Effect of capsular release in the treatment of shoulder stiffness concomitant with rotator cuff repair: diabetes as a predisposing factor associated with treatment outcome

What is the most predictive magnetic resonance imaging finding of rotator cuff tear concomitant with shoulder stiffness?

Background

Common magnetic resonance imaging (MRI) findings in adhesive capsulitis are not often evident in rotator cuff tear concomitant with shoulder stiffness. This study aimed to determine the most predictive MRI finding of rotator cuff tear with shoulder stiffness to differentiate from that without stiffness.

Materials and methods

The data of patients who underwent arthroscopic rotator cuff repair between January 2014 and October 2019 were retrospectively reviewed. Stiffness was defined as forward flexion <120°, external rotation at side <30°, and internal rotation at back 

Results

Anterior capsular thickness, glenoid capsular thickness in the axillary recess, and anterior and axillary capsular hyperintensities were significantly more dominant in the stiff group (all P < .05) than in the control group. Anterior capsular thickness and anterior capsular abnormal hyperintensity could be used to differentiate between the stiff and control groups (P < .05). Anterior capsular thickness showed high diagnostic performance with an area under the receiver operating characteristic curve of 0.993. The cut-off value for stiffness was 3.07 mm (sensitivity, 96.1%; specificity, 100%).

Conclusion

Anterior capsular thickening and abnormal hyperintensity were the most predictive MRI findings for stiffness in patients with rotator cuff tear and stiffness to differentiate from patients with rotator cuff tear without stiffness.

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Key Words

• Adhesive capsulitis
• Anterior capsular abnormal hyperintensity
• Anterior capsular thickness
• Magnetic resonance imaging
• Rotator cuff tear
• Stiff shoulder

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Affiliation(s)

Ji Young Yoon Department of Orthopaedic Surgery, National Police Hospital, Seoul, Republic of Korea
HeeSoo Han Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
Myoung Yeol Shin Department of Orthopaedic Surgery, National Police Hospital, Seoul, Republic of Korea
Hyeon Jang Jeong Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
Yusuhn Kang Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
Young Dae Jeon Department of Orthopaedic Surgery, Ulsan University College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
Ji Un Kim Department of Orthopaedic Surgery, Korea University College of Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
Joo Han Oh Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea

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One-stage rotator cuff repair in stiff shoulders shows comparable range of motion, clinical outcome and retear rates to non-stiff shoulders: a systematic review

BACKGROUND

One-stage treatment involving rotator cuff repair and shoulder capsule release is mainly used to treat patients with rotator cuff tears (RCTs) and concomitant shoulder stiffness. Despite the increasing attention to the efficacy and safety of one-stage treatment, controversy still remains. Therefore, this systematic review aims to summarize the indications, operation procedure and rehabilitation protocol, and compare the range of motions (ROMs), functional outcomes and retear rates of one-stage treatment for RCTs in stiff shoulders and non-stiff shoulders.

METHODS

Multiple databases (PubMed, the Cochrane Library, Embase and MEDLINE) were searched for studies that investigated outcomes after one-stage treatment for RCTs concomitant with shoulder stiffness compared with rotator cuff repair for RCTs alone, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Descriptive statistics, including range of motion, patient-reported outcome and retear rate, are presented without meta-analysis due to the heterogeneity and low levels of evidence.

RESULTS

A total of 9 cohort studies were included, with 305 patients treated with one-stage treatment involving rotator cuff repair and simultaneous shoulder capsular release and 1059 patients treated with rotator cuff repair alone. Patients in both groups had significant symptom improvement and functional recovery after the one-stage treatment for the stiffness group and standard repair for the non-stiffness group, and most patients could return to normal life and work within 6 months after the operation. The retear rate in the one-stage treatment group was not higher than that in the rotator cuff repair group. No statistically significant differences between the two groups were observed in terms of range of motion and patient-reported outcomes in the vast majority of studies at the final follow-up, including the visual analog scale for pain, the Constant score, the American Shoulder and Elbow Surgeons score, the University of California Los Angeles Shoulder Score, the Oxford shoulder score and the Simple Shoulder Test.

CONCLUSION

One-stage treatment for RCTs in stiff shoulders provides comparable ROM and patient-reported clinical outcomes as rotator cuff repair for non-stiff RCTs. In addition, the rate of postoperative retear in stiff shoulder treated with one-stage treatment was not higher than in non-stiff shoulders.

