Comparison between partial and full coverage repair in massive rotator cuff tears. A minimum five year follow-up

Supraspinatus Tendon Reconstruction Versus the Bridging Technique in a Rat Model: Histological, Biomechanical, and Functional Outcomes

BACKGROUND

Massive irreparable rotator cuff tears (MIRCTs) are among the most challenging shoulder conditions to treat surgically. Supraspinatus tendon reconstruction (STR) is a recently introduced technique for MIRCTs based on fascia lata-muscle interface healing, which completely differs from the classic bridging technique with fascia lata-tendon interface healing. However, histological and biomechanical comparisons of the fascia-muscle and fascia-tendon interfaces have not been performed.

PURPOSE

To investigate the histological and biomechanical healing of the fascia-bone interface and fascia-muscle interface after chronic MIRCTs in a rat model using different surgical methods.

STUDY DESIGN

Controlled laboratory study.

METHODS

The authors established a chronic MIRCT model in the right shoulder of rats and then repaired it using the STR or bridging repair technique. Evaluations were performed at 2, 4, 8, and 12 weeks, including histological, imaging, biomechanical, and functional analyses.

RESULTS

Both techniques resulted in good fascia-bone interface healing based on the histological results. The STR group had significantly more cartilage formation at 8 and 12 weeks and higher Modified Tendon Maturity Score after 12 weeks at the fascia-bone interface compared with the bridging repair group and formed the typical 4-layered structure. Collagen fibers in the fascia-muscle and fascia-tendon interfaces exhibited normal muscle-tendon interface characteristics at 12 weeks. However, the STR group had more improvement in fatty infiltration compared with the bridging repair group. The ultimate failure load and stiffness did not differ between the STR and bridging repair groups 4 weeks postoperatively in both the fascia-bone interface and supraspinatus muscle-fascia-bone integrity. Movement distance and grasp time were significantly longer in the STR group than in the bridging repair group at 12 weeks and attached the level in the normal control groups.

CONCLUSION

These results suggest that the fascia-muscle interface from the STR technique is histologically and functionally better than the fascia-tendon interface. Moreover, this study provides a theoretical basis for the clinical use of the STR technique.

CLINICAL RELEVANCE

The fascia-muscle interface and fascia-tendon interface were the key points of the STR and bridging techniques, respectively. The fascia-muscle interface is histologically and functionally superior to the bridging technique, and the STR technique might be a better choice for the treatment of MIRCTs.

Improved Clinical Outcomes After Partial Repair and In Situ Biceps Tenodesis for the Treatment of Massive Irreparable Rotator Cuff Tears

PURPOSE

To present the short-term outcomes of arthroscopic in situ biceps tenodesis combined with partial rotator cuff repair in patients with massive irreparable rotator cuff tears (MIRCTs) and minimal arthritis.

METHODS

A retrospective review was conducted using prospectively maintained institutional databases to identify patients who had undergone a partial rotator cuff repair with in situ biceps tenodesis between March 2017 and December 2022. Patients were included if they (1) were diagnosed pre- or intraoperatively with MIRCT and (2) had complete preoperative and minimum 1-year postoperative patient-reported outcome measures.

RESULTS

Thirty-nine patients met the eligibility criteria and were included for analysis. The mean age of the study participants was 65 ± 7 years (range, 46-76) with 76.9% (n = 30) being male. The average follow-up was 21 ± 12 months (range, 12-58). Patients experienced significant improvement in visual analog scale for pain (VAS), American Shoulder and Elbow Surgeons (ASES) score, and subjective assessment numeric evaluation (SANE) score (P < .001 for all comparisons). The pre- to postoperative improvement was 3.1 ± 2.3 for VAS, 27.5 ± 20.6 for ASES, and 31.3 ± 24.8 for SANE. Postoperatively, the average scores for VAS, ASES, and SANE were 1.3 ± 1.5, 79.5 ± 17.0, and 69.6 ± 20.1, respectively. Twenty-six patients (66.7%) achieved the minimal clinically important difference (MCID) for VAS, 33 patients (84.6%) achieved the MCID for ASES, and 30 patients (76.9%) achieved the MCID for SANE.

