Non-surgical and surgical treatments for rotator cuff disease: a pragmatic randomised clinical trial with 2-year follow-up after initial rehabilitation

Comparative analysis of functional outcomes in arthroscopic repair for traumatic and non-traumatic rotator cuff injuries

BACKGROUND

The impact of the etiology of rotator cuff injury (RCI) on outcomes after rotator cuff repair remains unclear. This study aimed to evaluate the postoperative outcomes of patients with RCIs of different etiologies and identify the risk factors affecting prognosis.

METHODS

This study included 73 patients with RCI who underwent arthroscopic rotator cuff repair. The patients were categorized into either a traumatic group or a non-traumatic group based on their history of trauma. Preoperative and postoperative assessments included shoulder range of motion, muscle strength, and physical examination findings specific to the shoulder for both groups. Clinical differences between arthroscopic repair of traumatic and non-traumatic RCIs were evaluated using univariate analysis. Logistic regression analysis determined independent risk factors for rotator cuff repair prognosis.

RESULTS

Among the 73 patients, 31 were in the traumatic group and 42 in the non-traumatic group, with a minimum postoperative follow-up of 12 months and a mean follow-up of 13.8 months. The duration of the disease was significantly longer in the non-traumatic group compared with the traumatic group (P < 0.001). The mean tear area was more significant in the traumatic group than in the non-traumatic group (P = 0.003), and the preoperative pain level and functional scores were better in the non-traumatic group compared with the traumatic group. Postoperatively, there were no differences between the two groups regarding scores, joint mobility, strength, and complications. At 12 months postoperatively, multivariate regression analysis indicated that full-layer tear (OR = 5.106, 95% CI: 1.137-22.927, P = 0.033), fat infiltration (OR = 6.020, 95% CI: 1.113-32.554, P = 0.037), and tear area (OR = 6.038, 95% CI: 2.122-17.177, P < 0.001) significantly affected the University of California at Los Angeles (UCLA) score.

CONCLUSION

Compared with non-traumatic RCI, traumatic RCI presents with more pronounced pain and impaired joint function preoperatively yet demonstrates comparable postoperative clinical outcomes. Full-layer tears, fat infiltration, and large tear areas are unfavorable factors affecting rotator cuff repair, and postoperative rehabilitation management of these patients should be emphasized.

Health-related quality of life influences surgical decisions in patients with rotator cuff disease

Aims

Rotator cuff disease (RCD) can considerably decrease quality of life. Here, we investigated whether health-related quality of life (HRQoL) influences the need for surgery in patients with RCD.

Methods

We performed an analysis of 417 patients with symptomatic RCD who were recruited from two hospitals between June 2008 and December 2014 to be randomized to receive non-surgical or surgical treatment. After a three-month rehabilitation period, 36-Item Short-Form Health Survey questionnaire (SF-36), shoulder pain (visual analogue scale (VAS)), and shoulder function (Constant-Murley score) data were available from 191 still-symptomatic patients who were eligible for surgery. A control group was formed from 87 excluded patients who were no longer eligible for surgery due to relief of symptoms.

Results

Mean pain on the VAS was 51.3 (SD 20.1) in the patients eligible for surgery and 41.7 (SD 21.2) in the control group. The following domains of the SF-36 were associated with being eligible for surgery in univariate analyses: bodily pain, general health, vitality, social functioning, and emotional wellbeing. In multivariate analysis, only bodily pain was associated with pursuing surgical treatment. The RCD population's values for physical role, bodily pain, and physical functioning were poorer compared to the values of the general population.

Conclusion

Lower HRQoL, as indicated by the lower bodily pain score on the SF-36, was associated with the decision to undergo surgical treatment in patients with RCD. Therefore, HRQoL should be considered when determining treatment options for RCD.

Use of a surgical referral algorithm within a standardized shoulder physical therapy program to assist clinical decision-making

PURPOSE

Determine (a) utility of a shoulder referral algorithm, (b) patients improving ≥15% on the Western Ontario Rotator Cuff(WORC) score with standardized Physical Therapy(PT) +home exercises, and (c) presenting characteristics among PT-Only, PT + Surgical Consult and Surgery participants.