A Modified Arthroscopic Outside-in Shoulder Release Approach for Severe Shoulder Stiffness

OBJECTIVE

Arthroscopic release is effective for patients with shoulder stiffness, but the traditional inside-out procedure cannot effectively alleviate the mobility of some severe stiff shoulder and even cause itrogenic injuries sometimes. The aim of this study is to evaluate the clinical efficacy and advantages of a modified outside-in shoulder release approach for severe shoulder stiffness.

METHODS

Included in this retrospective study were 15 patients (five male and 10 female) with severe shoulder stiffness who underwent modified outside-in shoulder release surgery at our hospital between June 2019 and March 2021. Of them, 10 patients had a primary frozen shoulder and five had secondary shoulder stiffness, involving the right shoulder in six cases and the left shoulder in nine cases. The mean age of the 15 patients was 56.7 (34-69) years. The patients were instructed to exercise passively from second-day post-operation and enhance the rehabilitation exercise gradually. All patients received a range of motion (ROM) examination before and after surgery. The American Shoulder and Elbow Surgeon's Score (ASES), Constant Score (CS), and Visual Analog Scale (VAS) score for pain were recorded. All data were tested by normal distribution first and then by paired T test, otherwise by Wilcoxon rank sum test.

RESULTS

The mean follow-up period was 18.2 (12-33) months. Compared with the preoperative value, the mean ASES score at the final follow-up improved from 38.4 ± 7.37 to 88.13 ± 6.33 points; the mean CS score from 43.27 ± 6.71 to 78.74 ± 6.93 points; the mean VAS score from 5.07 ± 1.03 to 0.81 ± 0.83 points; forward flexion from 81.93° ± 11.45° to 156.73° ± 9.12°; abduction from 65.93° ± 16.82° to 144.80° ± 8.83°; neutral external rotation from 13.53° ± 10.38° to 51.20° ± 4.77°; internal rotation from the buttock to waist (L3), all showing a significant difference (P < 0.0001). No serious complication was observed in any patient during the postoperative follow-up periods.

CONCLUSION

The present study has demonstrated that the modified arthroscopic outside-in shoulder release approach can improve ROM of patients and alleviate pain effectively, proving it to be an appropriate surgical option for the treatment of severe shoulder stiffness.

Influence of joint volume on range of motion after arthroscopic rotator cuff repair

BACKGROUND

Capsular contracture is a well-known etiology in the primary stiff shoulder; thus capsular contracture and resultant decreased joint volume could lead to postoperative stiffness, which is a commonly reported morbidity after arthroscopic rotator cuff repair (ARCR). The purpose of this study was (1) to quantify the joint volume (total joint volume and each quadrant compartmental volume) using computed tomography arthrography (CTA) and (2) to demonstrate the relationship between joint volume and postoperative range of motion (ROM) after ARCR.

MATERIALS AND METHODS

Eighty-three patients (60 ± 5.11 years, men = 26, women = 57) who had undergone ARCR between January 2015 to December 2020 due to small to medium full-thickness tear and followed by CTA 6 months postoperatively were retrospectively reviewed. An image reconstruction program (3D Slicer, version 4.11.2 software) was used to calculate the joint volume (total joint volume and quadrant compartment joint volumes; anteroinferior, anterosuperior, posterosuperior and posteroinferior). For shoulder ROM, data including scaption (Sc), external rotation on side (ERs), external rotation at 90° (ER90), and internal rotation on back (IRb) were collected 6 months postoperatively. An evaluation of the correlation between joint volume and each shoulder motion was performed.

RESULTS

There were moderate correlations between the total joint volume and each motion (Sc: Pearson coefficient, 0.32, p = 0.0047; ERs: Pearson coefficient, 0.24, p = 0.0296; ER90: Pearson coefficient, 0.33, p = 0.0023; IRb: Pearson coefficient, 0.23, p = 0.0336). Among the quadrant compartments, the anteroinferior (Sc: Pearson coefficient, 0.26, p = 0.0199; ERs: Pearson coefficient, 0.23, p = 0.0336; ER90: Pearson coefficient, 0.25, p = 0.0246; IRb: Pearson coefficient, 0.26, p = 0.0168) and posterosuperior (Sc: Pearson coefficient, 0.24, p = 0.029; ER90: Pearson coefficient, 0.29, p = 0.008; IRb: Pearson coefficient, 0.22, p = 0.0491) and posteroinferior (Sc: Pearson coefficient, 0.30, p = 0.0064; ER90: Pearson coefficient, 0.29, p = 0.0072) showed moderate correlations with each shoulder motion.

