2 trials compared exercise to surgery. At 12 months a significant improvement in pain of 0.47 (95% CI 0.07-0.88, I² = 53%, REM) favoured the surgical group and a significant improvement in shoulder external rotation ROM of 9° (95% CI 2.16-16.22, I² = 0%, FEM) favoured the exercise group. The median CERT score was 7/19 (range 4-12). The certainty of evidence was low or very low across all outcomes.

CONCLUSION

A paucity of high-quality research on the role of exercise in the management of L-MRCTTs exists with substantial discrepancies in the reporting of the exercise interventions in the published research.

Rotator cuff repair in patients with inflammatory arthritis: satisfactory midterm outcomes

Background

We aimed to evaluate midterm patient-reported outcomes and reoperation rates following rotator cuff repair in patients with either rheumatoid arthritis (RA) or other inflammatory arthritis (nonRA-IA) diagnoses.

Methods

We identified all patients with either RA or nonRA-IA who underwent a rotator cuff repair at our institution between 2008 and 2018. IA diagnoses included RA, systemic lupus erythematosus, psoriatic arthritis, and other unspecified inflammatory arthritis. We compiled a cohort of 51 shoulders, with an average follow-up time of 7.0 years. The average age was 60 years (range 39-81), and 55% of patients were female. Patients were contacted via phone to obtain patient-reported outcomes surveys. Univariate linear regression was used to evaluate associations between patient characteristics and outcomes.

Results

A review of preoperative radiographs demonstrated that 50% of patients presented with some degree of glenohumeral joint inflammatory degeneration. At the final follow-up, the mean visual analog score for pain was 2 (range 0-8), and the mean American Shoulder and Elbow Surgeons score (ASES) was 77 (standard deviation [SD] = 19). The mean subjective shoulder value was 75% (SD = 22%), and the average satisfaction was 9 (SD 1.9). The mean Patient-Reported Outcomes Measurement Information System upper extremity score was 41 (SD = 10.6). Female sex and a complete tear (vs. partial) were both associated with lower ASES scores, whereas no other characteristics were associated with postoperative ASES scores. The 5-year Kaplan-Meier survival estimate free of reoperation was 91.8% (95% confidence interval 83.0-99.8).

Conclusions

Rotator cuff repair in patients with RA or other inflammatory arthritis diagnoses resulted in satisfactory patient-reported outcomes that seem comparable to rotator cuff repair when performed in the general population. Furthermore, reoperations were rare, with a 5-year survival rate free of reoperation for any reason of over 90%. Altogether, an inflammatory arthritis diagnosis should not preclude by itself attempted rotator cuff repair surgery in these patients.

The clinical outcomes of infraspinatus rotational transfer for irreparable posterosuperior rotator cuff tears: a preliminary report

Background

This study aimed to examine the preliminary clinical results of the infraspinatus rotational transfer procedure for irreparable posterosuperior rotator cuff tears.

Methods

This study included 34 patients (mean age, 68.4 years). Their mean tear width and length measurements were 50.9 mm and 50.6 mm, respectively. The functional outcomes, including physician-determined and patient-reported scores, were evaluated before and at 1 year after surgery. The structural outcomes determined using the magnetic resonance imaging examination results were also assessed.

Results

The clinical scores significantly improved after surgery compared with the scores before surgery: the Constant-Murley score (53.3±21.1 to 76.8±10.5), University of California at Los Angeles Shoulder score (15.6±3.6 to 27.8±6.7), American Shoulder and Elbow Surgeons Shoulder score (51.8±18.3 to 89.1±13.5), and WORC score (925.0±436.8 to 480.3±373.2) (all p<0.001). Postoperative re-tears were noted in two patients (5.9%).

Conclusions

One year postoperatively, the patient’s clinical scores significantly improved, with a re-tear rate of 5.9%.

Double-Row Repair With Platelet-Rich Plasma Optimizes Retear Rates After Small to Medium Full-Thickness Rotator Cuff Repair: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

PURPOSE

To compare the different interventions described in the literature for the surgical treatment of small and medium complete rotator cuff tears.

METHODS

A systematic review of randomized controlled trials of small-medium, full-thickness rotator cuff tears published since 2000 was performed. Clinical characteristics, re-tear rates, range of motion (ROM), and patient-reported outcomes (PRO) data were collected. Interventions were compared via arm-based Bayesian network meta-analysis in a random-effects model. Interventions were ranked for each domain (re-tear risk, pain, ROM, and PROs) via surface under the cumulative ranking curves.

RESULTS

A total of 18 studies comprising 2046 shoulders (47% females, mean age 61 ± 3 years, mean follow-up 21 ± 5 months) were included. Interventions that ranked highest for minimizing re-tear risk included arthroscopic single-row repair (A+SR) or double-row repair (A+DR) with or without platelet-rich plasma (PRP). Open repair and A+SR repair with acromioplasty (ACP) ranked highest for pain relief. Interventions that ranked highest for ROM improvement included open repair, PT, and A+DR with or without ACP. Interventions that ranked highest for PROs included arthroscopic footprint microfracture with or without SR, open repair, and A+SR with or without ACP.

CONCLUSIONS

Based on a network meta-analysis of level 1 studies, arthroscopic rotator cuff repair with a SR or DR construct demonstrates similar retear rates, PROs, and clinical outcomes. The highest-ranking treatment for minimizing retears was arthroscopic repair with DR constructs and PRP augmentation, although open repair and arthroscopic SR remain reliable options with excellent clinical outcomes. Addition of PRP to DR constructs trended toward a 56% decreased risk of retear as compared to DR repair alone. Although no single treatment emerged superior, several interventions offered excellent clinical improvements in pain, ROM, and PROs that exceeded minimal clinically important difference thresholds.

LEVEL OF EVIDENCE

I, systematic review and meta-analysis of level I studies.

Retear After Arthroscopic Rotator Cuff Repair Results in Functional Outcome Deterioration Over Time

PURPOSE

This study aimed to evaluate the effect of retear on long-term functional outcomes and glenohumeral joint osteoarthritis (OA) progression after arthroscopic rotator cuff repair (ASRCR).

METHODS

We retrospectively reviewed 201 patients who underwent ASRCR and were followed up for at least 5 years. Rotator cuff tendon structural integrity was evaluated using magnetic resonance imaging and/or ultrasonography. Pain, active range of motion, and the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) were evaluated for functional outcomes. To evaluate deterioration over time, the minimal clinically important difference value of pain and ASES were used.

RESULTS

The mean follow-up period was 8.6 ± 2.2 years and overall retear rate was 21.4%. OA progression was strongly associated with retear (odds ratio 5.1, P < .001). Functional outcomes at the 2-year postoperative follow-up significantly improved compared to the preoperative status (all P < .017), regardless of retear. However, the retear group presented worse functional outcomes at the final follow-up (pain: 3.1 ± 2.6; ASES: 72.0 ± 17.4) than at the 2-year postoperative follow-up (pain: 1.2 ± 2.3, P = .014; ASES: 91.1 ± 9.9, P= .015) than the healed tendon group at final follow-up (pain: .6 ± 1.7; P < .001; ASES 95.5 ± 11.8; P < .001). The time for deterioration of pain (healed group vs. retear group: 5.5 ± 0.5 vs. 10.6 ± 0.4 years; P < .001) and ASES (healed group vs. retear group: 7.5 ± 0.5 vs. 12.8 ± 0.2 years; P < .001) decreased in the retear group.

