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

The Subscapularis Healing Index: A New Scoring System for Predicting Subscapularis Healing After Arthroscopic Repair

BACKGROUND

Previous research has emphasized the effect of prognostic factors on arthroscopic rotator cuff repair (ARCR) success, but a specific focus on subscapularis (SSC) tendon repair healing is lacking.

PURPOSE

To identify prognostic factors for SSC healing after ARCR and develop the Subscapularis Healing Index (SSC-HI) by incorporating these factors.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This was a retrospective study using prospectively maintained data collected from patients with isolated or combined SSC tears who underwent ARCR between 2011 and 2021 at a single institution with a minimum 2-year follow-up. Functional outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), and visual analog scale (VAS) pain scale. SSC tendon healing was evaluated via ultrasound at the final follow-up. Multivariate logistic regression analysis was performed to determine the factors affecting SSC healing, and based on these factors, the SSC-HI, which ranges from 0 to 15 points, was developed using odds ratios (ORs).

RESULTS

Among 1018 ARCR patients, 931 met the inclusion criteria; 279 returned voluntarily for postoperative SSC ultrasound assessment. The overall healing failure rate was 10.8% (30/279). Risk factors for healing failure included female sex (P = .008; OR, 3.119), body mass index (BMI) ≥30 (P = .053; OR, 2.323), supraspinatus fatty infiltration ≥3 (P = .033; OR, 3.211), lower SSC fatty infiltration ≥2 (P = .037; OR, 3.608), and Lafosse classification ≥3 (P = .007; OR, 3.224). A 15-point scoring system comprised the following: 3 points for female sex, 2 points for BMI ≥30, 3 points for supraspinatus fatty infiltration ≥3, 4 points for lower SSC fatty infiltration ≥2, and 3 points for Lafosse classification ≥3. Patients with ≤4 points had a 4% healing failure rate, while those with ≥9 points had a 55% rate of healing failure. Patients with a healed SSC reported significantly higher ASES (healed SSC: ΔASES, 44.7; unhealed SSC: ΔASES, 29; P < .01) and SSV (healed SSC: ΔSSV, 52.9; unhealed SSC: ΔSSV, 27.5; P < .01) and lower VAS (healed SSC: ΔVAS, -4.2; unhealed SSC: ΔVAS, -3; P < .01) scores compared with those with an unhealed SSC.

CONCLUSION

The SSC-HI scoring system integrates clinical and radiological factors to predict SSC healing after surgical repair. Successful SSC healing was found to be associated with enhanced functional outcomes, underscoring the clinical relevance of SSC healing prediction in the management of these tears.

Biomechanical comparison of suture bridge rotator cuff repair with and without dermal allograft pledgets

BACKGROUND

One method to augment rotator cuff repair is to pass dermal allograft pledgets along the sutures that bridge from the medial to the lateral row. It remains unclear whether this augmentation method alters repair biomechanics.

METHODS

This was a controlled laboratory study. After an a priori power analysis, 9 pairs of rotator cuffs underwent double-row suture bridge rotator cuff repair, half randomized to augmentation with dermal allograft pledgets passed along the suture bridge sutures. Repairs were then mounted on a material testing system and loaded cyclically 500 cycles to measure applied force and displacement. Repairs then underwent ultimate failure testing, and stiffness, ultimate failure force, and ultimate failure displacement were measured. Paired t tests were performed to compare between groups.

RESULTS

There were no differences between groups in construct gapping with cyclic loading after 500 cycles (P = .885). There were no differences between the augmented and control groups in yield force (103.5 ± 5.0 vs. 101.4 ± 5.9 N, respectively, P = .183), stiffness (94.2 ± 13.9 vs. 90.9 ± 13.8, P = .585), or ultimate failure force (255.3 ± 65.8 vs. 285.3 ± 83.2, P = .315). There were no differences between groups in failure modes, with most specimens failing by cuff tissue tearing within or medial to the construct.

CONCLUSION

The addition of dermal allograft pledgets does not positively or negatively influence the time-zero biomechanical characteristics of double-row suture bridge rotator cuff repair.

A modified Patte classification system for rotator cuff tendon retraction to predict reparability and tendon healing in arthroscopic rotator cuff repair

PURPOSE

The purpose of this study was to propose a modified Patte classification system for tendon retraction, including the cut-off points for predicting reparability and rotator cuff healing after arthroscopic rotator cuff repair (ARCR) and assess its prediction accuracy and measurement reliability.

METHODS

This retrospective study included 463 consecutive patients scheduled to undergo ARCR for full-thickness supraspinatus tears. Receiver operating characteristic (ROC) curve analysis was used to determine the cut-off points for predicting reparability and tendon healing. The modified Patte classification system, in which these cut-off points were combined with the original Patte classification, classified the tendon retraction as stages I-V. The prediction accuracy of reparability and tendon healing was assessed using the area under the curve (AUC). Measurement reliability was determined using Cohen's κ statistics.

RESULTS

Of the 402 included patients, 32 rotator cuff tears were irreparable and 71 of the remaining 370 were diagnosed with healing failure. ROC analysis determined the cut-off point of reparability at the medial one-fifth and that of tendon healing at the medial one-third of the humeral head. The AUC of the modified Patte classification for predicting reparability and tendon healing was 0.897 (excellent) and 0.768 (acceptable), respectively. Intra-rater reliability was almost perfect (mean κ value: 0.875), and inter-rater reliability was substantial (0.797).

CONCLUSION

Diagnostic performance of the modified Patte classification system was excellent for reparability and acceptable for rotator cuff healing, with high measurement reliability. The modified Patte classification system can be easily implemented in clinical practice for planning surgical procedures and counselling patients in the day-by-day clinical work.

LEVEL OF EVIDENCE

Level III.

Similar Healing Rates of Arthroscopic Rotator Cuff Repair With and Without Bone Marrow Stimulation: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Bone marrow stimulation (BMS) techniques such as microfracture, nanofracture, and the crimson duvet procedure expose the bone marrow of the proximal humerus to the rotator cuff tendon footprint. The effect of performing BMS on tendon healing is a subject of interest.

PURPOSE

To compare studies on arthroscopic rotator cuff repair with BMS versus without BMS for rotator cuff tears according to healing rates and clinical and radiological outcomes.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 2.

METHODS

The 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed in conducting a search. Studies that compared arthroscopic rotator cuff repair with and without BMS were included if they provided postoperative patient-reported outcomes and healing rates. Dichotomous outcomes were expressed as mean differences (MDs), while continuous outcomes were expressed as odds ratio.

RESULTS

Included were 5 studies (N = 499 shoulders); 4 studies had level 1 evidence, and 1 study had level 2 evidence. The healing rate of rotator cuff repair was similar between the 2 groups (ie, with and without BMS) (odds ratio, 1.58 [95% CI, 0.63 to 4.00]; P = .33). Furthermore, there were no significant differences in the postoperative Constant score (MD, 1.41 [95% CI, -0.58 to 3.39]; P = .16), American Shoulder and Elbow Surgeons score (MD, 0.77 [95% CI, -1.43 to 2.96]; P = .49), or range of motion for forward flexion (MD, 2.45 [95% CI, -0.66 to 5.57]; P = .12) and external rotation (MD, 0.81 [95% CI, -2.35 to 3.97]; P = .62) at the final follow-up between the 2 groups.

CONCLUSION

The healing rate of rotator cuff repair was similar, regardless of whether BMS was performed or not. Additionally, there was no significant difference in postoperative patient-reported outcome scores, range of motion, and complications.

REGISTRATION

CRD42023388427 (PROSPERO).

Neighborhood socioeconomic disadvantages influence outcomes following rotator cuff repair in the non-Medicaid population

BACKGROUND

Prior investigations have utilized various surrogate markers of socioeconomic status to assess how health care disparities impact outcomes after rotator cuff repair (RCR). When taken as individual markers, these factors have inconsistent associations. Medicaid insurance status is an accessible marker that has recently been correlated with less optimal outcomes after RCR. Socioeconomic disparities exist within the non-Medicaid population as well and are arguably more difficult to characterize. The Area Deprivation Index (ADI) uses seventeen socioeconomic variables to establish a spectrum of neighborhood health care disparity. The purpose of this study was to determine the influence of neighborhood socioeconomic disadvantages, quantified by ADI, on 2-year patient reported outcome scores following RCR in the non-Medicaid population.

METHODS

A retrospective review of patients who underwent RCR from 2015 to 2020 was performed. All procedures were performed by a group of 7 surgeons at a large academic center. Patient demographics and comorbidities were collected from charts. Rotator cuff tear size was assessed from arthroscopic pictures. ADI scores were calculated based on patients' home addresses using the Neighborhood Atlas tool. The primary outcome measure was American Shoulder and Elbow Surgeons (ASES) score with a minimum follow-up of 2 years. A linear regression analysis with covariate control for age and patient comorbidities was performed.

RESULTS

There were 287 patients with a mean age of 60.11 years. The linear regression model between ADI and 2-year ASES score was significant (P = .02). When controlling for both age and patient comorbidities, every 0.9-point reduction in ADI resulted in a 1-point increase in the ASES score (P = .03). Patients with an ADI of 8, 9, or 10 had lower mean 2-year ASES scores than those with an ADI of 1 (87.08 vs. 93.19, P = .04), but both groups had similar change from preoperative ASES score (40.17 vs. 32.88, P = .12). The change in ASES score at 2-years in our study surpassed all established minimal clinically important difference values irrespective of ADI.

CONCLUSION

Patients with greater levels of disparity in their home neighborhoods have worse final ASES scores at 2 years, but patients significantly improve from their preoperative state regardless of social disadvantages. This is the first study to the authors' knowledge that examines ADI and outcomes following RCR. Providers should be aware that patients with higher ADI scores may have inferior preoperative shoulder function. The results of this study support the utilization of primary RCR in applicable tears regardless of socioeconomic status.

Heated Tobacco Products Have Detrimental Effects on Rotator Cuff Healing, Similar to Conventional Cigarettes

BACKGROUND

Cigarette smoking impairs rotator cuff healing, but no study, to our knowledge, has focused on the association between heated tobacco products and rotator cuff tears.