CONCLUSION

Total joint volume, anteroinferior compartment joint volume, posterosuperior compartment joint volume and posteroinferior compartment joint volume were related to postoperative ROM after ARCR. Perioperative methods to increase the joint volume, especially the anteroinferior, posterosuperior and posteroinferior parts of the capsule may prevent postoperative stiffness after ARCR.

LEVEL OF EVIDENCE

Level III; Retrospective Case-Control Study.

Sex Is Associated with the Success or Failure of Manipulation Alone for Joint Stiffness Associated with Rotator Cuff Repair

Purpose: One-stage arthroscopic rotator cuff repair with manipulation has been recently performed for rotator cuff tears with shoulder stiffness, whereas some patients require capsular release due to severe stiffness that is difficult to treat with manipulation. The purpose of this study was to analyze patient backgrounds and related factors of success or failure of manipulation alone for the treatment of shoulder stiffness associated with rotator cuff tears. Methods: This study included 64 patients with rotator cuff tears and shoulder stiffness who underwent arthroscopic rotator cuff repair with manipulation alone or with manipulation and capsular release of the glenohumeral joint at our institution between January 2015 and September 2019. The patients were divided into two groups: those whose shoulder stiffness could be improved by manipulation alone (Manipulation group) and those whose stiffness could not be improved by manipulation alone and required capsular release (Capsular release addition group). Analysis was performed between the two groups regarding patient backgrounds and related factors, including rotator cuff tear morphology and range of motions pre- and postoperatively. Results: Exactly 45 patients and 19 patients were included in Manipulation group and Capsular release addition group, respectively. A comparison between the two groups showed that patient age (p = 0.0040), sex (p = 0.0005), and injury due to trauma (p = 0.0018) were significantly related to the success or failure of manipulation alone. Multivariate logistic regression analysis on these three factors showed that sex (odds ratio, 5.5; p = 0.048) was significantly associated with the success or failure of manipulation alone. In both groups, the passive ROM of all patients improved at the last postoperative follow-up compared to their pre-operative values (p < 0.001), except for internal rotation in the Capsular release addition group (p = 0.49). Conclusion: Young male patients who have shoulder stiffness associated with rotator cuff tears should be considered for arthroscopic capsular release rather than manipulation.

Effectiveness of surgical and non-surgical interventions for managing diabetic shoulder pain: a systematic review

PURPOSE

This systematic review evaluated and compared the effectiveness of non-surgical and surgical interventions for managing shoulder pain in patients with diabetes.

METHODS

PubMed, Scopus, CINAHL, EMBASE, Sport Discus, and Cochrane library were searched for studies published in the last 20 years. Randomized clinical trials (RCTs) and cohort studies that assessed shoulder pain in patients with diabetes and implemented one or a combination of non-surgical and surgical interventions were eligible for inclusion. The quality of the included studies was assessed using the Structured Effectiveness Quality Evaluation Scale (SEQES) tool. Data extracted from the eligible studies included study design, patient characteristics, duration of symptoms, type of interventions, outcome measures used to assess pain, follow-up intervals, and research findings.

RESULTS

A narrative synthesis with effect sizes (ES) or between-group differences was conducted. A total of 25 (14 non-surgical and 11 surgical) studies met the inclusion criteria. Six studies addressed physiotherapeutic interventions (three RCTs and three cohorts - ES = 0.07-1.3), three studies assessed the effect of steroid injections (two RCTs and one cohort - ES = 0.2-0.4), two cohorts addressed arthrographic capsular distension (between-group difference of 1.1 on Visual Analogue Scale), two cohorts addressed MUA, and one RCT addressed suprascapular nerve block (ES = 1-6). For the surgical studies, six cohorts addressed arthroscopic capsular release (ES = 0.2), three cohorts addressed arthroscopic rotator cuff repair (ES = 0.05-0.5), and one cohort addressed arthroplasty (ES = 0.3).