CONCLUSIONS

The functional status improved after ASRCR in short- and long-term follow-up, regardless of retear. However, retear was strongly associated with OA progression, and long-term functional outcomes deteriorated over time in retear cases, which was not observed during short-term follow-up.

STUDY DESIGN

III, retrospective cohort study.

Long-term Results of Arthroscopic Repair of Full-Thickness Traumatic Rotator Cuff Tears in Active Duty Military Patients Under the Age of 40 Years

BACKGROUND

Arthroscopic rotator cuff repair is an effective procedure through which to decrease pain and increase strength, with favorable long-term outcomes demonstrated in older patient populations with full-thickness rotator cuff tears. The long-term outcomes after this procedure in younger, higher-demand patients, however, is not as clearly defined.

PURPOSE

To report on the long-term outcomes after arthroscopic rotator cuff repair of traumatic full-thickness rotator cuff tears in active duty military patients under the age of 40 years at the time of surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Preoperative, midterm, and final evaluations were collected, including scores on the visual analog scale for pain, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons shoulder form. A total of 42 patients were screened for inclusion: 3 underwent additional surgical procedures on the operative shoulder and 2 were lost to follow-up, leaving 37 patients with mean follow-up of 104.51 months available for analysis. A subgroup analysis was performed comparing outcomes between patients with Southern California Orthopaedic Institute grade 1 or 2 tears and those with grade 3 or 4 tears.

RESULTS

At final follow-up, pain per the visual analog scale decreased to 1.16 from 8.03 (P < .0001); the Single Assessment Numeric Evaluation score increased to 87.32 from 48.24 (P < .0001); and the American Shoulder and Elbow Surgeons score increased to 88.68 from 41.00 (P < .0001). There was no statistically significant difference in outcome scores or range of motion between midterm and final follow-up. Improvement in outcome scores and range of motion at final follow-up did not vary between patients with small and large tears. Of 42 patients, 37 (88.1%) were able to return to full unrestricted active duty and sporting activity, while 5 (11.9%) were medically separated from the military.

CONCLUSION

Active duty military patients under the age of 40 years with traumatic full-thickness rotator cuff tears had statistically and clinically significant increases in outcome scores and decreases in pain after arthroscopic rotator cuff repair at long-term follow-up.

Mesenchymal Stem Cell Delivery via Topographically Tenoinductive Collagen Biotextile Enhances Regeneration of Segmental Tendon Defects

BACKGROUND

Successful management of massive rotator cuff (RC) tendon tears represents a treatment challenge because of the limited intrinsic healing capacity of native tendons and the risk of repair failure. Biologic augmentation of massive RC tears utilizing scaffolds-capable of regenerating bulk tendon tissue to achieve a mechanically functional repair-represents an area of increasing clinical interest.

PURPOSE

To investigate the histological and biomechanical outcomes after the use of a novel biologic scaffold fabricated from woven electrochemically aligned collagen (ELAC) threads as a suture-holding, fully load-bearing, defect-bridging scaffold with or without mesenchymal stem cells (MSCs) compared with direct repair in the treatment of critically sized RC defects using a rabbit model.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 34 New Zealand White rabbits underwent iatrogenic creation of a critically sized defect (6 mm) in the infraspinatus tendon of 1 shoulder, with the contralateral shoulder utilized as an intact control. Specimens were divided into 4 groups: (1) gap-negative control without repair; (2) direct repair of the infraspinatus tendon-operative control; (3) tendon repair using ELAC; and (4) tendon repair using ELAC + MSCs. Repair outcomes were assessed at 6 months using micro-computed tomography, biomechanical testing, histology, and immunohistochemistry.

RESULTS

Specimens treated with ELAC demonstrated significantly less tendon retraction when compared with the direct repair group specimens (P = .014). ELAC + MSCs possessed comparable biomechanical strength (178 ± 50 N) to intact control shoulders (199 ± 35 N) (P = .554). Histological analyses demonstrated abundant, well-aligned de novo collagen around ELAC threads in both the ELAC and the ELAC + MSC shoulders, with ELAC + MSC specimens demonstrating increased ELAC resorption (7% vs 37%, respectively; P = .002). The presence of extracellular matrix components, collagen type I, and tenomodulin, indicating tendon-like tissue formation, was appreciated in both the ELAC and the ELAC + MSC groups.

CONCLUSION

The application of MSCs to ELAC scaffolds improved biomechanical and histological outcomes when compared with direct repair for the treatment of critically sized defects of the RC in a rabbit model.

CLINICAL RELEVANCE

This study demonstrates the feasibility of repairing segmental tendon defects with a load-bearing, collagen biotextile in an animal model, showing the potential applicability of RC repair supplementation using allogeneic stem cells.

Changes From Baseline in Patient- Reported Outcomes at 1 Year Versus 2 Years After Rotator Cuff Repair: A Systematic Review and Meta-analysis

BACKGROUND

Most orthopaedic journals currently require reporting outcomes of surgical interventions for at least 2 postoperative years, but there have been no rigorous studies on this matter. Various patient-reported outcome (PRO) measures (PROMs) have been used to assess the status of the shoulder after rotator cuff repair (RCR).

HYPOTHESIS

We hypothesized that the mean shoulder-specific PROMs at 1 year improve substantially over baseline but that there is no clinically meaningful difference between the mean 1- and 2-year PROMs after RCR.

STUDY DESIGN

Meta-analysis; Level of evidence, 2.

METHODS

We conducted a systematic review of published randomized controlled trials (RCTs) and prospective cohort studies (level of evidence 1 and 2) reporting the shoulder-specific American Shoulder and Elbow Surgeons (ASES), the Constant, or the Western Ontario Rotator Cuff (WORC) Index scores at baseline, 1 year, and 2 years after RCR. The methodologic quality of studies was assessed. Also, the random effects meta-analyses of changes in PROMs for each of the first and second postoperative years were conducted.

RESULTS

Fifteen studies (n = 11 RCTs; n = 4 cohort studies) with a total of 1371 patients were included. Studies were highly heterogeneous, but no visual evidence of major publication bias was observed. The weighted means of the baseline PROMs were 46.2 points for the ASES score, 46.4 points for the Constant score, and 38.8 points for the WORC Index. The first-year summary increments were 41.1 (95% CI, 36.0-46.2) points for the ASES score, 34.2 (95% CI, 28.8-39.6) points for the Constant score, and 42.9 (95% CI, 37.3-48.4) points for the WORC Index. In contrast, the second-year summary increments were 2.3 (95% CI, 1-3.6) points for the ASES score, 3.2 (95% CI, 1.9-4.4) points for the Constant score, and 2 (95% CI, -0.1 to 4) points for the WORC Index.

CONCLUSION

All PROMs improved considerably from baseline to 1 year, but only very small gains that were below the minimal clinically important differences were observed between 1 year and 2 years after RCR. This study did not find any evidence for requiring a minimum of 2 years of follow-up for publication of PROs after RCR. Our results suggest that focusing on 1-year PROMs after RCR would foster more timely reporting, better control of selection bias, and better allocation of research resources.

