Arthroscopic rotator cuff repair using a suture bridge technique: is the repair integrity actually maintained?

Patient, imaging, and surgical factors associated with supraspinatus re-tear pattern after rotator cuff repair

Background

This study aimed to characterize patient, imaging, and surgical factors associated with re-tear patterns after rotator cuff repair, as well as to identify predictors of type 2 failure in a large patient cohort.

Methods

A retrospective case-control study was performed at a single urban academic institution. All patients who underwent an arthroscopic rotator cuff repair by 2 fellowship-trained shoulder and elbow surgeons between 2005 and 2022 and were subsequently found to have a symptomatic re-tear on magnetic resonance imaging were included. Patients were characterized as either a type 1 (failure at bone-tendon interface) or type 2 (failure medial to the bone-tendon junction) re-tear based on the Cho classification. Chart review was performed to collect demographic, imaging, and intraoperative surgical factors. Multivariable analysis was performed to determine patient and imaging factors associated with type 2 failure.

Results

Fifty-seven patients were included in the study. Overall, 33 (57.9%) patients were classified as a Cho 1 re-tear and 24 (42.1%) were classified as Cho 2 re-tear. No differences in preoperative tear characteristics (tear width, tear retraction, and tendon length) or fatty infiltration were found between Cho 1 and Cho 2 re-tears. Bivariate analysis comparing Cho 1 vs. Cho 2 found male sex was associated with a higher incidence of a Cho 2 re-tear (79.2% vs. 20.8%; P = .033). No significant differences in repair construct (single row vs. double row) (P = .816), biceps treatment (P = .552), concomitant subscapularis repair (P = .306), number of medial anchors (P = .533), or number of lateral anchors (P = .776) were noted between re-tear types. After controlling for potential confounding factors, multivariable regression analysis demonstrated that male sex was predictive of developing a Cho 2 re-tear (odds ratio 3.8; 95% confidence interval 1.1-13.3; P = .039). Repair construct was not found to be predictive of re-tear pattern (P = .580).

Conclusion

Repair construct used during rotator cuff repair does not appear to influence re-tear pattern. Male sex was associated with a higher rate of type 2 failure.

A Modified Mason-Allen Suture Enhancement Technique (Sunglasses Loop) for Single-Row Repair of Medium-to-Large Rotator Cuffs

We propose a single-row repair method for medium-to-large rotator cuff rotator cuff tears using a modified Mason-Allen suture enhancement technique (sunglasses loop), which uses high-tensile modified Mason-Allen sutures to close the medial rotator cuff tissues to form a sunglasses loop, resets the rotator cuff tissues via traction with the high-tensile suture, repairs the rotator cuff in a single row with triple-loaded suture anchor (anchor with 3 high-strength sutures), and finally employs an outer row of staples to secure the suture to the lateral aspect of the greater tuberosity, preventing the tendon from pulling out. This method uses a special sunglasses-shaped suture loop, which produces an increase in holding power and a reduction in tension relative to other single-row repair techniques and reduces the rate of rotator cuff retear.

Obesity is associated with muscle atrophy in rotator cuff tear

Objective

The primary goal of this study is to evaluate the relationship between Body Mass Index (BMI) and muscle atrophy in individuals with rotator cuff tears.

Methods

This study consists of patients with rotator cuff tears identified by MRI from two independent cohorts, the Rotator Cuff Outcomes Workgroup (ROW) and the Multicenter Orthopaedic Outcomes Network (MOON). Presence of atrophy (yes/no) and severity of atrophy (as an ordinal variable) were assessed on MRI by expert physicians. We used multivariable regression models to evaluate the relationship between BMI and muscle atrophy while adjusting for age and sex in each study, conducted sensitivity analyses for full-thickness tear and combined results using inverse variance-weighted meta-analysis.

Results

A total of 539 patients (MOON=395, ROW=144) from the combined cohorts had MRI data available on muscle atrophy. Among these patients, 246 (46%) had atrophy of at least one of the muscles of the rotator cuff and 282 (52%) had full-thickness tears. In meta-analysis across both cohorts, each 5 kg/m2 increase in BMI was associated with a 21% (aOR=1.21, 95% CI=1.02, 1.43) increased odds of having muscle atrophy among individuals with any tear size, and 36% (aOR=1.36, 95% CI=1.01-1.81) increased odds among individuals with full-thickness tear.

Conclusions

Higher BMI was associated with significantly higher odds of muscle atrophy in patiens with rotator cuff tears. More study is needed to unders1tand why and how this relationship exists, as well as whether interventions to reduce BMI may help improve outcomes for these patients.

Level of Evidence

III.

Re-tear after arthroscopic rotator cuff tear surgery: risk analysis using machine learning

BACKGROUND

Postoperative rotator cuff retear after arthroscopic rotator cuff repair (ARCR) is still a major problem. Various risk factors such as age, gender, and tear size have been reported. Recently, magnetic resonance imaging-based stump classification was reported as an index of rotator cuff fragility. Although stump type 3 is reported to have a high retear rate, there are few reports on the risk of postoperative retear based on this classification. Machine learning (ML), an artificial intelligence technique, allows for more flexible predictive models than conventional statistical methods and has been applied to predict clinical outcomes. In this study, we used ML to predict postoperative retear risk after ARCR.

METHODS

The retrospective case-control study included 353 patients who underwent surgical treatment for complete rotator cuff tear using the suture-bridge technique. Patients who initially presented with retears and traumatic tears were excluded. In study participants, after the initial tear repair, rotator cuff retears were diagnosed by magnetic resonance imaging; Sugaya classification types IV and V were defined as re-tears. Age, gender, stump classification, tear size, Goutallier classification, presence of diabetes, and hyperlipidemia were used for ML parameters to predict the risk of retear. Using Python's Scikit-learn as an ML library, five different AI models (logistic regression, random forest, AdaBoost, CatBoost, LightGBM) were trained on the existing data, and the prediction models were applied to the test dataset. The performance of these ML models was measured by the area under the receiver operating characteristic curve. Additionally, key features affecting retear were evaluated.

RESULTS

The area under the receiver operating characteristic curve for logistic regression was 0.78, random forest 0.82, AdaBoost 0.78, CatBoost 0.83, and LightGBM 0.87, respectively for each model. LightGBM showed the highest score. The important factors for model prediction were age, stump classification, and tear size.

CONCLUSIONS

The ML classifier model predicted retears after ARCR with high accuracy, and the AI model showed that the most important characteristics affecting retears were age and imaging findings, including stump classification. This model may be able to predict postoperative rotator cuff retears based on clinical features.

Combination of Superior and Posterior Capsular Release Versus Superior Capsular Release Alone in Arthroscopic Repair of Large-to-Massive Rotator Cuff Tears

Background

Superior capsular release has been used to reduce tendon tension, especially in arthroscopic repair of large-to-massive rotator cuff tears. Some clinicians have used a more extensive release of capsules in arthroscopic cuff repair for adequate reduction of torn tendons to footprints.

Purpose

To explore the effects of additional posterior capsular release for superior capsular release in arthroscopic repair of large-to-massive rotator cuff tears.

Study Design

Cohort study; Level of evidence, 3.

Methods

We compared 26 shoulders that underwent superior and posterior capsular release (group S&P) with 26 shoulders that underwent superior capsular release alone (group S) in arthroscopic repair of large-to-massive rotator cuff tears between January 23, 2013 and December 2, 2015. The visual analog scale for pain, American Shoulder and Elbow Surgeons score, Constant score, and range of motion (ROM) and muscle power were checked preoperatively and at 2 years postoperatively. Follow-up ultrasound was checked at 2 years postoperatively.

Results

In both groups, the overall mean functional outcomes improved from preoperatively to postoperatively. Patients in group S&P showed more pre- to postoperative improvement than patients in group S with regard to internal rotation ROM (mean difference, 30.0° vs 20.6°; P < .001) and internal rotation power (3.4 vs 1.8 kgf; P = .001). Patients in group S had a higher retear rate on the follow-up ultrasound than patients in group S&P, but this difference did not reach statistical significance (23.1% vs 11.5%, respectively; P = .465).

Conclusion

In the current study, patients who underwent superior and posterior capsular release in arthroscopic repair of large-to-massive rotator cuff tears had greater postoperative improvement in internal rotation ROM and power compared with patients who underwent superior capsular release alone.

Clinical outcomes of medialized single-row repair with fascia lata graft augmentation for large and massive rotator cuff tears

BACKGROUND

A high postoperative retear rate after arthroscopic rotator cuff repair (ARCR) of large and massive tears remains a problem. This study evaluated rotator cuff integrity after ARCR with fascia lata graft augmentation for large and massive rotator cuff tears and compared clinical outcomes between patients with intact repairs and retears.

METHODS

Forty-five patients with rotator cuff tears who could not undergo primary repair due to tendon retraction underwent arthroscopic medialized single-row repair with fascia lata graft augmentation. The patients' minimum follow-up was 2 (2-9) years. Supraspinatus cuff integrity was evaluated postoperatively by magnetic resonance imaging. We compared the clinical outcomes of patients with intact repairs vs. retears based on the University of California-Los Angeles (UCLA), Constant, and Japanese Orthopaedic Association (JOA) scores. We also evaluated their range of motion (ROM) and muscle strength.

