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Stern BZ, Zubizarreta N, Anthony SG, Poeran J, Gladstone JN. Association between timing of initiating supervised physical rehabilitation after rotator cuff repair and incidence of repeat repair and capsulitis: a population-based analysis. J Shoulder Elbow Surg 2024; 33:1747-1754. [PMID: 38378128 DOI: 10.1016/j.jse.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 12/21/2023] [Accepted: 01/01/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND There is limited consensus on the optimal time to initiate supervised physical rehabilitation after a rotator cuff repair (RCR). We examined whether timing of initiating supervised physical rehabilitation was associated with repeat RCR or development of adhesive capsulitis within 12 months postoperatively in an observational cohort of commercially insured adults. METHODS This retrospective cohort study used the IBM MarketScan Commercial Claims and Encounters Database. We included adults aged 18-64 who underwent a unilateral outpatient RCR between 2017 and 2020 and initiated supervised physical rehabilitation 1-90 days postoperatively. Multivariable logistic regression models examined the adjusted association between time of initiating supervised physical rehabilitation (1-13, 14-27, 28-41, and 42-90 days postoperatively) and each of the primary outcomes: repeat RCR and capsulitis. In a sensitivity analysis, time to rehabilitation was alternatively categorized using a data-driven approach of quartiles (1-7, 8-16, 17-30, and 31-90 days postoperatively). We report adjusted odds ratios (OR). RESULTS Among 33,841 patients (86.7% arthroscopic index RCR), the median time between index RCR and rehabilitation initiation was 16 days (interquartile range 7-30), with 39.9% initiating rehabilitation at 1-13 days. Additionally, 2.2% underwent repeat RCR within 12 months, and 12-month capsulitis was identified in 1.9% of patients. There were no significant associations between timing of initiating rehabilitation and 12-month repeat RCR (OR 0.85-0.93, P = .18-.49) or 12-month capsulitis (OR 0.83-0.94, P = .22-.63). Lack of associations between timing and outcomes was supported in sensitivity analyses. CONCLUSIONS Timing of initiating rehabilitation was not significantly associated with adverse outcomes after RCR. The finding of no increased odds of repeat RCR or capsulitis with the earliest timing may support earlier initiation of rehabilitation to accelerate return to daily activities. Findings should be replicated in another dataset of similarly-aged patients.
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Affiliation(s)
- Brocha Z Stern
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Nicole Zubizarreta
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shawn G Anthony
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jashvant Poeran
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James N Gladstone
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Darbandi A, Credille K, Darbandi A, Hevesi M, Dandu N, Bodendorfer BM, Wang Z, Garrigues G, Verma N, Yanke A. Fatty Infiltration, Tear Size, and Retraction Size Are Significant Risk Factors for Retear following Arthroscopic Rotator Cuff Repair: A Systematic Review. Arthroscopy 2024:S0749-8063(24)00488-2. [PMID: 38986851 DOI: 10.1016/j.arthro.2024.06.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/11/2024] [Accepted: 06/19/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE To assess the consistency and quality of risk factor reporting for rotator cuff repair (RCR) retear and identify risk factors most frequently associated with retear. METHODS A systematic review with PRISMA guidelines was performed. Of the initial 3,158 titles, a total of 31 studies met the following inclusion criteria: (1) clinical studies regarding RCR failure, (2) arthroscopic procedures involving RCR, (3) reporting clinical outcomes (4) performed within 5 years (5) and studies investigating pre-operative risk factors for retear. After full-text review, 18 risk factors were analyzed. RESULTS The most consistently significant risk factors were acromiohumeral distance (AHD) (80%), critical shoulder angle (CSA) (67%), tear size (63%), anterior/posterior (AP) dimension (60%), fatty infiltration (FI, 58%), and retraction size (56%). FI was analyzed using different methods between studies with 63% finding significant results and 50% of all studies performing ordinal analysis. Tear size was inconsistently analyzed quantitatively or qualitatively, with 58% finding significant results and 63% of all studies analyzing quantitatively. Risk factors consistently found to be non-significant included age, sex, diabetes mellitus (DM), symptom duration, hand dominance, repair technique, smoking and body mass index (BMI). CONCLUSIONS Tear size, fatty infiltration, and retraction size were found to be significant risk factors in the majority of included studies evaluating rotator cuff retear. Risk factors less likely reported as predictive included repair technique, age, sex, DM, symptom duration, hand dominance, repair technique, smoking, and BMI. Risk factors that require further investigation include CSA, AHD, and AP tear dimension. Level III, systematic review of Level III-V studies.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Adam Yanke
- Midwest Orthopedics at Rush, Chicago, IL.
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Lee J, Lho T, Lee J, Lee J, Chung SW. Influence of Frequent Corticosteroid Local Injections on the Expression of Genes and Proteins Related to Fatty Infiltration, Muscle Atrophy, Inflammation, and Fibrosis in Patients With Chronic Rotator Cuff Tears: A Pilot Study. Orthop J Sports Med 2024; 12:23259671241252421. [PMID: 38840789 PMCID: PMC11151761 DOI: 10.1177/23259671241252421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/09/2023] [Indexed: 06/07/2024] Open
Abstract
Background The effect of local corticosteroid (CS) injections on rotator cuff muscles remains poorly defined, despite the significance of muscle quality as a crucial prognostic factor for patients with rotator cuff tears (RCTs). Purpose To compare alterations in gene and protein expression patterns in the rotator cuff muscles of patients with RCTs who received frequent joint CS injections with alterations in those without a history of CS injections. Study Design Controlled laboratory study. Methods A total of 24 rotator cuff muscle samples with medium-sized tears from 12 patients with a frequent joint CS injection history (steroid group; 7 men and 5 women who had received ≥5 injections with at least 1 within the previous 3 months; mean age, 63.0 ± 7.2 years) and 12 age- and sex-matched control patients without a history of CS injections (no-steroid group) were acquired. Alterations in the expression of genes and proteins associated with adipogenesis, myogenesis, inflammation, and muscle fibrosis were compared between the groups using quantitative reverse transcription-polymerase chain reaction, Western blotting, and immunohistochemistry. Statistical analysis included comparison of group means using the Mann-Whitney U test, chi-square test, or Fisher exact test and logistic regression for multivariate analysis. Results In the steroid group, the mRNA expression levels of adipogenic CCAAT/enhancer-binding protein alpha (C/EBPα; P = .008) and muscle atrophy-related genes (atrogin; P = .019) were significantly higher, and those of myogenic differentiation 1 (MyoD; P = .035), inflammatory interleukin 6 (IL-6; P = .035), and high mobility group box 1 (P = .003) were significantly lower compared with the no-steroid group. In addition, MyoD (P = .041) and IL-6 (P = .026) expression were decreased in the steroid versus no-steroid group. Immunohistochemistry revealed increased expression of C/EBPα and atrogin and decreased expression of MyoD and IL-6 in the steroid versus no-steroid group. Conclusion Patients with RCTs and a history of frequent CS injections exhibited an upregulation of adipogenic and muscle atrophy-related genes and proteins within the rotator cuff muscles and a downregulation in the expression of myogenic and inflammatory genes and proteins in the same muscles. Clinical Relevance These altered gene and protein expressions by frequent local CS injections may cause poor outcomes in patients with RCTs.
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Affiliation(s)
- JiHwan Lee
- Department of Medicine, Korea University Graduate School, Seoul, Republic of Korea
| | - Taewoo Lho
- Department of Orthopaedic Surgery, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Jongwon Lee
- Department of Orthopaedic Surgery, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Jeongkun Lee
- Department of Orthopaedic Surgery, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Seok Won Chung
- Department of Orthopaedic Surgery, Konkuk University School of Medicine, Seoul, Republic of Korea
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Mlawer SJ, Frank EH, Connizzo BK. Aged tendons lack adaptive response to acute compressive injury. J Orthop Res 2024; 42:973-984. [PMID: 38041209 PMCID: PMC11009076 DOI: 10.1002/jor.25752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/24/2023] [Accepted: 11/29/2023] [Indexed: 12/03/2023]
Abstract
Rotator cuff tendinopathy has a multifactorial etiology, with both aging and external compression found to influence disease progression. However, tendon's response to these factors is still poorly understood and in vivo animal models make it difficult to decouple these effects. Therefore, we developed an explant culture model that allows us to directly apply compression to tendons and then observe their biological responses. Using this model, we applied a single acute compressive injury to C57BL/6J flexor digitorum longus tendon explants and observed changes in viability, metabolic activity, matrix composition, matrix biosynthesis, matrix structure, gene expression, and mechanical properties. We hypothesized that a single acute compressive load would result in an injury response in tendon and that this effect would be amplified in aged tendons. We found that young tendons had increased matrix turnover with a decrease in small leucine-rich proteoglycans, increase in compression-resistant proteoglycan aggrecan, increase in collagen synthesis, and an upregulation of collagen-degrading MMP-9. Aged tendons lacked any of these adaptive responses and instead had decreased metabolic activity and collagen synthesis. This implies that aged tendons lack the adaptation mechanisms required to return to homeostasis, and therefore are at greater risk for compression-induced injury. Overall, we present a novel compressive injury model that demonstrates lasting age-dependent changes and has the potential to examine the long-term response of tendon to a variety of compressive loading conditions.
