The effect of diabetes, hyperlipidemia, and statins on the development of rotator cuff disease: a nationwide, 11-year, longitudinal, population-based follow-up study

A causal association between lipid-lowering medications and rotator cuff syndrome: a drug-targeted mendelian randomization study

Background: Previous research has suggested that dyslipidemia may be a risk factor for rotator cuff syndrome (RCS), and lipid-lowering drugs may aid in its treatment, though conclusions have not been definitive. Mendelian randomization is a statistical method that explores the causal relationships between exposure factors and diseases. It overcomes the confounding issues inherent in traditional observational studies, thereby providing more reliable causal inferences. We employed this method to investigate whether hyperlipidemia is a risk factor for rotator cuff syndrome and whether lipid-lowering drugs can effectively treat this condition. Methods: Genetic variations linked to lipid traits low-density lipoprotein cholesterol (LDL-C), triglyceride (TG), and total cholesterol (TC) were acquired from the UK Biobank and the Global Lipids Genetics Consortium (GLGC). Data on genetic variation in rotator cuff syndrome were obtained from FinnGen, including 24,061 patients and 275,212 controls. In the next step, we carried out two-sample Mendelian randomization analyses to determine whether lipid traits correlate with rotator cuff syndrome risk. Additionally, we performed drug-target Mendelian randomization (MR) analyses on 10 drug targets related to rotator cuff syndrome. For the drug targets that showed significant results, further analysis was done using Summary-data-based Mendelian Randomization (SMR) and colocalization techniques. We performed a mediation analysis to identify potential mediators between HMG-CoA reductase (HMGCR) and RCS. Results: No causative link was established between these lipid traits and rotator cuff syndrome. However, a significant association has been identified where HMGCR inhibition corresponds to a reduced risk of rotator cuff disease (OR = 0.68, [95% CI, 0.56-0.83], p = 1.510 × 10-4). Additionally, enhanced expression of HMGCR in muscle tissues is also linked to a decreased risk of rotator cuff syndrome (OR = 0.88, [95% CI, 0.76-0.99], p = 0.03). Body mass index (BMI) mediated 22.97% of the total effect of HMGCR on RCS. Conclusion: This study does not support low-density LDL-C, TG, and TC as risk factors for rotator cuff syndrome. HMGCR represents a potential pharmaceutical target for preventing and treating rotator cuff syndrome. The protective action of statins on the rotator cuff syndrome might not be associated with their lipid-lowering properties.

Biomechanical comparison of suture bridge rotator cuff repair with and without dermal allograft pledgets

BACKGROUND

One method to augment rotator cuff repair is to pass dermal allograft pledgets along the sutures that bridge from the medial to the lateral row. It remains unclear whether this augmentation method alters repair biomechanics.

METHODS

This was a controlled laboratory study. After an a priori power analysis, 9 pairs of rotator cuffs underwent double-row suture bridge rotator cuff repair, half randomized to augmentation with dermal allograft pledgets passed along the suture bridge sutures. Repairs were then mounted on a material testing system and loaded cyclically 500 cycles to measure applied force and displacement. Repairs then underwent ultimate failure testing, and stiffness, ultimate failure force, and ultimate failure displacement were measured. Paired t tests were performed to compare between groups.

RESULTS

There were no differences between groups in construct gapping with cyclic loading after 500 cycles (P = .885). There were no differences between the augmented and control groups in yield force (103.5 ± 5.0 vs. 101.4 ± 5.9 N, respectively, P = .183), stiffness (94.2 ± 13.9 vs. 90.9 ± 13.8, P = .585), or ultimate failure force (255.3 ± 65.8 vs. 285.3 ± 83.2, P = .315). There were no differences between groups in failure modes, with most specimens failing by cuff tissue tearing within or medial to the construct.

CONCLUSION

The addition of dermal allograft pledgets does not positively or negatively influence the time-zero biomechanical characteristics of double-row suture bridge rotator cuff repair.

Clinical and Structural Outcomes of Arthroscopic Rotator Cuff Repair in Patients Over 75 Years Are Comparable to Those in Younger Patients: A Propensity Score-Matched Comparative Study

PURPOSE

To compare clinical and structural outcomes of arthroscopic rotator cuff repair (ARCR) in patients over 75 years and those under 75 years and to analyze the factors associated with retear and clinical outcomes after ARCR.

METHODS

This retrospective study reviewed patients who underwent ARCR between 2011 and 2021 with at least 2 years of follow-up. Using propensity score matching for sex, tear size, subscapularis involvement, and follow-up time, this study included 54 patients older than 75 years (group A) and 54 patients younger than 75 years (group B). Cuff integrity was evaluated using magnetic resonance imaging (MRI). Structural and clinical outcomes were compared between the 2 groups.

RESULTS

The mean improvements in external rotation (P = .030) and the American Shoulder and Elbow Surgeons (ASES) score (P = .043) were significantly higher in group A. Visual analog scales for pain and function, ASES score, and Constant score were significantly improved in both groups (all P = .001). On routine postoperative MRI at 6 months, the retear rate was 20.4% (11/54) in group A and 18.5% (10/54) in group B with no statistical difference between the 2 groups (P = .808). Factor analysis in group A showed that follow-up duration (P = .019), tear size in mediolateral dimension (P = .037), occupation ratio (P = .036), and incomplete repair (P = .034) were associated with retear, and mild glenohumeral arthritis (P = .003) and subscapularis involvement (P = .018) were associated with inferior Constant score.