RESULTS

Retears were observed in 11 of 45 patients. UCLA, Constant, and JOA scores significantly improved postoperatively compared to preoperatively in the intact repair (all P < .001) and retear (all P < .036) groups. The intact repair group had significantly higher Constant (75.6 [mean] ± 9.9 [SD] vs. 69.8 ± 7.9; P = .026) and JOA (94.4 ± 6.9 vs. 89.8 ± 5.9; P = .041) scores than the retear group. Forward elevation, abduction, and the strengths of abduction and external rotation significantly improved in the intact repair group (all P < .003) but not in the retear group (all P > .05). The intact repair group had significantly higher postoperative forward flexion (165° ± 15° vs. 154° ± 23°; P = .036), abduction (164° ± 17° vs. 151° ± 26°; P = .029), and abduction strength (3.5 ± 2.2 kg vs. 2.3 ± 1.2 kg; P = .017) than the retear group. In the intact repair group (n = 34), Sugaya type I:II ratio differed significantly between postoperative 3 months (2:32) and 24 months (24:10) (P < .001). Repaired tendon thickness did not decrease significantly between 3 months (7.1 mm) and 2 years (6.9 mm) (P = .543).

CONCLUSIONS

ARCR with fascia lata graft augmentation of large and massive rotator cuff tears showed a 24.4% retear rate but significantly improved the clinical scores, ROMs, and muscle strength with excellent cuff integrity in the intact repair group. However, the differences in the Constant and UCLA scores between the intact repair and retear groups were under the minimal clinically important difference, and their clinical significance is uncertain. Our results confirm that ARCR with fascia lata graft augmentation improves patients' postoperative outcomes if the repair site is maintained postoperatively.

Calcaneal tuberosity avulsion fractures - A review

Calcaneal tuberosity avulsion fracture, an extra-articular injury, is a rare fracture caused internally by Achilles tendon driven following intense contraction of gastrocnemius-soleus complex, and externally by low-energy (possibly high-energy). Moreover, the risk of injuries of the skin and Achilles tendon around calcaneal tuberosity is closely related to Lee classification and Carnero-Martín de Soto Classification of calcaneal tuberosity avulsion fracture. Although the diagnosis confirmed by X-ray, digital imaging and computed tomography (CT), magnetic resonance imaging (MRI) should also be used to evaluate soft tissue. In recent years, the understanding of this fracture has witnessed the development of different internal fixation devices and surgical procedures. These advances have been further elaborated scientifically in terms of their ability to provide stable fracture reduction ad resistance to Achilles tendon forces. In order to obtain a comprehensive knowledge of the disease, this article reviewed the new understanding of the anatomy, typing, risk factors, and treatment modalities of calcaneal tuberosity avulsion fracture in recent years.

Arthroscopic Double-Pulley Suture-Bridge Repair of Supraspinatus Tendon Tear

At present, the suture bridge is a widely used surgical pattern in the treatment of supraspinatus tendon tear, but the shortcomings of a suture bridge, including expensive lateral-row anchor and increased type 2 retear rate, is obvious. The double-pulley suture-bridge described in this Technical Note uses a double-loaded suture anchor (medial-row anchor) as lateral-row anchor instead of traditional lateral-row anchor, combined with double-pulley technology forming suture-bridge in treatment of supraspinatus tendon tears. The surgical technique is described in pearls, pitfalls, advantages, and disadvantages.

Arthroscopy Technique: Repair of Musculotendinous Junction Rotator Cuff Tears in the Shoulder Using a Dynamic Convergence Suture Bridge Technique

Musculotendinous junction (MTJ) rotator cuff tears in the shoulder are rare injuries in which the tendon fails medial to its tuberosity attachment. There is difficulty in striking a balance between restoring the length-tension relationship of the tendon while avoiding high suture tension at the repair site. In view of the rare incidences of these tears, there is a paucity of literature on their repair techniques. We seek to share our surgical technique in addressing type A MTJ tears-where the medial muscular tear margin is short but remains adequate for suture bridge repair, whereas the lateral tendon remains on the footprint. We used mattress sutures from the medial row of anchors, threaded through the lateral tendon stump, then passed medially to engage the medial stump, before being fixed to a lateral row in a knotless fashion. Pulling on this pair of sutures will thus bring into closer apposition of both medial and lateral tear margins in a dynamic convergence pattern. Our surgical technique is a safe and effective method of repairing type A MTJ tear that confers improved biological and biomechanical advantage via the formation of a dynamic convergence suture bridging technique in addition to a double-row repair construct.

Healthcare costs of failed rotator cuff repairs

Background

The goal of this study was to estimate the short-term (∼2 years) healthcare costs of failed primary arthroscopic rotator cuff repair (RCR) in the United States.

Methods

A review of current literature was performed to estimate the number of RCR performed in the United States in the year 2022 and the rate of progression of these patients to lose repair continuity, reach clinical failure, and progress to nonoperative intervention and revision procedures. A review of the current literature was performed to estimate the costs incurred by these failures over the ensuing 2-year postoperative time period.

Results

The direct and indirect healthcare costs of structural and clinical failure of primary RCR performed in 2022 are estimated to reach $438,892,670 in the short-term postoperative period. The majority of the costs come from the estimated $229,390,898 in nonoperative management that these patients undergo after they reach clinical failure.

Conclusion

The short-term healthcare costs of failed arthroscopic RCR performed in the United States in 2022 are predicted to be $438,892,670. Although RCR improves quality of life, pain, function, and is cost-effective, there remains great potential for reducing the economic burden of failed RCR repairs on the US society. Investments into research aimed to improve RCR healing rates are warranted.

Clinical Relevance

Although RCR improves quality of life, pain, function, and is cost-effective, this study provides evidence that there remains great potential for reducing the economic burden of failed RCR repairs on the US society. Investments into research aimed to improve RCR healing rates are warranted.

Global Compressive Loading from an Ultra-Thin PEEK Button Augment Enhances Fibrocartilage Regeneration of Rotator Cuff Enthesis

A PEEK button is developed to improve the tendon-to-bone compression area. In total, 18 goats were divided into 12-week, 4-week, and 0-week groups. All underwent bilateral detachment of the infraspinatus tendon. In the 12-week group, 6 were fixed with a 0.8-1 mm-thick PEEK augment (A-12, Augmented), and 6 were fixed with the double-row technique (DR-12). Overall, 6 infraspinatus were fixed with PEEK augment (A-4) and without PEEK augment (DR-4) in the 4-week group. The same condition was performed in the 0-week groups (A-0 and DR-0). Mechanical testing, immunohistochemistry assessment, cell responses, tissue alternation, surgical impact, remodeling, and the expression of type I, II, and III collagen of the native tendon-to-bone insertion and new footprint areas were evaluated. The average maximum load in the A-12 group (393.75 (84.40) N) was significantly larger than in the TOE-12 group (229.17 (43.94) N) (p < 0.001). Cell responses and tissue alternations in the 4-week group were slight. The new footprint area of the A-4 group had better fibrocartilage maturation and more type III collagen expression than in DR-4 group. This result proved the novel device is safe and provides superior load-displacement to the double-row technique. There is a trend toward better fibrocartilage maturation and more collagen III secretions in the PEEK augmentation group.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Meta-analysis.

METHOD

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

RESULTS

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

CONCLUSION

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

Prospective study of 90 arthroscopic rotator cuff repairs for isolated distal supraspinatus tear, assessing the impact of cardiovascular risk factors on tendon healing

INTRODUCTION

Cardiovascular risk factors have been shown to be relevant to onset of rotator cuff tear, but their influence on healing remains to be determined.

OBJECTIVE

To assess the individual and cumulative impact of cardiovascular risk factors on tendon healing after arthroscopic rotator cuff repair.

MATERIAL AND METHOD

A single-center prospective study included 90 patients undergoing arthroscopic repair of isolated distal supraspinatus tendon tear. Only isolated full-thickness tears without anteroposterior extension, retraction (Patte stage ≤ 2) or fatty involution were included. Tendon healing was assessed on ultrasound according to the 5 types of the Sugaya classification. Clinical and functional assessment at 12 months used Constant score. Cardiovascular comorbidities were screened for in the preoperative anesthesiology consultation and control consultation: smoking, high blood pressure, dyslipidemia, diabetes, obesity, cardiovascular history, and obstructive sleep apnea syndrome.

RESULTS

Ninety patients with a mean age of 59.6±6.95 years were included for analysis. 77.7% of cuffs showed healing on ultrasound, without signs of retear (stage 1-3), 16.6% showed partial retear (stage 4) and 6.6% showed no healing, with tendon retraction (stage 5). Mean Constant score improved by 37.5 points (p=0.001), for a global score of 78 at 12 months. Multivariate analysis identified several significant cardiovascular factors for poor healing: active smoking (p=0.002), dyslipidemia (p=0.006), high blood pressure (p≤0.001) and obesity (p=0.02). Cumulative comorbidity was associated with poor tendon healing, with significant impact as of 2 cardiovascular risk factors. Constant score decreased significantly according to healing stage (p≤0.001).

CONCLUSION

The present study confirmed the involvement of cardiovascular risk factors in bone-tendon healing disorder, with significant impact as of 2 factors.

LEVEL OF EVIDENCE

IV; low-power prospective clinical series.

Quantitative Magnetic Resonance Imaging-Based Tendon Healing of Different Regions of the Shoulder: Comparison Between the Suture-Bridge and Single-Row Techniques

Background

Rotator cuff retears occur more often at the proximal region with the suture-bridge (SB) technique than at the typical footprint region with the single-row (SR) technique. Few longitudinal clinical trials have focused on the postoperative tendon quality of the repaired rotator cuff at different regions between the 2 techniques.

Purpose

To compare tendon healing of the proximal and distal regions between the SB and SR techniques.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were consecutive patients who underwent arthroscopic rotator cuff repair and undertook clinical and magnetic resonance imaging (MRI) examinations at 3, 6, and 12 months postoperatively between 2016 and 2017. These patients were divided into the SB and SR groups according to the technique used. The repaired tendon was segmented into distal and proximal regions on ultrashort echo time-T2* mapping images. Clinical outcomes (Constant score, American Shoulder and Elbow Surgeons score, Fudan University Shoulder Score, and visual analog scale for pain) and MRI-based tendon healing (T2* values) of different regions were compared between the 2 groups. The differences in T2* values and clinical scores were determined by 1-way analysis of variance for repeated measurements.