Clinical outcomes secondary to time to surgery for atraumatic rotator cuff tears

BACKGROUND

The time from symptom onset to surgery has been shown to impact functional outcomes after repair of traumatic rotator cuff tears (RCTs), but this temporal relationship has not yet been evaluated in patients with atraumatic, degenerative cuff tears. Furthermore, it has been shown that over time, atraumatic cuff tears tend to enlarge and become more symptomatic, retracted, and atrophic-factors that have been shown to decrease success rates after repair. The aim of this study was to evaluate the relationship between the time from symptom onset to surgery and postoperative outcomes in patients with atraumatic RCTs.

METHODS

We performed a retrospective cohort study of patients with degenerative, atraumatic RCTs who underwent surgery performed by 2 fellowship-trained shoulder surgeons and had at least 12 months of postoperative follow-up. These patients were divided into 2 cohorts based on the duration between symptom onset and surgery: early (<12 months) and delayed (≥12 months). The primary outcome measures included reoperation rate and failure of repair. Secondary outcomes included clinical measures of strength and range of motion and patient-reported outcome measures consisting of the Subjective Shoulder Value, visual analog scale for pain, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment, and Brophy-Marx Activity Scale at last follow-up.

RESULTS

Of the 143 patients who met the inclusion criteria, 78 (54.5%) underwent surgery within 1 year of symptom onset whereas 65 (45.5%) underwent surgery after at least 1 year. There were no differences between groups regarding demographic or tear characteristics. At final follow-up, there were no differences between the early- and late-surgery groups regarding retear rate (12% vs. 9%, P = .65), reoperation rate (5% vs. 3%, P = .54), postoperative range of motion in any plane (P > .05), strength in external rotation and internal rotation, visual analog scale pain score, or Subjective Shoulder Value. A greater proportion of the early group (61%) than the late group (46%) experienced improvement in supraspinatus strength of ≥1 grade on manual muscle testing (P = .02) and post hoc analysis.

CONCLUSION

Despite our knowledge of the natural history of chronic, atraumatic RCTs, delaying surgical treatment for 1 year or more does not appear to significantly impact postoperative outcomes. Thus, it is reasonable for physicians to recommend either conservative or surgical treatment depending on patient-specific factors and expectations.

Clinical outcomes of rotator cuff repair in patients with concomitant glenohumeral osteoarthritis

BACKGROUND

Glenohumeral osteoarthritis (OA) is a common comorbidity in patients with rotator cuff tears. However, the efficacy of rotator cuff repair in patients with concomitant glenohumeral OA is still heavily debated. Thus, the purpose of this study was to compare the clinical and functional outcome measures following arthroscopic rotator cuff repairs in patients with concomitant glenohumeral OA vs. those without glenohumeral OA.

METHODS

A retrospective review of 206 consecutive patients who underwent arthroscopic supraspinatus repairs (both isolated and with accompanying infraspinatus and/or subscapularis involvement) between 2013 and 2018 with a minimum of 1-year follow-up was performed. Patients were separated into 2 groups based on the presence or absence of concomitant glenohumeral OA. The primary outcome was failure of repair, defined as the need for revision repair or a retear confirmed on postoperative magnetic resonance imaging. The secondary outcomes were patient-reported outcome measures including the visual analog scale pain score, Subjective Shoulder Value, and American Shoulder and Elbow Surgeons score; active range of motion (ROM); and strength testing. Within the OA cohort, a subgroup analysis was conducted to compare outcomes between patients with mild OA and patients with moderate to severe OA.

RESULTS

There were 91 patients in the glenohumeral OA group and 115 patients in the control group. Significant differences in postoperative forward flexion (FF) ROM (153.55° ± 21.07° vs. 160.14° ± 17.26°, P = .001) and external rotation (ER) ROM (46.91° ± 11.95° vs. 52.25° ± 11.60°, P = .001) were observed between the glenohumeral OA and control groups. There were no significant differences between groups in revision repairs, retears, postoperative internal rotation ROM, all preoperative ROMs, all patient-reported outcome measures, and all strength parameters (all P > .05). For the subgroup analysis, there were 70 patients in the mild OA group and 21 patients in the moderate to severe OA group. We found a significant difference in postoperative FF strength (88.4% vs. 61.9% with 5 of 5 strength, P = .010) and ER strength (89.9% vs. 71.4% with 5 of 5 strength, P = .046) between the mild OA group and moderate to severe OA group. There were no significant differences between the groups in all other outcome measures.

DISCUSSION

Rotator cuff repair remains an excellent treatment option in patients with concomitant glenohumeral OA. The data in this study demonstrate that rotator cuff repairs in patients with concomitant glenohumeral OA have similar clinical and functional outcomes to repairs in patients without OA with the exception of slightly decreased postoperative FF and ER ROM. Patients with moderate to severe OA may have slightly decreased FF and ER strength outcomes compared with patients with mild OA.

Neurostimulation as an Efficacious Nonpharmacologic Analgesic following Arthroscopic Rotator Cuff Repair

This case highlights the importance of pursuing nonpharmacologic analgesic modalities in orthopedic surgery to combat the current opioid epidemic. Presented is a patient who underwent an arthroscopic rotator cuff repair and biceps tenodesis operation and through the use of neurostimulation (in the form of auricular electrostimulation), fully recovered from surgery without the usage of any opioid or nonsteroidal anti-inflammatory medications. The patient was fitted with a novel auricular electrostimulation device (DyAnsys Primary Relief) in the immediate postoperative period that provided constant neurostimulation for 10 days, this neurostimulator was the only analgesic modality used in this case, and the patient reported minimal postoperative pain. The utility of this case centers around the lack of postoperative opioid use, presenting the idea that postsurgical orthopedic pain can be managed in a nonpharmacologic capacity, combatting the fields' ongoing opioid epidemic.

Effects of pain neuroscience education and rehabilitation following arthroscopic rotator cuff repair. A randomized clinical trial

OBJECTIVE

To compare the effectiveness of pain neuroscience education (PNE) versus biomedical education (BME) in a rehabilitation program following arthroscopic rotator cuff repair (ARCR) in patients with chronic shoulder pain.

METHODS

Twenty-nine patients who participated in a rehabilitation program were randomly assigned to either an experimental PNE group (N = 16) or a control BME group (N = 13). Measurements included pain intensity at rest and in movement, pain catastrophizing, kinesiophobia, disability and health-related quality of life (HRQoL). Outcomes were evaluated at baseline and at 4 and 8 weeks after the intervention.

RESULTS

A main effect for time was observed for: intensity of pain at rest (p < .01); pain with movement (p < .01); pain catastrophizing (p < .01); kinesiophobia (p < .01); disability (p < .01); and HRQoL (p < .01). No group interactions were significant for any variable, except for pain with movement, which favored the PNE group (p = .03). Large effect sizes (ranging from d = 0.79 to d = 2.65) were found for both interventions in all outcomes.

CONCLUSION

A rehabilitation program including either PNE or BME are equally effective in improving rest pain, pain catastrophizing, kinesiophobia, disability, and HRQoL in patients after ARCR, except for pain at movement in favor of the PNE group. The inclusion of PNE in the rehabilitation program appears to lead to clinically meaningful improvements in pain at rest in short term when treating patients with ARCR.