CONCLUSIONS

Clinical and structural outcomes after ARCR in patients aged 75 years or older are comparable to those in patients younger than 75 years.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Arthroscopic evaluation of the rotator cuff vasculature: inferences into the pathogenesis of cuff tear and re-tear

BACKGROUND

Little is known about alterations of the rotator cuff (RC) macroscopic vasculature associated with medical conditions and/or habits that predispose a person to diseases of the peripheral microcirculation. The high frequency of cuff tear and re-tear in patients with diabetes, hypercholesterolemia, uncontrolled arterial hypertension, or metabolic syndrome may be due to tissue hypovascularity.

METHODS

The macroscopic vasculature of both the articular and bursal sides of the posterosuperior RC was evaluated arthroscopically in 107 patients (mean age, 58.2 years) with no RC tear. Patients were divided into three groups according to medical comorbidities and lifestyle factors (group I, none; group II, smokers and/or drinkers and one comorbidity; and group III, two or more comorbidities). Pulsating vessels originating from both the myotendinous and osteotendinous junctions were assessed as "clearly evident," "poorly evident," or "not evident."

RESULTS

Groups I, II, and III comprised 36, 45, and 26 patients, respectively. Within the myotendinous junction, vessels were visualized in 22 group I patients (61%), 25 group II patients (55%), and 6 group III patients (23%) (P=0.007). Pulsating arterial vessels originating from the osteotendinous junction were seen in 42%, 36%, and 0% of patients, respectively (P<0.001). Within the bursal side of the RC, a dense anastomotic network was visualized (either clearly or poorly) in 94% (34), 80% (36), and 35% (9) of patients, respectively (P<0.001).

CONCLUSIONS

The macroscopic vasculature of the RC is influenced by pre-existing diseases and lifestyle factors, which may impair peripheral microcirculation. Level of evidence: III.

Current research trends on the effect of diabetes mellitus on rotator cuff tendon healing/tendinopathy

Rotator cuff tendon tears are a leading cause of shoulder pain. They are challenging to treat, and tendon-bone healing has a high failure rate despite successful surgery. Tendons connect the muscles and bones, which make them important for the body's overall mobility and stability. Metabolic diseases, including diabetes or high blood pressure, can affect the healing process after repair of a damaged tendon. With a global incidence of 9.3%, diabetes is considered as a significant risk factor for rotator cuff tendon healing because it causes structural, inflammatory, and vascular changes in the tendon. However, the mechanisms of how diabetes affects tendon healing remain unknown. Several factors have been suggested, including glycation product accumulation, adipokine dysregulation, increased levels of reactive oxygen species, apoptosis, inflammatory cytokines, imbalanced matrix-metalloproteinase-to-tissue-inhibitor ratio, and impaired angiogenesis and differentiation of the tendon sheath. Despite the effects of diabetes on tendon function and healing, few treatments are available to improve recovery in these patients. This review summarizes the current literature on the pathophysiological changes of the tendon in diabetes and hyperlipidemia. Preclinical and clinical evidence regarding the association between diabetes and tendon healing is presented. Moreover, current approaches to improve tendon healing in patients with diabetes are reviewed.

Risk factors associated with a history of iliotibial band syndrome (hITBS) in distance runners: a cross-sectional study in 76 654 race entrants - a SAFER XXXIII study

BACKGROUND

Despite the numerous health benefits of distance running, it is also associated with the development of 'gradual onset running-related injuries' (GORRIs) one of which is Iliotibial Band Syndrome (ITBS). Novel risk factors associated with a history of ITBS (hITBS) have not been described in a large cohort of distance runners.

OBJECTIVE

To identify risk factors associated with hITBS in distance runners.

DESIGN

Descriptive cross-sectional study.

SETTING

21.1 km and 56 km Two Oceans Marathon races (2012-2015).

PARTICIPANTS

106 743 race entrants completed the online pre-race medical screening questionnaire. A total of 1 314 runners confirmed an accurate hITBS diagnosis.

METHODS

Selected risk factors associated with hITBS explored included: demographics (race distance, sex, age groups), training/running variables, history of existing chronic diseases (including a composite chronic disease score) and history of any allergy. Prevalence (%) and prevalence ratios (PR; 95% CI) are reported (uni- & multiple regression analyzes).

RESULTS

1.63% entrants reported hITBS in a 12-month period. There was a higher (p < 0.0001) prevalence of hITBS in the longer race distance entrants (56 km), females, younger entrants, fewer years of recreational running (PR = 1.07; p = 0.0009) and faster average running speed (PR = 1.02; p = 0.0066). When adjusted for race distance, sex, age groups, a higher chronic disease composite score (PR = 2.38 times increased risk for every two additional chronic diseases; p < 0.0001) and a history of allergies (PR = 1.9; p < 0.0001) were independent risk factors associated with hITBS.

CONCLUSION

Apart from female sex, younger age, fewer years of running and slower running speed, two novel independent risk factors associated with hITBS in distance runners are an increased number of chronic diseases and a history of allergies. Identifying athletes at higher risk for ITBS can guide healthcare professionals in their prevention and rehabilitation efforts.

Dyslipidemia may impact initial recovery following arthroscopic rotator cuff repair: a retrospective study

BACKGROUND

The current literature shows that dyslipidemia can lead to a higher incidence of rotator cuff tears (RCTs) and an increased retear rate after repair. We aimed to evaluate the influence of preoperative dyslipidemia on postoperative pain, patient-reported outcomes (PROs), active range of motion (ROM), and structural integrity.

METHODS

A cohort of 111 patients who underwent arthroscopic RCT repair between January 2021 and July 2022, and whose complete preoperative serum lipid data were available within one week prior to surgery was retrospectively reviewed. Dyslipidemia was defined as the presence of an increase or decrease in at least one blood lipid profile (triglycerides, total cholesterol, low-density lipoprotein, high-density lipoprotein, or non-high-density lipoprotein). There were 43 patients in the dyslipidemia group and 68 in the ortholiposis group. Patient evaluations, including pain score, PROs, and ROMs, were conducted preoperatively; at 3 and 6 months postoperatively; and at the last follow-up. Structural integrity was assessed by magnetic resonance imaging (MRI) 6 months after surgery if possible, and Sugaya type 4 or 5 was considered a retear. Propensity score matching (PSM) was used to reduce bias.