CONCLUSIONS

Partial rotator cuff repair with in situ biceps tenodesis is an effective treatment for MIRCT, leading to significant improvements in patient-reported outcome and range-of-motion measures compared to preoperative conditions.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

History of mood and anxiety disorders affects return to work and return to sports after rotator cuff repair

INTRODUCTION

After rotator cuff repair (RCR), return to work and return to sports is affected by various psychosocial factors. The role of one of these factors - mood and anxiety disorders (MAD) - is still not clear. The primary objective of this study was to determine the influence of prior MAD on the return to work and return to sports after RCR. Our hypothesis was that patients with a history of MAD would take longer to return to work and to sports after RCR, and the rate of return would be lower, than for patients without MAD.

MATERIALS AND METHODS

This was a retrospective single-center study of patients who underwent arthroscopic RCR (distal supraspinatus tear). Patients who were employed and those who participated in sports before the surgery were included in the "working" and "sports" groups, respectively. The primary outcomes were the time to return to work and return to sports after surgery. The secondary outcomes were the ratio of patients returning to work and to sports at 3, 6 and 12 months; rate of return to same level of sports; need to change or stop working or sports. The effects of prior MAD on these various outcomes were determined using Bayesian multivariate analysis.

RESULTS

The "working" group consisted of 158 patients (of which 16.5% had MAD) and the "sports" group consisted of 118 patients (of which 17.8% had MAD). In those with a history of MAD, return to work was 21±11 weeks later and the return to sports was 17±8 weeks later than in those without MAD. There was a 98% probability that return to work or return to sports was delayed by at least 4 weeks in patients with history of MAD. The likelihood that patients with prior MAD who undergo RCR will completely abandon their sport was 2.8 times higher (OR=2.8 [1; 7.8]).

CONCLUSION

We found a negative influence of prior MAD on the return to work and return to sports after RCR.

LEVEL OF EVIDENCE

III; retrospective case-control study.

Interventions used to mitigate muscle fatty degeneration following the repair of massive rotator cuff tears. A systematic review of animal studies

BACKGROUND

Muscle fatty degeneration following rotator cuff tears has been unequivocally associated with poorer functional outcomes and increased risk for retear following rotator cuff repair. Promising results have emerged from animal studies, with the implementation of various interventions for biologic inhibition of this fatty muscle degeneration. The lack of high quality randomized human evidence on this topic, increases the impact of pooled results from animal literature. The aim of the present study was to systematically review the available published literature for animal studies evaluating the ability of several interventions used to mitigate muscle fatty degeneration following the repair of massive rotator cuff tears.

PATIENTS AND METHODS

A comprehensive search was conducted on Pubmed, Scopus and Google Scholar, covering the period from conception until 16th April 2022. Datasets were stratified based on the type of intervention performed. SYRCLE risk of bias instrument was implemented for quality assessment of the included studies.

RESULTS

Rotator cuff repair augmentation with Adipose derived stem cells (ADSC's), Mesenchymal stem cells (MSC's) and Nandrolone was effective against fatty infiltration, but less effective against muscle atrophy. More beneficial effect was shown by the utilization of Beige adipose tissue - Fibroadipogenic progenitors (BAT-FAP) stimulation, using either Amibregon or BAT-FAPs transplantation. Both provided good results in mitigating muscle atrophy, fatty infiltration and fibrosis.

DISCUSSION

ADSC's, MSC's, Nandrolone and BAT-FAP stimulation may have a role in mitigating muscle fatty degeneration following rotator cuff tears. Large scale human studies are required to further elucidate their role in the clinical setting.

LEVEL OF EVIDENCE

V; systematic review of pre-clinical studies.

History of mood and anxiety disorders does not affect the outcomes of arthroscopic rotator cuff repair

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.