Establishing minimal clinically important difference for the UCLA and ASES scores after rotator cuff repair

BACKGROUND/HYPOTHESIS

Minimal clinically important difference (MCID) is a vital tool in the analysis of clinical results. It allows the determination of clinical relevance of statistical data. Our hypothesis was that specific differences between preoperative and postoperative scores would be able to accurately predict patient perception of improvement and satisfaction as reflected by anchor and distribution-based questions.

METHODS

Retrospective cohort with patients that underwent rotator cuff repair. We evaluated the University of California at Los Angeles Shoulder Rating Scale (UCLA) and the American Shoulder and Elbow Surgeons Assessment Form (ASES) before and 12-months after surgery. Anchor-based, distribution-based and minimum detectable change (MDC) approaches were utilized.

RESULTS

We evaluated 289 shoulders. The MCID for the UCLA scale was 4.5 points using the anchor method, 2.5 by the distribution method and 3.6 by MDC. Patients with a baseline score>20 presented a lower MCID (1.5, 1.1 and 1.7, respectively). For the ASES score, the MCID was 6.1 by the anchor method, 10.5 based on the distribution method and 26.3 by MDC. In the group of patients above the 60 point cutoff, the obtained values were 2.4, 4.9 and 13.6, respectively.

CONCLUSION

The mean MCID value for the UCLA shoulder score is 3.5 points, ranging from 2.5 points (distribution method) to 4.5 points (anchor method). The mean MCID value for the ASES score was 15.2 points, ranging from 6.1 (anchor method) to 26.3 (MDC). Patients groups presenting with higher preoperative scores showed lower MCID values. This fact needs to be considered in postoperative comparisons between treatment groups.

LEVEL OF EVIDENCE

Basic Science Study, Validation of Outcomes Instruments/Classification Systems.

Analysis of Risk Factors, Complications, Reoperations, and Demographics Associated With Open and Arthroscopic Rotator Cuff Repair: An Analysis of a Large National Database

PURPOSE

To assess the national trends in arthroscopic and open rotator cuff repair surgery and the associated demographics, complications, and risk factors specific to each procedure.

METHODS

A retrospective cohort study was performed using the National Surgical Quality Improvement Program (NSQIP) dataset between the years 2007 and 2018. Patients were identified using Common Procedural Terminology codes for open and arthroscopic rotator cuff repair. Variables collected including basic demographics, procedural, and outcome specific variables as available through the NSQIP repository. Appropriate statistical measures were used to compare the groups, with the χ² test used for categorical variables and t test for continuous variables.

RESULTS

The arthroscopic cohort comprised 39,013 patients; the open group consisted of 8,664. Reported arthroscopic and open cases increased significantly between 2007 and 2018 from 135 to 7,269 and 65 to 1,168, respectively. Average operative time for arthroscopic procedure was 89 minutes and 76 minutes for open. The open group consisted of a slightly greater percentage of smokers, 18.3% versus 15.2%, and patients with diabetes, 18.2% versus 15.9%, both of which were statistically significant (P < .001). Open cases had an odds ratio of 3.05 for superficial infections and 7.40 for deep infections, both of which were statistically significant (P < .001). The open cohort also had an odds ratio of 1.71 for unplanned readmissions when compared with the arthroscopic cohort, which was also statistically significant (P < .001).

CONCLUSIONS

According to the NSQIP database, the increase in arthroscopic procedures is significantly outpacing the increase in open procedures during this study period, which matches the trends seen in previous studies. Patients with diabetes and who smoke also represent a greater risk group for postoperative complications when undergoing open surgery. These findings suggest that perhaps the decision to pursue one technique over the other may be influenced both by provider preference and patient-related factors.

LEVEL OF EVIDENCE

III, retrospective comparative trial.

Role of Delay Between Injury and Surgery on the Outcomes of Rotator Cuff Repair: A Systematic Review and Meta-analysis

BACKGROUND

Outcomes of rotator cuff repair (RCR) are influenced by several well-described factors, but the role of delay from injury to surgery on the outcomes is not clear.

PURPOSE

To assess the role of delay to surgery on the outcomes of RCR in the literature.

STUDY DESIGN

Systematic review with meta-analysis; Level of evidence, 4.

METHODS

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. All studies assessing outcomes after RCR-either retear rates or patient-reported outcome measures (PROMs)-and reporting delay to surgery were identified through June 2021 in PubMed, Embase, and Cochrane. Inclusion criteria consisted of traumatic injuries, mean age <65 years, minimum 6-month follow-up, and assessment of retear rates with radiologic examination or reporting of PROMs. Random-effect models were used to assess outcomes, reported in odds ratio (OR) or mean difference (MD) with 95% CIs.

RESULTS

A total of 8118 patients were included from 33 studies, with a mean age of 59 years (range, 53-64) and mean follow-up of 3.0 years (range, 0.5-8.2), among whom 53% were male and 74% had dominant-side injury. Patients undergoing surgery >3 months after injury did not have significantly higher retear rates (OR, 1.1 [95% CI, 0.5 to 3.1]; P = .700), lower Constant-Murley score (MD, -6.2 [95% CI, -16.4 to 4.1]; P = .240), or lower ASES score (American Shoulder and Elbow Surgeons; MD, -12.9 [95% CI, -26.0 to -0.2]; P = .050) compared with those having surgery within 3 months. Similarly, delaying surgery for 6 months did not result in higher retear rates (OR, 1.7 [95% CI, 0.8 to 3.7]; P = .190) or lower PROMs. Delaying surgery for 1 year, however, led to an increased likelihood of retear when compared with <1 year (OR, 2.9 [95% CI, 2.1 to 4.0]; P < .001), and this was similar for the 2-year cutoff (OR, 5.9 [95% CI, 1.1 to 32.1]; P = .040). It was also noted that patients with an intact cuff at follow-up had a mean 3.9 months' shorter time from injury to surgery than patients with retear (95% CI, 1.0-6.8 months; P = .009).

CONCLUSION

This systematic review with meta-analysis found that delaying rotator cuff surgery for 3 to 6 months did not lead to higher retear rates or inferior PROMs as compared with undergoing earlier surgery. However, delaying surgery for ≥1 year clearly resulted in higher retear rates after RCR. This study is limited by relying on retrospective studies, and larger prospective studies are needed to confirm these findings.

REGISTRATION

CRD42021240720 (PROSPERO).

Increasing incidence of rotator cuff surgery: A nationwide registry study in Chile

BACKGROUND

The rotator cuff surgery (RCS) incidence is rising rapidly in North America, Europe, Asia, and Australia. Despite this, multiple factors limit patients' access to surgery. In Latin America, barriers to orthopedic surgery have been largely ignored. The purpose of this study was to calculate the rate of RCS in Chile between 2008 and 2018, investigating possible associated factors to access such as age, sex, and the health insurance.

METHODS

An ecological study was carried out with nationwide data obtained from the Database of Hospital Discharges of the Department of Statistics. All Chilean inhabitants aged 25 years or more were included. We used the ICD-10 codes M751, M754, and S460. The annual incidence rate of surgeries and the incidence rate for the period studied per 100,000 inhabitants were calculated. Data were analyzed stratified by age, sex, year of study, and the health insurance. Negative binomial regression was used to compare rates. Statistical analyzes were performed with Stata v.14 software.