RESULTS

The RCT size, surgical technique, preoperative pain status, PROs, and active ROM were comparable between patients with dyslipidemia and those with ortholiposis. Three months after surgery, patients in the dyslipidemia group had worse average PROs (Constant score: P = 0.001; ASES score: P = 0.012; UCLA score: P = 0.015), forward flexion (P = 0.012), and internal rotation (P = 0.001) than patients in the ortholiposis group did. The difference between the two groups persisted after PSM but disappeared at the sixth month after surgery. No significant differences in pain score, PROs, or active ROMs were detected between the dyslipidemia and ortholiposis groups after a mean follow-up of 24 months. Of the 72 patients who underwent MRI, 4 retears (5.6%) were found, and all were in the ortholiposis group. There was no difference in the rate of retears between the two groups (P = 0.291) or with (P = 0.495) PSM.

CONCLUSIONS

In conclusion, we found that perioperative dyslipidemia may impact initial recovery within the first 3 months following arthroscopic rotator cuff repair but may have no effect on pain, PROs, or active ROMs at a mean 2-year follow-up or rotator cuff integrity at 6 months postoperatively. Trail registration Retrospectively registered.

Criteria, Timing, and Factors Associated With Return to Competitive Sport After Rotator Cuff Surgery

Rotator cuff pathology in competitive athletes is common and may produce chronic symptoms and joint disability, impairing sports participation and leading to premature retirement. Athletes are a high-functioning patient population with unique characteristics. Decision-making for return to sport is a complex and multifactorial process. Literature is sparse and does not provide precise guidelines to assist physicians to make the right decision. This review aimed to highlight factors affecting outcome, timing, and criteria for return to competitive sport after rotator cuff surgery to help physicians to clearly counsel athletes and make high-quality decisions for return to sport.

Risk of rotator cuff tear and rotator cuff repair surgery comparison between sodium-glucose cotransporter 2 inhibitors and glucagon like peptide-1 receptor agonists: A real-world study

AIM

Theoretically, sodium-glucose cotransporter 2 inhibitors (SGLT2is) reduce the risk of rotator cuff tear through an anti-inflammatory mechanism. To clarify this association, in this study, we compared SGLT2is users and glucagon-like peptide-1 receptor agonists (GLP-1RAs) users in terms of the risk of rotator cuff tear and the risk of receiving rotator cuff repair surgery.

METHODS

A retrospective cohort analysis was conducted using data from the TriNetX platform. A target trial design was adopted to identify patients with type 2 diabetes mellitus who started receiving SGLT2is or GLP-1RAs. Propensity score matching was used to form two homogeneous groups. The study outcomes were the risk of rotator cuff tear and the risk of receiving rotator cuff repair surgery. Hazard ratios (HRs) with 95 % confidence intervals (CIs) were calculated within the TriNetX platform.

RESULTS

Initially, 351,800 SGLT2is users and 387,616 GLP-1RAs users were identified. After propensity score matching, each group comprised 274,026 patients. The mean age was 59.5 years in both groups; the proportions of women in the SGLT2is and GLP-1RAs groups were 46.9 % and 46.7 %, respectively. Compared with the GLP-1RAs group, the SGLT2is group had significantly reduced risks of rotator cuff tear (HR 0.812 [0.761;0.867]) and rotator cuff repair surgery (HR 0.900 [0.815;0.994]).

CONCLUSION

SGLT2is appear to reduce the risk of rotator cuff tear and the risk of receiving rotator cuff repair surgery in patients with type 2 diabetes mellitus. Further prospective studies are needed to validate our findings.

Patellar tendon biomechanical and morphologic properties and their relationship to serum clinical variables in persons with prediabetes and type 2 diabetes

Tendon biomechanical properties and fibril organization are altered in patients with diabetes compared to healthy individuals, yet few biomarkers have been associated with in vivo tendon properties. We investigated the relationships between in vivo imaging-based tendon properties, serum variables, and patient characteristics across healthy controls (n = 14, age: 45 ± 5 years, body mass index [BMI]: 24 ± 1, hemoglobin A1c [HbA1c]: 5.3 ± 0.1%), prediabetes (n = 14, age: 54 ± 5 years, BMI: 29 ± 2; HbA1c: 5.7 ± 0.1), and type 2 diabetes (n = 13, age: 55 ± 3 years, BMI: 33 ± 2, HbA1c: 6.7 ± 0.3). We used ultrasound speckle-tracking and measurements from magnetic resonance imaging (MRI) to estimate the patellar tendon in vivo tangent modulus. Analysis of plasma c-peptide, interleukin-1β (IL-1β), IL-6, IL-8, tumor necrosis factor-α (TNF-α), adiponectin, leptin, insulin-like growth factor 1 (IGF-1), and C-reactive protein (CRP) was completed. We built regression models incorporating statistically significant covariates and indicators for the clinically defined groups. We found that tendon cross-sectional area normalized to body weight (BWN CSA) and modulus were lower in patients with type 2 diabetes than in healthy controls (p < 0.05). Our regression analysis revealed that a model that included BMI, leptin, high-density lipoprotein (HDL), low-density lipoprotein (LDL), age, and group explained ~70% of the variability in BWN CSA (R2  = 0.70, p < 0.001). For modulus, including the main effects LDL, groups, HbA1c, age, BMI, cholesterol, IGF-1, c-peptide, leptin, and IL-6, accounted for ~54% of the variability in modulus (R2  = 0.54, p < 0.05). While BWN CSA and modulus were lower in those with diabetes, group was a poor predicter of tendon properties when considering the selected covariates. These data highlight the multifactorial nature of tendon changes with diabetes and suggest that blood variables could be reliable predictors of tendon properties.