Results

A total of 31 patients (17 in SB group and 14 in SR group) were included. At 12-month follow-up, significant improvements from preoperatively were achieved for all patients in all clinical scores (P < .001 for all). No significant between-group differences were found in T2* values of the distal region at any time point; however, the mean T2* value of the proximal region at 3 months was significantly higher in the SB group compared with the SR group (P = .03). This difference became nonsignificant at subsequent follow-up time points.

Conclusion

Significant clinical improvements over time can be expected in the first year after arthroscopic rotator cuff repair. In the early postoperative period, higher T2* values in the proximal region of the repaired tendon (representing inferior tendon quality) were seen with the SB technique compared with the SR technique; however, this phenomenon was resolved over time.

Two-year outcomes with a bioinductive collagen implant used in augmentation of arthroscopic repair of full-thickness rotator cuff tears: final results of a prospective multicenter study

BACKGROUND

Full-thickness rotator cuff tears (FTRCTs) represent a common shoulder injury that, if untreated, can progress in size, become increasingly painful, and inhibit function. These lesions are often surgically repaired, with double-row arthroscopic repair often preferred for larger tears. Biological augmentation technologies have been developed to improve rates of postoperative radiographic retear and enhance patient-reported outcomes after surgical FTRCT repair. This study sought to confirm that augmented repair with a bioinductive bovine collagen implant results in favorable retear rates and patient outcomes with follow-up to 2 years.

METHODS

A prospective multicenter cohort study was undertaken to determine the efficacy and safety of augmenting single- or double-row arthroscopic repair of FTRCTs with a bioinductive bovine collagen implant. Of 115 adult patients participating, 66 (57.4%) had medium (1-3-cm) tears and 49 (42.6%) had large (3-5-cm) tears. Magnetic resonance imaging and patient-reported outcomes (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Constant-Murley Score [CMS]) were performed and recorded at baseline, 3 months, 1 year, and 2 years.

RESULTS

Mean duration of follow-up was 2.1 years (range, 1.5-2.9 years). Between baseline and 2-year follow-up, mean total thickness of the supraspinatus tendon increased by 12.5% for medium tears and by 17.1% for large tears. Radiographic retear was noted in 7 of 61 available patients (11.5%) with medium tears, and in 14 of 40 patients (35.0%) with large tears. In both groups, these tears primarily occurred before the 3-month follow-up visit (13 of 21 [61.9%]). Radiographic retear with the supplemented double-row (DR) repair technique was 13.2% overall (12 of 91 DR patients; 11.3% for medium tears and 15.8% for large tears). The minimal clinically important difference was achieved by >90% of patients with both medium and large tears for both ASES and CMS. There were 2 serious adverse events classified by the treating surgeon as being possibly related to the device and/or procedure (1 case of swelling/drainage and 1 case of intermittent pain). Nine patients (7.8%; 4 medium tears and 5 large tears) required reoperation of the index rotator cuff surgery.

CONCLUSION

Final 2-year data from this study confirm that using this implant in augmentation of arthroscopic double-row repair of FTRCTs provides favorable rates of radiographic retear and substantial functional recovery. The relative safety of the device is also further supported.

Patch augmentation does not provide better clinical outcomes than arthroscopic rotator cuff repair for large to massive rotator cuff tears

PURPOSE

Patch augmentation for large and massive rotator cuff tears (LMRCTs) has been suggested as a repair strategy that can mechanically reinforce tendons and biologically enhance healing potential. The purpose of this study was to determine whether patients who underwent patch augmentation would have lower rates of retears and superior functional outcomes.

METHODS

Patients who underwent arthroscopic rotator cuff repair (ARCR) with patch augmentation (group A) were matched by age, sex, degree of retraction, and supraspinatus muscle occupation ratio to those treated with ARCR without using a patch (group B) with a minimum follow-up of 24 months. The retear (Sugaya IV or V) rates were evaluated by magnetic resonance imaging at 3 and 12 months post-surgery. The Constant- Murley Score (CMS), Korean Shoulder Score (KSS), and University of California-Los Angeles Shoulder Rating Scale (UCLA) score were retrospectively analyzed.

RESULTS

This study included 34 patients (group A, n = 17; group B, n = 17). The mean follow-up period was 46.5 ± 17.4 months. At postoperative 1-year follow-up, group B (6 patients, 35.3%) showed higher rates of retears than group A (1 patient, 5.9%), which was statistically significant (P = 0.034). However, the postoperative CMS, KSS, and UCLA scores did not differ between the two groups at 3 months, 12 months, and the final follow-up. Additionally, the clinical outcomes of patients with retear were not significantly different from those of the healed patients in both groups.

CONCLUSION

The use of an allodermal patch for LMRCT is effective in preventing retears without complications. However, the clinical outcomes of ARCR using allodermal patch augmentation were not superior to those of only ARCR.

LEVEL OF EVIDENCE

III.

Clinical outcomes in patients with retear after arthroscopic rotator cuff repair: A meta-analysis

BACKGROUND

Rotator cuff retear is a major concern after arthroscopic rotator cuff repair (ARCR); however, the effects of retear remain unclear. Therefore, the purpose of this study was to assess the clinical outcomes of postoperative retear and intact tendons after ARCR.

METHODS

We searched PubMed, Cochrane Library, Scopus, and PEDro databases for studies performed from January 2000 to June 2020. Clinical outcomes included the Constant score, American Shoulder and Elbow Surgeons (ASES) score, University of California Los Angeles shoulder (UCLA) score, pain score, range of motion, and muscle strength. Meta-analysis using random-effects models was performed on the pooled results to determine significance.

RESULTS

The initial database search yielded 3141 records. After removal of duplicates, 26 of which met the inclusion criteria. Patients in the retear group had significantly lower Constant score [- 8.51 points (95% CI, - 10.29 to - 6.73); P < 0.001], ASES score [- 12.53 points (95% CI, - 16.27 to - 8.79); P < 0.001], UCLA score [- 3.77 points (95% CI, - 4.72 to - 2.82); P < 0.001], and significantly higher pain score [0.56 cm (95% CI, 0.10 to 1.01); P = 0.02] than the intact group. In addition, the retear group had significantly lower flexion [- 10.46° (95% CI, - 19.86 to - 1.07); P = 0.03], abduction [- 14.84° (95% CI, - 28.55 to - 1.14); P = 0.03], and external rotation [- 7.22° (95% CI, - 13.71 to - 0.74); P = 0.03] range of motion, and flexion [- 1.65 kg·f (95% CI, - 2.29 to - 1.01); P < 0.001], abduction [- 1.87 kg·f (95% CI, - 3.02 to - 0.72); P = 0.001], and external rotation [- 1.66 kg·f (95% CI, - 3.25 to - 0.07); P = 0.04] muscle strength.

CONCLUSION

Our results suggest that retear after ARCR leads to poor clinical outcomes after surgery.

Graft Augmentation of Repairable Rotator Cuff Tears: An Algorithmic Approach Based on Healing Rates

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.

H-loop Knotless Double-Row Repair Versus Knotted Suture Bridge for Rotator Cuff Tears: A Biomechanical and Histological Study in an Animal Model [Formula: see text]

BACKGROUND

Knotted suture bridge repair (KSBR) has been widely proven to be an effective method for rotator cuff repairs. However, the occurrence of type 2 failure after suture bridge repair remains a frequent problem because of the stress concentration and disturbance of tendon perfusion in the medial row. The authors have developed the H-loop knotless double-row repair (HLDR) to counteract these problems.

PURPOSE

To compare the biomechanical and histological outcomes of HLDR and KSBR for rotator cuff tear in the rabbit model.

STUDY DESIGN

Controlled laboratory study.

METHODS

Acute bilateral supraspinatus tears were created on the shoulders of 46 New Zealand White rabbits. HLDR and KSBR were randomly performed on the left side or right side. Thirteen animals each were sacrificed at 2, 4, and 8 weeks after surgery (n = 39), with 6 rabbits used for histological evaluation and the other 7 rabbits for biomechanical testing. The remaining 7 animals from the original 46 were only used for initial biomechanical evaluation at week 0.

RESULTS

Macroscopically, all repaired tendons were connected to their footprint on the greater tuberosity without postoperative complications at 8 weeks after surgery. The HLDR group had significantly better histological bone-to-tendon integration compared with the KSBR group in terms of fibrocartilage regeneration, collagen composition, and fiber organization. The biomechanical outcomes in the HLDR group were demonstrated to be better than those of the KSBR group at time 0 and 8 weeks after surgery.

CONCLUSION

Both repair techniques were effective for rotator cuff tears in a rabbit rotator cuff tear model; however, HLDR demonstrated more advantages in improving biomechanical properties and histological tendon-to-bone healing compared with KSBR.

CLINICAL RELEVANCE

This animal study suggested that HLDR might be an alternative choice for rotator cuff tears in humans to increase tendon-to-bone healing and reduce the rate of failure to heal.