METHODS

This study retrospectively investigated 1,133 patients who underwent arthroscopic repair of symptomatic rotator cuff tears between March 2011 and April 2021. Patients were grouped on the basis of their smoking patterns as nonsmokers, cigarette smokers, and heated tobacco smokers. Propensity score matching was used to reduce selection bias, and 45 subjects were selected from each group via 1:1:1 matching. Functional scores and active range of motion were compared among the 3 groups preoperatively and at a 2-year follow-up. Postoperative magnetic resonance imaging was performed 6 months after the surgical procedure to assess structural integrity.

RESULTS

Except for sex, similar baseline characteristics were achieved after propensity score matching. There were no differences in the clinical scores or range of motion between the matched groups either preoperatively or at the 2-year follow-up. However, the retear rate for the matched nonsmoker group was significantly lower (8.9%) than those for the matched cigarette smoker group (31.1%) and the heated tobacco smoker group (28.9%) (p = 0.022). Multivariable logistic regression analysis revealed that the retear rates were 3.403 times higher for the cigarette smoker group and 3.397 times higher for the heated tobacco smoker group than that for the nonsmoker group.

CONCLUSIONS

Heated tobacco users, like conventional cigarette smokers, have worse clinical outcomes with respect to rotator cuff healing than nonsmokers. Regardless of the type of cigarette, abstinence from smoking is necessary for patients undergoing rotator cuff repair surgery.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

The Effect of Denosumab on Rotator Cuff Repair in Women Aged 60 and over with Osteoporosis: A Prospective Observational Study

BACKGROUND

In previous studies, denosumab, a RANKL human monoclonal antibody used in osteoporosis treatment, has shown efficacy in tendon healing after rotator cuff repair. This prospective study investigated the effects of denosumab on tendon healing, re-tear rates, and clinical outcomes post rotator cuff repair in women with osteoporosis.

METHOD

This was a prospective, observational study, employing propensity score matching for the control group. From March 2018 to March 2023, female patients over the age of 60 with normal bone density undergoing arthroscopic rotator cuff repair were selected as controls through propensity score matching (PSM) and compared with female patients of the same age group with osteoporosis who were receiving denosumab treatment. The control group was matched using 1-to-2 propensity score matching. Radiological examinations and functional outcomes were assessed preoperatively and at 6 months postoperatively.

RESULTS

In the final analysis, the study comprised 34 patients in the denosumab treatment group (Group 1) and 68 patients in the control group (Group 2). The functional scores showed significant improvement at 6 months post-surgery in both groups. No significant difference in the functional scores was observed among the groups. The re-tear rate, defined according to Sugaya's classification (types IV and V) as re-tear, was slightly higher in Group 1 at 16.7% (6 of 34) compared to Group 2 at 11.7% (8 of 68), but the difference was not statistically significant (p = 0.469). The re-tear patterns, classified according to Rhee's classification, also showed no significant difference among the groups (Group 1: 2/4 of 6; Group 2: 4/4 of 8; p = 0.571). The occurrence of type I re-tear exhibited no significant difference between the two groups (5.9% vs. 5.9%; p = 1.000).

CONCLUSIONS

The administration of denosumab following arthroscopic rotator cuff repair in women aged 60 and over with osteoporosis resulted in a re-tear rate that was similar to that observed in patients without osteoporosis. This result suggests that denosumab administration might be beneficial for rotator cuff healing, particularly in the context of osteoporosis, a known risk factor for increased retear rates. Therefore, comprehensive osteoporosis screening and treatment should be considered in conjunction with rotator cuff repair surgery in middle-aged women.

A systematic review on sonoelastography for rotator-cuff post-repair assessment

Surgical repair of rotator cuff tears is performed routinely; however, the risks of re-tears and the associated consequences are significant. Sonoelastography, an imaging modality that evaluates the mechanical properties of tissues, can examine the dynamic transitions in rotator cuff stiffness following retear and investigate the relationship between these changes and the occurrences of retears. This systematic review aimed to summarize the role of perioperative sonoelastography in repaired rotator cuffs. A comprehensive search of the PubMed, Embase, and Cochrane databases was conducted, covering studies published until June 19, 2023. The Newcastle-Ottawa scale was used for quality assessment. The key information extracted from each study included the injury/surgery type, follow-up duration, sonoelastography mode, and main sonoelastographic findings. Eleven eligible studies comprising 355 patients were included. All studies focused on supraspinatus muscles and tendons with previous arthroscopic repairs. During the postoperative 1st - 6th months, muscle stiffness increased in the supraspinatus and decreased in the ipsilateral deltoid. Failure to recover supraspinatus muscle elasticity might be indicative of potential tendon re-tear; however, it is imperative to first establish correlations with other imaging modalities. Conflicting findings have been observed regarding stiffening or softening of the supraspinatus tendon after surgical repair. The preoperative stiffness of the supraspinatus tendon did not correlate with postoperative tendon integrity or function.

Arthroscopic Repair of Retracted Large and Massive Rotator Cuff Tears With and Without Augmentation With a Bio-Inductive Collagen Implant Reveals Substantial and Comparable Clinical Improvement

PURPOSE

To compare clinical and imaging results after repair of retracted large and massive full-thickness rotator cuff tears, including revision repairs, with and without augmentation with a bio-inductive collagen implant.

METHODS

The study group comprised 24 patients (17 male subjects) with retracted 2 or 3 tendon rotator cuff tears undergoing arthroscopic repair followed by onlay augmentation with a bio-inductive collagen implant. The control group comprised 24 patients (19 male subjects) matched by tear size undergoing repair without augmentation. Mean patient age at repair in both groups was 61 years. Active range of motion and patient-reported outcomes were recorded before and after surgery. Noncontrast high-field magnetic resonance imaging was obtained in 20 of 24 collagen implant patients and 17 of 24 control patients at minimum 6 months' follow-up to assess tendon healing.

RESULTS

American Shoulder and Elbow Surgeons and Simple Shoulder Test scores improved from 35 to 86 and 3.6 to 9.3, respectively, in the collagen implant group and from 39 to 87 and 3.9 to 9.7 in the control group. The visual analog score-pain improved from 6.0 to 0.9 and from 5.9 to 0.9 in the collagen implant and control groups, respectively (P < .001 for all). Overall improvements in range of motion and patient-reported outcomes were similar in both groups. Magnetic resonance imaging revealed intact repairs in 11 of 20 (55%) patients in the patch group and 9 of 17 (53%) in the control group. Two patients in each group were revised to reverse shoulder arthroplasty.

CONCLUSIONS

Arthroscopic repair of retracted large and massive rotator cuff tears, including revision repairs, with and without augmentation using a bio-inductive collagen implant results in substantial and comparable early clinical improvement, although predictable healing remains elusive. Further work is needed to optimize patient selection for massive rotator cuff repair and define more precisely the indications for augmentation of these repairs using the collagen implant.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Assessment of fatty infiltration of the hamstring muscles in chronic proximal hamstring ruptures and effect on clinical outcomes after surgical repair: a novel application of the Goutallier classification

INTRODUCTION

Increased time to surgery has been previously associated with poorer clinical outcomes after surgical treatment of proximal hamstring ruptures, though the etiology remains unclear. The purpose of this study was to evaluate whether degree of muscle atrophy, as assessed using the Goutallier classification system, is associated with worse outcomes following surgical treatment of chronic proximal hamstring ruptures.

MATERIALS AND METHODS

This was a retrospective case series of patients who underwent repair of proximal hamstring ruptures from 2012 to 2020 with minimum 2-year follow-up. Patients were included if they underwent primary repair of a proximal hamstring rupture ≥ 6 weeks after the date of injury and had accessible preoperative magnetic resonance imaging (MRI). Exclusion criteria were allograft reconstruction, endoscopic repair, or prior ipsilateral hip surgery. Patients were administered validated surveys: the modified Harris Hip Score (mHHS) and Perth Hamstring Assessment Tool (PHAT). Fatty atrophy on preoperative MRI was independently graded by two musculoskeletal radiologists using the Goutallier classification. Multivariate regression analysis was performed to evaluate associations of preoperative characteristics with muscle atrophy, as well as mHHS and PHAT scores.

RESULTS

Complete data sets were obtained for 27 patients. A majority of this cohort was male (63.0%), with a mean age of 51.5 ± 11.8 years and BMI of 26.3 ± 3.8. The mean follow-up time was 62.6 ± 23.1 months, and the mean time from injury-to-surgery was 20.4 ± 15.3 weeks. The Goutallier grading inter-reader weighted kappa coefficient was 0.655. Regression analysis demonstrated that atrophy was not significantly associated with PHAT (p = 0.542) or mHHS (p = 0.574) at latest follow-up. Increased age was significantly predictive of muscle atrophy (β = 0.62, p = 0.005) and was also found to be a significant predictor of poorer mHHS (β = - 0.75; p = 0.037).

CONCLUSIONS

The degree of atrophy was not found to be an independent predictor of clinical outcomes following repair of chronic proximal hamstring ruptures. Increasing age was significantly predictive of increased atrophy and poorer patient-reported outcomes.

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

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

Influence of body mass index on severity of rotator cuff tears

BACKGROUND

Research on the relationship between obesity and rotator cuff tears (RCTs) has been limited to the impact of obesity on the results of arthroscopic repair of RCTs; thus, a need for rigorous research controlling for other factors affecting RCTs is warranted, especially to better understand the impact of body mass index (BMI) on RCT severity.

METHODS

A retrospective study of admission records contained in electronic medical records pertaining to patients who were admitted for RCT repair on 1 shoulder between January 2018 and July 2022 was conducted. In total, 386 patients were included. In accordance with guidance regarding obesity from Taiwan's Ministry of Health and Welfare, patients were divided into three groups: underweight or normal weight (BMI <24.0 kg/m2), overweight (BMI 24.0-26.9 kg/m2), or obese (BMI ≥27.0 kg/m2). Magnetic resonance imaging was used to assess RCT severity in terms of four parameters: Patte stage (PS), fatty infiltration (FI), anteroposterior tear size (AP), and retraction size. Multinomial logistic regression analysis was performed on PS and FI grade data, and multiple linear regression analysis was performed on AP tear size and retraction size in order to analyze impact.