Analysis of differentially expressed genes in torn rotator cuff tendon tissues in diabetic patients through RNA-sequencing

BACKGROUND

Rotator cuff tears (RCT) is a common musculoskeletal disorder in the shoulder which cause pain and functional disability. Diabetes mellitus (DM) is characterized by impaired ability of producing or responding to insulin and has been reported to act as a risk factor of the progression of rotator cuff tendinopathy and tear. Long non-coding RNAs (lncRNAs) are involved in the development of various diseases, but little is known about their potential roles involved in RCT of diabetic patients.

METHODS

RNA-Sequencing (RNA-Seq) was used in this study to profile differentially expressed lncRNAs and mRNAs in RCT samples between 3 diabetic and 3 nondiabetic patients. Gene ontology (GO) and Kyoto encyclopedia of genes and genomes (KEGG) pathway analysis were performed to annotate the function of the differentially expressed genes (DEGs). LncRNA-mRNA co-expression network and competing endogenous RNA (ceRNA) network were constructed to elucidate the potential molecular mechanisms of DM affecting RCT.

RESULTS

In total, 505 lncRNAs and 388 mRNAs were detected to be differentially expressed in RCT samples between diabetic and nondiabetic patients. GO functional analysis indicated that related lncRNAs and mRNAs were involved in metabolic process, immune system process and others. KEGG pathway analysis indicated that related mRNAs were involved in ferroptosis, PI3K-Akt signaling pathway, Wnt signaling pathway, JAK-STAT signaling pathway and IL-17 signaling pathway and others. LncRNA-mRNA co-expression network was constructed, and ceRNA network showed the interaction of differentially expressed RNAs, comprising 5 lncRNAs, 2 mRNAs, and 142 miRNAs. TF regulation analysis revealed that STAT affected the progression of RCT by regulating the apoptosis pathway in diabetic patients.

CONCLUSIONS

We preliminarily dissected the differential expression profile of lncRNAs and mRNAs in torn rotator cuff tendon between diabetic and nondiabetic patients. And the bioinformatic analysis suggested some important RNAs and signaling pathways regarding inflammation and apoptosis were involved in diabetic RCT. Our findings offer a new perspective on the association between DM and progression of RCT.

Acidosis induces significant changes to the murine supraspinatus enthesis organic matrix

Rotator cuff pathology is a common musculoskeletal condition that disproportionately affects older adults, as well as patients with diabetes mellitus and chronic kidney disease. It is known that increased age and kidney dysfunction have been correlated to acidotic states, which may be related to the increased incidence of rotator cuff injury. In order to investigate the potential relationship between acidosis and rotator cuff composition and mechanics, this study utilizes a 14-day murine model of metabolic acidosis and examines the effects on the supraspinatus tendon-humeral head attachment complex. The elastic matrix in the enthesis exhibited significant changes beginning at day 3 of acidosis exposure. At day 3 and day 7 timepoints, there was a decrease in collagen content seen in both mineralized and unmineralized tissue as well as a decrease in mineral:matrix ratio. There is also evidence of both mineral dissolution and reprecipitation as buffering ions continually promote pH homeostasis. Mechanical properties of the tendon-to-bone attachment were studied; however, no significant changes were elicited in this 14-day model of acidosis. These findings suggest that acidosis can result in significant changes in enthesis composition over the course of 14 days; however, enthesis mechanics may be more structurally mediated rather than affected by compositional changes.

Current Research on the Influence of Statin Treatment on Rotator Cuff Healing

Rotator cuff tears are a condition characterized by damage to the muscles and tendons that connect the scapula and humerus, which are responsible for shoulder rotation and arm lifting. Metabolic factors such as diabetes, thyroid disease, high cholesterol, vitamin D deficiency, obesity, and smoking have been associated with an increased risk of rotator cuff tears. Interestingly, patients with hyperlipidemia, a condition characterized by high levels of cholesterol and other fats in the blood, have been found to have a higher incidence of rotator cuff tears and breakdown of tendon matrix. As a result, statin therapy, which is commonly used to lower cholesterol levels in hyperlipidemia, has been explored as a potential treatment to improve clinical outcomes in rotator cuff tears. However, the results of preclinical and clinical studies on the effects of statins on tendon healing in rotator cuff tears are limited and not well-defined. Moreover, since hyperlipidemia and rotator cuff tears are more prevalent in older individuals, a literature review on the efficacy and safety of statin therapy in this population is needed.

The Effect of Hyperlipidemia as a Risk Factor on Postoperative Complications in Patients Undergoing Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To analyze the effect of hyperlipidemia (HLD) on postoperative complications in patients who underwent anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

ACDF represents the standard procedure performed for focal anterior nerve root or spinal cord compression with low complication rates. HLD is well known as a risk factor for major complications after vascular and transplant surgery, and orthopedic surgery. To date, there have been no studies on HLD as a risk factor for cervical spine surgery.

PATIENTS AND METHODS

Patients who underwent ACDF from 2010 through quarter 3 of 2020 were enrolled using the MSpine subset of the PearlDiver Patient Record Database. The patients were divided into single-level ACDF and multilevel ACDF groups. In addition, each group was divided into subgroups according to the presence or absence of HLD. The incidence of surgical and medical complications was queried using relevant International Classification of Disease and Current Procedural Terminology codes. Charlson Comorbidity Index was used as a broad measure of comorbidity. χ 2 analysis, with populations matched for age, sex, and Charlson Comorbidity Index, was performed.