MATERIALS AND METHODS

Prospective cohort study of patients 30-65 years old with shoulder pain. A standardized PT program assessed pain, ROM, strength and exercise tolerance (i.e., referral algorithm) at 2-, 6- and 12-weeks to determine if a surgical consultation might be beneficial. A blinded research assessor evaluated pain, ROM, strength and WORC score at 6-, 12-weeks and 6-months. The proportion improving WORC scores ≥15% and group differences were also evaluated.

RESULTS

32/128 (25%) participants underwent consultation with 16 (12.5%) undergoing surgery. WORC scores improved ≥15% by 12-weeks in most PT-Only/PT + Surgical Consult participants (n = 77[70%]) and was maintained at 6-months. Surgery participants used more NSAIDs (p = 0.01), injections (p = 0.002) and trended to higher opioid use (p = 0.06). PT + Surgical Consult/Surgery participants (n = 16/32; 50%) knew diagnostic imaging results more than PT-Only (n = 26; 31%) (p = 0.02). Surgery participants presented with worse pain, ROM, strength and WORC scores than PT-Only (p < 0.05).

CONCLUSIONS

The algorithm identified those with worse symptomology (25%), 50% of whom underwent surgery. WORC scores improved ≥15% in most participants (70%). Presenting characteristics were significantly worse between PT-Only and Surgery participants.

Unravelling interacting barriers and facilitators to adherence and delivery of exercise-based care in the treatment of Subacromial Pain Syndrome - an exploratory qualitative study

PURPOSE

Subacromial Pain Syndrome (SAPS) is a common persistent pain condition. Exercise-based care is first-line recommendation, but an insufficient exercise dose hampers effectiveness. This study explores individual and contextual barriers and facilitators for delivery of and adherence to exercise-based care in people with SAPS.

MATERIALS AND METHODS

Participants in this exploratory qualitative study were involved in the management of SAPS in Denmark. Triangular interviews and analyses were conducted within 3 themes (delivery of recommended services, adherence to recommendations, and frames of the clinical pathways) using the Theoretical Domains Framework (TDF) and the Behavioural Change Wheel model (BCW) to map barriers and facilitators into the Capability, Opportunity, Motivation and Behaviour (COM-B) model.

RESULTS

From interviews with 10 persons with SAPS and 37 healthcare practitioners and double-deductive analyses, 30 subjects of target behaviour within 13 TDF domains emerged across perspectives and COM-B components. Central barriers to delivery and adherence were inconsistencies in diagnostic terminology, cross-professional disagreements, beliefs, and expectations towards pathway services.

CONCLUSION

We identified interrelated individual and contextual barriers to delivery and adherence across all aspects of the BCW, underpinning the complexity of the subject. Findings support that effectiveness of exercise-based care is linked to contextual barriers to delivery and adherence.

Fifteen-Year Results of a Comparative Analysis of Tendon Repair Versus Physiotherapy for Small-to-Medium-Sized Rotator Cuff Tears: A Concise Follow-up of Previous Reports

ABSTRACT

The optimal treatment for small-to-medium-sized rotator cuff tears remains a topic of debate. While both tendon repair and physiotherapy have shown comparable short-term results, there are concerns about the long-term effectiveness of physiotherapy. In 2 previous reports presenting the 5 and 10-year results of this trial, significant and increasing differences were observed in favor of tendon repair. Further investigation of the unexplored time interval after 10 years is essential to fully understand the implications of our treatment approaches. A total of 103 patients with a full-thickness rotator cuff tear not exceeding 3 cm were randomly allocated to tendon repair or physiotherapy with optional secondary repair. Measurements of shoulder function were performed by a blinded assessor at 6 months and 1, 2, 5, 10, and 15 years. The outcome of primary interest was the 15-year result for the Constant score. Secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons (ASES) score; the Short Form-36 (SF-36) Health Survey; assessments of pain, motion, and strength; and patient satisfaction. Tear-size increase in unrepaired tears was assessed by sonography. Statistical analysis was by mixed-model analysis for repeated measurements and by intention to treat. Eighty-three (81%) of 103 patients attended the 15-year follow-up. Fifteen of 51 patients in the physiotherapy group had crossed over to secondary surgery. Results from primary tendon repair were superior by a mean difference of 11.8 points for the Constant score (p = 0.001), 13.9 points for the ASES score (p < 0.001), 1.8 cm on a 10-cm visual analog scale for pain (p < 0.001), and 16.2° and 22.4°, respectively, for pain-free abduction and flexion (p = 0.04 and 0.001). On the SF-36, differences did not reach significance for any of the scoring scales. In 26 tears treated by physiotherapy only, the mean tear size had increased from 16.2 to 31.6 mm in the anterior-posterior direction. Long-term outcomes from primary tendon repair remained superior to physiotherapy up to 15 years of follow-up, supporting its use as the primary treatment for small-to-medium-sized rotator cuff tears.