CONCLUSION

Moderate- to very-low-quality evidence suggests large effects of physiotherapy modalities plus exercise and suprascapular nerve block, and trivial to small effects for surgical interventions for improving shoulder pain in patients with diabetes. Future well-designed studies are needed to provide accurate estimates of the true effects of these interventions on improving shoulder pain in patients with diabetes.Implications For RehabilitationShoulder pain may lead to disability in patients with diabetes.We recommend the use of physiotherapy interventions to reduce shoulder pain.Corticosteroid injections are recommended for short-term shoulder pain relief.

A new pathophysiology of atraumatic rotator cuff tears: adduction restriction of the glenohumeral joint

Background

The pathophysiology of atraumatic rotator cuff tears (ATTs) has not been fully understood. Adduction restriction of the glenohumeral joint can cause pain and disability in patients with ATTs. We aimed to use our adduction test (pushing the humerus toward the side in the coronal plane with scapular fixation) to fluoroscopically measure the glenohumeral adduction angle (GAA) and to assess the effectiveness of adduction manipulation.

Materials and methods

Fifty-five patients with ATTs were included in the study. The GAAs of the patients vs. healthy subjects without ATTs were measured fluoroscopically and compared. During the test, patients showed restriction and expressed pain. The visual analog scale (VAS) score, passive range of motion (ROM), and the American Shoulder and Elbow Surgeons score at the initial visit were compared with those after adduction manipulation.

Results

Of the patients, 41 (75%) had positive adduction test results. A higher percentage of positive adduction test results was observed in smaller tears. The average GAA was –21.4° on the affected side, which was smaller than that on the unaffected side, at –2.8° (P < .001), and that in healthy subjects, at 4.8° (P < .001). After manipulation, the GAA was –0.8° (P < .001) and the VAS score, the American Shoulder and Elbow Surgeons score, and all ROM values significantly improved up to the level on the unaffected side.

Conclusion

Adduction restriction of the glenohumeral joint was identified in 75% of all the patients with ATTs. Adduction manipulation significantly reduces the VAS score and restores the ROM. Adduction restriction is considered a crucial pathophysiology of ATTs.

Glenohumeral synovitis score predicts early shoulder stiffness following arthroscopic rotator cuff repair

Background

This study was conducted to determine if there is an association between an intraoperative glenohumeral synovitis score (GHSS) and postoperative shoulder stiffness in patients undergoing arthroscopic rotator cuff repair (ARCR).

Methods

Intraoperative GHSS was collected retrospectively from standardized arthroscopic images on consecutive patients undergoing primary ARCR. Range of motion was collected preoperatively and postoperatively at 3 and 6 months.

Results

290 consecutive patients underwent primary ARCR. At three-months follow-up, 32 (11.0%) patients had glenohumeral stiffness. Patients with stiffness had significantly higher mean GHSS.

Conclusion

Higher intraoperative GHSS was associated with early postoperative shoulder stiffness at three-months after ARCR.

A Rotator Cuff Tear Concomitant With Shoulder Stiffness Is Associated With a Lower Retear Rate After 1-Stage Arthroscopic Surgery

BACKGROUND

Few studies have reported on the radiological characteristics and repair integrity of coexistent rotator cuff tears (RCTs) and shoulder stiffness after simultaneous arthroscopic rotator cuff repair and capsular release.

PURPOSE

To evaluate the radiological characteristics and repair integrity of 1-stage arthroscopic surgery of RCTs concomitant with shoulder stiffness.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Among patients who underwent arthroscopic repair of full-thickness RCTs, the stiff group underwent simultaneous capsular release for shoulder stiffness, and the nonstiff group had no stiffness. Symptom duration, prevalence of diabetes, tear size, tendon involvement (type 1, supraspinatus; type 2, supraspinatus and subscapularis; and type 3, supraspinatus and infraspinatus; type 4, supraspinatus, subscapularis, and infraspinatus), and fatty infiltration (Goutallier stages 0-4) were evaluated. A retear was appraised using magnetic resonance imaging, and clinical outcomes were assessed using range of motion, the Korean Shoulder Scoring System (KSS), and the University of California, Los Angeles (UCLA) shoulder score.