RESULTS

A total of 24,936 patients who underwent single-level ACDF and 26,921 patients who underwent multilevel ACDF were included. In the multilevel ACDF group, wound complications were significantly higher in the patients with HLD. Among medical complications, myocardial infarction, renal failure, and urinary tract infection/urinary incontinence were significantly higher in the patients with HLD in both groups. Revision surgery and readmission were significantly higher in the patients with HLD who underwent multilevel ACDF.

CONCLUSIONS

In patients who underwent ACDF, several surgical and medical complications were found to be higher in patients with HLD than in patients without HLD. Preoperative serum lipid concentration levels and management of HLD should be considered during preoperative planning to prevent postoperative complications in patients undergoing ACDF.

Diabetes mellitus as a risk factor for postoperative complications following arthroscopic rotator cuff repair

Background

Patients with diabetes mellitus who undergo arthroscopic rotator cuff repair (aRCR) have an increased risk of postoperative complications when compared to nondiabetics. To further investigate these complications, we used a large national database to determine the 30-day postoperative complications associated with insulin-dependent and non-insulin-dependent diabetics following aRCR.

Methods

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all patients who underwent aRCR between 2015 and 2020. The study population was categorized into cohorts based on diabetes mellitus status: non-insulin-dependent diabetes mellitus (NIDDM), insulin-dependent diabetes mellitus (IDDM), and no diabetes. Multivariate analysis, adjusted for confounding demographics and comorbidities, was used to determine independently associated complications.

Results

There were 39,877 cases of aRCR in NQSIP included in this study. Diabetics comprised 6575 (16.7%) of these cases, with 4758 being NIDDM (11.9%) and 1817 being IDDM (4.6%). Bivariate logistic regression found both NIDDM and IDDM cohorts to be significantly associated with higher body mass index, ASA class ≥3, hypertension, chronic obstructive pulmonary disease, bleeding disorders, and preoperative wounds or infection (P < .001). NIDDM was an independently associated risk factor for sepsis (odds ratio [OR], 2.77; 95% confidence interval [CI]: 1.01-7.58; P = .047). IDDM was an independently associated risk factor for pneumonia (OR, 2.49; 95% CI: 1.13-5.48; P = .023), readmission (OR, 1.617; 95% CI: 1.19-2.33; P = .003), myocardial infarction (OR, 0.50; 95% CI: 0.12-1.00; P = .048), and on a ventilator >48 hours (OR, 5.63; 95% CI: 1.40-22.62; P = .015).

Conclusion

NIDDM is an independent risk factor for sepsis, while IDDM is an independent risk factor for pneumonia, readmission, myocardial infarction, and remaining on a ventilator for greater than 48 hours following aRCR.

Progress in studying the impact of hyperlipidemia and statins on rotator cuff injury and repair

This review delves into the intersection of two prevalent conditions, hyperlipidemia and rotator cuff injuries, both of which bear substantial healthcare burdens. Our investigation begins with an exploration of rotator cuff injuries, common musculoskeletal disorders that severely impair shoulder functionality and quality of life. These injuries are notably pervasive among sports enthusiasts and the older adult, with an incidence rate estimated at 5-10% in the general population. Despite their widespread occurrence and the diverse, multifactorial etiological factors, effective treatment strategies remain elusive. We then examine hyperlipidemia, a metabolic disorder affecting approximately 40% of the global adult population. Characterized by elevated levels of cholesterol and triglycerides, hyperlipidemia can precipitate severe cardiovascular complications and presents a significant socioeconomic burden. Although current management strategies encompass lifestyle modifications and pharmacological interventions, the condition remains a formidable health challenge. Central to this review is the exploration of a potential association between hyperlipidemia and rotator cuff injuries. We aim to synthesize the current understanding of hyperlipidemia's role in the pathophysiology of rotator cuff injuries, thereby offering fresh insights into their common etiological underpinnings, potential therapeutic targets, and drugs, such as Statins. The influence of other lipid-lowering therapeutics on tendon health is also considered, and further research into the molecular pathways and potential therapeutic benefits of these drugs is required. This pursuit aligns with broader efforts to enhance patient outcomes, minimize healthcare burdens, and contribute to the global understanding of these prevalent conditions.

The association of metabolic syndrome with rotator cuff tendinopathy: a two-sample Mendelian randomization study

BACKGROUND

Observational research reported the underlying correlation of metabolic syndrome (MetS) and its components with rotator cuff tendinopathy (RCT), but their causality remained unclear. This study aimed to investigate whether genetically predicted MetS was related to the risk of RCT.

METHODS

Both univariable and multivariable Mendelian randomization (MR) analysis was applied using summary-level data from the most comprehensive genome-wide association studies to estimate the associations of MetS and its component with RCT, with the inverse variance weighted (IVW) as the primary method, and the method of Causal Analysis Using Summary Effect Estimates (CAUSE) as a supplement for false positives detection. The mediation analysis was furtherly used for the assessment of direct and indirect effects.

RESULTS

Univariable analysis revealed that genetically predicted MetS (OR: 1.0793; 95% CI 1.0311 to 1.1297), body mass index (BMI) (OR 1.2239; 95% CI 1.1357 to 1.3189), and waist circumference (WAC) (OR 1.3177; 95% CI 1.2015 to 1.4451) had a significant positive association with the risk of RCT. Triglycerides and systolic blood pressure were suggestively associated with RCT risk. These associations were also identified by CAUSE. There was independent causality of BMI (OR: 1.1806; 95% CI 1.0788 to 1.2920) and WAC (OR 1.3716; 95% CI 1.2076 to 1.5580) on RCT after adjustment for confounders. No mediator was found in the causal associations.