RESULTS

Our results revealed that the average age of the 386 patients was 63.41 years (SD = 9.29) and the mean BMI was 25.88 (SD = 3.72) kg/m2. We found significant differences in PS (P = .003), FI (P < .001), retraction size (P = .001), and AP tear size (P = .001) among patients who were underweight or normal weight, overweight, and obese. After controlling for other risk factors, including age, gender, RCT-prone occupation, duration of shoulder pain prior to surgery, history of shoulder injury, and tobacco use, we found that obese patients had higher severity levels in PS (B = 1.21, OR = 3.36, P = .029), FI (B = 1.38, OR = 3.96, P < .001), retraction size (β = 0.18, P = .001), and AP tear size (β = 0.18, P = .001) compared to underweight or normal weight patients.

CONCLUSIONS

Our study demonstrates that a correlation exists between BMI-measured obesity and RCT severity. We therefore suggest that adults control their weight given that maintaining a healthy weight is highly associated with better shoulder health.

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

BACKGROUND

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

HYPOTHESIS

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

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

Fibroblast Growth Factor Soaked Collagen Membrane Shows No Biomechanical or Histological Advantages in the Treatment of Chronic Rotator Cuff Tears in a Rabbit Model

PURPOSE

To investigate the histological and biomechanical effects of a fibroblast growth factor (FGF-2)-soaked collagen membrane used to treat a full-thickness chronic rotator cuff (RC) rupture in a rabbit model.

METHODS

Forty-eight shoulders from 24 rabbits were used. At the beginning of the procedure, 8 rabbits were killed to assess the control group (Group IT) with intact tendons. To establish a chronic RC tear model, a full-thickness subscapularis tear was created on both shoulders of the remaining 16 rabbits and left for 3 months. The transosseous mattress suture technique was used to repair tears in the left shoulder (Group R). The tears in the right shoulder (Group CM) were treated using the same approach, with an FGF-soaked collagen membrane inserted and sutured over the repair site. Three months after the procedure, all rabbits were killed. Biomechanical testing was performed on the tendons to determine failure load, linear stiffness, elongation intervals, and displacement. Histologically, the modified Watkins score was used to evaluate tendon-bone healing.

RESULTS

There was no significant difference among the three groups in terms of failure load, displacement, linear stiffness, and elongation (P > .05). The total modified Watkins score was not affected by applying the FGF-soaked collagen membrane to the repair site (P > .05). Fibrocytes, parallel cells, large-diameter fibers, and the total modified Watkins score were significantly lower in both repair groups when compared to the intact tendon group (P < .05).

CONCLUSIONS

In addition to tendon repair, FGF-2 soaked collagen membrane -application at the repair site provides neither biomechanical nor histological advantages in the treatment of chronic RC tears.

CLINICAL RELEVANCE

FGF-soaked collagen membrane augmentation provides no impact on the chronic RC tear healing tissue. The need to investigate alternative methods that may have a positive effect on healing in chronic RC repairs continues.

Comparison of En Masse Repair versus Separate Double-Layer Repair for Delaminated Rotator Cuff Tears: A Systematic Review and Meta-Analysis

BACKGROUND

Delamination of cuff tendons has a negative impact on outcomes following arthroscopic rotator cuff repair (RCR). The purpose of this study is to compare en masse repair (EMR) and separate double-layer repair (SDLR) for delaminated rotator cuff tears.

METHODS

A systematic literature search was conducted on major databases (MEDLINE/PubMed, EMBASE, Cochrane Library, and Scopus) until 1 June 2023. Comparative studies with a minimum 24-month follow-up of patients undergoing arthroscopic RCR for delaminated tears were included. The outcomes assessed retear rates and functional outcomes.

RESULTS

Five eligible studies involving 325 cases were analyzed. The meta-analysis showed no significant difference in retear rates between SDLR and EMR for delaminated tears (OR = 0.73, 95% CI: 0.35-1.49). However, the meta-analysis demonstrated a significant intergroup difference in favor of the SDLR for the total Constant score (SMD = 0.68, 95% CI: 0.35 to 1.02), SST score (SMD = 0.37, 95% CI: 0.02 to 0.71), and postoperative range of abduction (SMD = 0.34, 95% CI: 0.03 to 0.64).

CONCLUSION

The evidence suggests that the SDLR in arthroscopic RCR for delaminated rotator cuff tears leads to improved short-term functional outcomes and range of motion compared to EMR. However, there is no significant difference in retear risk between the two approaches.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Suture Contamination During Arthroscopic Rotator Cuff Repair Is Associated With Significantly Higher Retear Rates in Magnetic Resonance Imaging: A Matched-Pair Analysis

PURPOSE

To evaluate the correlation between suture contamination and rotator cuff tendon retear after arthroscopic rotator cuff repair.

METHODS

Patients undergoing primary arthroscopic rotator cuff repair from April 1, 2020, to September 30, 2022, were enrolled. Those younger than 18 years, with a history of shoulder surgeries or shoulder infection episodes, or who declined participation were excluded. A 5-cm section of the first-cut suture, originating from the anchor eyelet ends, in each rotator cuff repair surgery was subjected to bacteria culture and polymerase chain reaction analysis. Patients with positive culture findings were matched 1:1 to those with negative culture reports based on age, sex, tear size as well as involved tendons, preoperative fatty infiltration grade (Goutallier grade), and preoperative muscle atrophy grade (Warner score). Postoperative rotator cuff tendon retear assessments were conducted at the 6-month mark using the Sugaya classification via magnetic resonance imaging. The Wilcoxon signed-rank test was used for matched-pair comparisons between the groups.

RESULTS

A total of 141 patients (60 men and 81 women) with a mean age of 61.0 ± 8 years were finally enrolled. Twenty-six patients (18 men and 8 women) had a positive culture, while 115 patients (42 men and 73 women) had a negative culture. After the propensity score matching process, 24 culture-negative patients (16 men and 8 women) were selected as the culture-negative group. Age, fatty infiltration grade, and muscle atrophy grade were not significantly different between matched groups. The retear grade in the culture-positive group was significantly higher than that in the culture-negative group (P = .020) under the matched-pair comparison. Cutibacterium acnes was the most prevalent bacterial species responsible for suture contamination.

CONCLUSIONS

The matched-pair analysis revealed that the presence of bacterial contamination on sutures was associated with a higher risk of retear on magnetic resonance imaging following arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Rotator cuff tears

Rotator cuff tears are the most common upper extremity condition seen by primary care and orthopaedic surgeons, with a spectrum ranging from tendinopathy to full-thickness tears with arthritic change. Some tears are traumatic, but most rotator cuff problems are degenerative. Not all tears are symptomatic and not all progress, and many patients in whom tears become more extensive do not experience symptom worsening. Hence, a standard algorithm for managing patients is challenging. The pathophysiology of rotator cuff tears is complex and encompasses an interplay between the tendon, bone and muscle. Rotator cuff tears begin as degenerative changes within the tendon, with matrix disorganization and inflammatory changes. Subsequently, tears progress to partial-thickness and then full-thickness tears. Muscle quality, as evidenced by the overall size of the muscle and intramuscular fatty infiltration, also influences symptoms, tear progression and the outcomes of surgery. Treatment depends primarily on symptoms, with non-operative management sufficient for most patients with rotator cuff problems. Modern arthroscopic repair techniques have improved recovery, but outcomes are still limited by a lack of understanding of how to improve tendon to bone healing in many patients.

Early Postoperative Stiffness After Arthroscopic Rotator Cuff Repair Correlates With Improved Tendon Healing

PURPOSE

To assess whether early postoperative stiffness predicts long-term stiffness and its relationship with repair integrity in patients who undergo arthroscopic rotator cuff repair (ARCR).

METHODS

This was a single-center retrospective study; 427 patients undergoing primary ARCR by a board-certified orthopaedic surgeon over 4 years were considered. Patients with at least 1 year of follow-up were categorized into stiff and non-stiff groups based on their range of motion (ROM) at 3 months' postoperatively. Stiffness was defined as passive forward flexion <120°, external rotation <30°, or internal rotation below L3. We evaluated clinical outcomes using demographics, ROM, Constant Shoulder (CS) score, University of California, Los Angeles (UCLA) score, and visual analog scale (VAS) for pain preoperatively and at 3, 6, and 12 months' postoperatively. Stiffness, retear rates, and tendon integrity were assessed via magnetic resonance imaging at 12 months.

RESULTS

Of 155 patients meeting the inclusion criteria, 68 (43.9%) were stiff, and 87 (56.1%) were non-stiff. The stiff group had significantly lower preoperative CS and UCLA scores (P = .013/.014) and greater VAS score (P = .034). At 3 months, this group showed lower ROM and functional scores (P < .001), persisting at 6 and 12 months (except internal rotation) (P < .001). Their 12-month VAS score was greater (P = .024). Postoperative stiffness occurred in 10.3% of the stiff group and 2.3% of the non-stiff group (P = .035). The 12-month retear rate was 5.9% in the stiff group and 17.2% in the non-stiff group (P = .032). Minimal clinically important difference analysis indicated ROM changes but limited functional score changes in the 2 groups.

CONCLUSIONS

This study showed that early postoperative shoulder stiffness correlates with lower preoperative functional scores and greater pain levels. Shoulder stiffness at 3 months' post-ARCR predicts 12-month shoulder stiffness but indicates better tendon integrity. While early stiffness is linked to lower functional scores and more pain, its long-term clinical impact seems limited.

LEVEL OF EVIDENCE

Level III, retrospective comparison study.

Cross-sectional areas of rotator cuff muscles in males without tears on shoulder MRI

OBJECTIVE

To establish reference values of rotator cuff (RC) cross sectional area (CSA) in males.