RESULTS

The stiff group showed a significantly lower retear rate (1/39, 2.6%) than the nonstiff group (47/320, 14.7%) ( P = .043). There were significant differences in symptom duration (7.4 ± 6.6 vs 15.0 ± 23.7 months, respectively; P < .001), mediolateral tear size (18.9 ± 8.9 vs 24.1 ± 12.0 mm, respectively; P = .002), tendon involvement (94.9%, 5.1%, 0.0%, and 0.0% vs 85.3%, 6.9%, 7.8%, and 0.0%, respectively; P = .048), and fatty infiltration of the subscapularis (66.7%, 33.3%, 0.0%, 0.0%, and 0.0% vs 31.9%, 61.3%, 5.6%, 1.3%, and 0.0%, respectively; P < .001) and teres minor (74.4%, 20.5%, 5.1%, 0.0%, and 0.0% vs 47.2%, 48.8%, 3.8%, 0.0%, and 0.3%, respectively; P = .007) between the stiff and nonstiff groups. Preoperatively, the stiff group showed significantly worse forward flexion (95.9° ± 23.6° vs 147.7° ± 4.2°, respectively; P < .001), external rotation (17.4° ± 10.1° vs 51.6° ± 12.1°, respectively; P < .001), and internal rotation (L5 vs L2, respectively; P < .001) and lower KSS (52.1 ± 13.8 vs 66.3 ± 13.5, respectively; P < .001) and UCLA scores (18.7 ± 4.8 vs 22.5 ± 4.5, respectively; P < .001) than the nonstiff group. However, these differences became insignificant from 3 months postoperatively for forward flexion ( P > .05) and KSS ( P > .05) and UCLA scores ( P > .05), from 1 year postoperatively for external rotation ( P > .05), and at the last follow-up for internal rotation ( P > .05). A multiple logistic regression analysis revealed that only mediolateral tear size (odds ratio, 1.043; P = .014) and type 2 tendon involvement (odds ratio, 4.493; P = .003) were independent predictors of a retear.

CONCLUSION

RCTs concomitant with shoulder stiffness showed a smaller mediolateral tear size, anterosuperior tendon involvement, and less severe fatty infiltration preoperatively and better repair integrity postoperatively than RCTs without stiffness. Furthermore, the clinical outcomes and range of motion at final follow-up were similar between the 2 groups.

Impact of different glucose metabolism status on clinical outcomes of open arthrolysis for post-traumatic elbow stiffness

BACKGROUND

Diabetes and prediabetes are worldwide public health problems and are considered predisposing factors for adverse functional outcomes after various orthopedic operations. The purpose of this retrospective study was to determine the impact of glucose metabolism status on functional outcomes and complications after open arthrolysis for post-traumatic elbow stiffness.

METHODS

The study included 152 patients with post-traumatic elbow stiffness undergoing arthrolysis, including 120 in the normoglycemic group, 21 in the impaired glucose regulation group, and 11 in the diabetes mellitus group. General patient data, functional performance, and complications were documented and analyzed.

RESULTS

Demographic data and disease characteristics were comparable at baseline. Postoperatively, significant differences were found in range of motion and the Mayo Elbow Performance Score: the diabetes mellitus group had the poorest clinical outcomes. However, there were no significant differences in forearm rotation, visual analog scale pain scores, and complication rates.

CONCLUSION

Patients with post-traumatic elbow stiffness and abnormal glucose metabolism were at increased risk of poorer outcomes after open arthrolysis, and patients with diabetes mellitus had the poorest performance. This study underlines the importance of glycemic control in patients with abnormal glucose metabolism before open arthrolysis.

[Effectiveness of rotator cuff repair with manipulation release and arthroscopic debridement for rotator cuff tear with shoulder stiffness]

Objective

To investigate effectiveness of rotator cuff repair with manipulation release and arthroscopic debridement for rotator cuff tear with shoulder stiffness.