CONCLUSION

Our study revealed the genetic causality of MetS and its components, especially BMI and WAC, with RCT risk. Early prevention and diagnosis of excess central adiposity contributing to MetS are significant in the RCT risk management.

Diabetes Mellitus Is a Possible Risk Factor for the Development of Trochanteric Bursitis-A Large-Scale Population-Based Study

BACKGROUND

Trochanteric Bursitis (TB) is a common reason to seek primary care, previously shown to be associated with female gender and obesity. Diabetes mellitus (DM) has several musculoskeletal manifestations, but was never found to be associated with TB.

PURPOSE

To explore the association between DM and TB, based on a large database. The secondary aim was to explore the influence of gender and insulin usage on the occurrence of TB.

STUDY DESIGN

cross-sectional study.

METHODS

A population-based cohort consisting of 60,610 patients (55,428 without DM and 5182 with DM), of whom 5418 were diagnosed with TB. A logistic regression model was applied to estimate propensity scores.

RESULTS

The odds of individuals with DM being diagnosed with TB were 55.8% higher compared to the odds of patients without DM (OR: 1.558, 95% CI: [1.429, 1.70], p < 0.0001). We found that insulin users had a lower risk of TB than patients not using insulin (log-rank p < 0.0001). Females are 3.3 times more likely to have TB than males (RR: 3.337, 95% CI: [3.115, 3.584], p < 0.0001).

CONCLUSIONS

DM is a risk factor for developing TB. Insulin had a protective effect against TB, suggesting that better glycemic control might prevent this painful infliction.

Comparison of Outcomes After Arthroscopic Superior Capsule Reconstruction Versus Arthroscopic Partial Repair or Arthroscopic Debridement for Irreparable Rotator Cuff Tears

Background

Arthroscopic superior capsule reconstruction (SCR), arthroscopic partial repair (PR), and arthroscopic debridement (DB) are valid treatment options for irreparable rotator cuff (RC) tears.

Purpose/Hypothesis

The purpose of this study was to compare clinical, functional, and radiological outcomes of arthroscopic SCR with arthroscopic PR and arthroscopic DB in patients with irreparable posterosuperior RC tears. It was hypothesized that SCR would lead to superior clinical and functional outcomes compared with PR or DB.

Study Design

Cohort study; Level of evidence, 3.

Methods

Clinical and functional outcomes of this single-center retrospective study included range of motion, strength, and the age- and sex-adjusted Constant-Murley score. Patient-reported outcome measures (PROMs) involved the quick Disabilities of the Arm, Shoulder and Hand score, the Subjective Shoulder Value, and the visual analog scale for pain. Graft and repaired tendon integrity was evaluated by magnetic resonance imaging (MRI) at 12 months of follow-up.

Results

In total, 57 patients treated with SCR (n = 20), PR (n = 17), and DB (n = 20) were included. The mean clinical follow-up was 33.8 ± 17.9 months. Preoperative clinical and functional characteristics were comparable among the 3 groups. The range of motion and clinical and functional scores of all 3 groups significantly improved from pre- to postoperatively. Postoperative PROMs showed no differences among all 3 study groups. SCR revealed significantly higher postoperative strength compared with PR (P = .001) and DB (P = .004). Postoperative MRI revealed a rerupture in 4 patients with SCR (20%). Postoperative MRI showed a rerupture in 9 patients with PR ( 53%). Fatty muscle infiltration of the supraspinatus and infraspinatus significantly progressed within all 3 study groups in postoperative MRI scans. No clinical and functional differences were observed between intact and reruptured PR.

Conclusion

Patients who underwent SCR had better postoperative strength recovery than patients who underwent PR or DB.

Effects of Statin Treatment on the Development of Tendinopathy: A Nationwide Population-Based Cohort Study

Background

Previous longitudinal cohort studies have reported the conflicting results of the relationship between statin use and the development of tendinopathy disorder. It is unclear if there is a relationship between statin use, particularly the type or cumulative doses, and the development of tendinopathy disorder.

Purpose

To investigate an association between statin treatment and the development of tendinopathy.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 594,130 participants were enrolled in this study in 2002 and evaluated until 2015. There were 84,102 statin users and 168,204 nonusers (controls) selected at a ratio of 1:2 using propensity score matching analysis. The types of included tendinopathy were as follows: (1) trigger finger, (2) radial styloid tenosynovitis, (3) elbow epicondylitis, (4) rotator cuff tendinopathy, and (5) Achilles tendinitis. Cox proportional hazards models with time-varying covariates were constructed to identify the association between statin use and tendinopathy development.

Results

Statin treatments regardless of statin types were associated with a significantly greater risk of all types of tendinopathy development (hazard ratio, 1.435; 95% CI, 1.411-1.460) compared with no statin treatment. A trend toward risk reduction was observed according to cumulative statin doses, which was indicated by hazard ratios of 2.337 (95% CI, 2.269-2.406), 2.210 (95% CI, 2.132-2.290), and 1.1 (95% CI, 1.098-1.146) in patients with cumulative defined daily doses of 90, 91-180, and >180, respectively.

Conclusion

This nationwide population-based cohort study suggests that statin use regardless of the statin type was associated with a greater risk of tendinopathy compared with that of nonusers. The risk of tendinopathy development was diluted with the increasing cumulative defined daily dose.

Abnormal Laboratory Values for Metabolic and Hormonal Syndromes Are Prevalent Among Patients Undergoing Rotator Cuff Repair

Purpose

To determine the prevalence of systemic laboratory abnormalities among patients undergoing rotator cuff repair (RCR).