Increased 30-Day Postoperative Readmission and Medical Complication Rates Among Patients 65 Years and Older Following Arthroscopic Rotator Cuff Repair

Purpose

Methods

Results

Conclusions

Chitosan-platelet-rich plasma implants improve rotator cuff repair in a large animal model: Pilot study

Freeze-dried formulations of chitosan can be solubilized in platelet-rich plasma (PRP) to form injectable implants that are used as an adjunct treatment during surgical repair of the rotator cuff. The purpose of the current study was to assess chitosan-PRP implant residency, test safety, and assess efficacy over standard-of-care controls in a sheep model of rotator cuff repair. The infraspinatus tendon was transected unilaterally and immediately repaired with suture anchors in 22 skeletally mature ewes. In treatment groups, formulations containing chitosan, trehalose, and calcium chloride were solubilized with autologous leukocyte-rich PRP and injected at the tendon-bone interface and on top of the repaired site (1 mL or 2 mL doses). Implant residency was assessed histologically at 1 day. Outcome measures included MRI assessment at baseline, 6 weeks, and 12 weeks, histopathology and clinical pathology. Chitosan-PRP implants were resident at the injection site at 1 day and induced recruitment of polymorphonuclear cells. The tendon gap, which corresponds to the length of abnormally hyperintense tissue attached to the humeral head, was decreased by treatment with the 2 mL dose when compared to controls at 12 weeks on MRI images. Some histological features were improved by the 2 mL dose treatment compared to controls at 12 weeks. There was no treatment-specific effect on all standard safety outcome measures, which suggests high safety. This study provides preliminary evidence on the safety and efficacy of chitosan-PRP implants in a large animal model that could potentially be translated to a clinical setting.

In Vivo Static Retraction and Dynamic Elongation of Rotator Cuff Repair Tissue After Surgical Repair: A Preliminary Analysis at 3 Months

Background:

Rotator cuff repair is a common orthopaedic procedure that provides pain relief for many patients, but unfortunately, an estimated 20% to 70% of repair procedures will fail. Previous research has shown that elongation (ie, retraction) of a repaired tendon is common even in patients with a repair construct that appears intact on magnetic resonance imaging. However, it is unknown how this repair tissue functions under dynamic conditions.

Purpose:

To quantify static retraction and maximum dynamic elongation of repair tissue after rotator cuff repair.

Study Design:

Case series; Level of evidence, 4.

Methods:

Data from 9 patients were analyzed for this study. During surgery, a 3.1-mm tantalum bead was sutured to the supraspinatus tendon, medial to the repair site. Glenohumeral kinematics were assessed at 1 week (static) and 3 months (static and during scapular-plane abduction) after surgery using a biplanar videoradiographic system. The 3-dimensional position of the bead was calculated relative to the tendon’s insertion on the humerus (ie, bead-to-insertion distance). Static retraction was calculated as the change in the bead-to-insertion distance under static conditions between 1 week and 3 months after surgery, and maximum dynamic elongation was calculated as the maximal positive change in the bead-to-insertion distance during dynamic motion relative to the start of motion. The magnitudes of static retraction and maximum dynamic elongation were assessed with 1-sample t tests.

Results:

At 3 months after surgery, static retraction occurred in all patients by a mean of 10.0 ± 9.1 mm (P = .01 compared with no elongation). During scapular-plane abduction, maximum dynamic elongation averaged 1.4 ± 1.0 mm (P < .01 compared with no elongation). Descriptively, dynamic elongation consistently took 1 of 2 forms: an initial increase in the bead-to-insertion distance (mean, 2.0 ± 0.6 mm) before decreasing until the end of motion or an immediate and substantial decrease in the bead-to-insertion distance at the onset of motion.

Conclusion:

Repair tissue elongation (static retraction and maximum dynamic elongation) appeared to be a common and significant finding at 3 months after arthroscopic rotator cuff repair. Dynamic elongation of repair tissue during scapular-plane abduction exhibited 1 of 2 distinct patterns, which may suggest different patterns of supraspinatus mechanical and neuromuscular function.

The "Greenhouse" Technique Using Knotless Single-Row Suture Bridge Combined With Bone Marrow Stimulation for the Arthroscopic Treatment of Rotator Cuff Tears

To simplify the arthroscopic rotator cuff repair technique and improve tendon healing, we have developed a method named the "Greenhouse" technique to repair rotator cuff. With bone marrow stimulation combined with knotless single-row suture bridge fixation, we provide a technique for reliable cuff fixation with enhanced biological features.

Clinical differences between patients with early and late revision surgery for symptomatic failed arthroscopic rotator cuff repair

PURPOSE

Time ranges of revision rotator cuff surgeries after arthroscopic repair are highly variable. However, the cause and clinical relevance of the different timings of revision surgeries have not been analyzed. The purpose of this study was to evaluate the clinical manifestations of patients who required revision surgeries at early and late periods after failed arthroscopic rotator cuff repair, and to identify clinical and radiological differences related to the timing of revision surgery.

METHODS

Sixty patients who underwent revision surgery due to symptomatic failed rotator cuff repair after arthroscopic repair were included. Patients were divided into two groups: patients who underwent revision surgeries within 1 year postoperatively (21 patients, group I) and patients who underwent revision surgeries more than 1 year postoperatively (39 patients, group II). Clinical and radiological characteristics were compared between the two groups before primary and revision surgery.

RESULTS

VAS for pain (5.9 ± 1.9 in group I, 3.9 ± 1.4 in group II, P < 0.001) and Constant score (50.7 ± 9.9 in group I, 60.4 ± 8.9 in group II, P < 0.001) at the time of revision surgery were significantly different between the two groups. In group II, isometric muscle strength of forward flexion (74.1 ± 21.1 to 63.9 ± 15.1, P = 0.020) and external rotation (73.0 ± 23.5 to 61.2 ± 15.0, P = 0.032) were significantly deteriorated after primary surgery, even with significant improvement of pain and shoulder function (VAS: 5.7 ± 1.9 to 3.9 ± 1.4, P < 0.001; Constant score: 50.3 ± 11.0 to 60.4 ± 8.9, P < 0.001). On postoperative MRI, re-tear at the tendon-bone interface on the greater tuberosity occurred significantly more in group I (81.0%) than group II (51.3%, P = 0.024). Incidence of full-thickness tear of the subscapularis tendon was significantly different between the two groups (42.9% in group I, 12.8% in group II, P = 0.012).

CONCLUSION

Patients who had early revision surgeries had significantly worse clinical outcomes after primary surgery than patients who had late revision surgeries. Healing failure at the tendon-bone interface on the greater tuberosity and re-tear combined with full-thickness tear of subscapularis tendon were related to early revision. Conversely, patients of the late revision group had muscle weakness that considerably impacted daily activities, even with improved pain and shoulder function.

LEVEL OF EVIDENCE

III.

Long-term outcomes after arthroscopic transosseous-equivalent repair: clinical and magnetic resonance imaging results of rotator cuff tears at a minimum follow-up of 10 years

PURPOSE

The objective of this study was to evaluate the long-term functional outcomes and structural integrity of medium to massive rotator cuff tears at 10-12 years of follow-up after arthroscopic transosseous-equivalent (TOE) repair.

METHODS

This was a retrospective study of a consecutive series of patients who underwent primary arthroscopic TOE repair of medium- to massive-sized degenerative rotator cuff tears performed by a single surgeon between January 2007 and August 2009. Patients were examined at a minimum follow-up of 10 years, and magnetic resonance imaging (MRI) was performed to assess tendon integrity. The Constant score (CS), American Shoulder and Elbow Surgeons score, and pain level documented using a visual analog scale were compared between intact repairs and recurrent defects. Univariate analysis was performed to identify factors related to recurrent defects.

RESULTS

A total of 102 patients met the inclusion criteria, and 79 shoulders in 76 patients (74.5% of eligible patients) with a mean age at surgery of 55 ± 8 years (range, 40-72 years) were available for clinical evaluation at a mean follow-up time of 10.9 years (range, 10-12 years). The mean anteroposterior tear size was 3.1 ± 1.1 cm, and there were 41 medium (52%), 26 large (33%), and 12 massive (15%) tears. MRI was performed in 72 shoulders in 69 patients (91% of available shoulders) and revealed that 13 shoulders had recurrent defects (Sugaya stages 4 and 5). During the follow-up period, 3 patients underwent revision surgery, and the overall recurrent defect rate was 21.3%. A clinically meaningful improvement was observed in all outcome measures at the final follow-up regardless of tendon integrity. Patients with intact repairs showed superior outcomes compared with those with recurrent defects; however, only the overall CS met the threshold for clinical relevance. A significant linear correlation was observed between the Sugaya classification and all outcome scores except the CS pain subscale; however, the strength of correlation was weak. The presence of diabetes (odds ratio [OR], 8.6; 95% confidence interval [CI], 2.25-33.2; P = .002), tear size (OR, 2.08; 95% CI, 1.16-3.46; P = .012), and tear retraction (OR, 4.07; 95% CI, 1.11-14.83; P = .033) were associated with recurrent defects in the univariate analysis.

CONCLUSION

Arthroscopic TOE repair of rotator cuff tears provided improved clinical outcomes with a recurrent defect rate of 21.3% at 10-12 years after surgery. Future research focusing on tendon healing is needed as repair integrity on MRI correlates with clinical outcomes.

The effect of estrogen-like compound on rotator cuff tendon healing in a murine model

Estrogen deficiency has been shown to negatively influence rotator cuff tendon healing. Therefore, the addition of an estrogen-like-compound (ELC) in a nonestrogen-deficient animal may improve the quality of a rotator cuff repair. The purpose of this study was to evaluate the effects of an ELC, diethylstilbestrol (DES), on tendon healing in a murine rotator cuff repair model. Thirty-three male wild-type mice (C57BL/6NJ) were randomly divided into three study groups. Group 1-unoperated mice with normal rotator cuff tendons. Groups 2 and 3 consisted of surgically repaired rotator cuff tendons; Group 2 (repair-only) was the standard repair group (no DES injected), whereas Group 3 (repair + DES) was the experimental repair group (injected with DES). Comparing the maximal thickness of calcified fibrocartilage to uncalcified fibrocartilage, the ratios for the control (intact tendon), repair-only, and repair + DES groups were 2:1, 0.9:1, and 1.7:1. RNA expression data demonstrated upregulation of chondrogenic, angiogenic, and tendon modulation genes in the repair- only group compared to the control (intact tendon) group (p < 0.04 for all), and that addition of DES further increased the osteogenic, angiogenic, and tendon modulation gene expression compared to the repair-only group (p < 0.02). Immunohistochemical analysis indicated that the addition of DES further increased osteogenic, angiogenic, and tendon maturation protein expression at the enthesis compared to standard repairs.