MATERIALS AND METHODS

We retrospectively analyzed shoulder MRIs from 500 patients aged 13-78 years, grouped as follows (N=100 in each): <20, 20-30, 30-40, 40-50, >50 years. All examinations were reviewed to exclude prior surgery, tears, or significant RC pathology. We segmented a standardized T1 sagittal MR image in each case to obtain CSA of supraspinatus (SUP), infraspinatus/teres minor (INF), and subscapularis (SUB) muscles. Across age groups, we recorded individual and total muscle CSA. We also performed ratios between individual muscle CSA and total CSA to examine total muscle mass contribution over age groups. We tested for differences between age groups controlled for BMI.

RESULTS

CSAs for SUP, INF, SUB, and total RC CSA were lower in subjects >50 years compared to all other groups (P<0.003 for all comparisons), persisting after controlling for BMI (P<0.03). Relative contribution of SUP CSA to total RC CSA was stable across age groups (P>0.32). INF CSA relative to total RC CSA increased with age, whereas SUB decreased (P<0.005). Subjects >50 years showed lower SUP (-15%), INF (-6%), and SUB (-21%) CSA, when compared to mean CSAs of all subjects <50 years. Total RC CSA significantly correlated with age (r=-0.34, P<0.001), persisting after controlling for BMI (r=-0.42, P<0.001).

CONCLUSION

RC muscles in male subjects with no tears on MRI show decreasing CSA with age, independent of BMI.

Preoperative thrombocytopenia and thrombocytosis predict complications after arthroscopic rotator cuff repair

Background

The purpose of this study was to investigate the association between preoperative platelet count and 30-day postoperative complications following arthroscopic rotator cuff repair (aRCR).

Methods

The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent aRCR between 2015 and 2021. The study population was divided into 5 groups based on preoperative platelet count: normal (200-450k, reference cohort), low-normal (150-200k), mild thrombocytopenia (100-150k), moderate-to-severe thrombocytopenia (<100k), and thrombocytosis (>450k). Thirty-day postoperative complications following aRCR were collected. Multivariate logistic regression analysis was conducted to investigate the relationship between preoperative platelet counts and postoperative complications.

Results

24,779 patients were included in this study: 18,697 (75.5%) in the normal group, 4730 (19.1%) in the low-normal group, 1012 (4.1%) in the mild thrombocytopenia group, 171 (0.7%) in the moderate-to-severe thrombocytopenia group, and 169 (0.7%) in the thrombocytosis group. Low-normal platelets were an independent predictor of urinary tract infection (odds ratio [OR] 2.06, 95% confidence interval [CI] 1.12-3.77; P = .020). Mild thrombocytopenia was not an independent predictor of any complications. Moderate-to-severe thrombocytopenia was an independent predictor of sepsis (OR 9.39, 95% CI 1.48-59.47; P = .017), pneumonia (OR 6.62, 95% CI 1.32-33.24; P = .022), and nonhome discharge (OR 3.34, 95% CI 1.20-9.25; P = .021). Thrombocytosis was an independent predictor of urinary tract infection (OR 4.91, 95% CI 1.16-20.78; P = .030).

Conclusion

Abnormal preoperative platelet counts, both low and high, were independent risk factors for 30-day postoperative complications following aRCR.

The Gluteus-Score-7 Predicts the Likelihood of Both Clinical Success and Failure Following Surgical Repair of the Hip Gluteus Medius and/or Minimus

PURPOSE

To identify patient preoperative history, examination, and imaging characteristics that increase the risk of postoperative failure of gluteus medius/minimus repair, and to develop a decision-making aid predictive of clinical outcomes for patients undergoing gluteus medius/minimus repair.

METHODS

Patients from 2012 to 2020 at a single institution undergoing gluteus medius/minimus repair with minimum 2-year follow-up were identified. MRIs were graded according to the "three-grade" classification system: grade 1: partial-thickness tear, grade 2: full-thickness tears with <2 cm of retraction, grade 3: full-thickness tears with ≥2 cm retraction. Failure was defined as undergoing revision within 2 years postoperatively or not achieving both a cohort-calculated minimal clinically important difference (MCID) and responding "no" to patient acceptable symptom state (PASS). Inversely, success was defined as reaching both an MCID and responding "yes" to PASS. Predictors of failure were verified on logistic regression and a predictive scoring model, the Gluteus-Score-7, was generated to guide treatment-decision making.

RESULTS

In total, 30 of 142 patients (21.1%) were clinical failures at mean ± SD follow-up of 27.0 ± 5.2 months. Preoperative smoking (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.0-8.4; P = .041), lower back pain (OR, 2.8; 95% CI, 1.1-7.3; P = .038), presence of a limp or Trendelenburg gait (OR, 3.8; 95% CI, 1.5-10.2; P = .006), history of psychiatric diagnosis (OR, 3.7; 95% CI, 1.3-10.8; P = .014), and increased MRI classification grades (P ≤ .042) were independent predictors of failure. The Gluteus-Score-7 was generated with each history/examination predictor assigned 1 point and MRI classes assigned corresponding 1-3 points (min 1, max 7 score). A score of ≥4/7 points was associated with risk of failure and a score ≤2/7 points was associated with clinical success.

CONCLUSIONS

Independent risk factors for revision or not achieving either MCID or PASS after gluteus medius and/or minimus tendon repair include smoking, preoperative lower back pain, psychiatric history, Trendelenburg gait, and full-thickness tears, especially tears with ≥2 cm retraction. The Gluteus-Score-7 tool incorporating these factors can identify patients at risk of both surgical treatment failure and success, which may be useful for clinical decision-making.

LEVEL OF EVIDENCE

Level IV, prognostic case series.

Fatty Degeneration of the Rotator Cuff Muscles Improves in Shoulders with Successful Arthroscopic Rotator Cuff Repair: A Prospective Study Using Quantitative T2 Mapping Techniques, with 2-Year Follow-up

Background

There remain arguments regarding whether fatty degeneration of the rotator cuff muscles improves following rotator cuff repair. The purpose of this study was to prospectively investigate changes in fatty degeneration of the rotator cuff muscles, quantitatively measured on magnetic resonance imaging (MRI) with use of transverse relaxation time (T2) mapping techniques, and to assess the relationship between these changes and clinical outcomes.

Methods

Patients were included if they were scheduled for arthroscopic rotator cuff repair using the suture-bridge technique between June 2014 and December 2015, underwent preoperative MRI including the T2 mapping sequence, and consented to participate in the study. Exclusion criteria consisted of trauma within 2 months before preoperative MRI, isolated subscapularis tears, patch augmentation, neuromuscular disease, and a follow-up duration of <2 years. MRI scans were acquired preoperatively and at 2 years postoperatively, and T2 values of the supraspinatus and infraspinatus muscles were measured, with smaller T2 values indicating less fat content. Shoulders were evaluated on the basis of active range of motion (ROM), Constant and University of California Los Angeles Shoulder Rating Scale scores, shoulder external rotation strength with the arm at the side, and rotator cuff integrity on postoperative MRI.

Results

A total of 103 patients (103 shoulders) with a mean age of 65 ± 9 years (range, 42 to 83 years) were included, of whom 52 were male and 51 were female. There were 13 partial, 18 small, 35 medium, 33 large, and 4 massive tears. Concomitant subscapularis tears were observed in 35 shoulders. Overall, ROM, clinical scores, and external rotation strength significantly improved postoperatively. Retears were found in 27 shoulders (26%). External rotation strength significantly improved postoperatively only in shoulders without a retear. Among shoulders without a retear, the postoperative T2 values of the supraspinatus and infraspinatus were significantly smaller than the preoperative values (p < 0.001 for both); however, no improvement was seen in shoulders with a retear.

Conclusions

Shoulders with successful repair demonstrated significantly smaller T2 values postoperatively as well as significantly improved external rotation strength. Fatty degeneration of the cuff muscles can be reversed, at least in part, and muscle strength improves in shoulders with successful repair.

Level of Evidence

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

Early versus delayed mobilization for arthroscopic rotator cuff repair (small to large sized tear): a meta-analysis of randomized controlled trials

BACKGROUND

The timing to start passive or active range of motion (ROM) after arthroscopic rotator cuff repair remains unclear. This systematic review and meta-analysis evaluated early versus delayed passive and active ROM protocols following arthroscopic rotator cuff repair. The aim of this study is to systematically review the literature on the outcomes of early active/passive versus delayed active/passive postoperative arthroscopic rotator cuff repair rehabilitation protocols.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) published up to April 2022 comparing early motion (EM) versus delayed motion (DM) rehabilitation protocols after arthroscopic rotator cuff repair for partial and full-thickness tear was conducted. The primary outcome was range of motion (anterior flexion, external rotation, internal rotation, abduction) and the secondary outcomes were Constant-Murley score (CMS), Simple Shoulder Test Score (SST score) and Visual Analogue Scale (VAS).

RESULTS

Thirteen RCTs with 1,082 patients were included in this study (7 RCTs for early passive motion (EPM) vs. delayed passive motion (DPM) and 7 RCTs for early active motion (EAM) vs. delayed active motion (DAM). Anterior flexion (1.40, 95% confidence interval (CI), 0.55-2.25) and abduction (2.73, 95%CI, 0.74-4.71) were higher in the EPM group compared to DPM. Similarly, EAM showed superiority in anterior flexion (1.57, 95%CI, 0.62-2.52) and external rotation (1.59, 95%CI, 0.36-2.82), compared to DAM. There was no difference between EPM and DPM for external rotation, retear rate, CMS and SST scores. There was no difference between EAM and DAM for retear rate, abduction, CMS and VAS.

CONCLUSION

EAM and EPM were both associated with superior ROM compared to the DAM and DPM protocols. EAM and EPM were both safe and beneficial to improve ROM after arthroscopic surgery for the patients with small to large sized tears.

Quantitative Assessment of Calf Muscle Volume, Strength, and Quality After Achilles Tendon Rupture Repair: A 1-Year Prospective Follow-up Study

BACKGROUND

A number of studies have reported that calf muscle atrophy is a common long-term problem after Achilles tendon repair; however, there is still a lack of data concerning early postoperative morphological changes in the calf muscle after surgery.