Arthroscopic advancement of the supraspinatus muscle and tendon for posterosuperior massive rotator cuff tears

The tension-free repair of retracted supraspinatus tears with the open muscle and tendon advancement technique first described by Debeyre in 1965 gave satisfactory clinical results. The purpose of this anatomical study was to test the feasibility of an arthroscopic supraspinatus advancement technique. A total of 10 cadaveric shoulders were operated. We assessed the feasibility, measured the slide distance, and recorded the position of the suprascapular nerve (SSN) for each shoulder. Reattachment of the tendon to its native footprint was achieved in all cases. The mean slide distance was 38.8 mm ± 3.6 (33-44). The SSN was released and tension-free in all shoulders. Arthroscopic advancement of the supraspinatus muscle and tendon enables complete rotator cuff repair in irreparable retracted posterosuperior tears and is a noteworthy alternative to the other techniques. Level of Evidence: IV.

Massive and Irreparable Rotator Cuff Tears: A Review of Current Definitions and Concepts

Background

While massive and irreparable rotator cuff tears (MIRCTs) have been abundantly studied, inconsistent definitions in the literature and theories about pain and dysfunction related to them can be difficult to navigate when considering an individual patient.

Purpose

To review the current literature for definitions and critical concepts that drive decision-making for MIRCTs.

Study Design

Narrative review.

Methods

A search of the PubMed database was performed to conduct a comprehensive literature review on MIRCTs. A total of 97 studies were included.

Results

Recent literature reflects added attention to clarifying the definitions of "massive, "irreparable," and "pseudoparalysis." In addition, numerous recent studies have added to the understanding of what generates pain and dysfunction from this condition and have reported on new techniques for addressing them.

Conclusion

The current literature provides a nuanced set of definitions and conceptual foundations on MIRCTs. These can be used to better define these complex conditions in patients when comparing current surgical techniques to address MIRCTs, as well as when interpreting the results of new techniques. While the number of effective treatment options has increased, high-quality and comparative evidence on treatments for MIRCTs is lacking.

Better functional outcomes and a lower infection rate can be expected after superior capsular reconstruction in comparison with latissimus dorsi tendon transfer for massive, irreparable posterosuperior rotator cuff tears: a systematic review

BACKGROUND

Massive, irreparable rotator cuff tears, if left untreated, may result in cuff tear arthropathy, which causes shoulder disability and pain. The primary outcome of this systematic review was to evaluate differences in functional outcomes between the arthroscopic superior capsular reconstruction (SCR) and latissimus dorsi tendon transfer (LDTT) for the treatment of massive, irreparable posterosuperior rotator cuff tears without arthritis. The secondary outcome was to compare complication and reoperation rates between the 2 surgical procedures.

METHODS

The PubMed, MEDLINE, Scopus, and Cochrane Central databases were searched using keywords, and 20 studies were included in this review. Data extracted for quantitative analysis included the American Shoulder and Elbow Surgeons score, the Constant-Murley score, the subjective shoulder value, the range of motion, the visual analog scale for pain, numbers and types of complications, and reoperation rate. The preoperative fatty degeneration of the muscles and the preoperative and follow-up acromiohumeral distance and glenohumeral osteoarthritis according to the Hamada grading system were also reported.

RESULTS

A total of 1112 patients were identified, among whom 407 and 399 underwent SCR and LDTT, respectively. The SCR group showed a higher mean age at the time of operation (64.5 ± 7.8 vs. 62.1 ± 8.9 years; P < .001). The SCR group showed a lower rate of previous surgical procedures on the shoulder (35 out of 407 vs. 111 out of 399; P < .001) and a shorter mean follow-up (30.4 ± 7.5 vs. 36.3 ± 10.3 months; P < .001). Patients who underwent SCR reported significantly better functionality and residual pain as measured by the Constant-Murley score (75.5 ± 11.2 vs. 65.6 ± 22.8, P < .001), the American Shoulder and Elbow Surgeons score (84.3 ± 13 vs. 67.7 ± 23, P < .001), the subjective shoulder value (79.4 ± 13 vs. 64.4 ± 23, P < .001), and the visual analog scale (1.4 ± 2 vs. 2.8 ± 3, P < .001) than patients who underwent LDTT. A greater acromiohumeral distance (5.8 ± 2.5 vs. 7.6 ± 2.7, P < .001) was found in the SCR group. The SCR group showed a significantly lower infection rate (0.2% vs. 2.8%., P = .003) and a higher graft failure rate (12.3% vs. 6.8%, P = .012). No differences in terms of reoperation for graft failure (1% vs. 2.3% for SCR and LDTT, respectively; P = .172) or for conversion to reverse total shoulder arthroplasty (1.7% vs. 2% for SCR and LDTT, respectively; P = .800) were found.

