COMPARATIVE ANALYSIS ON THE RESULT FOR ARTHROSCOPIC ROTATOR CUFF SUTURE BETWEEN SMOKING AND NON-SMOKING PATIENTS

Surgical Management of Massive Irreparable Posterosuperior Rotator Cuff Tears: Arthroscopic-Assisted Lower Trapezius Transfer

PURPOSE OF THE REVIEW

Functionally irreparable rotator cuff tears (FIRCTs) remain one of the most challenging pathologies treated in the shoulder. The lower trapezius transfer represents a very promising treatment option for posterosuperior FIRCT. This article reviews the role for the lower trapezius transfer in the treatment of patient with FIRCTs and highlights the tips and tricks to performing this arthroscopic-assisted procedure.

RECENT FINDINGS

The treatment of posterosuperior FIRCTs contemplates a wide array of surgical options, including partial repair, biceps tenodesis/tenotomy, superior capsule reconstruction, subacromial balloon, reverse shoulder arthroplasty, and open-/arthroscopic-assisted tendon transfers. Tendon transfers have emerged as very promising reconstructive options to rebalance the anterior-posterior force couple. Controversy remains regarding the relative indications of latissimus dorsi transfer (LDT) and lower trapezius transfer (LTT). Initially used with very good success in patients with brachial plexus injuries, the open LTT has shown excellent clinical and radiographic outcomes in a recent series of patients with FIRCTs. However, this technique should be reserved for patients with an intact or reparable subscapularis tendon and no advanced glenohumeral arthritis or humeral head femoralization. With advancements in surgical technique, the arthroscopic-assisted LTT has shown similar promising results. However, studies on arthroscopically assisted LTT are limited to short-term follow-up, and future comparative trials with large patient numbers and longer follow-up are needed to better understand the indications for this novel tendon transfer in the treatment of FIRCT. The arthroscopic-assisted LTT is a novel, promising option for the treatment of patients with functional irreparable posterosuperior rotator cuff tears. Careful attention to indications and technical pearls are paramount when performing this procedure to optimize postoperative clinical outcomes.

Effect of Cigarette Smoking on Patient-Reported Outcomes in Hip Arthroscopic Surgery: A Matched-Pair Controlled Study With a Minimum 2-Year Follow-up

Background

The rate of hip arthroscopic surgery has recently increased; however, there is limited literature examining patient-reported outcomes (PROs) in cigarette smokers.

Purpose/Hypothesis

The purpose of this study was to evaluate whether smoking status for patients undergoing hip arthroscopic surgery affects clinical findings and PRO scores. We hypothesized that patients who smoke and undergo primary hip arthroscopic surgery will have similar clinical examination findings and preoperative and postoperative PRO scores compared with nonsmoking patients.

Study Design

Cohort study; Level of evidence, 3.

Methods

Data were collected on all patients who underwent primary hip arthroscopic surgery from February 2008 to July 2015. A retrospective analysis of the data was then conducted to identify patients who reported cigarette use at the time of the index procedure. Patients were matched 1:2 (smoking:nonsmoking) based on sex, age within 5 years, labral treatment (repair vs reconstruction vs debridement), workers' compensation status, and body mass index within 5 kg/m². All patients were assessed preoperatively and postoperatively using 4 PRO measures: the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), and International Hip Outcome Tool-12 (iHOT-12). Pain was estimated using a visual analog scale. Satisfaction was measured on a scale from 0 to 10. Significance was set at P < .05.

Results

A total of 75 hips were included in the smoking group, and 150 hips were included in the control group. Preoperatively, the smoking group had significantly lower PRO scores compared with the control group for the mHHS, NAHS, and HOS-SSS. Both groups demonstrated significant improvement from preoperative levels. A minimum 2-year follow-up was achieved, with a mean of 42.5 months for the smoking group and 47.6 months for the control group (P = .07). At the latest follow-up, the smoking group reported inferior results for all outcome measures compared with controls. The improvement in PRO scores and rates of treatment failure, revision arthroscopic surgery, and complications was not statistically different between the groups.

Conclusion

Patients who smoke had lower PRO scores preoperatively and at the latest follow-up compared with nonsmokers. Both groups demonstrated significant improvement in all PRO scores. These results show that while hip arthroscopic surgery may still yield clinical benefit in smokers, these patients may ultimately achieve an inferior functional status. To optimize results, physicians should advise patients to cease smoking before undergoing hip arthroscopic surgery.

Outcome assessment in the treatment of rotator cuff tear: what is utilized in Brazil?