Methods

Patients who underwent RCR at the authors' institution for 1 year between October 2021 to September 2022 were retrospectively identified. Preoperative laboratory values, including serum sex hormones, vitamin D, hemoglobin A1C, and a lipid panel, were obtained as part of our routine practice during the study period. Demographics and tear characteristics were compared in patients with laboratory data and those without. For included patients with laboratory data, mean laboratory values and percentage of patients with abnormal laboratory values were recorded.

Results

During a 1-year period of time, 135 RCRs were performed, of which preoperative labs were obtained on 105. Of these, 67% were sex hormone deficient, 36% were vitamin D deficient, 45% had an abnormal hemoglobin A1C, and 64% had an abnormal lipid panel. In total 4% had "normal" labs.

Conclusions

In this retrospective study, sex hormone deficiency is highly prevalent among patients undergoing RCR. Nearly all patients undergoing RCR have systemic laboratory abnormalities involving either sex hormone deficiency, vitamin D deficiency, dyslipidemia, and/or prediabetes.

Level of Evidence

Level IV, prognostic case series.

Aetiopathogenesis of Rotator Cuff Tear in Patients Younger than 50 Years: Medical Conditions Play a Relevant Role

Background and Objectives: Studies on rotator cuff tears (RCT) in patients younger than 50 years have focused on the post-operative outcomes. Little is known about cuff tear etiopathogenesis, although it is a common belief that most tears are due to trauma. We have retrospectively verified the prevalence of medical conditions, whose role in tendon degeneration development have been widely demonstrated, in a group of patients younger than 50 years with postero-superior RCT. Materials and Methods: 64 patients [44M-20F; mean age (SD): 46.90 (2.80)] were enrolled. Personal data, BMI, smoking habit, diseases (diabetes, arterial hypertension, hypercholesterolaemia, thyroid diseases, and chronic obstructive pulmonary disease) were registered. The possible triggering cause and the affected side and tear dimensions were recorded, and statistical analysis was then performed. Results: 75% of patients had one or more diseases and/or a smoking habit for more than 10 years. In the remaining 25%, only four patients referred had had a traumatic event, while in the other eight patients, both medical condition and trauma were registered. The presence of two or more diseases did not affect RCT size. Conclusions: In our series, three quarters of patients with RCT had a smoking habit or medical conditions predisposing them to a tendon tear; therefore, the role of trauma in RCT onset in patients younger than 50 years is markedly resized. It is plausible that in the remaining 25%, RCT may be due to trauma or to genetic or acquired degeneration. Level of Evidence: IV.

Chronic diseases and allergies are risk factors predictive of a history of Medial Tibial Stress Syndrome (MTSS) in distance runners: SAFER study XXIV

BACKGROUND

Medial Tibial Stress Syndrome (MTSS) is one of the most common causes of exercise-associated lower leg pain in distance runners.

AIM

To identify risk factors predictive of a history of MTSS in distance runners entering the Two Oceans Marathon races (21.1 km and 56 km).

DESIGN

Cross-sectional study.

SETTING

2012 to 2015 Two Oceans Marathon races (21.1 km and 56 km).

PARTICIPANTS

Consenting race entrants.

METHODS

106,743 race entrants completed an online pre-race medical screening questionnaire. 76,654 consenting runners (71.8%) were studied. 558 verified MTSS injuries were reported in the previous 12 months. Risk factors predictive of a history of MTSS were explored using uni - & multivariate analyses: demographics (race distance, sex, and age groups), training/racing history, history of chronic diseases, allergies, and medication use.

RESULTS

Independent risk factors predictive of a history of MTSS (adjusted for sex, age group, and race distance) were a higher chronic disease composite score (PR = 3.1 times increase risk for every two additional chronic diseases; p < 0.0001) and a history of allergies (PR = 1.9; p < 0.0001). Chronic diseases (PR > 2) predictive of a history of MTSS were: symptoms of CVD (PR = 4.2; p < 0.0001); GIT disease (PR = 3.3; p < 0.0001); kidney/bladder disease (PR = 3.3; p < 0.0001); nervous system/psychiatric disease (PR = 3.2; p < 0.0001); respiratory disease (PR = 2.9; p < 0.0001) a history of CVD (PR = 2.9; p < 0.0001); and risk factors of CVD (PR = 2.4; p < 0.0001) (univariate analysis). Average running speed was associated with higher risk of MTSS.

CONCLUSION

Novel independent risk factors predictive of a history of MTSS in distance runners (56 km, 21.1 km) were multiple chronic diseases and a history of allergies. Identifying athletes at higher risk for MTSS can guide healthcare professionals in their prevention and rehabilitation efforts.

Postoperative HbA1c Level as a Predictor of Rotator Cuff Integrity After Arthroscopic Rotator Cuff Repair in Patients With Type 2 Diabetes

Background

In patients with type 2 diabetes mellitus (DM), preoperative glycosylated hemoglobin (HbA1c) is associated with outcomes after arthroscopic rotator cuff repair (ARCR); however, the relationship between outcomes and postoperative serum glycosylated hemoglobin (HbA1c) after ARCR has not been investigated.

Purpose

To evaluate outcomes after ARCR in patients (1) with and without DM and (2) with DM according to their pre- and postoperative HbA1c levels.

Study Design

Cohort study; Level of evidence, 3.

Method

Included in this study were 148 patients without DM and 35 patients with type 2 DM who underwent ARCR between January 1, 2017, and December 31, 2019. Clinical and radiological outcomes were evaluated preoperatively and at the latest clinical follow-up. Postoperative magnetic resonance imaging was performed after 12 months. In patients with type 2 DM, HbA1c levels were evaluated preoperatively as well as 6 and 12 months postoperatively; patients with an HbA1c level of ≥7% were defined as having uncontrolled DM. Multivariate logistic regression analyses were performed to determine the factors for retears after ARCR.