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Affiliation(s)
- Samuel J. Mlawer
- Department of Biomedical Engineering, Boston University, Boston, MA, 02215, United States
| | - Eliot H. Frank
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, United States
| | - Brianne K. Connizzo
- Department of Biomedical Engineering, Boston University, Boston, MA, 02215, United States
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Dean RS, Waterman BR. Editorial Commentary: Postoperative Zoledronic Acid Improves Tendon Healing but Does Not Affect Outcomes in Rotator Cuff Repair Patients With Postmenopausal Osteoporosis. Arthroscopy 2024; 40:723-725. [PMID: 38219090 DOI: 10.1016/j.arthro.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 11/17/2023] [Indexed: 01/15/2024]
Abstract
Understanding the preoperative risk factors for successful rotator cuff repair (RCR) and ways to optimize these factors is an evolving area of study. The Rotator Cuff Healing Index and other proxy risk factors for failed rotator cuff healing have implicated significant fatty infiltration, muscular atrophy, advanced chronological age, tear size and retraction, and ultimately, osteoporosis. Although structural (or biological) augmentation and tendon transfer have been proposed as solutions for the alarmingly high rate of failure after primary RCR, other options may preferentially focus on the enthesis and underlying osseous footprint. Currently, bisphosphonates are frequently used in the treatment of osteoporosis and prevention of fragility fractures. However, burgeoning evidence suggests that postoperative zoledronic acid may have clinical utility after rotator cuff and other tendon repairs. In the cost-conscious world of evidence-based medicine, the added economic burden of additional medications and office visits may or may not improve patient outcomes-much less confer added value. Our advice to fellow shoulder surgeons: Wait for further information, but continue to holistically consider and optimize risk factors for poor soft-tissue healing. Although the addition of postoperative bisphosphonates may improve suture anchor fixation and promote a better foundation for healing, it will not immediately transform your RCR success rates.
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Fairley JA, Pollock JW, McIlquham K, Lapner P. Bone channeling in arthroscopic rotator cuff repair: a systematic review and meta-analysis of level I studies. J Shoulder Elbow Surg 2024; 33:210-222. [PMID: 37757905 DOI: 10.1016/j.jse.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/08/2023] [Accepted: 08/15/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND There is ongoing controversy regarding the effect of bone channeling in arthroscopic rotator cuff repair. Since the most recent systematic reviews in 2019, several large high-level trials have been completed. This study assessed all available level I randomized controlled trials (RCTs) that compared arthroscopic rotator cuff repair with and without bone marrow channeling. METHODS A systematic search of the Ovid MEDLINE, Embase, and Cochrane Library databases was conducted through mid January 2023. Two reviewers performed screening of studies meeting the eligibility criteria: English-language RCTs in patients aged ≥18 years comparing arthroscopic rotator cuff repair of full-thickness tears with and without bone marrow channeling (channeling group and control group, respectively). Functional scores, pain, healing rates, and reoperations were reviewed using pooled analysis where appropriate. The methodologic quality of included studies was assessed using the Cochrane risk-of-bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS A total of 6 randomized studies (N = 593) met the inclusion criteria. Pooled analysis of all 6 studies showed no significant mean difference in function (1.32; 95% confidence interval [CI], -0.63 to 3.26), as measured by the Constant-Murley score. Retear rates were also not statistically different between groups (risk ratio, 0.99; 95% CI, 0.57 to 1.71), with pooled retear rates of 19.6% (48 of 245) with channeling and 19.8% (51 of 257) without. The other outcomes of interest were only available for analysis in a subset of studies. There were no standardized mean differences in pain (0.09; 95% CI, -0.18 to 0.36), and there were similar reoperation rates (risk ratio, 1.19; 95% CI, 0.43 to 3.34) in the channeling and control groups. For the included studies, the overall quality of evidence by outcome was judged to be moderate (function, pain, and reoperations) or low (retear rates), mainly owing to risk of bias (all outcomes) and inconsistency (retear rates). CONCLUSION The results of this study refute the findings of prior systematic reviews that showed that channeling reduces the retear rate when combined with arthroscopic rotator cuff repair. This meta-analysis of level I evidence, including recent larger RCTs, demonstrates that bone marrow stimulation in the setting of primary arthroscopic rotator cuff repair has no significant effect on functional outcomes, healing, pain, or reoperation rates.
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Affiliation(s)
- Jillian A Fairley
- Division of Orthopaedic Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - J W Pollock
- Division of Orthopaedic Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Katie McIlquham
- Division of Orthopaedic Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Peter Lapner
- Division of Orthopaedic Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
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Patel D, Roy G, Endres N, Ziino C. Preoperative vitamin D supplementation is a cost-effective intervention in arthroscopic rotator cuff repair. J Shoulder Elbow Surg 2023; 32:2473-2482. [PMID: 37308074 DOI: 10.1016/j.jse.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/16/2023] [Accepted: 05/06/2023] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- Dhiraj Patel
- Department of Orthopedic Surgery, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Gregory Roy
- Department of Orthopedic Surgery, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Nathan Endres
- Department of Orthopedic Surgery, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Chason Ziino
- Department of Orthopedic Surgery, University of Vermont Larner College of Medicine, Burlington, VT, USA.
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Ock J, Seo J, Koh KH, Kim N. Comparing the biomechanical properties of conventional suture and all-suture anchors using patient-specific and realistic osteoporotic and non-osteoporotic phantom using 3D printing. Sci Rep 2023; 13:20976. [PMID: 38017064 PMCID: PMC10684536 DOI: 10.1038/s41598-023-48392-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 11/26/2023] [Indexed: 11/30/2023] Open
Abstract
Conventional suture anchors (CAs) and all-suture anchors (ASAs) are used for rotator cuff repair. Pull-out strength (POS) is an important factor that affects surgical outcomes. While the fixation mechanism differs between the anchor types and relies on the quality, few studies have compared biomechanical properties of anchors based on bone quality. This study aimed to compare the biomechanical properties of anchors using osteoporotic bone (OB) and non-osteoporotic bone (NOB) simulators. Humerus simulators were fabricated using fused deposition modeling of 3D printing and acrylonitrile butadiene styrene adjusting the thickness of cortical bone and density of cancellous bone based on CT images. Cyclic loading from 10 to 50 N, 10 to 100 N, and 10 to 150 N for 10 cycles was clinically determined at each anchor because the supraspinatus generates a force of 67-125 N in daily activities of normal control. After cyclic loading, the anchor was extruded at a load of 5 mm/min. Displacement, POS, and stiffness were measured. In OB simulators, CAs revealed bigger gap displacement than ASAs with cyclic loading of 10-150 N. ASA showed higher values for POS and stiffness. In NOB simulators, ASAs revealed bigger gap displacement than CAs with cyclic loading of 10-150 N. ASA showed higher values for POS and CA showed higher values for stiffness. POS of anchors depends on anchors 'displacement and bone stiffness. In conclusion, ASA demonstrated better biomechanical performance than CA in terms of stability under cyclic loading and stiffness with similar POS in OB.
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Affiliation(s)
- Junhyeok Ock
- Department of Biomedical Engineering, Asan Medical Center, Asan Medical Institute of Convergence Science and Technology, University of Ulsan College of Medicine, Pungnap2-dong, Songpa-gu, Seoul, South Korea
| | - Junghyun Seo
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil Songpa-Gu, Seoul, 05505, South Korea
| | - Kyoung Hwan Koh
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil Songpa-Gu, Seoul, 05505, South Korea.
| | - Namkug Kim
- Department of Biomedical Engineering, Asan Medical Center, Asan Medical Institute of Convergence Science and Technology, University of Ulsan College of Medicine, Pungnap2-dong, Songpa-gu, Seoul, South Korea.
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap2-dong, Songpa-gu, Seoul, South Korea.
- Department of Convergence Medicine, Asan Medical Center, Asan Medical Institute of Convergence Science and Technology, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil Songpa-Gu, Seoul, 05505, South Korea.
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Dujeux C, Antoni M, Thery C, Eichler D, Meyer N, Clavert P. History of mood and anxiety disorders does not affect the outcomes of arthroscopic rotator cuff repair. Orthop Traumatol Surg Res 2023; 109:103550. [PMID: 36642405 DOI: 10.1016/j.otsr.2023.103550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 10/21/2022] [Accepted: 11/15/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND A pre-existing mood and anxiety disorder (MAD) is often present in patients with rotator cuff pathology, but its presumed negative effect on the outcomes has not been demonstrated. AIM OF STUDY AND HYPOTHESIS The primary objective of this study was to evaluate how a history of MAD affects the clinical outcomes 1 year after arthroscopic rotator cuff repair (RCR). The secondary objectives were to evaluate how a history of MAD affects tendon healing, analgesic consumption and the occurrence of complications. MATERIALS AND METHODS The study population consisted of 219 patients (mean age 54.5±6.6 years) who underwent arthroscopic repair for a distal supraspinatus tendon tear, with 17% (38/219) presenting an history of MAD (depression, unspecified mood disorder, anxiety, and bipolar disorder). Using univariate and multivariate analyses, the joint range of motion, Constant score, analgesic consumption, occurrence of complications during the first postoperative year and tendon healing at 1 year (MRI or CT arthrography) were compared between the two groups (with or without MAD). RESULTS The Constant score was lower preoperatively in patients with history of MAD (-4 points, p=.04) but there were no significant differences between the two groups at the various postoperative follow-up time points (p>.05). No significant difference was found between the two groups of patients in their analgesic consumption at the various postoperative time points (p>.05), tendon healing at 1 year (p=.17) or the occurrence of postoperative complications (p=.59). DISCUSSION/CONCLUSION Pre-existing MAD had no effect on the clinical outcomes after arthroscopic RCR at 1 year and no effect on tendon healing, analgesic consumption or the occurrence of complications in our study population. LEVEL OF EVIDENCE III; retrospective case-control study.