CONCLUSION

Patients undergoing SCR report better functional outcomes and greater acromiohumeral distance than those undergoing LDTT. The LDTT group shows a significantly higher infection rate, while the SCR group shows a significantly higher graft failure rate, but there are no differences in terms of reoperation between the 2 surgical procedures.

Does the Fatty Infiltration Influence the Re-tear Rate and Functional Outcome After Rotator Cuff Repair? A Systematic Review and Meta-analysis

Purpose

Fatty infiltration (FI) of the rotator cuff muscles occurs after rotator cuff tears (RCTs), which may affect the outcome of the repair procedure. This study aimed to determine the relationship between preoperative FI and the rate of re-tear and functional outcomes after rotator cuff repair.

Methods

Computerized databases, including PubMed, EMBASE, Web of Science, and Cochrane Library database were searched for studies published from the inception date to January 2022. Two reviewers independently screened the titles and abstracts using prespecified criteria. Articles were included if they clearly stated the effect of varying degrees of FI on the outcome after shoulder cuff repair. Comparison was performed by different degrees of FI analysis: no FI is grade 0-1, FI is grade 2 and above. Statistical analysis was performed using Review Manager 5.4.1 software.

Results

A total of 16 articles involving 1383 patients from 8 countries were included. The follow-up period ranged from 8 to 121 months. In terms of re-tear rate: patients with preoperative FI had significantly higher rates of re-tear compared with patients without FI (OR 4.60, 95% CI 2.22-9.54, p < 0.0001), supraspinatus FI VS no FI (OR 2.06, 95% CI 1.00-4.24, p = 0.05), infraspinatus FI VS no FI (OR 2.42, 95% CI 1.19-4.91, p = 0.01). In terms of functional scoring: patients without FI had higher postoperative Constant-Murley (Constant) scores than those with FI (MD - 5.06, 95% CI - 9.40 to - 0.72, p = 0.02), there was no clear evidence that preoperative FI was related to postoperative American Society of shoulder and elbow physicians scores and the University of California at Los Angeles scores and range of motion.

Conclusion

FI after RCTs significantly increases the risk of postoperative re-tear and leads to worse functional scores, especially FI of the infraspinatus muscle. However, FI does not seem to reduce postoperative range of motion.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-022-00807-0.

Superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement or balloon spacers for large and massive irreparable rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

Multiple non-arthroplasty surgical techniques are described for the management of large and massive irreparable rotator cuff tears. There is currently no consensus on the best management strategy. Our aim was to compare clinical outcomes following arthroscopic debridement, arthroscopic partial cuff repair, superior capsule reconstruction, balloon spacers or graft interposition for the management of large and massive irreparable rotator cuff tears.

METHODS

A comprehensive search was performed of the following databases: Medline, Embase, CINAHL and Cochrane Database of Systematic Reviews. Data were extracted from relevant studies published since January 2000 according to the pre-specified inclusion criteria. The primary outcome was the post-operative improvement in shoulder scores. Meta-analysis of the primary outcome was performed. Secondary outcomes included retear rates and complications.

RESULTS

Eighty-two studies were included reporting the outcomes of 2790 shoulders. Fifty-one studies were included in the meta-analysis of the primary outcome. The definition of an irreparable tear varied. All procedures resulted in improved shoulder scores at early follow-up. Shoulder scores declined after 2 years following balloon spacers, arthroscopic debridement and partial cuff repair. High retear rates were seen with partial cuff repairs (45%), graft interposition (21%) and superior capsule reconstruction (21%).

CONCLUSIONS

Large initial improvements in shoulder scores were demonstrated for all techniques despite high retear rates for reconstructive procedures. Shoulder scores may decline at mid- to long-term follow-up.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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