LEVEL OF EVIDENCE

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

A threshold of lower preoperative mental health is associated with decreased achievement of comfort and capability benchmarks following rotator cuff repair: a retrospective cohort study

BACKGROUND

Preoperative biomedical patient characteristics are known to affect the time to achievement of clinically significant outcomes (CSOs) following arthroscopic rotator cuff repair (RCR). However, less is known about the association between preoperative mental status and the time to achievement of CSOs. We hypothesize that higher preoperative mental status is associated with faster achievement of CSOs following arthroscopic RCR.

METHODS

Patient-reported outcome measures (PROMs) were collected preoperatively and at postoperative intervals up to 2 years. PROMs included pain visual analog scale (VAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), and Veterans RAND 12-Item Health Survey (VR-12) scores. Threshold values for CSOs were obtained from previous literature. Mean time to achievement of CSOs was calculated using a Kaplan-Meier analysis. A Cox proportional hazards regression analysis was performed to identify preoperative variables associated with earlier achievement of CSOs.

RESULTS

Sixty-nine patients with an average age of 59 ± 8 years were included. Patients with higher preoperative mental status, as measured by VR-12 mental component summary (MCS), experienced significantly earlier substantial pain improvement postoperatively (P = .0471). Patients with higher preoperative mental status also achieved CSOs for physical health at earlier time points (P = .0187). Preoperative VR-12 MCS scores ≥ 40 were associated with earlier achievement of CSOs for pain (P = .0005) and physical health (P = .0015). Ninety-eight percent of patients with preoperative MCS scores ≥40 achieved acceptable pain relief at 4.5 months vs. 56% of all other patients at 12.3 months (P = .0001). Patients with preoperative MCS scores ≥40 experienced significantly faster improvement in physical health compared to patients with preoperative MCS scores <40 (P = .0006).

CONCLUSIONS

Higher preoperative mental status, especially a preoperative MCS score ≥40, is associated with significantly faster improvement in pain and physical function following arthroscopic RCR. Nearly all patients (98%) with preoperative MCS score ≥40 achieved an acceptable state of pain relief compared with only 56% of patients with preoperative MCS score <40. These findings indicate that a holistic approach with equal consideration of preoperative mental health and rotator cuff pathophysiology is vital to the successful management of rotator cuff tendinopathy.

Short-Term Effects of Cold Therapy and Kinesio Taping on Pain Relief and Upper Extremity Functionality in Individuals with Rotator Cuff Tendonitis: A Randomized Study

Background and Objectives: Rotator cuff tendonitis (RCT) is one of the most common shoulder pathologies. It causes pain, limits shoulder joint movements, and impairs function. Despite various treatment methods, there are currently no specific guidelines regarding the most effective intervention for RCT. To the best of our knowledge, no studies have compared the effects of Kinesio taping (KT) and cold therapy (CT) on individuals with RCT. To this end, this study aimed to investigate and compare the short-term effects of KT and CT on pain relief and upper extremity functionality in individuals with RCT. Materials and Methods: One hundred and fourteen individuals were assessed for eligibility. Fifty-two individuals with RCT who met the inclusion criteria and agreed to participate were randomly allocated into either the KT or the CT group. A standardized home exercise program was given to all the participants. Their pain intensity, upper extremity function, shoulder range of motion (ROM), and grip strength were evaluated initially and after the three days of KT or CT applications. Results: All the assessment values significantly improved in the KT group. In the CT group, only the pain scores (except for the numerical rating scale (NRS) pain score during activity) were significantly improved in the CT group at the end of the third day of application compared to the initial values (p < 0.05). For all the measurement outcomes, the effects of time × group interactions were statistically significant (p < 0.05) in favor of the KT group, except for the resting pain (p = 0.688). Conclusions: The findings suggest that KT and CT could be used as adjunctive modalities to exercise for resting and night pain relief in patients with RCT. KT also had positive effects on the activity pain, function, ROM, and grip strength. The use of KT along with an exercise program could be a more effective therapeutic choice than the use of CT for improving night pain, activity pain, and upper extremity function during the short-term rehabilitation of RCT patients.