Combined therapy of platelet-rich plasma and basic fibroblast growth factor using gelatin-hydrogel sheet for rotator cuff healing in rat models

Introduction

Excellent outcomes of arthroscopic rotator cuff repair for small and medium tears have been recently reported. However, re-tears after surgery have been a common complication after surgical repair of large and massive rotator cuff tears and often occur in early postoperative phase. It was previously reported that basic fibroblast growth factor and platelet-rich plasma enhanced rotator cuff tear healing. We hypothesized that this combined therapy could enhance rotator cuff healing after rotator cuff repair in a rat model. This study aimed to evaluate the efficacy of combined therapy of platelet-rich plasma and basic fibroblast growth factor with gelatin-hydrogel sheet.

Methods

To create a rotator cuff defect, the infraspinatus tendon of Sprague Dawley rat was resected from the greater tuberosity. The infraspinatus tendons were repaired and covered with gelatin-hydrogel sheet impregnated with PBS (control group), basic fibroblast growth factor (bFGF group), platelet-rich plasma (PRP group), or both basic fibroblast growth factor and platelet-rich plasma (combined group). Histological examinations were conducted using hematoxylin and eosin, safranin O, and immunofluorescence staining, such as Isolectin B4, type II collagen at 2 weeks postoperatively. For mechanical analysis, ultimate failure load of the tendon-humeral head complex was evaluated at 6 weeks postoperatively.

Results

In the hematoxylin and eosin staining, the tendon maturing score of the combined group was higher than that of the control group at postoperative 2 weeks. In the safranin O staining, stronger proteoglycan staining was observed in the combined group compared with the other groups at postoperative 2 weeks. Vascular staining with isolectin B4 in 3 treatment groups was significantly higher than that in the control group. Type II collagen expression in the combined group was significantly higher than those in the other groups. The ultimate failure load of the combined group was significantly higher than that of the control group.

Conclusion

Combined therapy of basic fibroblast growth factor and platelet-rich plasma promoted angiogenesis, tendon maturing and fibrocartilage regeneration at the enthesis, which could enhance the mechanical strength. It was suggested that combined basic fibroblast growth factor and platelet-rich plasma might enhance both tendon and bone–tendon junction healing, and basic fibroblast growth factor and platelet-rich plasma might be synergistic.

Presurgical tear characteristics and estimated shear modulus as predictors of repair integrity and shoulder function one year after rotator cuff repair

Background

Rotator cuff repair provides pain relief for many patients; however, retears are relatively common and affect approximately 20%-70% of patients after repair. Although magnetic resonance imaging (MRI) offers the ability to assess tissue characteristics such as tear size, retraction, and fatty infiltration, it provides little insight into the quality of the musculotendinous tissues the surgeon will encounter during surgery. However, shear wave elastography (SWE) could provide an indirect assessment of quality (ie, stiffness) by measuring the speed of shear waves propagating through tissue. The objective of this study was to determine the extent to which estimated shear modulus predicts repair integrity and functional outcomes 1 year after rotator cuff repair.

Methods

Thirty-three individuals scheduled to undergo arthroscopic rotator cuff repair were enrolled in this study. Before surgery, shear modulus of the supraspinatus tendon and muscle was estimated using ultrasound SWE. MRIs were obtained before and 1 year after surgery to assess tear characteristics and repair integrity, respectively. Shoulder strength, range of motion, and patient-reported pain and function were assessed before and after surgery. Functional outcomes were compared between groups and across time using a two-factor mixed model analysis of variance. Stepwise regression with model comparison was used to investigate the extent to which MRI and shear modulus predicted repair integrity and function at 1 year after surgery.

Results

At 1 year after surgery, 56.5% of patients had an intact repair. No significant differences were found in any demographic variable, presurgical tear characteristic, or shear modulus between patients with an intact repair and those with a recurrent tear. Compared with presurgical measures, patients in both groups demonstrated significant improvements at 1 year after surgery in pain (P < .01), self-reported function (P < .01), range of motion (P < .01), and shoulder strength (P < .01). In addition, neither presurgical MRI variables (P > .16) nor shear modulus (P > .52) was significantly different between groups at 1 year after surgery. Finally, presurgical shear modulus generally did not improve the prediction of functional outcomes above and beyond that provided by MRI variables alone (P > .22).

Conclusion

Although SWE remains a promising modality for many clinical applications, this study found that SWE-estimated shear modulus did not predict repair integrity or functional outcomes at 1 year after surgery, nor did it add to the prediction of outcomes above and beyond that provided by traditional presurgical MRI measures of tear characteristics. Therefore, it appears that further research is needed to fully understand the clinical utility of SWE for musculoskeletal tissue and its potential use for predicting outcomes after surgical rotator cuff repair.

Suture Slippage After Arthroscopic Cuff Repair: Medial Displacement of Suture Knots on Follow-up Ultrasonography

Background:

Compared with the single-row technique, the double-row rotator cuff repair technique is known to have a higher load to failure and a lower frequency of gap formation, leading to a lower retear rate. There are some patients with poor clinical outcomes or poor muscle strength without radiologic retear.

Purpose/Hypothesis:

To assess the postoperative position of suture knots via serial ultrasonography in patients who had undergone arthroscopic rotator cuff repair with the suture-bridge technique. Our hypothesis was that the suture would pull out of the lateral anchor (suture slippage), changing the positions of the medial suture knots during healing.

Study Design:

Case series; Level of evidence, 4.

Methods:

This study included 53 patients (55 shoulders) who underwent arthroscopic suture-bridge repair and were evaluated for a minimum of 24 months. On serial ultrasonography, a straight line was drawn between the top of the greater tuberosity and the medial cortex of the anchor hole. The distances between the knots of the medial rows and the perpendicular line through the center of the anchor hole were measured in longitudinal plane images of the supraspinatus. Follow-up ultrasonography was performed at 2, 3, and 6 months postoperatively as well as at the final visit. The visual analog scale, the American Shoulder and Elbow Surgeons score, the Constant score, and the University of California, Los Angeles shoulder score were recorded preoperatively and on the final follow-up.

Results:

Of the 55 shoulders, 6 developed retears at repaired sites. The mean follow-up duration was 37.5 months (range, 24-65 months). Slippage distance increased significantly over time (P < .001). The slippage at the final visit did not differ between patients with retear and no retear (13.4 mm for retear group; 10.6 mm for no retear group [P = .096]).

Conclusion:

Suture knots of the medial row migrated medially via a suture pullout from the lateral row anchor of suture-bridge technique. Suture slippage distance did not differ significantly between retear and no retear groups.

Stump classification was correlated with retear in the suture-bridge and double-row repair techniques for arthroscopic rotator cuff repair

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.

Locating the rotator cable during subacromial arthroscopy: bursal- and articular-sided anatomy

BACKGROUND

The rotator cable (RCa) is an important articular-sided structure of the cuff capsular complex that helps prevent suture pull out during rotator cuff repairs (RCRs) and plays a role in force transmission. Yet, the RCa cannot be located during bursal-sided RCRs. The purpose of this study is to develop a method to locate the RCa in the subacromial space and compare its bursal- and articular-sided dimensions.

METHODS

In 20 fresh-frozen cadaveric specimens, the RCa was found from the articular side, outlined with stitches, and then evaluated from the bursal side using an easily identifiable reference point, the intersection of a line bisecting the supraspinatus (SS) tendon and posterior SS myotendinous junction (MTJ). Four bursal-sided lengths were measured on the SS-bisecting line as well as the RCa's outside anteroposterior base. For the articular-sided measurements, the rotator cuff capsular complex was detached from bone and optically scanned creating 3D solid models. Using the 3D models, 4 articular-sided lengths were made, including the RCa's inside and outside anteroposterior base.

RESULTS

The RCa's medial arch was located 9.9 ± 5.6 mm from the reference point in 10 intact specimens and 4.1 ± 2.4 mm in 10 torn specimens (P = .007). The RCa's width was 10.9 ± 2.1 mm, and the distance from the lateral edge of the RCa to the lateral SS insertion was 13.9 ± 4.8 mm. The bursal- and articular-sided outside anteroposterior base measured 48.1 ± 6.4 mm and 49.6 ± 6.5 mm, respectively (P = .268). The average inside anteroposterior base measurement was 37.3 ± 5.9 mm.

DISCUSSION

The medial arch of the RCa can be reliably located during subacromial arthroscopy using the reference point, analogous to the posterior SS MTJ. The RCa is located 10 mm in intact and 4 mm in torn tendons (P = .007) from the posterior SS MTJ. If the above 6-mm shift in location of the RCa is not taken into consideration during rotator cuff suture placement, it could negatively affect time zero repair strength. The inside anteroposterior base of the RCa measures on average 37 mm; therefore, rotator cuff tears measuring >37 mm are at risk of rupturing part or all of the RCa's 2 humeral attachments, which if not recognized and addressed could impact postoperative function.

Trends in rotator cuff surgery: Research through the decades

INTRODUCTION

The aim of this study is to analyse the most cited articles in rotator cuff surgery and identify trends in topics by decade to see which areas may still need further investigation.