RESULTS

39,366 RCSs were performed, with a total rate for the period of 32.36 per 100,000 inhabitants. The annual rate of surgeries from 2008 to 2018 increased from 24.55 to 49.11 per 100,000/year. When adjusting for year, an annual increase in surgery rates of 8.19% (95% CI 6.7-9.6) and 101% growth between 2008 and 2018 (95% CI 90-109%, p < 0.001) was observed. When comparing the global rates according to the health insurance, the public system corresponds to 21.3 per 100,000 and the private system to 72 per 100,000, the latter being 3.4-times higher (95% CI 2.7-4.4; p < 0.001).

CONCLUSION

RCS rates are increasing in Chile concordantly with previous reports of other western countries. The most important factor associated with RCS rate found was the patients' health insurance, with higher rates observed for the private sector.

The fate of sutures post rotator cuff repair

BACKGROUND

Ultrasonographic imaging has been widely used as a diagnostic tool for rotator cuff tears. Several studies have explored the changes in rotator cuff tendon morphology after arthroscopic cuff repair; however, none have addressed the fate of sutures. The aim of this study was to determine (1) if the sutures migrate through the tendon during the postoperative healing period in patients who have had arthroscopic rotator cuff repair; (2) if the sutures do migrate, the time point at which it does; and (3) if the quality of the tendon, in terms of tendon stiffness, modulus of elasticity, bursal thickness, and anatomic footprint, affects suture migration.

METHODS

This was a prospective study involving 21 patients who had primary arthroscopic rotator cuff repair performed by a single surgeon. All patients were assessed at 8 days, 6 weeks, 12 weeks, and 24 weeks postrepair; during each assessment, patients underwent an ultrasonographic examination (using a Siemens ACUSON S3000 ultrasonographic system, following a standardized protocol), where supraspinatus tendon thickness and thickness of tendon tissues below and above the suture were measured. Measurements of anatomic footprint, bursal thickness, tendon stiffness, and modulus of elasticity were obtained to assess tendon quality.

RESULTS

Of the 21 participants, 14 (67%) had full-thickness tears and 7 (33%) had partial-thickness tears. Between the 12th- and 24th-week follow-up, 2 patients' tendons were found to be not intact. Within the first 12 weeks of the postrepair healing period, the sutures migrated inferiorly, through to the middle of the tendon at the footprint-articular junction (ie, ratio of tendon tissue thickness below the suture to the total tendon thickness = 0.5) (P = .03). The mean anatomic footprint increased from 8.4 ± 1.6 mm to 9.1 ± 1.2 mm between 8 days and 6 weeks (P = .04); bursal thickness decreased during the 24-week period from 1.5 ± 0.9 mm to 0.7 ± 0.4 mm (P = .005); tendon modulus of elasticity increased from 154 ± 75 kPa to 205 ± 96 kPa between 8 days and 24 weeks (P = .05).

DISCUSSION

This is the first study to investigate suture position and migration post arthroscopic rotator cuff repair. The findings of this study suggest that sutures migrating to the middle of the tendon during the postoperative healing process is a normal phenomenon observed on ultrasonography.

Reliability of supraspinatus intramuscular fatty infiltration estimates on T1-weighted MRI in potential candidates for rotator cuff repair surgery: full-thickness tear versus high-grade partial-thickness tear

OBJECTIVE

Patients with supraspinatus high-grade partial-thickness tear or full-thickness tear are potential candidates for rotator cuff repair surgery. We sought (1) to compare supraspinatus intramuscular fatty infiltration between these groups by Goutallier grade, fuzzy C-means and an orthopaedic surgeon visible percentage estimate, (2) and to determine the reliability of each method.

MATERIALS AND METHODS

We performed a retrospective cross-sectional study of supraspinatus intramuscular fatty infiltration on T1-weighted MR images for 93 shoulders with either supraspinatus partial-thickness tear > 50% tendon thickness or full-thickness tear by Goutallier grade, fuzzy C-means and an orthopaedic surgeon visible percentage estimate, by two observers for each method. Descriptive statistics were performed to compare groups. Inter- and intra-observer reliability was determined. Correlative analysis among the three methods was performed.

RESULTS

Significant differences of mean supraspinatus intramuscular fatty infiltration were present when comparing supraspinatus high-grade partial-thickness tear versus full-thickness tears by Goutallier grade (p = 0.004), fuzzy C-means (p = 0.002) and orthopaedic surgeon visible percentage estimate (p = 0.001). There was no significant difference for age (55.0 ± 11.1 years versus 56.1 ± 9.6 years) or sex (35.4% male versus 47.8% male) for supraspinatus high-grade partial-thickness tear and full-thickness tear, respectively. A significant difference existed among the subgroup of full-thickness tears stratified by tear size by all three methods (p < 0.020). Inter- and intra-observer reliability was Goutallier grade 0.590 and 0.624, fuzzy C-means 0.768 and 0.925 and orthopaedic surgeon visible percentage estimate 0.858 and 0.686, respectively. For shoulders with mean Goutallier grade ≥ 2.0, inter-observer reliability was 0.878 and 0.802 for fuzzy C-means and orthopaedic surgeon visible percentage estimate, respectively. A strong correlation was present among the three methods of supraspinatus FI analysis (rho ≥ 0.72).

CONCLUSION

Supraspinatus full-thickness tears have higher amounts of intramuscular fatty infiltration compared to high-grade partial-thickness tear. Quantitative fuzzy C-means shows excellent inter-observer reliability for estimating supraspinatus intramuscular fat. Experienced orthopaedic surgeons' semi-quantitative estimation of supraspinatus visible intramuscular fat may offer improved reliability as compared to semi-quantitative Goutallier grade.

Operative versus conservative treatment of small, nontraumatic supraspinatus tears in patients older than 55 years: over 5-year follow-up of a randomized controlled trial

BACKGROUND

Nontraumatic rotator cuff tear is a common shoulder problem that can be treated either conservatively or operatively. In the previous publications of the 1- and 2-year results of this trial, we found no significant between-group clinical differences. The aim of this study was to investigate the differences in mid-term clinical and radiologic outcomes in patients older than 55 years.

MATERIALS AND METHODS

One hundred eighty shoulders with symptomatic, nontraumatic supraspinatus tears were randomly assigned to 1 of the 3 cumulatively designed treatment groups: physiotherapy (group 1); acromioplasty and physiotherapy (group 2); and rotator cuff repair, acromioplasty, and physiotherapy (group 3). The change in the Constant score was the primary outcome measure. The secondary outcome measures were the change in the visual analog scale score for pain and patient satisfaction. Radiologic analysis included evaluation of glenohumeral osteoarthritis (OA) and rotator cuff tear arthropathy (CTA).

RESULTS

A total of 150 shoulders (mean age, 71 years) were available for analysis after a mean follow-up period of 6.2 years. The mean sagittal tear size of the supraspinatus tendon tear at baseline was 10 mm in all groups (P = .33). During follow-up, 8 shoulders in group 1 and 2 shoulders in group 2 crossed over to rotator cuff repair. The mean baseline Constant score was 57.1, 58.2, and 58.7 in groups 1, 2, and 3, respectively (P = .85). There were no significant differences (P = .84) in the mean change in the Constant score: 18.5 in group 1, 17.9 in group 2, and 20.0 in group 3. There were no statistically significant differences in the change in the visual analog scale pain score (P = .74) and patient satisfaction (P = .83). At follow-up, there were no statistically significant differences in the mean progression of glenohumeral OA (P = .538) or CTA (P = .485) among the groups. However, the mean progression of glenohumeral OA from baseline to follow-up was statistically significant in the trial population (P = .0045).