Methods

A retrospectively study was performed on the data of 15 patients with rotator cuff tear combined with shoulder stiffness (stiff group) and 24 patients without stiffness (non-stiff group) between January 2014 and December 2015. The patients in the stiff group underwent arthroscopic rotator cuff repair with manipulation release and arthroscopic debridement while the patients in the non-stiff group only received arthroscopic rotator cuff repair. The patients in the stiff group were older than the patients in the non-stiff group, showing significant difference ( P<0.05). There was no significant difference in gender, type of rotator cuff tear, side of rotator cuff tear, and combined with diabetes between 2 groups ( P>0.05). The visual analogue scale (VAS) score, University of California Los Angeles (UCLA) score, American Shoulder and Elbow Surgeons (ASES) score, and range of motion (ROM) were used to evaluate the effectiveness after operation.

Results

All incisions healed by first intention without any complication after operation. The patients were followed up 13-31 months in the stiff group (mean, 19.2 months) and 13-23 months in the non-stiff group (mean, 20.3 months). There was no significant difference in follow- up time between 2 groups ( t=-0.573, P=0.570). The VAS score in the stiff group was higher than that in the non-stiff group before operation ( t=-2.166, P=0.037); there was no significant difference between 2 groups at 3, 6, 12 months and last follow-up ( P>0.05). The forward flexion and external rotation were significantly lower in the stiff group than those in the non-stiff group before operation and at 3 months after operation ( P<0.05); there was no significant difference between 2 groups at 6, 12 months and last follow-up ( P>0.05). At last follow-up, the internal rotation was beyond L ₃ level in 2 groups. The preoperative UCLA score was significant lower in the stiff group than that in the non-stiff group ( P=0.037); but there was no significant difference in UCLA score at last follow-up between 2 groups ( P=0.786). There was no significant difference in pre- and post-operative ASES scores between 2 groups ( P>0.05).

Conclusion

Satisfactory effectiveness can be achieved in the patients with rotator cuff tear combined with shoulder stiffness after rotator cuff repair with manipulation release and arthroscopic debridement, although the patients with shoulder stiffness had slower postoperative recovery of ROM until 6 months after operation.

A Long Preoperative Duration of Symptoms Is Associated With Worse Functional Outcomes After 1-Stage Arthroscopic Treatment of Rotator Cuff Tears With Shoulder Stiffness

BACKGROUND

Rotator cuff tears with shoulder stiffness remain a difficult issue. Despite the reported satisfactory results of 1-stage surgery, little information is available regarding the factors that affect clinical outcomes. Purpose/Hypothesis: To evaluate the 1-stage arthroscopic treatment of rotator cuff tears with shoulder stiffness and to present the influence of duration of symptoms (DOS) on postoperative functional outcomes. The hypothesis was that a long preoperative DOS is related to worse functional outcomes.

HYPOTHESIS

A long preoperative DOS is related to worse functional outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A cohort study was performed with consecutive patients who underwent 1-stage surgery between January 2012 and July 2014. Forty-four patients were enrolled in the long DOS group (DOS ≥6 months or LDOS), and 38 were enrolled in the short DOS group (DOS <6 months or SDOS). There were no significant differences in the other variables between the groups. The patients were followed for a mean of 33.8 months, and the functional and radiographic outcomes were compared.

RESULTS

Both groups achieved apparent functional postoperative improvements in terms of range of motion, pain, strength, and functional scores ( P < .001 for all). Despite the overall improvements, the patients in the SDOS group had significantly better outcomes according to all functional instruments. The mean postoperative abduction and external rotation at the side in the SDOS group were higher than in the LDOS group (abduction: 162.2° vs 152.8°, respectively [ P = .002]; external rotation: 64.7° vs 56.9°, respectively [ P = .004]). The mean postoperative functional scores in the SDOS group were all higher than in the LDOS group (American Shoulder and Elbow Surgeons [ASES] score: 91.1 vs 81.9, respectively; Constant-Murley score: 76.9 vs 71.8, respectively; Fudan University Shoulder Score [FUSS], 90.6 vs 81.1, respectively), and the mean postoperative visual analog scale (VAS) score for pain in the SDOS group was lower (0.7 vs 1.8, respectively) ( P < .001 for all). The difference in the retear rates was not significant, with 7 retears in the SDOS group and 4 in the LDOS group ( P = .216).

CONCLUSION

One-stage surgery effectively achieved overall improvements. A preoperative DOS of ≥6 months led to poorer functional outcomes, which suggests that surgeons should propose a surgical treatment for this condition before symptoms persist for 6 months.