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Affiliation(s)
- Clément Dujeux
- Service de chirurgie du membre supérieur, hôpital de Hautepierre 2 - CHU Strasbourg, avenue Molière, 67000 Strasbourg, France
| | - Maxime Antoni
- Service de chirurgie du membre supérieur, hôpital de Hautepierre 2 - CHU Strasbourg, avenue Molière, 67000 Strasbourg, France.
| | - Charles Thery
- Service de chirurgie du membre supérieur, hôpital de Hautepierre 2 - CHU Strasbourg, avenue Molière, 67000 Strasbourg, France
| | - David Eichler
- Service de chirurgie du membre supérieur, hôpital de Hautepierre 2 - CHU Strasbourg, avenue Molière, 67000 Strasbourg, France
| | - Nicolas Meyer
- Service de chirurgie du membre supérieur, hôpital de Hautepierre 2 - CHU Strasbourg, avenue Molière, 67000 Strasbourg, France; Pôle de santé publique, secteur méthodologie et biostatistiques, hôpitaux universitaires de Strasbourg, 1, place de l'hôpital, 67000 Strasbourg, France
| | - Philippe Clavert
- Service de chirurgie du membre supérieur, hôpital de Hautepierre 2 - CHU Strasbourg, avenue Molière, 67000 Strasbourg, France
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Johnson J, von Stade D, Gadomski B, Regan D, Easley J, Sikes KJ, Troyer K, Zhou T, Schlegel T, McGilvray K. Biomechanical and histological changes secondary to aging in the human rotator cuff: A preliminary analysis. J Orthop Res 2023; 41:2221-2231. [PMID: 36722700 DOI: 10.1002/jor.25529] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 01/23/2023] [Accepted: 01/30/2023] [Indexed: 02/02/2023]
Abstract
The high failure rate of rotator cuff repair surgeries is positively correlated with age, yet the biomechanical changes to the tendons of the rotator cuff with age have not been described. As such, we sought to benchmark and characterize the biomechanical and histopathological properties with the accompanying gene expression of human rotator cuff tendons as a function of age and histopathological degeneration. All four rotator cuff tendons from fresh human cadaver shoulders underwent biomechanical, histopathological, and gene expression analyses. Following cadaver availability, samples were grouped into Younger (i.e., less than 36 years of age, n = 2 donors) and Aged (i.e., greater than 55 years of age, n = 3 donors) as a means of characterizing and quantifying the age-related changes exhibited by the tendons. Biomechanical testing and subsequent computational modeling techniques revealed both differences in properties between tendons and greater Young's moduli in the Younger tendons (supraspinatus 3.06x, infraspinatus 1.76x, subscapularis 1.25x, and teres minor 1.32x). Histopathological scoring using the semi-quantitative Bonar scoring scheme revealed a positive correlation with age across all tendons (r = 0.508, p < 0.001). These data contextualize the biomechanical and histopathological changes to tendons that occurs naturally with aging, highlighting the innate differences in biomechanical properties of all four rotator cuff tendons, as well as the difference in their degenerative trajectories. Additionally, the histopathological scoring revealed moderate signs of degeneration within the Younger supraspinatus tendons, suggesting tissue quality may decrease in this specific tendon in patients less than 40 years old, before clinical symptoms or tears.
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Affiliation(s)
- James Johnson
- Orthopaedic Bioengineering Research Laboratory, Colorado State University, Fort Collins, Colorado, USA
| | - Devin von Stade
- Orthopaedic Bioengineering Research Laboratory, Colorado State University, Fort Collins, Colorado, USA
| | - Ben Gadomski
- Orthopaedic Bioengineering Research Laboratory, Colorado State University, Fort Collins, Colorado, USA
| | - Daniel Regan
- Department of Microbiology, Immunology, & Pathology, Flint Animal Cancer Center, Fort Collins, Colorado, USA
| | - Jeremiah Easley
- Preclinical Surgical Research Laboratory, Colorado State University, Fort Collins, Colorado, USA
| | - Katie J Sikes
- Preclinical Surgical Research Laboratory, Colorado State University, Fort Collins, Colorado, USA
| | - Kevin Troyer
- Orthopaedic Bioengineering Research Laboratory, Colorado State University, Fort Collins, Colorado, USA
| | - Tianjian Zhou
- Department of Statistics, Colorado State University, Fort Collins, Colorado, USA
| | - Ted Schlegel
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kirk McGilvray
- Orthopaedic Bioengineering Research Laboratory, Colorado State University, Fort Collins, Colorado, USA
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Dommer LM, Chlasta A, Rojas JT, Hayoz A, Schär M, Zumstein MA. Massive rotator cuff tears with short tendon length can be successfully repaired using synthetic patch augmentation. J Shoulder Elbow Surg 2023; 32:2089-2096. [PMID: 37178963 DOI: 10.1016/j.jse.2023.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/24/2023] [Accepted: 03/30/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Choosing the optimal treatment for massive rotator cuff tears (MRCTs) still poses a surgical problem. In MRCTs with good muscle quality, but short tendon length, nonaugmented repairs lead to high failure rates of up to 90%. The aim of the study was to evaluate midterm clinical and radiologic outcomes of massive rotator cuff tears with good muscle quality, but short tendon length, which were repaired with synthetic patch augmentation. METHODS A retrospective study of patients who underwent arthroscopic or open rotator cuff repairs with patch augmentation between 2016 and 2019 was performed. We included patients older than 18 years, who presented with an MRCT confirmed by an magnetic resonance imaging (MRI) arthrogram showing good muscle quality (Goutallier ≤ II) and short tendon length (length <15 mm). Constant-Murley score (CS), Subjective Shoulder Value (SSV), and range of motion (ROM) were compared pre- and postoperatively. We excluded patients older than 75 years or with presence of rotator cuff arthropathy Hamada stage ≥2a. Patients were followed up for 2 years minimum. Clinical failures were defined by reoperation, forward flexion <120° or a relative CS < 70. Structural integrity of the repair was assessed using an MRI scan. Comparison between different variables and outcomes was performed using Wilcoxon-Mann-Whitney and χ2 tests. RESULTS Fifteen patients (mean age 57 years, 13 [86.7%] male, 9 [60%] right shoulders) were reevaluated with a mean follow-up of 43.8 months (27-55 months). There was a significant improvement in the absolute CS (from 33 to 81 points, P = .03), the relative CS (from 41% to 88%, P = .04), the SSV (from 31% to 93%, P = .007), and forward flexion (from 111° to 163°, P = .004) but not in external rotation (from 37° to 38°, P = .5). There were 3 clinical failures (1 atraumatic, 2 traumatic) with reoperations (2 reverse total shoulder arthroplasties and 1 refixation). Structurally, there were 3 Sugaya grade 4 and 5 Sugaya grade 5 reruptures resulting in a retear rate of 53%. The presence of a complete or partial rerupture was not associated with inferior outcomes compared with intact cuff repairs. There were no correlations between the grade of retraction, muscle quality, or rotator cuff tear configuration and rerupture or functional outcomes. CONCLUSION Patch augmented cuff repair leads to a significant improvement of functional and structural outcomes. Partial reruptures were not associated with inferior functional outcomes. Prospective randomized trials are needed to confirm the results found in our study.
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Affiliation(s)
- Lukas M Dommer
- Shoulder, Elbow and Orthopaedic Sports Medicine, Sonnenhof Orthopaedics, Bern, Switzerland
| | - Adrian Chlasta
- Shoulder, Elbow and Orthopaedic Sports Medicine, Sonnenhof Orthopaedics, Bern, Switzerland
| | - J Tomás Rojas
- Shoulder, Elbow and Orthopaedic Sports Medicine, Sonnenhof Orthopaedics, Bern, Switzerland; Department of Orthopaedics and Trauma Surgery, Hospital San José - Clínica Santa María, Santiago, Chile
| | - Annabel Hayoz
- Shoulder, Elbow and Orthopaedic Sports Medicine, Sonnenhof Orthopaedics, Bern, Switzerland
| | - Michael Schär
- Shoulder, Elbow and Orthopaedic Sports Medicine, Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Matthias A Zumstein
- Shoulder, Elbow and Orthopaedic Sports Medicine, Sonnenhof Orthopaedics, Bern, Switzerland; Shoulder, Elbow and Orthopaedic Sports Medicine, Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Bern, Switzerland; Campus Stiftung Lindenhof Bern, Swiss Institute for Translational and Entrepreneurial Medicine, Bern, Switzerland.
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Allaart LJH, Lech J, Macken AA, Kling A, Lafosse L, Lafosse T, van den Bekerom MPJ, Buijze GA. Biomodulating healing after arthroscopic rotator cuff repair: the protocol of a randomised proof of concept trial (BIOHACK). BMJ Open 2023; 13:e071078. [PMID: 37586862 PMCID: PMC10432644 DOI: 10.1136/bmjopen-2022-071078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 07/13/2023] [Indexed: 08/18/2023] Open
Abstract
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.