CONCLUSIONS

On the basis of this study, operative treatment is no better than conservative treatment regarding small, nontraumatic, single-tendon supraspinatus tears in patients older than 55 years. Operative treatment does not protect against degeneration of the glenohumeral joint or CTA. Conservative treatment is a reasonable option for the primary initial treatment of these tears.

[Influencing factors of preoperative pulmonary function in elderly patients undergoing rotator cuff surgery]

OBJECTIVE

To analyze the preoperative pulmonary function in rotator cuff injury patients and the possible influencing factors.

METHODS

All the rotator cuff surgery patients who underwent pre-operative pulmonary function examination in Peking University Third Hospital from Jan. 2020 to Jun. 2020 were retrospectively reviewed. Their perioperative medical records and main parameters of pulmonary function were collected from database management system, and their gender, age, body mass index (BMI), smoking history, time from injury, visual analogue scale (VAS) and other factors impacting on preoperative pulmonary function were studied.

RESULTS

Twenty-nine patients with rotator cuff injury were included, among whom 1 patient was reported to have restrictive ventilation dysfunction and 2 patients to have obstructive ventilation dysfunction. All the three patients denied the history of respiratory diseases, and had no respiratory symptoms. In all enrolled patients, the mean forced expiratory volume in one second (FEV1)/ forced vital capacity (FVC) was 79.2%±5.9%, and the mean VAS pain score was 3.66±1.26. In addition, the dynamic pulmonary functions (FVC, FEV1) were reduced in more than half of the elderly, and the total lung capacity (TLC) was lower than the estimated value in 2/3 of the elderly. There were significant differences in three main indexes of pulmonary functions between genders, and the percentage of the estimated TLC between normal BMI group (18 kg/m² < BMI < 24 kg/m²) and overweight/obesity group (BMI≥24 kg/m²) was significantly different. Based on the injury time longer than 1 year or not, the results indicated that FVC and TLC were significantly different between the two groups.

CONCLUSION

In addition to gender and age, time from injury and severity of pain, as well as overweight/obesity, may influence pulmonary function outcomes in the elderly rotator cuff patients. Targeted intervention can be carried out on these factors before surgery. Preoperative lung function test can be used as one of the basic evaluation indexes for respiratory training and rehabilitation of patients.

A 5-Year Follow-up of Patients Treated for Full-Thickness Rotator Cuff Tears: A Prospective Cohort Study

Background:

The evidence in support of operative versus nonoperative management of rotator cuff tears (RCTs) is limited, based primarily on observational studies of lower scientific merit.

Purpose:

To (1) compare the efficacy of operative versus nonoperative management of full-thickness RCTs across time and (2) detect variables that predict success within each group.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

We included patients with symptomatic full-thickness RCTs who were enrolled in an institutional shoulder registry. Patient enrollment began in 2009 and continued until early 2018. The following outcome measures were collected at baseline, then 6 months, 1 year, and annually up to 5 years postoperatively: Western Ontario Rotator Cuff Index (WORC), American Shoulder and Elbow Surgeons (ASES) score, Veterans RAND 12-Item Health Survey (VR-12) mental and physical component subscales (MCS and PCS, respectively), 100-point Single Assessment Numeric Evaluation (SANE) rating, and 100-point visual analog scale (VAS) for pain and for patient satisfaction. We performed regression models for all outcome variables across all 5 years of follow-up and included the following predictor variables: treatment type (operative vs nonoperative), sex, age, symptom duration, smoking status, diabetes status, injury side, and obesity status.

Results:

A total of 595 patients were included. Longitudinal mixed-effects regression revealed that patients who received operative treatment did better across time on all outcomes. Women (n = 242; 40.7%) did not fare as well as did men on the ASES, WORC, or VR-12 PCS. Older patients tended to improve less on the VR-12 PCS and more on the VR12-MCS. Patients with longer symptom duration at baseline had better scores across time on the ASES, WORC, VAS for pain, and SANE. Current or recent smokers and patients with diabetes tended to have lower scores on all measures across time. For changes in scores from baseline, patients in the operative group improved to a larger degree out to 3 years compared with those in the nonoperative group.

Conclusion:

Patients with RCTs tended to improve regardless of whether they received operative or nonoperative treatment, but patients who underwent operative treatment improved faster. There appear to be several predictors of improved and worsened outcomes for patients with RCTs undergoing operative or nonoperative treatment.

Treadmill running initiation times and bone-tendon interface repair in a murine rotator cuff repair model

Postoperative exercise has been demonstrated to be beneficial for bone-tendon interface (BTI) healing, yet the debate regarding the optimal time to initiate exercise after tendon enthesis repair is ongoing. This study aimed to evaluate the initiation times for exercise after enthesis repair. A total of 192 C57BL/6 mice underwent acute supraspinatus tendon injury repair. The animals were then randomly assigned to four groups: free cage activity after repair (control group); treadmill running started on postoperative day 2 (2-day delayed group); treadmill running started on postoperative day 7 (7-day delayed group), and treadmill running started on postoperative day 14 (14-day delayed group). Mice were euthanized at 4 and 8 weeks postoperatively, and histological, biomechanical, and bone morphometric tests were performed. Higher failure loads and bone volume fractions were found for the 7-day delayed group and the 14-day delayed group at 4 weeks postoperatively. The 7-day delayed group had better biomechanical properties and higher bone volume fractions than the 2-day delayed group at 4 weeks postoperatively. Histologically, the 7-day delayed group exhibited lower modified tendon-to-bone maturity scores than the control group and the 2-day delayed group at 4 and 8 weeks postoperatively. Quantitative reverse-transcription polymerase chain reaction results showed that the 7-day delayed group had higher expressions of chondrogenic- and osteogenic-related genes. Statement of clinical significance: Postoperative treadmill running initiated on postoperative day 7 had a more prominent effect on BTI healing than other treatment regimens in this study and could accelerate BTI healing and rotator cuff repair.

Expression of Substance P and Nerve Growth Factor in Degenerative Long Head of Biceps Tendon in Patients with Painful Rotator Cuff Tear

Purpose

Degenerative long head of biceps tendon (LHBT) has been recognized as a notable pain source in patients with rotator cuff tear (RCT). Tenotomy or tenodesis of LHBT is frequently indicated together with arthroscopic rotator cuff repair (ARCR) aiming for complete pain relief; however, it has not been fully investigated whether resected LHBT is really a source of pain. The purpose of this study was to investigate expression levels of pain-associated mediators in LHBT and its association with preoperative pain profiles.

Methods

Twenty-seven RCT patients who underwent ARCR with LHBT resection were included. Each LHBT was resected due to its abnormal arthroscopic findings including tenosynovitis, hypertrophy, and partial tear. Worst macroscopic lesion of the LHBT was obtained, and expression levels of substance P (SP) and nerve growth factor (NGF) were evaluated using enzyme-linked immunosorbent assay (ELISA). Ten healthy knee flexor tendons were analyzed as non-degenerative samples. Preoperatively, subjective shoulder pain VAS and pain duration were investigated. Conventional LHBT pain provocation tests (Speed, Yergason, O’Brien) were performed. Pressure pain threshold (PPT) of bilateral LHBT on the groove was recorded.