Altered Gene and Protein Expressions in Torn Rotator Cuff Tendon Tissues in Diabetic Patients

PURPOSE

To analyze and compare the gene and protein expression characteristics in torn rotator cuff tendon tissues between diabetic and nondiabetic patients.

METHODS

This was a pilot study. Twelve samples of rotator cuff tendon tissue from diabetic patients (mean age, 62.3 ± 9.9 years) and 12 age- and sex-matched nondiabetic tendon tissues (62.3 ± 9.9 years) were acquired from the torn tendon end of medium rotator cuff tears during arthroscopic surgery, after applying the same inclusion and exclusion criteria. Expressions of various genes of interest, including collagens I and III, matrix metalloprotease (MMP)-2, MMP-3, MMP-9, MMP-13, interleukin (IL)-1, IL-6, insulin-like growth factor-1, vascular endothelial growth factor, tenomodulin, tumor necrosis factor-α, and p53, were analyzed with real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR). In addition, immunohistochemistry and western blot assay were performed for the genes that revealed significantly different expressions in real-time qRT-PCR between groups.

RESULTS

Gene expression levels of MMP-9, MMP-13, IL-6, and tenomodulin were significantly higher in the diabetic than in the nondiabetic group by real-time qRT-PCR analyses (P = .011, .004, .009, and .010, respectively). The density of cells expressing MMP-9 and IL-6 was significantly increased in the torn tendons of the diabetic patients on immunohistochemical analysis, and the density of MMP-9 and IL-6 protein expressions was significantly higher in the diabetic group on western blot (P = .018 and .044, respectively).

CONCLUSIONS

Diabetic torn cuff tendon tissues showed MMP-9 and IL-6 overexpressions compared with controls.

CLINICAL RELEVANCE

The overexpressions of MMP-9 and IL-6 may be one of the explanations for the high healing failure rate after rotator cuff repair in the diabetic patients.

Correlations of coracohumeral ligament and range of motion restriction in patients with recurrent anterior glenohumeral instability evaluated by magnetic resonance arthrography

BACKGROUND

Evaluation of range of motion (ROM) restriction before treatment of shoulder disorders is important for predicting the final functional outcomes. The purpose of this study was to investigate correlations of thickness of the coracohumeral ligament (CHL) and ROM restriction in patients with recurrent anterior glenohumeral instability.

METHODS

Between January 2005 and March 2015, 181 shoulders (137 male and 44 female patients; mean age, 29.3 years) with recurrent anterior glenohumeral instability treated with an arthroscopic Bankart repair were enrolled in this study. We evaluated preoperative ROM, thickness of the CHL, and obliteration of the subcoracoid fat triangle on magnetic resonance arthrography. ROM measurements, including forward flexion (FF), external rotation with the arm at the side (ER), and hand behind the back (HBB), were made in a standing position.

RESULTS

There were significant negative correlations between FF and age (P < .001) and between HBB and age (P < .001) but not between ER and age (P = .11). The thickness of the CHL significantly increased with age (P < .001). FF, ER, and HBB were significantly restricted in patients with obliteration compared with those without obliteration (P < .001, P = .004, P < .001, respectively).

CONCLUSIONS

Obliteration of the subcoracoid fat triangle and the thickness of the CHL positively correlated with ROM restrictions, and these changes were greater with age in patients with recurrent anterior glenohumeral instability.

Arthroscopic Rotator Cuff Repair With Concomitant Capsular Release

Patients with rotator cuff tears may present with or subsequently develop concomitant shoulder stiffness. The treatment of rotator cuff tears in the face of passive glenohumeral motion loss is controversial. Preoperative shoulder stiffness has been considered by some a contraindication to rotator cuff repair. Some surgeons recommend staging surgical procedures and delaying rotator cuff repair until shoulder stiffness has resolved. However, this can lead to prolonged recovery times and patient dissatisfaction. We describe a surgical technique that allows for the single-stage arthroscopic management of rotator cuff tears with associated adhesive capsulitis. Arthroscopic capsular release and shoulder manipulation are performed in the same operative setting as arthroscopic rotator cuff repair. We have found that this combined, single-stage arthroscopic approach can effectively treat patients with rotator cuff tears and concomitant shoulder stiffness.