PURPOSE

To investigate changes over time in calf muscle volume and fatty degeneration during 1 year after Achilles tendon repair.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A prospective 1-year serial magnetic resonance imaging study was carried out with 20 patients who underwent tendon repair for unilateral acute Achilles tendon rupture. The magnetic resonance imaging assessment in addition to clinical and functional evaluations was performed at 1, 3, 6, and 12 months after surgery. The muscle volume of the medial and lateral gastrocnemius, soleus, and flexor hallucis longus (FHL) and fatty degeneration of the medial and lateral gastrocnemius and soleus were measured for the calf muscles, and the relative volume and fatty degeneration changes in the affected leg compared with the healthy contralateral leg were calculated as a percentage ([injured/healthy control] × 100) to assess structural changes over time.

RESULTS

Muscle volumes of the medial gastrocnemius, lateral gastrocnemius, soleus, and FHL were 92.3%, 92.8%, 84.6%, and 95.9% at 12 months after surgery, respectively. Medial and lateral gastrocnemius and FHL muscle volumes improved over time and recovered to almost equal to that of the healthy side at 12 months after surgery. The soleus muscle volume did not recover significantly over time and was statistically significantly smaller than that of the healthy side at 12 months (P = .029). Fatty degeneration rates of the medial gastrocnemius, lateral gastrocnemius, and soleus were 118.2%, 113.9% and 121.1% at 12 months after surgery, respectively. Fatty degeneration of the medial and lateral gastrocnemius did not change significantly, but there was a statistically significant increase in fatty degeneration of the soleus over time (P < .001).

CONCLUSION

Within the triceps surae muscle, the soleus was the most negatively affected by injury and repair for both muscle volume and fatty degeneration. Postoperative management to recover the soleus muscle function before a return to sporting activities should be considered in the future.

Application of Nondegradable Synthetic Materials for Tendon and Ligament Injury

Tendon and ligament injuries, prevalent requiring surgical intervention, significantly impact joint stability and function. Owing to excellent mechanical properties and biochemical stability, Nondegradable synthetic materials, including polyethylene terephthalate (PET) and polytetrafluoroethylene (PTFE), have demonstrated significant potential in the treatment of tendon and ligament injuries. These above materials offer substantial mechanical support, joint mobility, and tissue healing promotion of the shoulder, knee, and ankle joint. This review conclude the latest development and application of nondegradable materials such as artificial patches and ligaments in tendon and ligament injuries including rotator cuff tears (RCTs), anterior cruciate ligament (ACL) injuries, and Achilles tendon ruptures.

Total Intravenous Anesthesia Compared to Inhalational Anesthesia in Patients Undergoing Arthroscopic Rotator Cuff Repair

Background Inhalation anesthesia (IA) and total intravenous anesthesia (TIVA) are common general anesthesia techniques. During rotator cuff repair (RCR), an interscalene block is beneficial for intraoperative and early postoperative pain control. This study aimed to evaluate postoperative outcomes and opioid usage in patients undergoing arthroscopic RCR with an interscalene block and either IA or TIVA. Methodology A retrospective observational study was performed of 478 patients undergoing RCR at a single institution. Demographics, surgical details, intra and postoperative medications, and 90-day outcomes were collected. Univariate and multivariate analyses were performed to evaluate differences between groups. Results In total, 309 (64.6%) patients received IA and 169 (35.3%) received TIVA. Patients receiving IA were more likely to have comorbidities, such as diabetes (p = 0.002), sleep apnea (p = 0.006), gastroesophageal reflux disease (p < 0.001), and hypertension (p < 0.001). After adjusting for differences between groups in the multivariate analysis, patients who received TIVA had significantly shorter surgical time (β = -14.85, p < 0.001) and perioperative time (β = -21.01, p < 0.001) and significantly lower first post-anesthesia care unit Pasero opioid-induced sedation scores (β = -0.022, p = 0.040). Patients who received TIVA were less likely to receive intraoperative narcotics (odds ratio = 0.38; p = 0.031). Conclusions TIVA appears to be a safe and effective anesthetic for patients undergoing arthroscopic RCR. TIVA is a potentially beneficial alternative to IA for this patient population.

Preoperative vitamin D supplementation is a cost-effective intervention in arthroscopic rotator cuff repair

BACKGROUND

This study investigates the potential role of preoperative 25(OH)D supplementation as a cost-effective strategy to decrease revision rotator cuff repair (RCR) rates and lower the total health care burden from patients undergoing primary arthroscopic RCR. Previous literature has emphasized the importance of vitamin D on bone health maintenance, soft tissue healing, and outcomes in RCR. Inadequate preoperative vitamin D levels may increase revision RCR rates following primary arthroscopic RCR. Although 25(OH)D deficiency is common in RCR patients, serum screening is not routinely performed.

METHODS

A cost-estimation model was developed to determine the cost-effectiveness of both preoperative selective and nonselective 25(OH)D supplementation in RCR patients in order to reduce revision RCR rates. Prevalence and surgical cost data were obtained from published literature through systematic reviews. Cost of serum 25(OH)D assay and supplementation were obtained from public-use data. Mean and lower and upper bounds of 1-year cost savings were calculated for both the selective and nonselective supplementation scenarios.

RESULTS

Preoperative 25(OH)D screening and subsequent selective 25(OH)D supplementation was calculated to result in a mean cost savings of $6,099,341 (range: -$2,993,000 to $15,191,683) per 250,000 primary arthroscopic RCR cases. Nonselective 25(OH)D supplementation of all arthroscopic RCR patients was calculated to result in a mean cost savings of $11,584,742 (range: $2,492,401-$20,677,085) per 250,000 primary arthroscopic RCR cases. Univariate adjustment projects that selective supplementation is a cost-effective strategy in clinical contexts where the cost of revision RCR exceeds $14,824.69 and prevalence of 25(OH)D deficiency exceeds 6.67%. Additionally, nonselective supplementation is a cost-effective strategy in clinical scenarios where revision RCR cost is ≥$4216.06 and prevalence of 25(OH)D deficiency is ≥1.93%.

CONCLUSIONS

This cost-predictive model promotes the role of preoperative 25(OH)D supplementation as a cost-effective mechanism to reduce revision RCR rates and lower the overall health care burden from arthroscopic RCR. Nonselective supplementation appears to be more cost-effective than selective supplementation, likely due to the lower cost of 25(OH)D supplementation compared to serum assays.

Contrast-Enhanced Ultrasound-Assessed Supraspinatus Muscle Perfusion Indicates Better Tissue Vitality and Outcome After Supraspinatus Tendon Repair and Subacromial Decompression

OBJECTIVE

Supraspinatus tendon (SSP) tears are a frequent indication for shoulder surgery. Therapy options include physiotherapy, tendon repair and less invasive surgical options like subacromial decompression (SAD). The selection of the most appropriate treatment depends on the specific characteristics and needs of each patient subgroup. Typically, physically active patients are candidates for tendon repair, while a conservative approach is preferred for individuals with severe muscle degeneration or low physical demands. The goal of this study was to assess the impact of contrast-enhanced ultrasound (CEUS)-assessed SSP muscle perfusion on post-operative shoulder function and tendon healing in patients undergoing SSP repair or SAD, thereby enhancing personalized therapy for SSP tendon tears.

METHODS

Two cohorts of patients with SSP tendon tears were treated either by SAD or tendon repair. Pre-operative and 6-month post-operative SSP muscle perfusion was quantified using CEUS and investigated as a surrogate for tissue vitality. The magnetic resonance imaging-derived parameters fatty infiltration and tendon retraction and established shoulder function scores were assessed pre- and post-operatively.

RESULTS

Thirty-five SSP repair patients were compared with 20 SAD patients. Pre-operative perfusion was comparable in the SAD and SSP repair cohorts when a re-tear occurred (wash-in perfusion index = 103.8 ± 124.0 vs. 114.6 ± 155.0, p = 0.83), while being significantly higher among patients with an intact repair (103.8 ± 124 vs. 325.4 ± 388.6, p = 0.006). Below-median pre-operative muscle perfusion was associated with lower post-operative shoulder function (Constant score: 59 ± 28 vs. 78 ± 19, p = 0.012).

CONCLUSION

CEUS can visualize SSP muscle perfusion as a surrogate for tissue vitality and tendon healing, which is associated with better post-operative shoulder function.

Early versus late physiotherapy following arthroscopic repair of small and medium size rotator cuff tear: a randomized clinical trial

PURPOSE

We compared early and late physiotherapy for patients with small and medium size rotator cuff tears following arthroscopic repair.

METHODS

A single-centre, single-blinded, prospective parallel RCT was performed with two arms: early physiotherapy (start within the first week) versus late physiotherapy (start 4 weeks after surgery). Patients with small- to medium-sized isolated full-thickness superior rotator cuff tears were included and followed for 12 months. The primary outcome measures were shoulder function and range of motion (ROM) measured by the Constant-Murley score (CMS) at three months, six months, and 12 months. The other outcomes were the visual analog scale (VAS) pain and the rotator cuff ultrasound (US) evaluation by the Sugaya classification.

RESULTS

In three and six month follow-ups, CMS was significantly superior in the intervention group compared to controls (P < 0.05). However, only at the three month follow-up between-group difference met the minimal clinically important difference (MCID) (MCID = 10.4) (59.8 vs. 48.9). The intervention group experienced less pain than controls in the first six months (P < 0.001), and only the three month follow-up was clinically meaningful based on MCID (MCID = 1.4). Moreover, in the first six months, the shoulder ROM favoured the intervention group (P < 0.05). US grading of the supraspinatus and infraspinatus was similar between groups (P = 0.07). One retear occurred in the intervention group and another in the controls, detected by examination and US evaluation.

CONCLUSION

Following the arthroscopic repair of a small- to medium-sized rotator cuff tear, early physiotherapy showed promising results for pain, function, and range of motion.

LEVEL OF EVIDENCE

Level I therapeutic.

Hypertension and postoperative complications following arthroscopic rotator cuff repair

Background

The purpose of this study was to investigate the relationship between hypertension and postoperative complications following arthroscopic rotator cuff repair (aRCR).

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was surveyed for all patients who underwent aRCR between 2015 and 2021. Patient demographics, comorbidities, and 30-day postoperative complication data were analyzed. Multivariate logistic regression identified postoperative complications associated with hypertension.