A Pilot Study for Effectiveness and Safety of Adjunctive Pharmacopuncture to Acupuncture Treatment for Rotator Cuff Diseases: A Pragmatic Randomized Controlled Trial

Purpose

Pharmacopuncture therapy has been used in the conservative treatment of rotator cuff disease adjuvant to acupuncture treatment. Despite the increasing utilization of pharmacopuncture therapy, there is still a lack of high-quality research to support its effectiveness. This pilot study aimed to assess the feasibility of pharmacopuncture therapy adjuvant to acupuncture treatment for rotator cuff disease.

Patients and Methods

This was a parallel-grouped, pragmatic randomized controlled, pilot study. Forty patients were randomly allocated to either the experimental or the control group. All patients received acupuncture treatment for four weeks, and pharmacopuncture was additionally administered to the experimental group. After eight treatments were delivered over four weeks, follow-up assessments were performed. The primary outcome was the mean change in the visual analog scale (VAS) score for shoulder pain from baseline to visit 8. Secondary outcomes included shoulder pain and disability index (SPADI) at visits 4, 8, and 9, shoulder range of motion (ROM) at visits 4, 8, and 9, EuroQol 5-Dimension 5-Level questionnaire (EQ-5D-5L) at visits 8 and 9, patient global impression of change (PGIC) at visits 8 and 9, and mean rescue medication consumption at visits 8 and 9.

Results

Both groups showed that each treatment effectively improved rotator cuff disease in most assessments. Particularly, the group that received acupuncture plus pharmacopuncture required fewer rescue medications than the group that received acupuncture alone. However, there was little statistically significant difference between the two groups. There were no serious adverse events experienced by patients in this study.

Conclusion

Although there was little statistical difference between the two groups, the combination of acupuncture and pharmacopuncture for rotator cuff disease was associated with a reduction in the rescue medicine dosage compared with acupuncture alone. Also, it confirmed the safety of pharmacopuncture therapy. This pilot study would help design future research on the effectiveness of pharmacopuncture in rotator cuff disease.

Stem cell-based therapeutic strategies for rotator cuff tendinopathy

Rotator cuff tendinopathy is a common musculoskeletal disorder that imposes significant health and economic burden. Stem cell therapy has brought hope for tendon healing in patients with final stage rotator cuff tendinopathy. Some clinical trials have confirmed the effectiveness of stem cell therapy for rotator cuff tendinopathy, but its application has not been promoted and approved. There are still many issues that should be solved prior to using stem cell therapy in clinical applications. The optimal source and dose of stem cells for rotator cuff tendinopathy should be determined. We also proposed novel prospective approaches that can overcome cell population heterogeneity and standardize patient types for stem cell applications.

The translational potential of this article

This review explores the optimal sources of stem cells for rotator cuff tendinopathy and the principles for selecting stem cell dosages. Key strategies are provided for stem cell population standardization and recipient selection.

Tailored modulation of S100A1 and RASSF8 expression by butanediamide augments healing of rotator cuff tears

Objectives

This investigation sought to elucidate promising treatment modalities for rotator cuff tears (RCTs) by delving into the molecular machinations instigating the affliction. The focus was on differentially expressed genes (DEGs) linked to RCTs, and the exploration of their roles and operative pathways.

Methods

DEGs were discerned from GEO datasets, followed by the establishment of a protein-protein interaction (PPI) network. Subsequently, the network's core genes were determined employing a Venn diagram. Enrichment analysis facilitated the unveiling of the biological roles and signal transduction pathways of these pivotal genes, thus shedding light on molecular strategies for RCT-targeted treatment. The Discovery Studio 2019 software was employed to sift through FDA-sanctioned drugs targeting these essential proteins. Moreover, the efficaciousness of these FDA-endorsed drugs vis-à-vis RCTs was corroborated by the construction of an in vivo animal model of the injury and the in vitro cultivation of tendon-derived stem cells.