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Affiliation(s)
- Laurens Jan Houterman Allaart
- Division of Orthopaedics and Trauma Surgery, Clinique Générale Annecy, Annecy, France
- Department of Human Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Shoulder and Elbow Unit, Joint Research, Department of Orthopaedic Surgery, OLVG, Amsterdam, The Netherlands
| | - James Lech
- Radiology, Universiteit van Amsterdam, Amsterdam, The Netherlands
- Department of Physics and Astronomy, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Arno Alexander Macken
- Division of Orthopaedics and Trauma Surgery, Clinique Générale Annecy, Annecy, France
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Agathe Kling
- Division of Orthopaedics and Trauma Surgery, Clinique Générale Annecy, Annecy, France
| | - Laurent Lafosse
- Division of Orthopaedics and Trauma Surgery, Clinique Générale Annecy, Annecy, France
| | - Thibault Lafosse
- Division of Orthopaedics and Trauma Surgery, Clinique Générale Annecy, Annecy, France
| | - Michel P J van den Bekerom
- Department of Human Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Shoulder and Elbow Unit, Joint Research, Department of Orthopaedic Surgery, OLVG, Amsterdam, The Netherlands
| | - Geert Alexander Buijze
- Division of Orthopaedics and Trauma Surgery, Clinique Générale Annecy, Annecy, France
- Department of Orthopedic Surgery, University of Amsterdam, Amsterdam, The Netherlands
- Department of Orthopedic Surgery, Montpellier University Medical Center, Lapeyronie Hospital, University of Montpellier, Montpellier, France
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Zhang J, Tang X, Zhang Q, Wang X, Guo Z, He Y. Mid-Term Outcomes of Arthroscopic Rotator Cuff Repair in Patients with Rheumatoid Arthritis. Orthop Surg 2023; 15:2116-2123. [PMID: 37232062 PMCID: PMC10432454 DOI: 10.1111/os.13757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 03/28/2023] [Accepted: 04/04/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE The effectiveness of arthroscopic rotator cuff repair (ARCR) on rheumatoid arthritis (RA) patients remains a controversial topic. This study investigates the mid-term outcomes of ARCR in RA patients and identifies the factors influencing clinical efficacy. METHODS This retrospective study enrolled RA patients with small or medium rotator cuff tears (RCTs) between February 2014 and February 2019. Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons (ASES), and Constant-Murley scores were collected at each follow-up time. Ultimately, magnetic resonance imaging (MRI) and X-ray were employed to assess rotator cuff integrity and progression of shoulder bone destruction, respectively. Statistical methods used two-way repeated-measures ANOVA or generalized estimation equations. RESULTS A total of 157 patients were identified and divided into ARCR (n = 75) and conservative treatment (n = 82) groups. ARCR group continued to be divided into small tear (n = 35) and medium tear (n = 40) groups. At the final, all scores were better in ARCR group than in the conservative treatment group (p < 0.05). A radiographic evaluation of the final follow-up demonstrated that the progression rate in ARCR group (18.67%) was significantly lower than that of the conservative treatment group (39.02%, p < 0.05). In the comparison of the small tear and medium tear groups, all scores increased significantly after surgery (p < 0.05), and the final follow-up scores were better than preoperative scores (p < 0.05) but worse than those of the 6-month postoperative follow-up (p < 0.05). Comparison between the two groups revealed that all scores of the small tear group were significantly better than those of the medium tear group at 6-month postoperative follow-up (p < 0.05). Although the scores of small tear group remained better than those of the medium group at the final postoperative follow-up, the difference was not statistically significant (p > 0.05). Radiographic assessment of the final follow-up demonstrated that the progression rate in the small tear group (8.57%) was significantly lower than that in the medium group (27.50%, p < 0.05), and the retear rate of small tear group (14.29%) was significantly lower than that of the medium tear group (35.00%, p < 0.05). CONCLUSION ARCR could effectively improve the quality of life for RA patients with small or medium RCTs, at least in the medium term. Despite the progression of joint destruction in some patients, postoperative retear rates were comparable to those in the general population. ARCR is more likely to benefit RA patients than conservative treatment.
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Affiliation(s)
- Jie‐chao Zhang
- Department of Orthopaedic SurgeryGuanghua Hospital Affiliated to Shanghai University of Traditional Chinese MedicineShanghaiChina
| | - Xiao‐ye Tang
- Department of Orthopaedic SurgeryGuanghua Hospital Affiliated to Shanghai University of Traditional Chinese MedicineShanghaiChina
| | - Qian Zhang
- Department of Orthopaedic SurgeryWuxi Ninth People's Hospital Affiliated to Soochow UniversityWuxiChina
| | - Xue‐peng Wang
- Shanghai University of Traditional Chinese MedicineShanghaiChina
| | - Zi‐cheng Guo
- Shanghai University of Traditional Chinese MedicineShanghaiChina
| | - Yong He
- Department of Orthopaedic SurgeryGuanghua Hospital Affiliated to Shanghai University of Traditional Chinese MedicineShanghaiChina
- Institute of Arthritis Research in Integrative MedicineShanghai Academy of Traditional Chinese MedicineShanghaiChina
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Patterson BM, Bozoghlian MF. Modifiable and Nonmodifiable Risk Factors Associated with the Development of Recurrent Rotator Cuff Tears. Orthop Clin North Am 2023; 54:319-326. [PMID: 37271560 DOI: 10.1016/j.ocl.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
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.
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Affiliation(s)
- Brendan M Patterson
- Department of Orthopedics and Rehabilitation, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Maria F Bozoghlian
- Department of Orthopedics and Rehabilitation, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
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Tokunaga T, Karasugi T, Tanimura S, Miyamoto T. Association of Severe Histological Degeneration of the Torn Supraspinatus Tendon and Retear After Arthroscopic Repair of Full-Thickness Rotator Cuff Tears Using the Suture Bridge Technique. Am J Sports Med 2023; 51:2411-2421. [PMID: 37345285 DOI: 10.1177/03635465231178294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
BACKGROUND Previous studies have demonstrated several prognostic factors for retear after arthroscopic rotator cuff repair (ARCR). However, studies that histologically evaluate the quality of the torn rotator cuff (RC) tendon and its association with postoperative outcomes are limited. PURPOSE To investigate factors associated with retear after ARCR using the suture bridge (SB) technique, including the degree of histological degeneration of the RC tendon edge. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS The authors retrospectively evaluated 187 patients who underwent ARCR for full-thickness tears using the SB technique; intraoperative biopsy samples were taken to assess the degree of histological degeneration using the Bonar score. The cohort was divided into healed (n = 165) and retear (n = 22) groups according to magnetic resonance imaging results obtained ≥6 months postoperatively. The evaluation included preoperative patient data (age, sex, symptom duration, trauma history, history of heavy manual work, smoking habit, hypertension, diabetes mellitus, and hyperlipidemia) and radiological data (Hamada classification, Patte classification, Goutallier classification, and global fatty degeneration index [GFDI]). Additionally, intraoperative data (anteroposterior tear size, Lafosse classification for concomitant subscapularis tendon tear, and long head of biceps injury) and preoperative and postoperative clinical findings (active range of motion, University of California, Los Angeles [UCLA], score) were evaluated. RESULTS The retear rate was 11.8%. The retear group had a higher percentage of men (P = .031), higher Bonar score (P < .001), higher mean GFDI value (P = .002), higher rate of tear retraction degree (P = .010), and larger anteroposterior tear size (P = .020) than the healed group. The retear group had lower postoperative internal rotation (P = .031) and lower UCLA score (P < .001). Multivariate logistic regression analysis with a stepwise variable selection revealed anteroposterior tear size (odds ratio [OR], 2.4; 95% CI, 1.3-4.5; P = .004) and Bonar score (OR, 1.7; 95% CI, 1.3-2.4; P < .001) as independent predictors for a retear. CONCLUSION The results indicate that end-stage severe tendon degeneration might affect retear. Therefore, further investigation on the progression mechanisms of tendon degeneration and development of methods to assess degenerative tissue might improve clinical outcomes after ARCR.
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Affiliation(s)
- Takuya Tokunaga
- Department of Orthopaedic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Tatsuki Karasugi
- Department of Orthopaedic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Shuntaro Tanimura
- Department of Orthopaedic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Takeshi Miyamoto
- Department of Orthopaedic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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16
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Baumann A, Indermuhle T, Curtis D, Perez J, Leland JM. Factors Affecting Postoperative Rehabilitation Therapy Utilization After Arthroscopic Rotator Cuff Repair: An Epidemiological Analysis. Cureus 2023; 15:e36740. [PMID: 37123773 PMCID: PMC10132080 DOI: 10.7759/cureus.36740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 03/29/2023] Open
Abstract
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.