Results

Levels of SP and NGF expression were significantly higher compared with non-degenerative tendons (P<0.01). Shoulder pain VAS and pain duration were not directly associated with SP and NGF expression level. Patients with positive O’Brien test expressed greater SP than negative patients (P=0.001). Significant negative correlation between the PPT ratio (ipsilateral/contralateral) and SP expression level was observed (r=−0.453, P=0.034).

Conclusion

Greater expression of SP and NGF in degenerative LHBT supported our hypothesis that it would be a pain source in RCT patients. SP was likely to be expressed highly in patients with localized pressure pain hypersensitivity and positive O’Brien test (ie, altered mechanistic pain profile of LHBT), which may help when considering simultaneous LHBT resection during ARCR.

Clinical Registration

UMIN000023943.

Minimal Clinically Important Difference and Patient Acceptable Symptom State for the Pittsburgh Sleep Quality Index in Patients Who Underwent Rotator Cuff Tear Repair

The Pittsburgh Sleep Quality Index (PSQI) is a valid patient-reported outcome measure developed to assess sleep quality and disturbances in clinical populations. This study aimed to calculate the minimum clinically important difference (MCID) and the patient acceptable symptom state (PASS) for the PSQI in patients who underwent rotator cuff repair (RCR). Preoperative and six-month postoperative follow-up questionnaires were completed by 50 patients (25 males and 25 females, mean age 58.7 ± 11.1 years). The MCID of the PSQI was calculated using distribution-based and anchor methods. To calculate the PSQI’s PASS, the 75th percentile approach and the receiver operating characteristic (ROC) curve were used. The MCID from preoperative to 6 months postoperative follow-up is 4.4. Patients who improved their PSQI score of 4.4 from baseline to 6 months follow-up had a clinically significant increase in their health status. The PASS is 5.5 for PSQI; therefore, a value of PSQI at least 5.5 at six months follow-up indicates that the symptom state can be considered acceptable by most patients.

Rotator cuff repair rehabilitation considerations and respective guidelines: a narrative review

Current rotator cuff repair rehabilitation protocols focus on multiple areas, including protecting the healing tissue, optimizing range of motion and strength, and returning the individual to labor demanding and sport-specific tasks. Post-operative rehabilitation timelines with consideration of the tear size remain variable among practitioners. Prognostic factors, healing rates, range of motion timeline, exercise progressions, and guidance on return to sport and work activity are the many factors that can help guide rotator cuff repair rehabilitation and ultimately may reduce failure rates and improve outcomes. The purpose of this narrative review is to outline the multi-factorial nature of rotator cuff pathology and guide treatment based on a multitude of factors.

Mesenchymal stem cell-derived exosomes: therapeutic implications for rotator cuff injury

Rotator cuff injuries are a common clinical condition of the shoulder joint. Surgery that involves reattaching the torn tendon to its humeral head bony attachment has a somewhat lower success rate. The scar tissue formed during healing of the rotator cuff leads to poor tendon-related mechanical properties. To promote healing, a range of genetic interventions, as well as cell transplantation, and many other techniques have been explored. In recent years, the therapeutic promise of mesenchymal stem cells (MSCs) has been well documented in animal and clinical studies. Some data have suggested that MSCs can promote angiogenesis, reduce inflammation and cell proliferation and increase collagen deposition. These functions are likely paracrine effects of MSCs, particularly mediated through exosomes. Here, we review the use of MSCs-related exosomes in tissues and organs. We also discuss their potential utility for treating rotator cuff injuries, and explore the underlying mechanisms of their effects.

Repair of high-grade partial thickness supraspinatus tears after surgical completion of the tear have a lower retear rate when compared to full-thickness tear repair

PURPOSE

High-grade partial thickness rotator cuff tears (i.e., those involving at least 50% of the tendon thickness) are especially challenging to treat and various treatment strategies have been described. Prior studies have demonstrated equivalent outcomes between in situ tear fixation and tear completion repair techniques. However, it is unknown how repair of completed high-grade partial thickness tears to full tears compares to repair of full-thickness tears. The purpose of this study was to compare clinical outcome measures at least 1 year postoperatively between patients who had completion of a high-grade partial thickness supraspinatus tear to a full-thickness tear (PT) and those who had an isolated full-thickness supraspinatus tear (FT). The hypothesis of this study was equivalent retear rates as well as equivalent clinical and patient-reported outcomes between the two groups.

METHODS

A retrospective review of 100 patients who underwent isolated arthroscopic supraspinatus repair between 2013 and 2018 with a minimum of 1 year follow-up was performed. Patients were separated into two groups based on their treatment: 56 had completion of a partial thickness supraspinatus tear to full-thickness tear with repair (PT) and 44 had isolated full-thickness supraspinatus repairs (FT). The primary outcome was rotator cuff retear, which was defined as a supraspinatus retear requiring revision repair. Secondary outcomes were patient-reported outcome measures (PROs) including visual analog pain scale (VAS) and subjective shoulder value (SSV), range of motion (ROM) and strength in forward flexion (FF), external rotation (ER), and internal rotation (IR).

RESULTS

There was a significantly lower rate of retear between the PT versus FT groups (3.6% vs. 16.3%, p = 0.040). There were no significant differences between groups for all PROs, all ROM parameters, and all strength parameters (all n.s.).

DISCUSSION

The data from this study demonstrated that the PT group had a significantly lower retear rate at 1 year follow-up than the FT group, while PROs, ROM, and strength were similar between the two groups. Patients with PT supraspinatus tears can have excellent outcomes, equivalent to FT tears, after completion of the tear, and subsequent repair with low retear rates. These findings may aid the treating surgeon when choosing between in situ fixation of the PT supraspinatus tear or completion of the tear and subsequent repair, as it allows the treating surgeon to choose the procedure based on comfort and experience level.

LEVEL OF EVIDENCE

Level III.

Treatment of Rotator Cuff Tears with platelet rich plasma: a prospective study with 2 year follow-up

BACKGROUND

Surgical treatment of full-thickness rotator cuff (RC) tears is associated with generally good results. There is no consensus regarding treatment of partial thickness tears that fail conservative treatment. The purpose of this study was to look at the efficacy and confirm the safety of dual injection PRP into the shoulder of patients with rotator cuff pathology who have failed conservative treatment with followup to two years.

METHODS

Seventy-one shoulders with MRI confirmed, rotator cuff pathology who failed conservative treatment, had dual PRP injection into the rotator cuff. Global improvement, Quick DASH and VAS scores were collected at 6, 12, and 24 months after treatment and comparison of means was used to analyze changes.