METHODS

Journal Citation Index was searched to find articles using the search terms pertaining to "rotator cuff repair". All articles were ranked according to most cited, and then further analysed to find most cited articles in each decade. Articles were grouped into topics to find themes for each decade.

RESULTS

All the most cited articles were published in 6 orthopaedic journals. Only 4 of the top 30 citations provided level I evidence. Each decade's most cited articles seemed to fit into a broad topic, with platelet-rich plasma and biologic augmentation being prominent in the last decade.

CONCLUSION

There are still many unanswered questions in rotator cuff surgery, but this may be because success of certain treatment options are highly dependent on patient selection. Despite growing numbers of articles being published on rotator cuff repairs, the level of evidence remains low. Larger, collaborative projects may help in answering the common dilemmas that still face shoulder surgeons.

Operative Management of Failed Rotator Cuff Repair With Soft Tissue Release

Background We hypothesize that revision surgery that includes soft tissue releases for patients with residual pain and reduced range of motion following rotator cuff repair can provide pain relief and improvement of motion and function. Methods Patients were identified via a retrospective chart over a 10-year period who had a history of previous rotator cuff repair and had revision surgery with or without a rotator cuff repair and soft tissue release. Changes in visual analog scores (VAS) pain score on a 10-point scale and shoulder motion including forward flexion and external rotation were evaluated from the preoperative visit to the postoperative visit. Results In total, 73 patients underwent procedures to address their symptoms following failed rotator cuff repair. Patients that underwent soft tissue release with revision rotator cuff repair and those who underwent isolated soft tissue release had decreased postoperative VAS pain scores (absolute reduction of 3 and 1.6 points, respectively) and improved postoperative forward flexion (15.3° and 13.6° respectively). Patients that have had one previous surgery had decreased pain (absolute reduction of 3.2 points), increased forward flexion and external rotation (16.2° and 4.9°). Patients that underwent two or more previous surgeries had decreased pain (absolute reduction of 1.8 points) and increased forward flexion (12.7°). Patients who were filing a Worker's compensation claim also had decreased pain (absolute reduction of 2.2 points) and increased forward flexion (14.9°). Overall, there was a VAS pain scores absolute reduction of 2.6 points or 49.5% when examining the entire patient population. Conclusion Operative management by performing soft tissue release with or without concurrent revision rotator cuff repair is successful for both decreasing pain as well as improving motion. This effect was noted both in patients with commercial insurance and worker's compensation claims. Improvements of pain and motion were more significant in patients who had undergone one prior surgery compared to those who have had multiple prior procedures.

Comparison of Cellular Responses to TGF-β1 and BMP-2 Between Healthy and Torn Tendons

BACKGROUND

Tendons heal by fibrotic repair, increasing the likelihood of reinjury. Animal tendon injury and overuse models have identified transforming growth factor beta (TGF-β) and bone morphogenetic proteins (BMPs) as growth factors actively involved in the development of fibrosis, by mediating extracellular matrix synthesis and cell differentiation.

PURPOSE

To understand how TGF-β and BMPs contribute to fibrotic processes using tendon-derived cells isolated from healthy and diseased human tendons.

STUDY DESIGN

Controlled laboratory study.

METHODS

Tendon-derived cells were isolated from patients with a chronic rotator cuff tendon tear (large to massive, diseased) and healthy hamstring tendons of patients undergoing anterior cruciate ligament repair. Isolated cells were incubated with TGF-β1 (10 ng/mL) or BMP-2 (100 ng/mL) for 3 days. Gene expression was measured by real-time quantitative polymerase chain reaction. Cell signaling pathway activation was determined by Western blotting.

RESULTS

TGF-β1 treatment induced ACAN mRNA expression in both cell types but less in the diseased compared with healthy cells (P < .05). BMP-2 treatment induced BGN mRNA expression in healthy but not diseased cells (P < .01). In the diseased cells, TGF-β1 treatment induced increased ACTA2 mRNA expression (P < .01) and increased small mothers against decapentaplegic (SMAD) signaling (P < .05) compared with those of healthy cells. Moreover, BMP-2 treatment induced ACTA2 mRNA expression in the diseased cells only (P < .05).

CONCLUSION

Diseased tendon-derived cells show reduced expression of the proteoglycans aggrecan and biglycan in response to TGF-β1 and BMP-2 treatments. These same treatments induced enhanced fibrotic differentiation and canonical SMAD cell signaling in diseased compared with healthy cells.

CLINICAL RELEVANCE

Findings from this study suggest that diseased tendon-derived cells respond differently than healthy cells in the presence of TGF-β1 and BMP-2. The altered responses of diseased cells may influence fibrotic repair processes during tendon healing.

Re-tears after rotator cuff repair: Current concepts review

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.

Repair Integrity and Functional Outcomes Between Knot-Tying and Knotless Suture-Bridge Arthroscopic Rotator Cuff Repair: A Prospective Randomized Clinical Trial

Background:

Knot-tying suture-bridge (SB) rotator cuff repair may compromise the vascularity of the repaired tendon, causing tendon strangulation and medial repair failure. The knotless SB repair technique has been proposed to overcome this possibility and decrease retear rates.

Purpose:

To compare clinical and structural outcomes and retear patterns between the knot-tying and knotless SB techniques. We hypothesized that the knotless technique would result in lower retear rates owing to the preservation of intratendinous vascularity.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

A total of 104 patients with full-thickness rotator cuff tears were randomly and prospectively allocated to undergo knot-tying (group 1) or knotless (group 2) SB repair. Clinical outcome measures included range of motion, the visual analog scale (VAS) for pain, and the Constant score for function. Repair integrity was evaluated on magnetic resonance imaging scans using the Sugaya classification. Retears were also classified according to their pattern as type 1 (lateral) or type 2 (medial).

Results:

Overall, 88 patients (group 1: n = 42 [mean ± SD age, 54.3 ± 9.8 years]; group 2: n = 46 [mean ± SD age, 55.8 ± 8.2 years]) were included in the final analysis. The mean ± SD follow-up period was 25.4 ± 8.3 and 23.3 ± 7.2 months for groups 1 and 2, respectively. From preoperatively to postoperatively, the mean VAS pain score improved significantly in both groups (group 1: from 7.4 ± 1.7 to 1.0 ± 1.7; group 2: from 7.1 ± 1.9 to 1.3 ± 2.0; P < .0001 for both), as did the mean ± SD Constant score (group 1: from 51.7 ± 13.4 to 86.0 ± 11.5; group 2: from 49.4 ± 18.4 to 87.2 ± 14.8; P < .0001 for both). There was no significant difference between the groups for the postoperative VAS or Constant score. The retear rate was not significantly different between the groups (19.0% [8/42] in group 1 and 28.3% [13/46] in group 2; P > .05). There was a significant difference in the type 2 failure rate (75.0% [6/8] in group 1 and 23.1% [3/13] in group 2; P = .03).

Conclusion:

Both techniques showed excellent improvement and comparable clinical outcomes, and there was no significant difference in retear rates. Consistent with previously published data, the type 2 failure rate was significantly higher with the knot-tying technique.

Registration:

NCT03982108 (ClinicalTrials.gov identifier).

Comparison between single and double suture passing techniques in the suture bridge rotator cuff repair with a 2-mm tape: A simulation study using a three-dimensional finite element method

BACKGROUND

Suture bridge repair has been widely used as one of the standard procedures in the arthroscopic rotator cuff repair. We compared the intratendinous stress distribution between single and double suture passing techniques in the suture bridge repair using a 2-mm tape and clarified the roles of tensioning in this procedure.

METHODS

A board-like model of the supraspinatus tendon and humeral head was used in order to standardize conditions and exclude the influence of anatomical variations between individuals. Reattachment of the supraspinatus tendon to the bone was simulated using both single and double suture passing techniques for the suture bridge repair using a 2-mm tape. A tensile load was applied to the medial end of the tendon, and the stress distribution pattern was observed. Elastic analysis enabled comparison of the von Mises equivalent and maximum principal stresses between the single and double suture passing techniques. The tape configuration was subsequently translated 1 mm toward the insertion points of lateral anchors to simulate the tensioning maneuver.

RESULTS

Although the distribution pattern of both the equivalent and the maximum principal stresses was similar for both models, areas with a high stress concentration were smaller in the single suture passing model than those in the double suture passing model. The equivalent stress concentrated within the tendon beneath the tapes as well as in the area between the crossing tapes and the lateral end of the tendon, whereas the maximum principal stress concentrated medial to the sites of suture penetration.

CONCLUSIONS

Single suture passing technique can reduce the extent of intratendinous stress concentration compared with double suture passing technique, which might be beneficial to reduce the incidence of type 2 retear after suture bridge repair of rotator cuff tendon using a 2-mm tape.

Captured Rotator Cuff: A Poor Prognostic Factor in Rotator Cuff Repair

Objective  To describe a new presentation of tears and retears of the rotator cuff, which we denominate captured rotator cuff (CRC). We also aim to evaluate it clinically and through images.

Methods  We assessed retrospectively 16 patients with intraoperative diagnosis of CRC between March 2005 and September 2017; by means of imaging (radiography and magnetic resonance imaging [MRI]) and functional scores (UCLA and Constant & Murley). In images we analyzed the evolution for rotator cuff arthropathy and presence of retears. Functionally, we compared the affected side with the contralateral side and extensive lesions with nonextensive.

Results  Five (31.25%) patients presented with rotator cuff arthropathy, and 10 (62.5%) with retears. Three (75%) patients with nonextensive lesions had good/excellent UCLA and Constant & Murley scores. In patients with extensive lesions, when the Constant & Murley score was evaluated, 6 (50%) presented good/excellent results, and in the UCLA score, 7 (58.3%). Comparing the affected side (Constant 74.72 points; UCLA 20 points) with the contralateral side (Constant 96.96 points; UCLA 25.63 points), there were worse functional results with statistical significance.