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17
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Migliorini F, Maffulli N, Eschweiler J, Schenker H, Tingart M, Betsch M. Arthroscopic versus mini-open rotator cuff repair: A meta-analysis. Surgeon 2023; 21:e1-e12. [PMID: 34961701 DOI: 10.1016/j.surge.2021.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 10/22/2021] [Accepted: 11/05/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND An all-arthroscopic rotator cuff repair (ASR) may result in less postoperative pain and better functional outcomes than the mini-open (MOR) approach. This meta-analysis provides an updated assessment of the current literature which compares the clinical outcomes of mini-open versus all arthroscopic rotator cuff repair techniques. MATERIAL AND METHODS The main online databases were accessed in October 2021. All the trials directly comparing primary ASR versus MOR for rotator cuff rupture were accessed. Studies concerning revision settings were not eligible, nor where those combining the surgical procedures with other adjuvants. RESULTS A total of 21 articles were retrieved. Data from 1644 procedures (ASR = 995, MOR = 649) were collected. The mean follow-up was 26.7 (6.0-56.4) months. Comparability was found between ASR and MOR groups at baseline with regards to age (P = 0.3), gender (P = 0.7) and mean duration of the follow-up (P = 0.7). No difference was found between ASR and MOR with regard to surgical duration (P = 0.05), Constant score (P = 0.2), University of California at Los Angeles Shoulder (P = 0.3), American Shoulder and Elbow Surgeons Shoulder (P = 0.5), VAS (P = 0.2), forward flexion (P = 0.3), abduction (P = 0.3), external rotation (P = 0.2), internal rotation (P = 0.7), re-tear (P = 0.9), adhesive capsulitis (P = 0.5). CONCLUSION Arthroscopic and mini-open rotator cuff repair result in similar clinical outcomes. Male gender and older age lead to greater rates of rotator cuff re-tears, while longer surgical duration was associated with a greater rate of adhesive capsulitis.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, 52074 Aachen, Germany.
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, Baronissi 84081, SA, Italy; School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent, England, UK; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, England, UK.
| | - Joerg Eschweiler
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, 52074 Aachen, Germany.
| | - Hanno Schenker
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, 52074 Aachen, Germany.
| | - Markus Tingart
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, 52074 Aachen, Germany.
| | - Marcel Betsch
- Department of Orthopaedics and Trauma Surgery, University Medical Center Mannheim of the University Heidelberg, Mannheim, Germany.
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18
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Surgery and Rotator Cuff Disease. Clin Sports Med 2023; 42:1-24. [DOI: 10.1016/j.csm.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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19
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Collagen and platelet-rich plasma in partial-thickness rotator cuff injuries. Friends or only indifferent neighbours? Randomised controlled trial. BMC Musculoskelet Disord 2022; 23:1109. [PMID: 36536333 PMCID: PMC9764482 DOI: 10.1186/s12891-022-06089-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Partial-thickness rotator cuff injuries (PTRCI) are the sum of degenerative, overload, and microtrauma processes. An external supply of collagen and platelet-rich plasma (PRP) could potentially counteract the deterioration of degenerative tendinopathy. This study aimed to compare the effectiveness of collagen with PRP, PRP alone, and collagen alone in the treatment of PTRCI. METHODS Ninety patients with PTRCI were randomised and treated with ultrasound-guided injections into the shoulder bursa every consecutive week: Group A - collagen with PRP (n = 30), Group B - collagen alone (n = 30), and Group C - PRP alone (n = 30). Primary outcomes were pain intensity measured in control points on a numeric rating scale (NRS), QuickDash, and EQ-5D-5L questionnaires at the initial assessment (IA) and control assessments after 6 (T1), 12 (T2), and 24 (T3) weeks, respectively. RESULTS No statistical differences were found between groups in primary outcomes, although there was a trend towards improvement in Groups A and C (opposite to Group B) between T2 and T3. The following parameters were also observed: rotator cuff discontinuity (n = 3, one case in each group) and rotator cuff regeneration (n = 22 in Group A, n = 20 in Group B, and n = 23 in Group C). CONCLUSIONS Combined therapy of collagen and PRP in PTRCI presents similar effectiveness to monotherapies with collagen or PRP. TRIAL REGISTRATION The study was prospectively registered on the NCT Trial Center (identification number: NCT04492748 ) on 30.07.2020.
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Schoch BS, Werner BC, Shapiro SA, Camp CL, Chalmers PN, Cancienne JM. Effect of Bone Marrow Aspirate Concentrate and Platelet-Rich Plasma Augmentation on the Rate of Revision Rotator Cuff Repair. Orthop J Sports Med 2022; 10:23259671221127004. [PMID: 36353396 PMCID: PMC9638537 DOI: 10.1177/23259671221127004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/05/2022] [Indexed: 11/05/2022] Open
Abstract
Background: The application of orthobiologics at the time of arthroscopic rotator cuff
repair (RCR) has received an increasing amount of clinical interest despite
a relative scarcity of human clinical studies on their efficacy. Purpose: To utilize a national administrative database to determine the association of
bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP)
applied at the time of RCR with revision surgery rates. Study Design: Cohort study; Level of evidence, 3. Methods: The Mariner data set from the PearlDiver patient records repository was
utilized to identify patients undergoing RCR using Current Procedural
Terminology (CPT) code 29827. Patients receiving BMAC or PRP at the time of
RCR were then identified using CPT coding. For comparison purposes, a
matched cohort was created consisting of patients who underwent RCR without
biologic augmentation in a 5:1 fashion for each biologic separately. Cases
were matched according to age, sex, tobacco use, biceps tenodesis, distal
clavicle excision, and subacromial decompression. All groups were then
queried for revision RCR or conversion to reverse shoulder arthroplasty.
Revision rates were compared utilizing a multivariate binomial logistic
regression analysis. Adjusted odds ratios (ORs) and 95% CIs were
calculated. Results: A total of 760 patients who underwent biologic augmentation during RCR were
identified, including 646 patients in the PRP group and 114 patients in the
BMAC group. They were compared with 3800 matched controls without documented
biologic application at the time of surgery. Compared with matched controls,
patients who received BMAC at the time of surgery experienced a
significantly lower incidence of revision surgery at 2 years (OR, 0.36; 95%
CI, 0.15-0.82; P = .015). There was no significant
difference in revision rates between PRP and matched controls (OR, 0.87; 95%
CI, 0.62-1.23; P = .183). Conclusion: The application of BMAC at the time of RCR was associated with a significant
decrease in the incidence of revision surgery. There was no apparent effect
of PRP on the incidence of revision surgery after primary RCR. Higher-level
clinical studies considering surgical factors are needed to more clearly
define the role of biologic adjuvants in RCR.
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Affiliation(s)
- Bradley S. Schoch
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Brian C. Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Shane A. Shapiro
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Peter N. Chalmers
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
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Clinical and Radiologic Outcomes after Anatomical Total Shoulder Replacement Using a Modular Metal-Backed Glenoid after a Mean Follow-Up of 5.7 Years. J Clin Med 2022; 11:jcm11206107. [PMID: 36294428 PMCID: PMC9604620 DOI: 10.3390/jcm11206107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/06/2022] [Accepted: 10/14/2022] [Indexed: 11/18/2022] Open
Abstract
Background: Glenoid wear is a common complication of anatomical total shoulder arthroplasty (aTSA) with a metal-backed glenoid (MBG), and the clinical and radiological results of historical implants are poor. The aim of this work was to evaluate the clinical and radiological results of 25 participants as well as the longevity after implantation of an anatomic shoulder prosthesis with a recent, modular cementless flat metal-backed glenoid component after a mean follow-up of 5.7 years. Methods: Clinically, the Simple Shoulder Test (SST), UCLA Activity Score (UCLA), and Constant Murley Score (CMS) were evaluated. Radiographically, the radiolucent lines (RLs), humeral head migration (HHM), and lateral glenohumeral offset (LGHO) were assessed. Survival was calculated with Kaplan−Meier curves and life-table analysis. Results: The mean CMS at follow-up was 46.2 points (range: 14−77; SD: 19.5). In terms of the SST score, the average value was 6.5 points (range: 1−10; SD: 3.5). The UCLA activity score showed a mean value of 5.9 points (range: 1−9; SD: 2.1). There were 17 revisions after a mean follow-up of 68.2 months (range: 1.8−119.6; SD: 27.9). HHM occurred in every patient, with a mean measurement of 6.4 mm (range: 0.5−13.4; SD: 3.9; p < 0.0001). The mean LGHO between the initial postoperative and follow-up images was 2.6 mm (range: 0−4.0; SD: 1.5; p < 0.0001). RLs were found in 22 patients (88%) around the glenoid and in 21 patients (84%) around the humeral head prosthesis. Conclusion: The clinical and radiographic outcomes after metal-backed glenoids were poor at 2.2 to 8.4 years of follow-up. We determined devastating survival in the majority of cases (68%), with mostly inlay wear (71%) as the main reason that led to revision surgery. The use of metalback genoids cannot be recommended based on the data of this study.