Results

Forty-six thousand five hundred and sixty-two patients were included in the analysis: 20,999 (45.1%) patients in the hypertensive cohort and 25,563 (54.9%) in the nonhypertensive cohort. Hypertension was associated with male gender (P < .001), age ≥ 65 years (P < .001), body mass index > 30 (P < .001), dependent functional status (P < .001), American Society of Anesthesiologists classification ≥ 3 (P < .001), current smoker (P < .001), diabetes (P < .001), chronic obstructive pulmonary disease (P < .001), and bleeding disorders (P < .001). Thrity-day postoperative complications significantly associated with hypertension included pneumonia (P = .012), reintubation (P = .009), urinary tract infection (P = .002), stroke (P = .044), myocardial infarction (P = .004), ventilator > 48 hours (P = .017), readmission (P < .001), non-home discharge (P < .001), and mortality (P = .020). After adjusting for patient demographics and comorbidities, readmission (odds ratio [OR] 1.41; 95% confidence interval [CI] 1.13-1.75; P = .002) was independently associated with hypertension.

Conclusion

Hypertension was identified as a risk factor for various postoperative complications following aRCR. Hypertension was found to be an independent predictor for readmission following aRCR.

Comparison of Early versus Traditional Rehabilitation Protocol after Rotator Cuff Repair: An Umbrella-Review

Rehabilitation after rotator cuff repair is crucial for functional recovery and for minimizing the risk of retear. There are two rehabilitation protocols (early and traditional) and the debate about which is the best is open. This umbrella review aimed to compare the effect of these rehabilitation protocols in terms of reduction in pain, functional recovery, and retear risk. We selected systematic reviews and meta-analyses published between 2012 and 2022 dealing with the aim. Nineteen systematic reviews were included. No significant differences were found between early and traditional protocols in terms of pain reduction. Early rehabilitation provided better short-term results regarding Range of Motion improvement, but long-term functional outcomes were similar. Retear risk remains a significant concern for the early protocol. We found major differences between the analyzed protocols. This review suggests that both protocols are useful to recover global shoulder function, but the standard protocol has a greater safety profile for larger tears. On the other hand, the early protocol may be preferable for smaller lesions, allowing a faster recovery and having less impact on medical costs. Further research is needed to identify optimal rehabilitation strategies tailored to the individual patient's needs and characteristics.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

High degree of consensus on diagnosis and management of rotator cuff tears: a Delphi approach

PURPOSE

To develop a consensus on diagnosis and treatment of rotator cuff tears. The study focused on selected areas: imaging, prognostic factors, treatment options, surgical techniques.

METHODS

Panel was composed of all members of the shoulder committee of the Italian Society of Arthroscopy, Knee, Upper arm, Sport, Cartilage and Orthopedic techniques (SIAGASCOT). Four rounds were performed. The first round consisted of gathering questions which were then divided into seven blocks referring to: imaging, patient-related prognostic factors, treatment options, surgical steps, reparative techniques, surgical predictive factors, advanced techniques. Subsequent rounds consisted of condensation by means of online questionnaire and debates. Consensus was defined as two-thirds agreement on one answer. Descriptive statistic was used to summarize the data.

RESULTS

Forty-one shoulder experts were involved. Fifty-six statements were finally formulated. A consensus could be achieved on 51. Experts agreed that preoperative magnetic resonance imaging is strongly recommended because it allows a careful evaluation of tear characteristics, while the role of US remains debatable. Controversial patient-related factors such as age, comorbidities, smoking and stiffness do not contraindicate the repair. From a surgical standpoint, the experts highlighted that pseudo-paralysis is not a contraindication to rotator cuff repair. Consensus on specific surgical steps was also achieved: capsular release should be performed only in stiff shoulders; footprint preparation is mandatory, while debridement of tendon edges is not essential. If necessary, a rotator interval release could be performed without interrupting the continuity between subscapularis and supraspinatus tendon; posterior delamination should be always included in the repair. Advanced techniques such as tendon transfers should be selected based on the main clinical deficit, while the superior capsule reconstruction plays a role only in combination with a functional repair.

CONCLUSION

A consensus was achieved almost on every topic of controversy explored. Particularly, MRI was deemed necessary to determine tear characteristics, while radiographs remain important for differential diagnosis; age should not be considered a contraindication to surgery; pseudo-paralysis does not represent a contraindication to arthroscopic rotator cuff repair, but superior capsule reconstruction plays a role only in combination with a functional repair. Latissimus dorsi transfer plays a role when the main functional deficit is in elevation, while the lower trapezius transfer plays a role when the main functional deficit is the external-rotation.

LEVEL OF EVIDENCE

V.

Prediction of Retear After Arthroscopic Rotator Cuff Repair Based on Intraoperative Arthroscopic Images Using Deep Learning

BACKGROUND

It is challenging to predict retear after arthroscopic rotator cuff repair (ARCR). The usefulness of arthroscopic intraoperative images as predictors of the ARCR prognosis has not been analyzed.

PURPOSE

To evaluate the usefulness of arthroscopic images for the prediction of retear after ARCR using deep learning (DL) algorithms.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

In total, 1394 arthroscopic intraoperative images were retrospectively obtained from 580 patients. Repaired tendon integrity was evaluated using magnetic resonance imaging performed within 2 years after surgery. Images obtained immediately after ARCR were included. We used 3 DL architectures to predict retear based on arthroscopic images. Three pretrained DL algorithms (VGG16, DenseNet, and Xception) were used for transfer learning. Training and test sets were split into 8:2. Threefold stratified validation was used to fine-tune the hyperparameters using the training data set. The validation results of each fold were evaluated. The performance of each model in the test set was evaluated in terms of accuracy, area under the receiver operating characteristic curve (AUC), F1-score, sensitivity, and specificity.

RESULTS

In total, 1138 and 256 arthroscopic images were obtained from 514 patients and 66 patients in the nonretear and retear groups, respectively. The mean validation accuracy of each model was 83% for VGG16, 89% for Xception, and 91% for DenseNet. The accuracy for the test set was 76% for VGG16, 87% for Xception, and 91% for DenseNet. The AUC was highest for DenseNet (0.92); it was 0.83 for VGG16 and 0.91 for Xception. For the test set, the specificity and sensitivity were 0.93 and 0.84 for DenseNet, 0.89 and 0.84 for Xception, and 0.70 and 0.80 for VGG16, respectively.

CONCLUSION

The application of DL algorithms to intraoperative arthroscopic images has demonstrated a high level of accuracy in predicting retear occurrences.

Preoperative factors affecting the quality of life after arthroscopic rotator cuff repair: a prospective study

Background

Rotator cuff tears are well known to cause significant pain and disability, having a marked impact on an individual's quality of life. This prospective study aimed to analyze the various patient factors and their impact on health-related quality of life (HrQoL) post arthroscopic rotator cuff repair (RCR).

Material and Methods

We prospectively analyzed 95 patients at one year and 81 patients at two years, with complete rotator cuff tear, who underwent arthroscopic repair of the same. The 36-Item Short Form Survey (physical and mental component score), visual analog scale (pain, function), and QuickDASH questionnaires were administered to all the patients preoperatively and at one- and two-year follow-ups. Relationships between various patient factors (age, gender, side, duration of symptoms, pseudoparalysis, diabetes mellitus [DM], type, and size of tear) and outcome measures were analyzed.

Results

All outcome parameters showed significant improvement at one- and two-year follow-ups. Patient factors, such as gender, tear type (traumatic vs degenerative), and DM, affected all outcome parameters and were significant even in the regression analysis model at a 2-year follow-up. Factors such as age and symptoms duration were significant only at 1-year follow-up, with older age and patients with symptoms > 6 weeks showing more disability. Side (dominant or nondominant), tear size, and pseudoparalysis do not affect outcomes.

Conclusions

This study showed that arthroscopic RCR significantly improved HrQoL post arthroscopic RCRs. Factors independently affecting HrQoL were noted as gender, tear type, and DM. On the other hand, age, side involved, duration of symptoms, pseudoparalysis, and tear size had no independent effect on HrQoL at a two-year follow-up.

"Double Row Rip-Stop" Arthroscopic Repair Technique for Acute, Retracted Rotator Cuff Tears

Acute, retracted rotator cuff tendon tears are important to recognize and can present unique technical challenges to repair. Various arthroscopic techniques and suture configurations have been proposed for repair of acute tears with aims to maximize the repair footprint and optimize tendon fixation. The double row rip-stop configuration was designed and has been used for rotator cuff repair due to its potential advantages related to suture pullout, footprint reapproximation and load sharing. The purpose of this article is to present the author's arthroscopic technique for repair of acute, retracted rotator cuff tendon tears using a double-row, rip-stop suture configuration. The indications and authors' preferred arthroscopic technique for biceps tenodesis are also discussed.

Biomodulating healing after arthroscopic rotator cuff repair: the protocol of a randomised proof of concept trial (BIOHACK)

PURPOSE/INTRODUCTION

Over the last decades, there has been increasing interest in biological stimulation or bioaugmentation after rotator cuff repair. So far, there is no consensus on the appropriate composition of biologicals or which patients would benefit most, and moreover, these biologicals are often expensive. However, there are other, non-pharmacological strategies that are also believed to achieve biological stimulation. This randomised controlled trial evaluates the possible cumulative effect of pragmatic application of cryobiomodulation, photobiomodulation and electrobiomodulation-collectively called biomodulation-on the bone-to-tendon healing process after rotator cuff repair.

METHODS

In this randomised, controlled proof of concept study, 146 patients undergoing arthroscopic repair of a full thickness posterosuperior or anterosuperior rotator cuff tear will be 1:1 randomly assigned to either a control group or to the additional biomodulation protocol group. The adjuvant biomodulation protocol consists of seven self-applicable therapies and will be administered during the first 6 weeks after surgery. Primary outcome will be healing of the rotator cuff as evaluated by the Sugaya classification on MRI at 1-year postoperatively.

ETHICS AND DISSEMINATION

This study has been accepted by the National Ethical Review Board CPP Sud-Est IV in France and has been registered at Clinicaltrials.gov. The results of this study will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04618484.