Conclusion  The diagnosis of CRC is suspected by characteristic findings on MRI and confirmed in arthroscopy. The affected shoulders present worse functional postoperative scores.

Partial and complete repairs of massive rotator cuff tears maintain similar long-term improvements in clinical scores

PURPOSE

The authors have previously published early outcomes of arthroscopic repairs of 86 massive rotator cuff tears (mRCTs) and aimed to determine whether their clinical scores are maintained or deteriorate after 5 more years.

METHODS

Of the initial series of 86 shoulders, 2 had deceased, 16 lost to follow-up and 4 reoperated, leaving 64 for assessment. The repairs were complete in 44 and partial in 20, and 17 shoulders had pseudoparalysis. Preoperative assessment included absolute Constant score, shoulder strength, tear pattern, tendon retraction, and fatty infiltration. Patients were evaluated at 8.1 ± 0.6 years (range 7.1-9.3) using absolute and age-/sex-adjusted Constant score, subjective shoulder value (SSV), and simple shoulder test (SST).

RESULTS

Absolute Constant score was 80.0 ± 11.7 at first follow-up (at 2-5 years) but diminished to 76.7 ± 10.2 at second follow-up (at 7-10 years) (p < 0.001). Adjusted Constant score was 99.7 ± 15.9 at first follow-up and remained 98.8 ± 15.9 at second follow-up (ns). Comparing other outcomes revealed a decrease in strength over time (p < 0.001) but no change in pain, SSV or SST. Partially-repaired shoulders had lower strength at both follow-ups (p < 0.05). Pseudoparalytic shoulders had lower absolute and adjusted Constant score at second follow-up (p < 0.05), but their net improvements in absolute Constant score were higher (p = 0.014).

CONCLUSIONS

Both partial and complete arthroscopic repairs grant satisfactory long-term outcomes for patients with mRCTs, regardless of their tear pattern, fatty infiltration and presence of pseudoparalysis. Absolute Constant score decreased over time for both repair types, but adjusted Constant score remained stable, suggesting that decline is due to aging rather than tissue degeneration. The clinical relevance of this study is that arthroscopic repair should be considered for mRCTs, even if not completely repairable, rather than more invasive and/or risky treatments, such as reverse shoulder arthroplasty.

LEVEL OF EVIDENCE

IV.

Retear rates and clinical outcomes at 1 year after repair of full-thickness rotator cuff tears augmented with a bioinductive collagen implant: a prospective multicenter study

Background

Biologic technologies can potentially augment existing arthroscopic rotator cuff repair to improve retear rates and postoperative outcomes. The purpose of this study was to evaluate healing rates and clinical outcomes of full-thickness rotator cuff repairs augmented with a bioinductive bovine collagen implant.

Methods

In this prospective multicenter study, investigators enrolled 115 patients (mean age, 60.4 years) with full-thickness rotator cuff tears. There were 66 (57.4%) medium (1-3 cm) tears and 49 (42.6%) large (3-5 cm) tears. Eligible patients consisted of those ≥21 years of age with chronic shoulder pain lasting longer than 3 months and unresponsive to conservative therapy. Patients underwent single- or double-row repair augmented with a bioinductive bovine collagen implant. At the baseline, 3 months, and 1 year, magnetic resonance imaging was performed and patients were assessed for American Shoulder and Elbow Surgeons (ASES) Shoulder Score and Constant-Murley Score (CMS). The primary failure end point was retear, classified as any new full-thickness defect observed on magnetic resonance imaging.

Results

There were 13 retears (11.3%) at 3 months, with an additional 6 (19 total [16.5%]) found at 1 year. In large tears, double-row repair had a significantly lower rate of retear at 3 months (P = .0004) and 1 year (P = .0001) compared with single-row repair. ASES and CMS scores significantly improved between the baseline and 1 year for medium and large tears. At 1 year, the minimally clinically important difference for ASES and CMS was met by 91.7% (95% CI: 84.9-96.1) and 86.4% (95% CI: 78.2-92.4) of patients, respectively. Patients without retear and those <65 years of age had significantly better CMS scores at 1 year when compared with those with retear and those ≥65 years (P < .05). There was no statistically significant difference in outcomes based on treatment of the biceps tendon. Of 9 reported reoperations in the operative shoulder, only 2 were considered potentially related to the collagen implant.

Conclusion

Interim results from this prospective study indicate a favorable rate of retear relative to the literature and improvement in clinical function at 1 year after adjunctive treatment with the study implant augmenting standard arthroscopic repair techniques.

A case series of recurrent myotendinous rotator cuff tears repaired and augmented with dermal allograft: clinical outcomes at two years

When rotator cuff tears occur after a primary repair at the footprint, they often fail medially at the myotendinous junction, also called type II tears. These are difficult tears to treat, and little research has been published on how to address tears at the myotendinous junction and the clinical outcomes of the revised repairs. The purpose of this study is to evaluate the outcomes of type II rotator cuff tears repaired with a dermal allograft augmentation.

MATERIALS AND METHODS

We conducted a retrospective chart review of 9 patients with a type II rotator cuff tear medially at the myotendinous junction, arthroscopically repaired and augmented with acellular dermal allograft by a single surgeon. Two-year follow-up was obtained to evaluate pain, function, range of motion, and structural integrity of the repair via ultrasound.

RESULTS

Of all 9 patients, the mean visual analog scale preoperatively was 5.1 (standard error, ±2.1). With 9 patients having 2-year follow-up, the mean visual analog scale score continued to improve to 1.9 (standard error, ±2.4). At 2 years, the mean American Shoulder and Elbow Surgeons based on 8 patients was 76.1, and the mean Short Form 36 for all 9 patients was 78.7. All 9 patients with 2-year follow-up had an intact repair on ultrasound read by a musculoskeletal fellowship-trained radiologist.

DISCUSSION

Based on the early outcome data, patient satisfaction scores, and intact repairs visualized on ultrasound at 2 years postoperatively, the use of acellular human dermal matrix augmentation appears to be an efficacious and worthwhile treatment option for patients with recurrent rotator cuff tears at the medial myotendinous junction.

Acromial morphology is not associated with rotator cuff tearing or repair healing

BACKGROUND

The purposes of this study were to determine whether acromial morphology (1) could be measured accurately on magnetic resonance images (MRIs) as compared to computed tomographs (CTs) as a gold standard, (2) could be measured reliably on MRIs, (3) differed between patients with rotator cuff tears (RCTs) and those without evidence of RCTs or glenohumeral osteoarthritis, and (4) differed between patients with rotator cuff repairs (RCRs) that healed and those that did not.

METHODS

This is a retrospective comparative study. We measured coronal, axial, and sagittal acromial tilt; acromial width, acromial anterior and posterior coverage, and glenoid version and inclination on MRI corrected into the plane of the glenoid. We determined accuracy by comparison with CT via intraclass correlation coefficients (ICCs). To determine reliability, these same measurements were made on MRI by 2 observers and ICCs calculated. We compared these measurements between patients with a full-thickness RCT and patients aged >50 years without evidence of an RCT or glenohumeral osteoarthritis. We then compared these measurements between those patients with healed RCRs and those with a retorn rotator cuff on MRI. In this portion, we only included patients with both a preoperative MRI and a postoperative MRI at least 1 year from RCR. Only those patients without tendon defects on postoperative MRIs were considered to be healed. In these patients, we also radiographically measured the critical shoulder angle.

RESULTS

In a validation cohort of 30 patients with MRI and CT, all ICCs were greater than 0.86. In these patients, the inter-rater ICCs of the MRI measurements were >0.53. In our RCT group of 110 patients, there was greater acromial width [mean difference (95% confidence interval) = 0.1 (0, 0.2) mm, P = .012] and significantly less sagittal acromial tilt [9° (5°-12°), P < .001] than in our comparison group of 107 patients. A total of 110 RCRs were included. Postoperative MRI scans were obtained at a mean follow-up of 24.2 ± 15.8 months, showing 84 patients (76%) had healed RCRs. Aside from acromial width, which was 0.2 mm different and thus did not have clinical significance, there was no association between healing and any of the measured morphologic characteristics. Patients with healed repairs had significantly smaller tears in terms of both width (P < .001) and retraction (P < .001).

CONCLUSION

Although the acromion is wider in RCTs, the difference of 0.1 mm likely has no clinical significance. The acromion is more steeply sloped from posteroinferior to anterosuperior in those with RCTs. These findings call into question subacromial impingement due to native acromial morphology as a cause of rotator cuff tearing. Acromial morphology, critical shoulder angle, and glenoid inclination were not associated with healing after RCR. This study does not support lateral acromioplasty.

Outcomes of the Star Repair for Large and Massive Rotator Cuff Tears: A Modified Triple-Row Technique

Background:

Large and massive rotator cuff repairs constitute a true challenge for arthroscopic shoulder surgeons. Retear rates as high as 20% have been reported after arthroscopic double-row and suture-bridge techniques used for these tears.

Hypothesis:

A modified triple-row repair will provide satisfactory clinical results with lower risk for retear.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between March 2016 and August 2017, a total of 52 patients with large and massive rotator cuff tears received a modified triple-row cuff repair. A middle repositioning anchor was inserted between the medial and the lateral rows. The middle anchor sutures were loaded to lateral knotless anchors in a star-shaped configuration. Functional evaluation was performed using the American Shoulder and Elbow Surgeons score, University of California, Los Angeles score, Constant-Murley score, and Simple Shoulder Test. Subjective evaluation was carried out using a visual analog scale for pain and a subjective shoulder value score. Health-related as well as disease-specific quality-of-life scores were also used. Retear rates were assessed by means of musculoskeletal ultrasonography. Patients were evaluated for a minimum of 24 months.