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22
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Aydın M, Veizi E, Çepni Ş, Şahin A, Fırat A. Transosseous repair with a cortical implant for greater tubercle cyst-related rotator cuff tear results in good clinical outcomes, but significant implant migration. Knee Surg Sports Traumatol Arthrosc 2022; 30:3499-3507. [PMID: 35366077 DOI: 10.1007/s00167-022-06958-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/18/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate whether an arthroscopic transosseous technique (ATO) with cortical implants is effective for rotator cuff tear (RCT) repair in patients with cysts of the greater tuberosity (GTC). METHODS Patients treated with the ATO technique between January 2013 and October 2017 were evaluated. Inclusion criteria were patients treated for both cyst-related and non-cyst-related RCTs and patients with a moderate-sized tear (1-3 cm) according to the DeOrio and Cofield classification. A total of 39 patients were separated into two groups: Group 1 (n = 16) patients with cyst-associated RCT, and Group 2 (n = 23) patients with no cyst. Implant pull-out and migration were evaluated radiologically on standard antero-posterior shoulder radiographs and rotator cuff re-tear was assessed on magnetic resonance images at the final follow-up examination. Group 1 patients were separated into two subgroups according to cyst size (cyst < 5 mm and cyst ≥ 5 mm) and subgroup analysis was performed. Clinical assessment was performed using a visual analog scale, the Constant score and Oxford shoulder score. RESULTS The mean follow-up time was 33.7 ± 11.7 months. The mean cyst size was 5.4 ± 1.5 mm. There was no significant difference in re-tear rates between the cystic and non-cystic groups. The mean implant migration distance was 3.0 ± 2.2 mm in patients with a RCT -related cyst and 0.7 ± 0.8 mm in those without a cyst. A statistically significant difference was found between the groups (p = 0.002). There was no statistically significant difference between the groups in respect of clinical scores. No implant failure was observed. CONCLUSION The ATO method performed with a cortical implant in RCTs resulted in satisfactory recovery and clinical outcomes in the short to medium term with low failure rates. While no implant failures were observed, implant migration was associated with cyst presence. Therefore, judicious use is advocated in the choice of transosseous fixation for cyst-related RCTs and patients should be informed of the possibility of implant migration. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Mustafa Aydın
- Department of Orthopedics and Traumatology, Gülhane Training and Research Hospital, 06000, Ankara, Turkey
| | - Enejd Veizi
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara, Turkey.
| | - Şahin Çepni
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara, Turkey
| | - Ali Şahin
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara, Turkey
| | - Ahmet Fırat
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara, Turkey
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宁 梓, 施 政, 杨 光, 钟 瑞, 余 鸿, 王 扬, 王 国, 李 彦. [Evaluation methods of postoperative healing of supraspinatus tendon tear]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:1172-1177. [PMID: 36111482 PMCID: PMC9626287 DOI: 10.7507/1002-1892.202206054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/22/2022] [Accepted: 07/22/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To summarize the evaluation methods of postoperative healing of supraspinatus tendon tear in recent years, in order to provide reference for clinic. METHODS CNKI, Wanfang, PubMed, and Foreign Medical Literature Retrieval Service (FMRS) databases were used to search the literatures between 2005 and 2022. The literature related to the diagnosis and postoperative healing of supraspinatus tendon tear was included. Finally, 50 articles were reviewed. RESULTS Supraspinatus tendon tear is a common shoulder disease. Physical examination, clinical score, and imaging examination are used to predict and evaluate the postoperative healing. Among them, physical examination and clinical score are non-invasive and the most economical methods, but their accuracy and sensitivity are lower than imaging examination, so they can only be used as auxiliary methods. The acromio-humeral distance (AHD) and upward migration index (UMI) measured by X-ray films can directly reflect the change of supraspinatus tendon thickness, but they are impossible to distinguish whether there is tear or not. Ultrasound and MRI are the main methods for the clinical diagnosis of supraspinatus tendon tear, but the commonly used MRI sequence can not accurately judge the internal healing of the tendon. Shear wave elastrography (SWE) and ultrashort-echo-time (UTE) techniques are the latest research directions in recent years, but different studies have shown opposite conclusions on the application of SWE technique. This conclusion shows that the principle of SWE technique and its relationship with tendons need to be further studied. UTE technique has good clinical effect, and the T2* value obtained by UTE technique is more accurate than that of traditional Sugaya typing, but there are still few research samples. CONCLUSION AHD and UMI measured by X-ray film and T2* value measured by UTE technique can be used as effective methods for evaluating the healing of supraspinatus tendon tear after repairing, and can be used as a follow-up evaluation method combined with physical examination and clinical score for patients with supraspinatus tendon tear.
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Affiliation(s)
- 梓文 宁
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 政良 施
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 光 杨
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 瑞颖 钟
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 鸿 余
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 扬 王
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 国梁 王
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 彦林 李
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
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24
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Jackson GR, Bedi A, Denard PJ. Graft Augmentation of Repairable Rotator Cuff Tears: An Algorithmic Approach Based on Healing Rates. Arthroscopy 2022; 38:2342-2347. [PMID: 34767956 DOI: 10.1016/j.arthro.2021.10.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 02/02/2023]
Abstract
We provide our algorithm for tissue augmentation of rotator cuff repairs based on the current available evidence regarding rotator cuff healing. A variety of factors are associated with healing following rotator cuff repair. Increasing tear size and retraction as well as severe fatty degeneration have been associated with worsening rates of tendon healing. Given the correlation between tendon healing and postoperative outcomes, it is important to identify patients at high risk for failure and to modify their treatment accordingly to minimize the risk of early biomechanical failure and maximize the potential for structural healing. One approach that may be used to improve healing is tissue augmentation. Tissue augmentation is the use of tissue patches and scaffolds to provide rotator cuff reinforcement. Surgical management for rotator cuff tears (RCTs) continues to be a challenging task in orthopaedic surgery today. Appropriate treatment measures require an in depth understanding and consideration of the patient's prognostic factors such as age, fatty infiltration of the rotator cuff muscles, bone mineral density, rotator cuff retraction, anteroposterior tear size, work activity, and degenerative changes of the joint. Using these factors within the Rotator Cuff Healing Index, we can determine a patient's surgical treatment that will yield the maximum healing rate. For nonarthritic RCTs, joint-preserving strategies should be first-line treatment options. For young, active patients with a reparable RCT and minimal fatty infiltration, a complete repair can be effective. For young patients with irreparable RCTs, superior capsular reconstructions, and tendon transfers are viable options. For elderly patients with low work activity, an irreparable RCT and significant fatty infiltration, a partial repair with or without graft augmentation can be attempted if minimal to no arthritic changes are seen. LEVEL OF EVIDENCE: Level V, expert opinion.
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Affiliation(s)
- Garrett R Jackson
- American University of the Caribbean School of Medicine, Sint Maarten
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
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25
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Quigley R, Verma N, Evuarherhe A, Cole BJ. Rotator Cuff Repair with Graft Augmentation Improves Function, Decreases Revisions, and Is Cost-Effective. Arthroscopy 2022; 38:2166-2174. [PMID: 35066111 DOI: 10.1016/j.arthro.2022.01.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 01/07/2022] [Accepted: 01/08/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study is to evaluate the cost effectiveness of the use of extracellular matrix (ECM) augment at the time of primary rotator cuff repair utilizing a decision tree analysis. METHODS A decision tree model was created utilizing the existing literature for retear rates with and without dermal graft augmentation. Costs for rotator cuff repair (hospital and surgeon fees) were based on published studies and the cost for graft augmentation was based on institutional data. Utility measures were based upon EQ-5D (European Quality of Life 5 Dimension) scores to assess for improvement in quality adjusted life years (QALY) over a 10-year postoperative period with and without graft augmentation. Cost effectiveness was assessed using the incremental cost effectiveness ratio (ICER), or the incremental cost for per QALY with graft augmentation. Cost effectiveness is based on previous literature whereby an intervention is considered cost effective if the ICER is less than $50,000/QALY. RESULTS On the basis of our decision tree analysis, total cost for rotator cuff tear without augmentation was $12,763, while the cost increased to $16,039 with ECM augmentation. With graft augmentation there was an improvement in 2.29 QALY, while there was an improvement of 2.05 without graft augmentation. The ICER of graft augmentation is $14,000/QALY, well below the cost effectiveness cut-off of $50,000/QALY. Sensitivity analysis showed the maximum cost of the ECM augment to be cost effective is $11,921. CONCLUSION Graft augmentation does come with a significant upfront cost; however, on the basis of our decision-tree analysis, it may represent a cost-effective procedure. There is evidence to potentially consider more routine use in rotator cuff repairs, while being cost effective. LEVEL OF EVIDENCE Economic: Level IV: computer simulation model (Monte Carlo simulation, Markov model) with inputs derived from Level IV studies.
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Affiliation(s)
- Ryan Quigley
- Kaiser Permanente, Sacramento, California, U.S.A
| | - Nikhil Verma
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Aghogho Evuarherhe
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Brian J Cole
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A..
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26
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Evuarherhe A, Condron NB, Gilat R, Knapik DM, Patel S, Wagner KR, Garrigues GE, Romeo A, Verma N, Cole BJ. Defining Clinically Significant Outcomes Following Superior Capsular Reconstruction With Acellular Dermal Allograft. Arthroscopy 2022; 38:1444-1453.e1. [PMID: 34863902 DOI: 10.1016/j.arthro.2021.11.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/12/2021] [Accepted: 11/20/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To define clinically significant outcomes (CSO) thresholds for minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptomatic state (PASS) in patients undergoing superior capsular reconstruction (SCR) with an acellular dermal allograft. We also evaluated patient-specific variables predictive of achieving CSO thresholds. METHODS The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), and subjective Constant-Murley (Constant) scores were collected preoperatively and at the most recent follow up for patients undergoing SCR from 2010 to 2019. A distribution-based approach was used to calculate MCID, and an anchor-based approach was used to calculate SCB and PASS. Logistic regression was used to determine factors associated with CSO achievement. RESULTS Fifty-eight patients were identified (n = 39 males; n = 19 females) with a mean age of 53.4 ± 14.1 years at surgery and an average follow-up of 23 months. The MCID, SCB, and PASS were 11.2, 18.02, and 68.82 for ASES, 14.5, 23.13, and 69.9 for SANE, and 3.6, 10, and 18 for Constant, respectively. Subscapularis tear, female sex, and workers compensation (WC) status reduced odds of achieving MCID. Reduced odds of achieving Constant SCB were associated with older age, female sex, and WC status, while concomitant distal clavicle excision during SCR and lower preoperative ASES increased odds of achieving ASES SCB. Reduced odds for achieving ASES PASS were associated with female sex and WC status, while reduced odds for achieving SANE PASS were associated with subscapularis tearing preoperatively. CONCLUSION On the basis of calculated values for MCID, SCB, and PASS, subscapularis tearing, WC status, age, and sex are associated with failure to achieve clinically significant outcomes following SCR. Concomitant distal clavicle excision during SCR and lower preoperative ASES was predictive for achievement of MCID and SCB. By defining the thresholds and variables predictive of achieving CSOs following SCR, surgeons may better counsel patients prior to SCR. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Aghogho Evuarherhe
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Nolan B Condron
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Ron Gilat
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Derrick M Knapik
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Sumit Patel
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Kyle R Wagner
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Anthony Romeo
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Nikhil Verma
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Brian J Cole
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A..