RESULTS

No adverse events were seen in any patient. Based on global rating scores positive results were seen in 77.9 % of patients at 6 months, 71.6 % at 1 year, and 68.8 % of patients at 2 years. Mean VAS scores improved from 50.2 [CI 44.4-56.0] pre-injection to 26.2 [CI 19.5-32.9] at 6 months, 22.4[CI 16.1-28.7] at 1 year and 18.2 [CI 12.3-24.1] at 2 years (p < 0.0001 for all). The mean Q- DASH scores (0-100, 100 worse) improved from 39.2 [CI 34.3-44.1] for all patients before treatment to 20.7[CI 15.0-26.4] at 6 months, 18.0[CI 12.9-23.1] at 1 year, and 13.8 [CI 8.4-18.8] at 2 years (p < 0.0001 for all). No patient with partial tear had clinical evidence of progression to full thickness tear. When separated into subgroups based on rotator cuff status, all subgroups showed improvement. Patients in the > 50 % partial tear group had the best overall improvement based on Global Rating scores while those in the tendinitis group had the poorest outcomes.

CONCLUSIONS

PRP injection is a safe and effective treatment for RC cuff injury in patients who have failed conservative treatment of activity modification and physical therapy without deterioration of results two years after treatment. Better results are obtained with greater structural tendon damage than in shoulders with inflammation without structural damage.

TRIAL REGISTRATION

This is not a clinical trial.

"Current concepts and expert practice report: Augmentation of rotator cuff repairs"

Rotator cuff tears are common shoulder injuries expected to increase with the growth of the aging population. Although a small subset of patients with low functional demands can be treated nonoperatively, surgical intervention is a cost-effective solution, which can restore shoulder function and help patients return to activity sooner. While multiple surgical options are available, rotator cuff repair is a highly utilized procedure with varying success. Due to a large proportion of rotator cuff repairs still failing to completely heal, this procedure requires careful planning to achieve anatomical and biomechanically stability. New technology and techniques are being explored to help increase the success of rotator cuff repairs with an increasing focus on augmentation. The current article gives a brief overview of pertinent anatomy, treatment options, and challenges in healing of rotator cuff repairs. Thereafter, the merits of different types of rotator cuff repair augmentation available will be discussed as well as the authors' experience in utilizing biologic augmentation and surgical technique.

Effect of Microcurrent Stimulation on Pain, Shoulder Function, and Grip Strength in Early Post-Operative Phase after Rotator Cuff Repair

Background and Objectives: The purpose of this study was to investigate the effects of microcurrent stimulation on pain, shoulder function, and grip strength in patients with rotator cuff repair. Materials and Methods: This randomized single-blind controlled trial was conducted on inpatients of the rehabilitation department, and included 28 patients who underwent rotator cuff repair. Participants were randomly assigned to the experimental group (n = 14), treated with microcurrent stimulation, and the control group (n = 14), treated with false microcurrent stimulation. The microcurrent stimulation administered to the experimental group underwent general physical therapy and microcurrent stimulation three times a week for 4 weeks. Results: Changes in pain, range of motion in shoulder, simple shoulder test, and grip strength were assessed before and after the intervention. Both groups showed a significant decrease in pain and shoulder function (t = 27.412, 22.079, 19.079, and 18.561; p < 0.001), and grip strength showed a significant increase (t = −8.251 and −9.946; p < 0.001). The experimental group that underwent microcurrent stimulation exhibited a significant effect on pain, shoulder function, and grip strength compared with the control group that underwent false microcurrent stimulation (t = −2.17, −2.22, and 2.213; p = 0.039, 0.035, and 0.036). Conclusions: This study confirmed that microcurrent stimulation is effective for the treatment of rotator cuff repair patients.

Post-surgery rehabilitation following rotator cuff repair. A survey of current (2020) Italian clinical practice

AIMS

To analyse the clinical practice of Italian physiotherapists within the framework of postoperative rehabilitation of rotator cuff (RC) surgery patients, and to compare it with similar studies carried out in other countries.

METHODS

A web-based, voluntary, cross-sectional survey with 27 closed multiple-choice questions was developed and submitted to Italian-based physiotherapists in order to assess their clinical practice.

RESULTS

Data from 1160 questionnaires were then analysed. Thirty-five percent of respondents (n = 413/1160) reported that they commence passive range of motion from the first postoperative week, while 49.2% (n = 571/1160) start during the second or third week. The majority of respondents (n = 603/1160, 52.0%) introduce active mobilisation between the fourth and the sixth week after surgery and 41.1% (n = 477/1160) introduce overhead movements between the fourth and the sixth week after surgery.

DISCUSSION AND CONCLUSIONS

When managing the postoperative rehabilitation of RC surgery patients, Italian physiotherapists' practice is congruent with the guidelines published by American Society of Shoulder and Elbow Therapists (ASSET) and also with other UK surveys. However, while Italian physiotherapists manage immobilisation periods, active and passive mobilisation and the return to sport activities, according to evidence-based best practice guidelines, there is less consistency with respect to physical exercise, patient follow-up and referral.IMPLICATIONS FOR REHABILITATIONItalian physiotherapists' practice with patients following rotator cuff (RC) repair complies with evidence-based practice guidelines regarding immobilisation periods, passive and active mobilisation, and return to sport activities.There is less consistency between reported/declared practice and available evidence concerning physical exercise, patient follow-up, and referral.Physiotherapist with Orthopaedic Manipulative Physical Therapy (OMPT) training is more aligned with the current literature compared to physiotherapists without specific training, in terms of managing rehabilitation programmes, period of immobilisation and therapeutic exercise.More careful adherence to the international guidelines is recommended, in order to manage patients following RC repair in accordance with the evidence and to achieve the best possible outcomes.

Swiss-wide multicentre evaluation and prediction of core outcomes in arthroscopic rotator cuff repair: protocol for the ARCR_Pred cohort study

INTRODUCTION

In the field of arthroscopic rotator cuff repair (ARCR), reporting standards of published studies differ dramatically, notably concerning adverse events (AEs). In addition, prognostic studies are overall methodologically poor, based on small data sets and explore only limited numbers of influencing factors. We aim to develop prognostic models for individual ARCR patients, primarily for the patient-reported assessment of shoulder function (Oxford Shoulder Score (OSS)) and the occurrence of shoulder stiffness 6 months after surgery. We also aim to evaluate the use of a consensus core event set (CES) for AEs and validate a severity classification for these events, considering the patient's perspective.

METHODS AND ANALYSIS

A cohort of 970 primary ARCR patients will be prospectively documented from several Swiss and German orthopaedic clinics up to 24 months postoperatively. Patient clinical examinations at 6 and 12 months will include shoulder range of motion and strength (Constant Score). Tendon repair integrity status will be assessed by ultrasound at 12 months. Patient-reported questionnaires at 6, 12 and 24 months will determine functional scores (subjective shoulder value, OSS), anxiety and depression scores, working status, sports activities, and quality of life (European Quality of Life 5 Dimensions 5 Level questionnaire). AEs will be documented according to a CES. Prognostic models will be developed using an internationally supported regression methodology. Multiple prognostic factors, including patient baseline demographics, psychological, socioeconomic and clinical factors, rotator cuff integrity, concomitant local findings, and (post)operative management factors, will be investigated.

ETHICS AND DISSEMINATION

This project contributes to the development of personalised risk predictions for supporting the surgical decision process in ARCR. The consensus CES may become an international reference for the reporting of complications in clinical studies and registries. Ethical approval was obtained on 1 April 2020 from the lead ethics committee (EKNZ, Basel, Switzerland; ID: 2019-02076). All participants will provide informed written consent before enrolment in the study.

TRIAL REGISTRATION NUMBER

NCT04321005.

PROTOCOL VERSION

Version 2 (13 December 2019).