Results

Bioinformatics outcomes revealed a significant overexpression of S100A1 and RASSF8 in RCT patients. The FDA drug repository indicated that Butanediamide has a selective affinity for S100A1 and RASSF8. Subsequent in vivo and in vitro experimentation demonstrated that Butanediamide could suppress S100A1 expression and bolster TDSC proliferation, thereby facilitating RCT healing.

Conclusions

S100A1 and RASSF8 are pivotal genes implicated in RCTs, and their roles have been elucidated. The FDA-approved compound, Butanediamide, may represent a prospective therapeutic agent for RCTs by targeting S100A1 and RASSF8, respectively.

Clinical value of three-dimensional ultrasonography in the morphologic evaluation of rotator cuff tear: a prospective study

OBJECTIVE

To study the clinical value of three-dimensional ultrasonography (3D-US) in the morphological evaluation of rotator cuff tears (RCTs).

METHODS

Based on previously published literature, RCT patterns in our study were divided into crescent, L-shaped with the remnant tendon retracted to the anterior rotator cuff (aL-shaped), L-shaped with the remnant tendon retracted to the posterior rotator cuff (pL-shaped), T-shaped (a tear pattern that is a combination of aL-shaped and pL-shaped), U-shaped, and massive type. Two radiologists prospectively assessed the tear patterns using 3D-US as well as magnetic resonance imaging (MRI) and compared these results using arthroscopy to calculate diagnostic accuracy.

RESULT

Fifty-two patients (52 shoulders) were enrolled. The overall diagnostic accuracy of 3D-US in evaluating RCT patterns (82.7%, 43/52; 95% CI: 72.1-93.3%) was significantly higher (p = 0.008) than that of the MRI (57.7%, 31/52; 95% CI: 45.8-73.4%). The accuracy of 3D-US was higher than that of MRI for most types of tears (crescent: 95.0% vs. 55.0%, aL-shaped: 83.3% vs. 77.8%, pL-shaped: 50.0% vs. 25.0%, T-shaped: 75.0% vs. 0.0%, and massive type: 80.0% vs. 100.0%). The accuracies of 3D-US with respect to evaluation by the two radiologists were 84.6% (44/52) and 76.9% (40/52), and there was substantial agreement evident (κ = 0.709). The time taken by the two radiologists to reconstruct the 3D-US images and evaluate the tear pattern was < 5 min.

CONCLUSION

The 3D-US can be used for the preoperative evaluation of RCT patterns, and thus be useful for the correct selection of the surgical repair technique for RCTs.

KEY POINTS

• Few studies have been found exploring the value of 3D-US for the morphological evaluation of RCTs and correlated with the arthroscopic findings. • Based on previous studies on the morphological classification, anterior L shape (aL-shaped), and posterior L shape (pL-shaped) were used for the first time to describe the torn patterns of RCT.

Identifying Conservative Interventions for Individuals with Subacromial Pain Syndrome Prior to Undergoing a Subacromial Decompression: A Scoping Review

Background

Subacromial decompression (SAD) surgery remains a common treatment for individuals suffering from subacromial pain syndrome (SAPS), despite numerous studies indicating that SAD provides no benefit over conservative care. Surgical protocols typically recommend surgery only after exhausting conservative measures; however, there is no consensus in the published literature detailing what constitutes conservative care "best practice" before undergoing surgery.

Purpose

To describe conservative interventions received by individuals with SAPS prior to undergoing a SAD.

Study Design

Scoping review.

Methods

An electronic search using MEDLINE, CINAHL, PubMed, and Scopus databases was conducted. Peer-reviewed randomized controlled control trials and cohort studies published between January 2000 and February 2022 that included subjects diagnosed with SAPS who progressed to receive a SAD were eligible. Subjects who received previous or concurrent rotator cuff repair with SAPS were excluded. Conservative interventions and treatment details that subjects received prior to undergoing a SAD were extracted.

Results

Forty-seven studies were included after screening 1,426 studies. Thirty-six studies (76.6%) provided physical therapy (PT) services, and six studies (12.8%) included only a home exercise program. Twelve studies (25.5%) specifically detailed the delivered PT services, and 20 studies (42.6%) stated who provided the PT interventions. Subacromial injections (SI) (55.3%, n=26) and non-steroidal anti-inflammatories (NSAIDs) (31.9%, n=15) were the next most frequently delivered interventions. Thirteen studies (27.7%) included combined PT and SI. The duration of conservative care varied from 1.5 months to 16 months.