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de Andrade ALL, Garcia TA, Brandão HDS, Sardeli AV, Mouraria GG, Belangero WD. Benefits of Patch Augmentation on Rotator Cuff Repair: A Systematic Review and Meta-analysis. Orthop J Sports Med 2022; 10:23259671211071146. [PMID: 35360882 PMCID: PMC8961381 DOI: 10.1177/23259671211071146] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/12/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Despite technological advances, the overall retear rate on rotator cuff
repair is still high. Patches have shown significant reduction in retear
rate and pain scores; however, this is not a universal finding and
conflicting results have been shown among functional shoulder scales. Purpose: To analyze previous controlled trials of the literature to bring a consensus
about the effectiveness of patch use on rotator cuff repair. Study Design: Systematic review; Level of evidence, 1. Methods: The search was conducted in PubMed, Web of Science, EMBASE, Scopus, and
Cochrane in April 2020. The results of rotator cuff repair with patch
augmentation versus without augmentation (control) were compared through
odds ratio (OR), raw mean difference (RMD), and standardized mean difference
(SMD) of retear rate; functional shoulder scales; strength; and range of
motion (ROM). Results: Of 733 initial studies, 7 of them met the criteria to be included in the
analysis. Compared with the control group, the patch augmentation group had
a significantly lower retear rate (OR, 0.32 [95% CI, 0.18 to 0.55];
P < .001), lower pain (SMD, –0.42 [–0.71 to –0.12];
P < .01), a higher University of California Los
Angeles Shoulder Rating Scale (RMD, 0.87 [0.15 to 1.60], P
= .017), and a trend toward higher strength (SMD, 0.95 [–0.03 to 1.94],
P = .05) and lower forward elevation ROM (RMD, –10.50
[–21.86 to 0.67]; P = .06), while no changes were noted for
other functional scales or for internal and external rotation ROM. Conclusion: The results point to benefits of patch augmentation in rotator cuff repair,
particularly a reduction in retear rate. More interventional studies with
better methodological quality should be conducted to confirm the results of
this initial review.
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Affiliation(s)
| | - Thiago Alves Garcia
- Orthopaedic Biomaterials Laboratory (LABIMO), School of Medical Sciences, State University of Campinas, Campinas, São Paulo, Brazil
| | | | - Amanda Veiga Sardeli
- Exercise Physiology Laboratory, School of Medical Sciences, State University of Campinas, Campinas, São Paulo, Brazil
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Effect of Physical Therapy and Rehabilitation Timing on Rotator Cuff Repair Revisions and Capsulitis. J Am Acad Orthop Surg 2022; 30:e444-e452. [PMID: 35772092 DOI: 10.5435/jaaos-d-21-00899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 11/03/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION One variable that could potentially affect failure of a rotator cuff repair (RCR) is the timing of beginning physical therapy (PT) after the procedure. Although many studies have demonstrated decreased stiffness with beginning PT early, studies have also demonstrated that early PT increases repair failure. The goal of this study was to identify revision surgery and capsulitis rates after RCRs from an available database and determine whether an association was present with the timing of PT post-RCR. METHODS Medicare patients within the PearlDiver database who underwent RCR were stratified based on the timing of their first PT session postoperatively, and revision surgery and capsulitis rates were determined among the groups for both open and arthroscopic RCR. Demographics and comorbidities of the cohort were also used to formulate a multivariate analysis for revision surgery rate. RESULTS The cohort consisted of 64,842 patients who underwent RCR and started PT within 13 weeks of surgery. Starting PT within 1 week postoperatively resulted in a significantly higher revision surgery rate compared with starting PT in weeks 2 to 5, 6 to 9, or 10 to 13 (6.9% vs. 3.6% among all other groups, P = <0.001). The multivariate analysis for revision surgery further demonstrated that starting PT within 1 week postoperatively was associated with a significantly higher rate of revision surgery compared with beginning PT after 1 week (OR = 2.086, P < 0.001). No association was found between timing of beginning PT and capsulitis rates. CONCLUSION In the Medicare patient cohort, beginning PT within 1 week postoperatively was associated with a significantly higher revision surgery rate; however, no associated benefit was noted in capsulitis rates for beginning PT early. This calls into question the use of an early passive range of motion protocol for older patient cohort; however, further studies should be completed to conclusively determine the most efficacious time to begin rehabilitation post-RCR. LEVEL OF EVIDENCE Level III.
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Chen P, Wang A, Haynes W, Landao-Bassonga E, Lee C, Ruan R, Breidahl W, Shiroud Heidari B, Mitchell CA, Zheng M. A bio-inductive collagen scaffold that supports human primary tendon-derived cell growth for rotator cuff repair. J Orthop Translat 2022; 31:91-101. [PMID: 34976729 PMCID: PMC8671806 DOI: 10.1016/j.jot.2021.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/20/2021] [Accepted: 10/22/2021] [Indexed: 02/05/2023] Open
Abstract
Background Rotator Cuff (RC) tendon tearing is a common clinical problem and there is a high incidence of revision surgery due to re-tearing. In an effort to improve patient outcome and reduce surgical revision, scaffolds have been widely used for augmentation of RC repairs. However, little is known about how scaffolds support tendon stem cell growth or facilitate tendon regeneration. The purpose of this study is to evaluate the structural and biological properties of a bioactive collagen scaffold (BCS) with the potential to promote tendon repair. Additionally, we conducted a pilot clinical study to assess the safety and feasibility of using the BCS for repair of RC tears. Methods A series of physical, ultrastructural, molecular and in vitro tests determined the biocompatibility and teno-inductive properties of this BCS. In addition, a prospective case study of 18 patients with RC tendon tears (>20 mm in diameter) was performed in an open-label, single-arm study, involving either mini-open or arthroscopic surgical RC repair with the BCS. Clinical assessment of RC repair status was undertaken by MRI-imaging at baseline, 6 and 12 months and patient evaluated questionnaires were taken at baseline as well as 3, 6 & 12 months. Results The BCS consists of highly purified type-I collagen, in bundles of varying diameter, arranged in a higher order tri-laminar structure. BCS have minimal immunogenicity, being cell and essentially DNA-free as well as uniformly negative for the porcine α-Gal protein. BCS seeded with human primary tendon-derived cells and exposed to 6% uniaxial loading conditions in vitro, supported increased levels of growth and proliferation as well as up-regulating expression of tenocyte differentiation marker genes including TNMD, Ten-C, Mohawk and Collagen-1α1. To test the safety and feasibility of using the BCS for augmentation of RC repairs, we followed the IDEAL framework and conducted a first, open-label single arm prospective case series study of 18 patients. One patient was withdrawn from the study at 3 months due to wound infection unrelated to the BCS. The remaining 17 cases showed that the BCS is safe to be implanted. The patients reported encouraging improvements in functional outcomes (ASES, OSS and Constant-Murley scores), as well as quality of life assessments (AQoL) and a reduction in VAS pain scores. MRI assessment at 12 months revealed complete healing in 64.8% patients (11/17), 3 partial thickness re-tears (17.6%) and 3 full thickness re-tears (17.6%). Conclusion The BCS is composed of type-I collagen that is free of immunogenic proteins and supports tendon-derived cell growth under mechanical loading in vitro. This pilot study shows that it is safe and feasible to use BCS for RC argumentation and further controlled prospective studies are required to demonstrate its efficacy. The Translational potential of this article The results of this study indicate that this bioactive collagen scaffold has unique properties for supporting tendon growth and that it is non-immunogenic. The clinical study further confirms that the scaffold is a promising biological device for augment of human rotator cuff repairs.