The effect of concomitant glenohumeral joint capsule release during rotator cuff repair--a comparative study

BACKGROUND

There is debate as to whether to operate or to defer surgery on patients with concomitant rotator cuff tear and shoulder stiffness. The purpose of this study was therefore to compare the outcomes in those patients who had both their rotator cuff tear and shoulder stiffness treated with the outcomes of patients who had a rotator cuff repair but no stiffness.

METHODS

Twenty-five patients formed the stiffness group (receiving a concomitant rotator cuff repair and manipulation under anesthesia ± arthroscopic capsular release for preoperative ipsilateral stiffness), and a chronologically matched group of 170 rotator cuff repair-only patients formed the nonstiffness group. Patients ranked their pain and function scores preoperatively and at 1 week, 6 weeks, 12 weeks, 6 months, and 2 years postoperatively; examiners recorded range of motion, strength, and presence of impingement signs. Repair integrity was determined using ultrasound.

RESULTS

Patients from both groups had significantly improved clinical outcomes at the 2-year follow-up compared with preoperative values. Range of motion was similar between groups at 2 years for forward flexion, abduction, and external rotation, whereas the nonstiffness group had a superior range of internal rotation (P = .014). Stiffness patients had 0 of 25 (0%) retears at 2 years compared with 34 of 170 (20%) in the nonstiffness group (P = .009).

CONCLUSIONS

The good outcomes of rotator cuff repair with glenohumeral capsular release disproved our hypothesis and suggest that there is no advantage in delaying repair of a rotator cuff tear to allow stiffness to resolve and that stiffness confers an advantage in terms of repair integrity.

LEVEL OF EVIDENCE

Level III; Retrospective Cohort Design; Treatment Study.

Outcomes of Combined Bone Marrow Stimulation and Patch Augmentation for Massive Rotator Cuff Tears

BACKGROUND

The high failure rate after surgical repair of massive rotator cuff tears is a consistent problem.

PURPOSE

To evaluate the clinical and radiological outcomes of arthroscopic rotator cuff repair with bone marrow stimulation and patch augmentation in patients with massive rotator cuff tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study included 21 patients who underwent bone marrow stimulation and patch augmentation (group 1) and 54 patients who underwent conventional repair (group 2) for massive rotator cuff tears. Postoperative clinical outcomes were evaluated based on visual analog scale (VAS) for pain, simple shoulder test (SST), University of California, Los Angeles (UCLA), Constant, and American Shoulder and Elbow Surgeons (ASES) scores at baseline, 1 year postoperatively, and final follow-up. Anatomic outcomes were evaluated by using postoperative magnetic resonance imaging at 1 year after surgery.

RESULTS

No significant differences in demographic characteristics and baseline data were observed between groups 1 and 2. Clinical symptoms were significantly improved at the final follow-up in both groups (P < .001). At the final follow-up, no significant differences were found in VAS pain (P = .676), SST (P = .598), UCLA (P = .100), Constant (P = .469), or ASES (P = .880) scores. However, the retear rate was lower in group 1 (4/21, 19.0%) than in group 2 (25/54, 46.3%) (P = .036), and the medial-row failure rate (type 2 retears) was much lower in group 1 (0/4, 0%) than in group 2 (18/25, 72.0%) (P = .014).

CONCLUSION

Concomitant bone marrow stimulation and patch augmentation significantly reduced retear and medial-row failure rates in the arthroscopic repair of massive rotator cuff tears.

Hormones and tendinopathies: the current evidence

BACKGROUND

Tendinopathies negatively affect the quality of life of millions of people, but we still do not know the factors involved in the development of tendon conditions.

SOURCES OF DATA

Published articles in English in PubMed and Google Scholar up to June 2015 about hormonal influence on tendinopathies onset. One hundred and two papers were included following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

AREAS OF AGREEMENT

In vitro and in vivo, tenocytes showed changes in their morphology and in their functional properties according to hormonal imbalances.

AREAS OF CONTROVERSY

Genetic pattern, sex, age and comorbidities can influence the hormonal effect on tendons.

GROWING POINTS

The increasing prevalence of metabolic disorders prompts to investigate the possible connection between metabolic problems and musculoskeletal diseases.

AREAS TIMELY FOR DEVELOPING RESEARCH

The influence of hormones on tendon structure and metabolism needs to be further investigated. If found to be significant, multidisciplinary preventive and therapeutic strategies should then be developed.