Arthroscopic Treatment of Shoulder Stiffness With Rotator Cuff Repair Yields Similar Outcomes to Isolated Rotator Cuff Repair

Purpose

To compare patient-reported and surgical outcome measures in patients with and without secondary shoulder stiffness (SSS) undergoing rotator cuff repair (RCR).

Methods

Patients undergoing rotator cuff repair from 2014 to 2020 with complete patient-reported outcome measures (PROMs) by the short-form 12 survey (SF-12) were retrospectively reviewed to identify if operative intervention for SSS was performed alongside the RCR. Those patients with operative intervention for SSS were propensity matched to a group without prior intervention for stiffness by age, sex, laterality, body mass index, diabetes mellitus status, and the presence of a thyroid disorder. The groups were compared by rotator cuff tear (RCT) size, surgical outcomes, further surgical intervention, rotator cuff retear rate, postoperative range of motion (ROM), and SF-12 results at 1 year after surgery. Delta values were calculated for component scores of the SF-12 and ROM values by subtracting the preoperative result from the postoperative result.

Results

A total of 89 patients with SSS were compared to 156 patients in the control group at final analysis. The patients in the SSS group experienced a significant improvement in the delta mental health component score (MCS-12) of the SF-12 survey that was not seen in the control group (P = .005 to P = .539). Both groups experienced significant improvement by the delta physical health component score (PCS-12) of the SF-12 survey (SSS: 7.68; P < .001; control: 6.95; P < .001). The SSS group also experienced greater improvement of their forward flexion (25.8° vs 12.9°; P = .005) and external rotation (7.13° vs 1.65°; P = .031) ROM than the control group.

Conclusions

Operative intervention of SSS at the time of RCR has equivalent postoperative SF-12 survey outcome scores when compared to patients undergoing RCR without preoperative stiffness despite those patients having lower preoperative scores.

Level of Evidence

Level III retrospective comparative study.

Comparison of Arthroscopic Single-row and Double-row Repair for Rotator Cuff Injuries With Different Tear Sizes: A Systematic Review and Meta-analysis

Background

There is no clinical gold standard for the indications for single-row (SR) versus double-row (DR) repair according to small, large, or massive rotator cuff tear size.

Purpose

To conduct a meta-analysis to compare the clinical outcomes and retear rates after arthroscopic SR and DR repair for rotator cuff injuries with different tear sizes.

Study Design

Systematic review; Level of evidence, 3.

Methods

On the basis of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria, the PubMed, Embase, Cochrane Library databases, Web of Science, China National Knowledge Infrastructure, and China BioMedical Literature database were searched for relevant studies published before November 1, 2021, using the following search terms: "Rotator Cuff Injuries," "Rotator Cuff Tears," "Arthroscopy," "Arthroscopic Surgery," "single-row," and "double-row"; a total of 489 articles were retrieved. Quality evaluation was conducted for all the studies that met the inclusion criteria. This study evaluated the Constant-Murley score, American Shoulder and Elbow Surgeons (ASES) score, University of California, Los Angeles (UCLA) score, and range of motion (ROM) as well as retear rate. A fixed-effects or random-effects model was adopted to calculate the results and assess risk.

Results

A total of 10 clinical studies were included, with 404 cases of DR and 387 cases of SR. Regarding overall results, DR had better forward elevation ROM (mean difference [MD] = -4.03° [95% CI, -6.00° to -2.06°]; P < .0001; I 2 = 46%) and a lower retear rate (MD = 2.39 [95% CI, 1.40 to 4.08]; P = .001; I 2 = 0%) compared with SR repair. With regard to small tears (<3 cm), there was no noticeable difference on any of the 3 outcome scores between SR and DR. For large rotator cuff tears (≥3 cm), DR repair showed significantly better ASES scores (MD = -3.09 [95% CI, -6.19 to 0.02]; P = .05; I 2 = 73%) and UCLA scores (MD = -1.47 [95% CI, -2.21 to -0.72]; P = .0001; I 2 = 31%) compared with SR repair.

Conclusion

Our meta-analysis revealed that DR had better UCLA scores, ASES scores, and ROM in forward elevation and lower retear rates. In rotator cuff tears <3 cm, there were no statistical differences in clinical outcome between SR and DR.

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

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

Risk Factors for Rotator Cuff Repair Failure and Reliability of the Rotator Cuff Healing Index (RoHI) in Thai Patients: Comparison of the RoHI With a Modified Scoring System

Background

The success rate of surgical treatment for rotator cuff (RC) tear ranges from 16% to 94%. The Rotator Cuff Healing Index (RoHI) is a system for predicting failure after RC repair and is based on a combined score of factors, including age, anteroposterior (AP) tear size, tendon retraction, fatty infiltration of the infraspinatus muscle, bone mineral density (BMD), and level of work activity.

Purpose

To determine the factors leading to RC repair failure in a Thai population, to test the reliability of the RoHI in this population, and to compare the RoHI with a modified RoHI (m-RoHI) based on the factors for repair failure as determined.

Study Design

Case-control study; Level of evidence, 3.

Methods

This study included 133 Thai patients who underwent arthroscopic RC repair between February 2012 and February 2021. Postoperative magnetic resonance imaging was performed at 6 to 24 months to evaluate RC healing. Variables that might affect failure rates were evaluated, including demographic characteristics, AP tear size and retraction, radiographic measurements, and magnetic resonance imaging findings. The m-RoHI was created using factors that significantly predicted repair failure on multivariate analysis. The area under the receiver operating characteristic curve was calculated to determine the reliability of the RoHI and to compare the reliability of the RoHI and m-RoHI to predict failure rates.

Results

Multivariate logistic regression analysis revealed that body mass index ≥23 (adjusted odds ratio [OR], 9.02; P = .034), high work activity (adjusted OR, 19.53; P = .008), AP tear size ≥2.5 cm (adjusted OR, 19.04; P = .001), and a retraction size of 2 to <3 cm (adjusted OR, 20.36; P = .013) were the independent factors that predicted repair failure in our population. BMD was not independently predictive of repair failure. We used these 4 significant independent factors to generate the m-RoHI. The area under the curve of the final adjusted m-RoHI was slightly improved as compared with the original RoHI, but this difference was not significant (0.827 [95% CI, 0.741-0.913] vs 0.780 [95% CI, 0.686-0.875], respectively; P = .447).

Conclusion

The m-RoHI had a similar predictive value for repair failure to the original RoHI in our study population, but it did not require obtaining BMD. The m-RoHI may be useful in populations where BMD is not routinely obtained.

High Acromial Slope and Low Acromiohumeral Distance Increase the Risk of Retear of the Supraspinatus Tendon After Repair

BACKGROUND

Retearing of the supraspinatus (SSP) tendon after repair is relatively common, but its cause is rarely clear. Although the role of acromion morphology and glenoid orientation in the pathogenesis of primary SSP tendon tears have frequently been analyzed, their association with the risk of rerupture of a repaired SSP tendon is poorly understood.

QUESTIONS/PURPOSES

(1) Is acromial morphology associated with the risk of retear after SSP tendon repair? (2) Is there an association between inclination and version of the glenoid and the odds for retear of the SSP tendon after repair? (3) Are there differences in outcome scores between patients who had intact cuff repairs and those who had retears?

METHODS

Between August 2012 and December 2015, we treated 92 patients for SSP tendon tears; all of these patients were considered for inclusion in the present study. We considered patients with complete tear of the SSP that was reconstructed with a double-row repair and a minimum follow-up of 2 years as potentially eligible. Based on these criteria, 28% (26 of 92) were excluded because they had a partial rupture and did not receive a double-row reconstruction. A further 9% (eight of 92) were excluded because of missing planes or slices (such as sagittal, axial, or frontal) on MRI, and another 3% (three of 92) were lost before the minimum study follow-up interval or had incomplete datasets, leaving 60% (55 of 92) for inclusion in the present analysis. All included patients had a minimum follow-up of 2 years; follow-up with MRI occurred at a mean duration of 2.3 ± 0.4 years postoperatively. All patients were asked to complete the Western Ontario Rotator Cuff Index and Oxford Shoulder Scores, and they underwent MRI of the operated-on shoulder. Preoperative true AP radiographs and MR images of the affected shoulders were retrospectively assessed by measuring the acromiohumeral interval, critical shoulder angle, acromial slope, acromial tilt, acromial index, lateral acromial angle, and glenoid version and inclination. The patients also underwent acromioplasty, in which the underface of the acromion was flattened. To rule out any change in the above parameters because of acromioplasty, these parameters were compared using preoperative and postoperative MR images and showed no difference. In addition, the tendon integrity and quality on postoperative MRI were analyzed independently of one another by the same two observers using the Sugaya and Castricini classifications, accounting for atrophy and fatty degeneration of the SSP muscle. To assess interobserver reliability, the two observers took measurements independently from each other. They were orthopaedic residents who completed a training session before taking the measurements. All measurements had excellent intrarater (Cronbach alpha 0.996 [95% confidence interval (CI) 0.99 to 1.00; p > 0.01) and interrater (interrater correlation coefficient 0.975 [95% CI 0.97 to 0.98]; p > 0.01) reliabilities. To answer the study's first question, SSP integrity on postoperative MRI was compared with acromial morphologic parameters measured on preoperative AP radiographs and MR images. To answer the second question, the postoperative integrity and quality of the SSP tendon were correlated with glenoid inclination and glenoid version. To answer our third question, we compared outcome scores between patients with intact SSP tendons and those with reruptured SSP tendons. To investigate any correlation among the acromial morphology, glenoid orientation, and postoperative outcomes, a binomial logarithmic regression analysis was performed. Receiver operating characteristic curves were used to determine cutoff points for the radiologic parameters that showed a correlation in the binomial regression analysis.