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Affiliation(s)
- Peilin Chen
- Centre for Orthopaedic Research, The UWA Medical School, The University of Western Australia, Crawley, WA, 6009, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Australia
| | - Allan Wang
- Centre for Orthopaedic Research, The UWA Medical School, The University of Western Australia, Crawley, WA, 6009, Australia
| | - William Haynes
- Umhlanga Ridge Orthopaedic Centre, Suite 514 5th Floor, Gateway Private Hospital, 36 Aurora Drive, Umhlanga, 4320, South Africa
| | - Euphemie Landao-Bassonga
- Centre for Orthopaedic Research, The UWA Medical School, The University of Western Australia, Crawley, WA, 6009, Australia
| | - Clair Lee
- Centre for Orthopaedic Research, The UWA Medical School, The University of Western Australia, Crawley, WA, 6009, Australia
| | - Rui Ruan
- Centre for Orthopaedic Research, The UWA Medical School, The University of Western Australia, Crawley, WA, 6009, Australia
| | | | - Behzad Shiroud Heidari
- Perron Institute for Neurological and Translational Science, Perth, Western Australia, 6009, Australia.,Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, Australia.,UWA Centre for Medical Research, The University of Western Australia, Perth, Australia.,School of Engineering, The University of Western Australia, Perth, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Australia
| | - Christopher A Mitchell
- Centre for Orthopaedic Research, The UWA Medical School, The University of Western Australia, Crawley, WA, 6009, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Australia
| | - Minghao Zheng
- Centre for Orthopaedic Research, The UWA Medical School, The University of Western Australia, Crawley, WA, 6009, Australia.,Perron Institute for Neurological and Translational Science, Perth, Western Australia, 6009, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Australia
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Chevrier A, Hurtig MB, Lavertu M. Chitosan-Platelet-Rich Plasma Implants Improve Rotator Cuff Repair in a Large Animal Model: Pivotal Study. Pharmaceutics 2021; 13:pharmaceutics13111955. [PMID: 34834370 PMCID: PMC8622568 DOI: 10.3390/pharmaceutics13111955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 11/11/2021] [Accepted: 11/16/2021] [Indexed: 11/16/2022] Open
Abstract
The purpose of this study was to assess the safety and efficacy of chitosan-platelet-rich plasma (PRP) hybrid implants used as an adjunct to surgical rotator cuff repair in a pivotal Good Laboratory Practice (GLP)-compliant study. The infraspinatus tendon was transected in 48 skeletally mature ewes and repaired with a transosseous-equivalent (TOE) technique. In the two treatment groups, a chitosan-PRP solution was injected at the footprint between the tendon and the bone and on top of the repaired site (2 mL or 3 mL doses, n = 12 per group). To further assess chitosan safety, a chitosan-water solution was injected at the same sites (3 mL, n = 12). Outcome measures included Magnetic Resonance Imaging (MRI) assessment and clinical pathology at 3 months and 6 months and histopathology at 6 months. The tendon gap was decreased at 3 months on MRI images and certain histopathological features were improved at 6 months by chitosan-PRP treatment compared to controls. The group treated with chitosan-water was not different from controls. Chitosan-PRP treatment induced no negative effects in the sheep, which suggests high safety. This study provides further evidence on the safety and efficacy of chitosan-PRP for rotator cuff repair augmentation, which could eventually be used in a clinical setting.
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Affiliation(s)
- Anik Chevrier
- Chemical Engineering Department, Polytechnique Montreal, 2900 Boul. Édouard-Montpetit, Montreal, QC H3T 1J4, Canada;
| | - Mark B. Hurtig
- Department of Clinical Studies, University of Guelph, Guelph, ON N1G 2W1, Canada;
| | - Marc Lavertu
- Chemical Engineering Department, Polytechnique Montreal, 2900 Boul. Édouard-Montpetit, Montreal, QC H3T 1J4, Canada;
- Biomedical Engineering Institute, Polytechnique Montreal, 2900 Boul, Édouard-Montpetit, Montreal, QC H3T 1J4, Canada
- Correspondence: ; Tel.: +1-514-340-4711 (ext. 3906)
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Takeuchi N, Kozono N, Nishii A, Matsuura K, Ishitani E, Onizuka T, Zaitsu Y, Okada T, Mizuki Y, Kimura T, Yuge H, Uchimura T, Iura K, Mori T, Ueda K, Miake G, Senju T, Takagishi K, Nakashima Y. Stump classification was correlated with retear in the suture-bridge and double-row repair techniques for arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc 2021; 29:2587-2594. [PMID: 33459835 DOI: 10.1007/s00167-020-06415-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/10/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE The Stump classification is significantly correlated with a retear after arthroscopic rotator cuff repair. However, no study has evaluated whether or not the stump classification is correlated with retear in the suture-bridge or double-row repair techniques. The aim of this study was to evaluate the relationship between a retear and the stump classification in the suture-bridge and double-row repair techniques. METHODS Among 389 patients who underwent arthroscopic repairs of full-thickness rotator cuff tears using suture-bridge or double-row repair techniques, 326 patients (median age 67.0 years; range 25-85) were included. There were 51 small, 172 medium, 83 large, and 20 massive tears. Two hundred forty patients were treated with the suture-bridge technique, and 86 patients were treated with the double-row technique. The following variables were analyzed: age, sex, the Cofield classification, anteroposterior and mediolateral tear size on preoperative MRI, global fatty degeneration index, and the stump classification. Cuff integrity was evaluated on magnetic resonance imaging at 6 months after surgery. The patients were divided into the intact and retear groups and the relationship between the variables and retear was evaluated by multivariate logistic regression analysis. RESULTS The overall retear rate was 10.1%. In the multivariate logistic regression analysis, the independent predictors of a retear were the stump classification type 3 (Odds ratio: 4.71, p = 0.0246), global fatty degeneration index (Odds ratio: 3.87, p = 0.0030), and anteroposterior tear size (Odds ratio: 1.07, p = 0.0077) in the suture bridge technique. In the double-row technique, the independent predictors of retear were stump classification type 3 (Odds ratio: 7.82, p = 0.0348), and age (Odds ratio: 1.22, p = 0.0163). CONCLUSION The stump classification was significantly correlated with retear in the suture-bridge and double-row repair technique. Stump classification type 3 was indicated to be an important risk factor for predicting retear. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Naohide Takeuchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, Fukuoka, 812-8582, Japan.
| | - Naoya Kozono
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, Fukuoka, 812-8582, Japan
| | - Akihiro Nishii
- Department of Orthopaedic Surgery, Kitakyushu Municipal Medical Center, Kitakyushu City, Fukuoka, 802-0077, Japan
| | - Koumei Matsuura
- Department of Orthopaedic Surgery, Saiseikai Yahata General Hospital, Kitakyushu City, Fukuoka, 805-0050, Japan
| | - Eiichi Ishitani
- Department of Orthopaedic Surgery, Fukuoka Shion Hospital, Ogori City, Fukuoka, 838-0101, Japan
| | - Toshihiro Onizuka
- Department of Orthopaedic Surgery, Kyushu Rosai Hospital, Kitakyushu City, Fukuoka, 800-0296, Japan
| | - Yoshihisa Zaitsu
- Department of Orthopaedic Surgery, Mizoguchi Orthopaedic Hospital, Fukuoka City, Fukuoka, 810-0001, Japan
| | - Takamitsu Okada
- Department of Orthopaedic Surgery, Nakabaru Hospital, Kasuya District, Fukuoka, 811-2233, Japan
| | - Yasuhiro Mizuki
- Department of Orthopaedic Surgery, Sasebo Kyosai Hospital, Sasebo City, Fukuoka, 857-0879, Japan
| | - Takehiro Kimura
- Department of Orthopaedic Surgery, Moro-oka Orthopaedic Hospital, Chikushi District, Fukuoka, 811-1201, Japan
| | - Hidehiko Yuge
- Department of Orthopaedic Surgery, Mizoguchi Orthopaedic Hospital, Fukuoka City, Fukuoka, 810-0001, Japan
| | - Taiki Uchimura
- Department of Orthopaedic Surgery, Sasebo Kyosai Hospital, Sasebo City, Fukuoka, 857-0879, Japan
| | - Kunio Iura
- Department of Orthopaedic Surgery, Fukuoka Orthopaedic Hospital, Fukuoka City, Fukuoka, 815-0063, Japan
| | - Tatsuya Mori
- Department of Orthopaedic Surgery, Kyushu Rosai Hospital, Kitakyushu City, Fukuoka, 800-0296, Japan
| | - Koki Ueda
- Department of Orthopaedic Surgery, Sasebo Kyosai Hospital, Sasebo City, Fukuoka, 857-0879, Japan
| | - Go Miake
- Department of Orthopaedic Surgery, Kyushu Rosai Hospital, Kitakyushu City, Fukuoka, 800-0296, Japan
| | - Takahiro Senju
- Department of Orthopaedic Surgery, Sasebo Kyosai Hospital, Sasebo City, Fukuoka, 857-0879, Japan
| | - Kenji Takagishi
- Department of Orthopaedic Surgery, Sada Hospital, Fukuoka City, Fukuoka, 810-0004, Japan
| | - Yasuharu Nakashima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, Fukuoka, 812-8582, Japan
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Mandaleson A. Re-tears after rotator cuff repair: Current concepts review. J Clin Orthop Trauma 2021; 19:168-174. [PMID: 34123722 PMCID: PMC8170498 DOI: 10.1016/j.jcot.2021.05.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022] Open
Abstract
Re-tear following rotator cuff repair is common and has been reported to range from between 13 and 94% despite satisfactory clinical outcomes following rotator cuff surgery. Various risk factors have been associated with an increased tear rate, including patient factors, tear and shoulder morphology, repair technique, and rehabilitation regimes. Different modes of rotator cuff failure have been described. The management of re-tear in patients following rotator cuff repair is challenging and depends on the age, functional status and requirements of the patient, and re-tear size and residual tendon length. This article aims to review the factors associated with rotator cuff re-tear. It describes which of these are associated with poor clinical outcomes, and discusses the long-term outcomes of re-tear and treatment options.
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