This review evaluated the outcomes used in clinical studies involving rotator cuff tear published in the last decade in the two leading Brazilian orthopedic journals. A literature review was performed using the journals Revista Brasileira de Ortopedia and Acta Ortopédica Brasileira. It included all original clinical articles describing at least one outcome measured before or after any clinical or surgical intervention related to rotator cuff tear, published between 2006 and 2015. The authors evaluated range of motion, muscle strength, patient satisfaction, and tendon integrity and functional outcomes scores. There were 25 clinical studies published about rotator cuff in the two principal Brazilian orthopedic journals in the last decade, 20 case series (80%), one case-control (4%), and four cohorts (16%). Objective measures such as muscle strength, patient satisfaction, and evaluation of tendon integrity were little used. Range of motion measurements were performed in 52% of the articles. Evaluations of muscle strength and patient satisfaction were reported by 28% and 16% of the studies, respectively. Only 28% of the articles evaluated tendon integrity after surgery. Of these, 16% did so by magnetic resonance imaging and 12% by ultrasonography. The most used scale was the UCLA, present in 92% of the articles, while the Constant-Murley appeared in 20%. Scales deemed reliable, with high internal consistency and good responsiveness, were rarely used.

What is the role of systemic conditions and options for manipulation of bone formation and bone resorption in rotator cuff tendon healing and repair?

Rotator cuff pathology is a significant cause of shoulder pain. Operative repair of rotator cuff is an established standard of care for these patient, however, failure of the procedure is common. Systemic conditions such as diabetes mellitus, hypocholesteremia, thyroid disease, and smoking significantly affect the outcomes of rotator cuff repair and have significant implications for the management of these patients. Diabetes mellitus has been proposed to damage tendons through non-enzymatic glycosylation of collagen with advanced glycation end product formation and impaired microcirculation. Hypocholesteremia may lead to fatty infiltration and subsequent pro-inflammatory degenerative enzymatic degeneration. Thyroid disease may disrupt tendon homeostasis through the alteration of collagen production and the accumulation of glycosaminoglycans. Lastly, smoking inhibits tendon healing through the induction of hypovascularity and hypoperfusion. Understanding of the implications these systemic conditions have on the outcomes is important in the management of rotator cuff disease.

Rotator cuff injuries and factors associated with reoperation

OBJECTIVE

To evaluate the prevalence of rotator cuff tears and describe the profile of reoperated patients, causes of repeated tendon tears, tear evolution and range of times between surgical procedures.

METHOD

This was a cross-sectional study involving 604 surgical procedures performed at two regional referral hospitals between January 2006 and December 2012. After approval by the ethics committee, data describing the patients' epidemiological profile were gathered at a single time, using Cofield's classification to measure the extent of the tears, all of which underwent arthroscopic surgery. The data were entered into Epi Info 3.5.3 and were analyzed using SPSS version 18.0.

RESULTS

Among the 604 surgical procedures, females were affected in more cases (351; 58.1%). When the dominant limb was the right limb, it was affected in 90% of the cases (p < 0.05). The supraspinatus tendon was affected in 574 cases (95%) and the tears were of medium size in 300 cases (49.7%). Eighteen reoperations were performed (2.98%) and the upper right limb was the most affected (66.6%). The cause was non-traumatic in 12 patients. The repeated tears were mostly smaller (44%), and the length of time between the two surgical procedures ranged from 6 to 298 weeks.

CONCLUSION

Female gender, smaller extent in the second procedure and non-traumatic cause were found in most of the cases analyzed.

Comparative analysis on arthroscopic sutures of large and extensive rotator cuff injuries in relation to the degree of osteopenia

OBJECTIVE

To analyze the results from arthroscopic suturing of large and extensive rotator cuff injuries, according to the patient's degree of osteopenia.

METHOD

138 patients who underwent arthroscopic suturing of large and extensive rotator cuff injuries between 2003 and 2011 were analyzed. Those operated from October 2008 onwards formed a prospective cohort, while the remainder formed a retrospective cohort. Also from October 2008 onwards, bone densitometry evaluation was requested at the time of the surgical treatment. For the patients operated before this date, densitometry examinations performed up to two years before or after the surgical treatment were investigated. The patients were divided into three groups. Those with osteoporosis formed group 1 (n = 16); those with osteopenia, group 2 (n = 33); and normal individuals, group 3 (n = 55).

RESULTS

In analyzing the University of California at Los Angeles (UCLA) scores of group 3 and comparing them with group 2, no statistically significant difference was seen (p = 0.070). Analysis on group 3 in comparison with group 1 showed a statistically significant difference (p = 0.027).

CONCLUSION

The results from arthroscopic suturing of large and extensive rotator cuff injuries seem to be influenced by the patient's bone mineral density, as assessed using bone densitometry.