Conclusion

Conservative care that individuals with SAPS receive to prevent advancement to SAD appears inadequate based on the literature. Interventions, such as PT, SI, and NSAIDs, are either underreported or not offered to individuals with SAP prior to advancing to surgery. Many questions regarding optimal conservative management for SAPS persists.

Level of Evidence

n/a.

Rotator Cuff Health, Pathology, and Repair in the Perspective of Hyperlipidemia

Rotator Cuff Injuries (RCI) are prevalent cause of shoulder pain affecting over 20% of the population in the USA. Surgical repair of the torn rotator cuff helps in relieving the pressure on the rotator cuff tendon and from symptoms, however tendon-to-bone healing after rotator cuff surgery still has a high failure rate. Hyperlipidemia has been strongly associated with RCI although the cellular and molecular mechanisms are largely unknown. The focus of this critical review is to further explore the role of hyperlipidemia in RCI and rotator cuff tissue repair to determine its implication as a risk factor for tears, repair, and retears. A literature review was conducted to elucidate the role of hyperlipidemia as an inflammatory mediator and catalyst for structural instability within the shoulder. The results from various studies were critically reviewed to summarize the relationship between hyperlipidemia and rotator cuff pathology. Hyperlipidemia induces LDL-particle entrapment within the dense regular collagen of rotator cuff tendons resulting in foam cell aggregation and macrophage recruitment. Subsequent inflammatory pathways including the JAK2/STAT3 pathway and NLRP3 inflammasome pathway led to persistent inflammation and Extracellular Matrix (ECM) degradation within the rotator cuff. While arthroscopic repair remains the most common treatment modality, nonsurgical treatment including statins, vitamin D, and targeting miRNA are also of therapeutic benefit. Hyperlipidemia interferes with arthroscopic repairs by inducing inflammation and stiffness within tendons and increases the risk of retears. Most notably, targeting underlying mechanisms influencing inflammation has large therapeutic value as a novel treatment strategy for the management of rotator cuff pathology.

Cryoanalgesia for shoulder pain: a motor-sparing approach to rotator cuff disease

Introduction

Rotator cuff disease is a common cause of musculoskeletal pain and disability, and the management can be challenging. Joint denervation emerges as a new technique, but the literature on shoulder neural ablation procedure is largely limited to pulsed radiofrequency due to the concern of motor impairment. We described a novel motor-sparing approach of cryoablation for the management of shoulder pain based on the recent literature on the innervation of shoulder.

Methods

Four patients with a history of rotator cuff disease refractory to conservative therapy and not amenable to surgery underwent a ultrasound-guided cryoablation of the capsular branches of the shoulder joint after a positive diagnostic injection. The target articular branches were based on the anatomical landmarks described in recent publication. They were the acromial, superior and inferior branches of the suprascapular nerve, the anterior branch of the axillary nerve, the nerve to the subscapularis, which were all located around the superior, posterior and anterior glenoid. The lateral pectoral nerve articular branch was targeted at the coracoclavicular space.

Results

All four patients experienced at least 60% pain relief with improvement in function for 6–12 months following the procedure without any clinical evidence of motor impairment. No adverse effect was observed.

Discussion

Based on the current understanding of the glenohumeral joint articular branches and their relationship to the bony landmark, targeting the articular branches only was feasible and led to good outcomes. Further large prospective cohort study is needed.

Editorial Commentary: Arthroscopic Treatment Should No Longer Be Offered to People With Subacromial Impingement

Arthroscopic treatment should no longer be offered to people with subacromial impingement. In many people, subacromial impingement (or subacromial pain syndrome) is self-limiting and may not require any specific treatment. This is evident by the fact that almost 50% of people with new-onset shoulder pain consult their primary care doctor only once. The best-available evidence from randomized controlled trials indicates that glucocorticoid injection provides rapid, modest, short-term pain relief. Exercise therapy has also been found to provide no added benefit over glucocorticoid injection. Subacromial decompression (bursectomy and acromioplasty) for subacromial pain syndrome provides no important benefit on pain, function, or health-related quality of life. Acromioplasty does not improve the outcomes of rotator cuff repair.

Rotator cuff repair with biodegradable high-purity magnesium suture anchor in sheep model

Background

Rotator cuff tear has become one of the diseases affecting people's living quality. Conventional anchor materials such as titanium alloy and poly-lactic acid can lead to postoperative complications like bone defects and aseptic inflammation. Magnesium (Mg)-based implants are biodegradable and biocompatible, with strong potential to be applied in orthopaedics.