Results:

This study included 34 female and 18 male patients with a mean age of 57.17 ± 6.7 years. There were 35 patients (67.3%) with large tears and 17 patients (32.7%) with massive tears. Significant improvement from preoperative values was seen in all functional and subjective scores (P < .001). The mean forward flexion was 163° ± 9.7°, and the mean lateral abduction was 159.4° ± 9.4°. All patients had excellent scores on the general health-related and disease-specific quality-of-life scales. No retears were reported at the end of the follow-up period.

Conclusion:

The star-shaped, modified triple-row cuff repair is a valid and effective solution for surgical management of large and massive rotator cuff tears, providing excellent results and low risk for retears.

Effect of Preoperative Frozen Shoulder on Clinical Outcomes After Arthroscopic Rotator Cuff Repair

Background:

A concomitant rotator cuff tear (RCT) with frozen shoulder is a common but challenging clinical scenario. The effect of frozen shoulder on clinical outcomes is open to discussion.

Purpose/Hypothesis:

This study aimed to evaluate the effect of preoperative frozen shoulder on postoperative clinical outcomes of an RCT. We hypothesized that the treatment results of an RCT concomitant with preoperative frozen shoulder would be comparable with those of an isolated RCT.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 212 patients were divided into 2 groups: 154 in the non–frozen shoulder (NFS) group and 58 in the preoperative frozen shoulder (FS) group. All patients underwent a thorough preoperative evaluation that included range of motion (ROM) and the pain visual analog scale, functional visual analog scale, Constant score, and American Shoulder and Elbow Surgeons (ASES) score. The same evaluation was performed at 6 months and 1 and 2 years postoperatively. The healing status of the repaired RCT of all patients was evaluated by postoperative magnetic resonance imaging.

Results:

The FS group showed statistically significantly worse functional outcomes than the NFS group at 6 months and 1 year postoperatively (P < .05). At 2 years postoperatively, active assisted ROM was equivalent between the groups, although the ASES and Constant scores were significantly lower for the FS group (P < .033 and P < .001, respectively). The retear rates were 5.3% and 12.3% for the FS and NFS groups, respectively (P = .013).

Conclusion:

Preoperative frozen shoulder positively affected rotator cuff healing but negatively affected most functional outcomes, including ROM, at 6 months and 1 year postoperatively. At 2 years after surgery, there was no significant difference in active motion, but outcome scores remained lower in the FS group. For patients with preoperative frozen shoulder, a delay in surgery for additional physical therapy might not be necessary. The retear rate for the NFS group was more than double that for the FS group in the current study, which indicates that surgery for an RCT combined with frozen shoulder might provide better results in the long term because of an intact, healed rotator cuff.

Repair Integrity and Retear Pattern After Arthroscopic Medial Knot-Tying After Suture-Bridge Lateral Row Rotator Cuff Repair

BACKGROUND

Type 2 failure is a big issue after suture-bridge rotator cuff repair, which may be because of stress concentration at the medial row stitches. We have been performing medial knot-tying after suture-bridge lateral row repair to avoid the stress concentration. This study aimed to evaluate clinical and radiological outcomes after arthroscopic rotator cuff repair using this technique.

HYPOTHESIS

This technique would yield better radiological outcomes with a reduced type 2 failure rate compared with reported outcomes after conventional suture-bridge repair.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The inclusion criteria of this study were (1) full-thickness tears, (2) primary surgery, and (3) minimum 2-year follow-up with pre- and postoperative magnetic resonance imaging (MRI). We investigated active ranges of motion (forward elevation and external rotation), as well as the Japanese Orthopaedic Association (JOA) and University of California, Los Angeles (UCLA), scores preoperatively and at the final follow-up.

RESULTS

This study included 384 shoulders in 373 patients (205 men and 168 women) with a mean age of 65 years (range, 24-89 years) at the time of surgery. The mean follow-up was 29 months (range, 24-60 months). There were 91 small, 137 medium, 121 large, and 35 massive tears. Postoperative MRI scans demonstrated successful repair in 324 shoulders (84.4%, group S) and retear in 60 shoulders (15.6%). Among 60 retears, 40 shoulders (67%) had type 1 failure (group F1) and 20 shoulders (33%) had type 2 failure (group F2). Forward elevation and external rotation significantly improved after surgery (P < .001 for both). Postoperative JOA and UCLA scores in group F2 were significantly lower than those in the other groups.

CONCLUSION

The medial knot-tying after suture-bridge lateral row repair demonstrated excellent functional and radiological outcomes after surgery, with a retear rate of 15.6%. The type 2 failure showed significantly inferior functional outcomes; however, the rate of type 2 failure was less relative to previous studies using conventional suture-bridge techniques. Our technique could be a good alternative to conventional suture-bridging rotator cuff repair because it may reduce the rate of postoperative type 2 failure.

Medium-term outcomes of a cohort of revision rotator cuff repairs

BACKGROUND

There are limited medium- and long-term studies investigating clinical outcomes following revision rotator cuff surgery. The aim of the current study was to analyze the medium-term pain and functional outcomes of a cohort of revision rotator cuff repairs.

METHODS

This was a multicenter, prospective cohort study of revision rotator cuff repairs undertaken between March 2009 and December 2010. Pain, function (Flex-SF), and postoperative data were collected at baseline; 6, 12, and 24 months; and 5 years.

RESULTS

A total of 125 revision rotator cuff repairs were included in this study. Average improvement in Flex-SF and pain from baseline to 5 years was 8.5 (P < .001) and 2.1 points, respectively (P < .001). The improvement was not as pronounced as those who underwent primary repair. Significantly lower pain scores were seen in nonsmokers (P < .001) and in those who underwent tenotomy rather than tenodesis (2 vs. 3.5, P < .05) for a damaged long head of biceps. Significantly higher function scores were seen in those with only 1 tendon involved (P < .05). The patient-reported retear rate was 32.6%, and the reoperation rate was 34.7%.

CONCLUSION

Revision rotator cuff repair provides significant improvement in both pain and function at 5 years postoperation, though not as good as primary repair. Superior clinical outcomes are seen in nonsmokers, those with only 1 tendon affected, and those who undergo tenotomy instead of tenodesis for a damaged long head of biceps tendon.

Is residual tendon a predictor of outcome following arthroscopic rotator cuff repair? A preliminary outlook at short-term follow-up

BACKGROUND

Multiple factors including muscle atrophy, fatty infiltration, smoking, advanced patient age, and increasing tear size have been identified as risk factors for retear after rotator cuff repair. However, little is known about what effect the length of the residual rotator cuff tendon has on the success of repair and patient outcomes.

METHODS

This study included 64 patients. Patients were stratified based on a residual tendon length of greater than 15 mm (group 1, residual tendon) or 15 mm or less (group 2, no residual tendon). Rotator cuff tendon integrity was then evaluated using ultrasound imaging at 6 months. Outcome measures included the Single Assessment Numeric Evaluation score, visual analog scale score, EQ5D Index score, Global Rating of Change score, and Penn Shoulder Score.

RESULTS

No differences were found between groups regarding demographic data or repair configuration. Assessment of tendon healing demonstrated an increased rate of tendons that had "not healed" in group 2 (19.3% [n = 5] vs. 13.2% [n = 5]), but this difference was not statistically significant (P = .55). Functional outcome scores improved significantly from preoperatively to final follow-up in both groups and displayed no differences at 6-month follow-up.

CONCLUSION

A smaller residual tendon length was not a negative predictor of clinical outcomes following arthroscopic rotator cuff repair in patients with short-term follow-up. Although there was a trend toward a decreased rate of healing in patients with smaller residual tendons, this was not significant.

Maximum Bridging Suture Tension Provides Better Clinical Outcomes in Transosseous-Equivalent Rotator Cuff Repair: A Clinical, Prospective Randomized Comparative Study

BACKGROUND

Some studies reporting clinical outcomes after transosseous-equivalent (TOE) repair have attributed type II rotator cuff failure to excessive bridging suture tension, as it can cause overloading on the medial row. In a previous biomechanical cadaveric study, increasing bridging suture tension over 90 N did not improve the contact area and ultimate failure load of the TOE construct, despite increasing the contact force and contact pressure.

PURPOSE

To compare the clinical outcomes of different bridging suture tensions after TOE rotator cuff repair based on the results of a previous biomechanical study.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

A total of 78 patients who underwent arthroscopic rotator cuff repair for medium- to large-sized tears were prospectively enrolled and randomly divided into 2 groups according to the applied bridging suture tension: optimum tension group (96.3 ± 4.9 N) and maximum tension group (199.0 ± 20.3 N). Bridging suture tension was measured with a customized tensiometer, as used in the previous biomechanical study. The functional outcome was measured at the final follow-up (27.4 ± 5.9 months [range, 24-45 months]) using the visual analog scale for pain, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and Constant score, and the anatomic outcome was evaluated using magnetic resonance imaging or ultrasonography at least 12 months after surgery.

RESULTS

Overall, 64 patients (32 in each group) were analyzed. The functional outcomes improved significantly compared with preoperative values (all P < .05) but did not show significant differences between the 2 groups (all P > .05). Regarding the anatomic outcomes, the maximum tension group (n = 1; 3.1%) had a significantly lower healing failure rate than the optimum tension group (n = 9; 28.1%) (P = .013). One patient in the maximum tension group had a type II failure.

CONCLUSION

Maximum bridging suture tension in TOE repair for medium- to large-sized rotator cuff tears provided better anatomic healing with less risk of medial rotator cuff failure, which differs from the results of a previous time-zero biomechanical study.