RESULTS

After controlling for potentially confounding variables such as acromioplasty or preoperative fatty infiltration as well as muscle atrophy, the only morphological parameters associated with a higher risk (adjusted odds ratio) of SSP tendon rerupture were the acromiohumeral interval (adjusted OR 0.9 [95% CI 0.9 to 0.99]; p < 0.01) and acromial slope (adjusted OR 1.4 [95% CI 1.1 to 1.8]; p < 0.01). The critical shoulder angle, acromial tilt, acromial index, and lateral acromial angle were not associated with the risk of rerupture. The cutoff values for acromial slope and acromiohumeral interval were 24.5° and 7.4 mm, respectively. Patients with an acromiohumeral interval smaller than 7.4 mm or an acromial slope greater than 24.5° had higher odds (acromiohumeral interval: OR 11 [95% CI 2 to 46]; p = 0.01 and acromial slope: OR 9 [95% CI 2 to 46]; p = 0.04) for rerupture of the SSP. No difference was found between patients with intact SSP tendons and those with reruptured SSP tendons in terms of glenoid inclination (6° ± 4° versus 6° ± 3°, mean difference 0.8° [-1° to 3°]; p < 0.48) and glenoid version (-2° ± 3° versus -3° ± 3°, mean difference 1° [-1° to 3°]; p < 0.30). No difference was found between the intact and reruptured SSP groups regarding clinical outcomes (Western Ontario Rotator Cuff Index: 98 ± 2 versus 97 ± 3, mean difference 0.73 [95% CI -0.30 to 0.31]; p = 0.96; Oxford Shoulder Score: 26 ± 13 versus 23 ± 10, mean difference 2.80 [95% CI -4.12 to 9.72]; p = 0.41).

CONCLUSION

The preoperative acromiohumeral interval and acromial slope are associated with SSP tendon rerupture after repair. Conversely, the critical shoulder angle, acromial tilt, lateral acromial angle, and acromial index had no association with the postoperative outcome. Additionally, glenoid inclination and version were not associated with the rerupture rate after SSP tendon repair. A detailed analysis of the acromiohumeral interval and acromial slope is recommended in clinical practice in patients undergoing SSP tendon repair. Surgeons should consider measuring the acromiohumeral interval and acromial slope preoperatively when performing SSP repair, especially in the context of planned acromioplasties. Future studies should investigate the role of acromioplasty during SSP repair in patients with a pathologic acromial slope and acromiohumeral interval. In this context, it should be determined whether a more-radical acromioplasty could reduce the risk of rerupture of the SSP in these patients.

LEVEL OF EVIDENCE

Level III, therapeutic study.

A comparison between knotted and knotless medial row of suture bridge technique in arthroscopic rotator cuff repair surgery: a meta-analysis

BACKGROUND

The shoulder arthroscopic suture bridge technique is currently very popular, but scientific evidence relating to the clinical outcomes of the medial row with or without knots has not been systematic reviewed.

PURPOSE

The purpose of this study was to compare the clinical outcomes of knotted versus knotless double-row suture bridges for rotator cuff repairs.

STUDY DESIGN

Meta-analysis.

METHOD

Five databases that contain literature in English were searched (Medline, PubMed, Embase, Web of Science, and the Cochrane Library), with a focus on works published between 2011 and 2022. Clinical data relating to arthroscopic rotator cuff repair with the suture bridge approach was examined and the outcomes of medial row knotting contrasted with that of the knotless technique. The search phrase used was: (double row) AND (rotator cuff) AND (repair), and the search method is subject term plus free word search. Literature quality evaluation was performed using the Cochrane "risk of bias" tool 1.0 and the Newcastle-Ottawa scale quality assessment instrument.

RESULTS

One randomized controlled trial, four prospective cohort studies, and five retrospective cohort studies were included in this meta-analysis. Data pertaining to 1146 patients was drawn from these ten original papers and analyzed. Meta-analyses that were performed on 11 postoperative outcomes revealed that none of the differences were statistically significant (P > 0.05) and that the publications were unbiased (P > 0.05). Postoperative retear rate and postoperative retear categorization were the outcomes assessed. Scores on postoperative pain, forward flexion, abduction, and external rotation mobility were collated and evaluated. The University of California, Los Angeles scoring systems in the first year following surgery, the American Shoulder and Elbow Surgeons score and Constant scales in the first and second years after surgery were the secondary outcomes spotlighted in this study.

CONCLUSION

The clinical outcomes of shoulder arthroscopic rotator cuff repair with the suture bridge technique with or without a knotted medial row was proven to be equivalent. These outcomes are about postoperative retear, postoperative retear classification, postoperative shoulder function score, postoperative shoulder mobility, and postoperative pain, respectively. It should be noted that the conclusions are based on short-term clinical follow-up data.

Factors Affecting Postoperative Rehabilitation Therapy Utilization After Arthroscopic Rotator Cuff Repair: An Epidemiological Analysis

Background and objective Rotator cuff tear (RCT) is an orthopedic shoulder pathology commonly managed via arthroscopic rotator cuff repair (ARCR) after the failure of conservative treatment options. Physical therapy (PT) after ARCR is an important component of patient recovery. Postoperative complications, such as postoperative shoulder stiffness (POSS), are frequent among these patients and place a significant burden on patients and clinicians. The purpose of this study is to analyze temporal PT utilization among patients after ARCR and its potential to improve patient outcomes and examine possible factors affecting postoperative complication rates. Methods An epidemiological study was performed by using a large de-identified national health research network (TriNetX) within the United States to search for patients with a diagnosis of partial or complete RCT and subsequent ARCR. Data were collected on patient demographics, number of postoperative PT visits, and PT visits distribution in the early postoperative period. Statistical analysis was performed to analyze factors that impacted the utilization of postoperative PT after ARCR. Results A total of 21,540 patients underwent ARCR with 11,312 receiving ARCR for partial RCT and 10,228 for complete RCT. Of all ARCR patients, 6,923 (32.1%) received postoperative PT within one year of ARCR. Patients with partial RCT had a greater number of PT visits (mean ±SD: 3.85 ± 8.33; min-max: 0-110; t = 15.2) compared to patients with complete RCT (2.90 ± 7.97; min-max: 0-125) after ARCR (p<0.001). Patients with ARCR for partial RCT also had more visits within the first 12 weeks after ARCR as compared to patients with ARCR for complete RCT (p<0.001). Female patients had more visits than male patients after ARCR, regardless of the RCT extent (p<0.001). Conclusion Partial RCT and female sex are associated with increased postoperative PT usage after ARCR. Postoperative PT utilization has high variability after ARCR, regardless of the RCT extent. More research is needed to further explore the impact of PT utilization on postoperative complications after ARCR.

A shallow morphology of the intertubercular groove is associated with medial and bilateral but not lateral pulley lesions

PURPOSE

To investigate the influence of intertubercular groove (IG) morphology on the development of different types of biceps reflection pulley (BRP) injuries.

METHODS

A consecutive cohort of 221 patients with ventral shoulder pain and a preoperative diagnosis suspecting BRP injury, who underwent arthroscopy, was retrospectively reviewed. The presence or absence as well as type of pulley injury (medial, lateral or bilateral) was confirmed arthroscopically. The intertubercular groove was evaluated on MRIs after triplanar reconstruction of the axial plane. IG depth, width, medial wall angle (MWA), lateral wall angle (LWA) and total opening angle (TOA) were measured. IG depth and width were expressed in relation to the humeral head diameter. Measurements were performed by two clinicians independently and averaged.

RESULTS

Of 166 included patients 43 had bilateral, 65 medial and 38 lateral BRP lesions. 20 patients had intact BRPs and represented the control group. The intra-class correlation coefficient of measurements was 0.843-0.955. Patients with a medial or bilateral BRP injury had a flatter MWA (38.8° or 40.0° vs. 47.9°, p < 0.001), wider TOA (96.1° or 96.6° vs. 82.6°, p < 0.001), greater width (12.5 or 12.3 vs. 10.8 mm, p = 0.013) and shallower depth (5.5 or 5.4 vs. 6.2 mm, p < 0.001) than the control group. Conversely, the IG morphology of those with lateral BRP injuries did not differ significantly from the control group. The odds ratio for a medial or bilateral BRP injury when the TOA exceeded 95° was 6.8 (95% confidence interval 3.04-15.2).

CONCLUSION

A dysplastic type of IG morphology with a wide TOA, flat MWA, decreased depth and increased width is associated with the presence of medial and bilateral BRP injuries. A TOA of > 95° increases the likelihood of a medial or bilateral BRP injury 6.8-fold. Lateral BRP injuries are not associated with dysplastic IG morphology. Concomitant LHBT surgery may, therefore, not always be necessary during isolated supraspinatus tendon repair.

LEVEL OF EVIDENCE

Level III.

Developing a machine learning algorithm to predict probability of retear and functional outcomes in patients undergoing rotator cuff repair surgery: protocol for a retrospective, multicentre study

INTRODUCTION

The effectiveness of rotator cuff tear repair surgery is influenced by multiple patient-related, pathology-centred and technical factors, which is thought to contribute to the reported retear rates between 17% and 94%. Adequate patient selection is thought to be essential in reaching satisfactory results. However, no clear consensus has been reached on which factors are most predictive of successful surgery. A clinical decision tool that encompassed all aspects is still to be made. Artificial intelligence (AI) and machine learning algorithms use complex self-learning models that can be used to make patient-specific decision-making tools. The aim of this study is to develop and train an algorithm that can be used as an online available clinical prediction tool, to predict the risk of retear in patients undergoing rotator cuff repair.

METHODS AND ANALYSIS

This is a retrospective, multicentre, cohort study using pooled individual patient data from multiple studies of patients who have undergone rotator cuff repair and were evaluated by advanced imaging for healing at a minimum of 6 months after surgery. This study consists of two parts. Part one: collecting all potential factors that might influence retear risks from retrospective multicentre data, aiming to include more than 1000 patients worldwide. Part two: combining all influencing factors into a model that can clinically be used as a prediction tool using machine learning.

ETHICS AND DISSEMINATION

For safe multicentre data exchange and analysis, our Machine Learning Consortium adheres to the WHO regulation 'Policy on Use and Sharing of Data Collected by WHO in Member States Outside the Context of Public Health Emergencies'. The study results will be disseminated through publication in a peer-reviewed journal. Institutional Review Board approval does not apply to the current study protocol.