Methods

In this study, we developed a high-purity (HP) Mg suture anchor and studied its mechanical properties and degradation behavior in vitro. Furthermore, we described the use of high-purity Mg to prepare suture anchor for the rotator cuff repair in sheep.

Results

The in vitro tests showed that HP Mg suture anchor possess proper degradation behavior and appropriate mechanical property. Animal experiment indicated that HP Mg suture anchor provided reliable anchoring function in 12 weeks and showed no toxic effect on animal organs.

Conclusion

In summary, the HP Mg anchor presented in this study had favorable mechanical property and biosecurity.

The translational potential of this article: The translational potential of this article is to use high-purity Mg to develop a degradable suture anchor and verify the feasibility of the application in animal model. This study provides a basis for further research on the clinical application of biodegradable high-purity Mg suture anchor.

Benefits and Harms of Interventions With Surgery Compared to Interventions Without Surgery for Musculoskeletal Conditions: A Systematic Review With Meta-analysis

OBJECTIVE

To estimate the benefits and harms of interventions with and without surgery for musculoskeletal (MSK) conditions.

DESIGN

Intervention systematic review with meta-analysis of randomized controlled trials (RCTs).

LITERATURE SEARCH

MEDLINE, EMBASE, CINAHL, Web of Science, and CENTRAL, all up to January 7, 2021.

STUDY SELECTION CRITERIA

RCTs (English, German, Danish, Swedish, and Norwegian) of interventions with and without surgery conducted in any setting for any non-fracture MSK condition in adults (mean age: 18+ years) evaluating the outcomes on a continuous (benefits) or count (harms) scale. Outcomes were pain, self-reported physical function, quality of life, serious adverse events (SAEs), and death at 1 year.

DATA SYNTHESIS

Random-effects metaanalyses for MSK conditions where there were data from at least 2 trials.

RESULTS

One hundred RCTs (n = 12 645 patients) across 28 different conditions at 9 body sites were included. For 9 out of 13 conditions with data on pain (exceptions include some spine conditions), 11 out of 11 for function, and 9 out of 9 for quality of life, there were no clinically relevant differences (standardized mean difference of 0.50 or above) between interventions with and without surgery. For 13 out of 16 conditions with data on SAEs and 16 out of 16 for death, there were no differences in harms. Only 6 trials were at low risk of bias.

CONCLUSION

The low certainty of evidence does not support recommending surgery over nonsurgical alternatives for most MSK conditions with available RCTs. Further high-quality RCTs may change this conclusion. J Orthop Sports Phys Ther 2022;52(6):312-344. doi:10.2519/jospt.2022.11075.

Inhibition of IKKβ/NF-κB signaling facilitates tendinopathy healing by rejuvenating inflamm-aging induced tendon-derived stem/progenitor cell senescence

Degenerative rotator cuff tendinopathy (RCT) is a chronic tendon disease caused by degeneration and inflammation, which often affects the elderly population. Mesenchymal stem cell senescence is generally recognized as an important pathophysiological mechanism in many age-related skeletal diseases. Herein, we collected human tendon-derived stem/progenitor cells (TSPCs) from degenerative supraspinatus tendons and found that TSPC senescence is closely related to RCT. We further identified that nuclear factor κB (NF-κB) pathway activation is involved in age-related inflammation (inflamm-aging) of degenerative RCT. Moreover, whole genome RNA sequencing revealed that in vitro inhibition of the I kappa B kinase β (IKKβ)/NF-κB signaling pathway could reverse the aged TSPC phenotype with decreased TSPC senescence and increased tenogenic potential. To achieve effective in vivo inhibition of IKKβ/NF-κB signaling, we fabricated IKKβ small interfering RNA (siRNA)-loaded gold nanoclusters (AuNC-siRNA) for efficient and convenient intra-articular delivery of IKKβ siRNA. We found that AuNC-siRNA prevented inflamm-aging-induced TSPC senescence and dysfunction in a degenerative RCT aged rat model. Together, these data show that inflamm-aging causes degenerative RCT through inducing TSPC senescence, which can be reversed by blocking the IKKβ/NF-κB pathway in vivo. Thus, our study provides a promising therapeutic strategy for degenerative RCT via intra-articular delivery of IKKβ siRNA using AuNCs.

Rotator cuff repair vs. nonoperative treatment: a systematic review with meta-analysis

BACKGROUND

Rotator cuff (RC) tears have been widely studied as many treatment strategies have been recommended. However, optimal management for patients with RC tears is still unclear.

PURPOSE

The main aim of this systematic review was to analyze randomized controlled trials using meta-analysis to compare repair to conservative treatments for patients with any type of RC tear.

METHODS

MEDLINE, Cochrane Library (CENTRAL database), PEDro, and Scopus databases were used. Two independent reviewers selected randomized controlled trials that compared surgical to conservative treatments for RC tear patients. The studies included were assessed using Cochrane Risk of Bias 2 tools, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the certainty of evidence and to summarize the study conclusions.

RESULTS

Six trials were included. Pooled results showed improvement in function and pain perception in favor of the repair group at 6 months (mean difference 1.26, 95% CI -2.34, 4.85, P = .49; and -0.59, 95% CI -0.84, -0.33, P < .001, respectively), at 12 months (mean difference 5.25, 95% CI 1.55, 8.95, P = .005, for function; and -0.41, 95% CI -0.70, -0.12, P = .006, for pain) and at 24 months (mean difference 5.57, 95% CI 1.86, 9.29, P = .003, for function; and -0.92, 95% CI -1.31, -0.52, P < .001, for pain) in RC tear patients. However, these differences did not reach the minimum clinically important difference. The certainty of evidence ranged from low to moderate because of imprecision in the studies included.

CONCLUSIONS

Overall analysis showed that in patients with RC tear, repair compared with conservative treatment could result in increased pain reduction and functional improvement at 6, 12, and 24 months. Even if these effects were often statistically significant, their clinical relevance was limited. Moreover, the certainty of body of evidence ranged from low to moderate.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Effectiveness of Adding a Large Dose of Shoulder Strengthening to Current Nonoperative Care for Subacromial Impingement: A Pragmatic, Double-Blind Randomized Controlled Trial (SExSI Trial)

BACKGROUND

A strong recommendation against subacromial decompression surgery was issued in 2019. This leaves nonoperative care as the only treatment option, but recent studies suggest that the dose of strengthening exercise is not sufficient in current nonoperative care. At this point, it is unknown if adding more strengthening to current nonoperative care is of clinical value.

PURPOSE

To assess the effectiveness of adding a large dose of shoulder strengthening to current nonoperative care for subacromial impingement compared with usual care alone.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

In this double-blinded, pragmatic randomized controlled trial, we randomly allocated 200 consecutive patients referred to orthopaedic shoulder specialist care for long-standing shoulder pain (>3 months), aged 18 to 65 years and diagnosed with subacromial impingement using validated criteria, to the intervention group (IG) or control group (CG). Outcome assessors were blinded, and participants were blinded to the study hypothesis as well as to the treatment method in the other group. The CG received usual nonoperative care; the IG underwent the same plus an add-on intervention designed to at least double the total dose of shoulder strengthening. The primary outcome was the Shoulder Pain and Disability Index (SPADI; 0-100) at 4-month follow-up, with 10 points defined as the minimal clinically important difference. Secondary outcomes included shoulder strength, range of motion, health-related quality of life, and the Patient Acceptable Symptom State (PASS).

RESULTS

Intention-to-treat and per-protocol analyses showed no significant or clinically relevant between-group differences for any outcome. From baseline to 4-month follow-up, SPADI scores improved in both groups (intention-to-treat analysis; IG, -22.1 points; CG, -22.7 points; between-group mean difference, 0.6 points [95% CI, -5.5 to 6.6]). At 4 months after randomization, only 54% of the IG and 48% of the CG (P = .4127) reached the PASS. No serious adverse events were reported.

CONCLUSION

Adding a large dose of shoulder strengthening to current nonoperative care for patients with subacromial impingement did not result in superior shoulder-specific patient-reported outcomes. Moreover, approximately half of all randomized patients did not achieve the PASS after 4 months of nonoperative care, leaving many of these patients with unacceptable symptoms. This study showed that adding more exercise is not a viable solution to this problem.

REGISTRATION

NCT02747251 (ClinicalTrials.gov identifier).