Results

The retear rates after ARCR were 22.9% (8/35) and 16.9% (25/148) in patients with and without DM, respectively. The retear rates were significantly higher in the 6-month postoperative uncontrolled DM group than in the controlled DM and non-DM groups (50% vs 8.7% and 16.8%; P < .05). The odds ratio for retears in the postoperative uncontrolled DM group was 5.555 (P =0.01) compared with the non-DM group. Among the patients with DM, in the uncontrolled DM group, 6-month postoperative hyperglycemia was superior in accuracy, sensitivity, and specificity for predicting retears after ARCR than preoperative hyperglycemia (77.1% vs 62.9%, 75% vs 37.5%, and 77.8% vs 70.4%, respectively).

Conclusion

This study demonstrated the association between uncontrolled postoperative DM and an increased risk of retears compared with no DM or controlled DM. Furthermore, postoperative HbA1c values were correlated more closely with the risk of retears than preoperative HbA1c values.

Risk factors for rotator cuff disease: A systematic review and meta-analysis of diabetes, hypertension, and hyperlipidemia

BACKGROUND

Rotator cuff disease is a common cause of shoulder pain. Comorbidities such as diabetes, hypertension, and hyperlipidemia may be associated with rotator cuff disease, likely because of mechanisms related to vascular insufficiency.

OBJECTIVES

We performed a systematic review of the association of diabetes, hypertension, and hyperlipidemia with the diagnosis of rotator cuff disease.

METHODS

Following systematic queries of PubMed, Embase, Cochrane, CINAHL, and Science Direct, articles meeting eligibility criteria and reporting on the association of one or more risk factors (diabetes, hypertension, and hyperlipidemia) and rotator cuff disease were considered. Meta-analysis was performed to quantitatively summarize the associations between each risk factor and rotator cuff disease. We assessed study quality with the Newcastle-Ottawa Scale (NOS) and performed a qualitative assessment of risk of bias.

RESULTS

After a full-text review of 212 articles, 12 articles assessing diabetes, 5 assessing hypertension and 8 assessing hyperlipidemia were eligible. The odds of having rotator cuff disease was increased with diabetes (odds ratio [OR] 1.49, 95% confidence interval [CI] 1.43-1.55), hypertension (OR 1.40, 95% CI 1.19-1.65) and hyperlipidemia/dyslipidemia (OR 1.48, 95% CI 1.42-1.55). Diabetes was also specifically associated with rotator cuff tears (OR 1.28, 95% CI 1.07-1.52). Synthesizing assessment for risk of bias suggested that current epidemiologic evidence for an association was plausible for diabetes and hyperlipidemia but not hypertension.

CONCLUSIONS

Diabetes, hypertension, and hyperlipidemia were associated with rotator cuff disease in our meta-analysis. However, the possibility of bias exists for all 3 co-morbidities evaluated and is likely highest for hypertension. High-quality studies with the ability to incorporate time since first diagnosis of co-morbidity are scarce and much needed.

Simvastatin promotes rat Achilles tendon-bone interface healing by promoting osteogenesis and chondrogenic differentiation of stem cells

To investigate the effect and mechanism of simvastatin on cell components of tendon-bone healing interface. The tendon-bone healing model was established by inserting the end of the Achilles tendon into the tibial tunnel on 24 rats, and simvastatin was used locally at the tendon-bone interface. Healing was evaluated at 8 weeks by mechanical testing, micro-CT, and qualitative histology including H&E, Toluidine blue, and immunohistochemical staining. In vitro, bone marrow stromal cells (BMSCs) and tendon-derived mesenchymal stem cells (TDSCs) underwent osteogenic and chondrogenic differentiation respectively by plate co-culture. An analysis was performed on days 7 and 14 of cell differentiation. Biomechanical testing demonstrated a significant increase in maximum stiffness in the simvastatin-treated group. Micro-CT analysis showed that the bone tunnels in the simvastatin group were smaller in diameter and had higher bone density. H&E and Toluidine blue staining demonstrated that tendon-bone healing was significantly greater with better tissue arrangement and more extracellular matrix in the simvastatin-treated group than that in the control group, and immunohistochemical staining showed the expression of VEGF in simvastatin group was significantly higher. Histological staining and RT-PCR confirmed that simvastatin could promote the differentiation of co-cultured BMSCs and TDSCs into osteoblasts and chondroblasts, respectively. The effect of promoting osteogenic differentiation was more tremendous at 14 days, while its effect on promoting chondroblast differentiation was more evident on the 7th day of differentiation. In conclusion, local administration of simvastatin can promote the tendon-bone healing by enhancing neovascularization, chondrogenesis, and osteogenesis in different stages of the tendon-bone healing process.

Increased HbA1c Levels in Diabetics During the Postoperative 3-6 Months After Rotator Cuff Repair Correlated With Increased Retear Rates

PURPOSE

To evaluate whether glycemic control affects the integrity of the repaired rotator cuff during the postoperative healing period after arthroscopic double-row suture bridge rotator cuff repair (RCR) METHODS: We retrospectively reviewed patients with diabetes mellitus (DM) who underwent arthroscopic double-row suture bridge RCR at our institution between March 2016 and November 2019. We included the patients who evaluated for serum glycosylated hemoglobin (HbA1c) levels within 1 month before and 3-6 months after surgery. Magnetic resonance imaging was conducted 6 months after surgery to evaluate the integrity of the repaired cuff tendon. Patients were categorized into two groups based on comparison between preoperative and postoperative HbA1c values: Group I (increased postoperative HbA1c) and Group D (same or decreased postoperative HbA1c). The correlation between preoperative/postoperative HbA1c, HbA1c increase/same or decrease (during the healing period), and post-RCR integrity was evaluated, including various demographic and radiologic factors.

RESULTS

A total of 103 patients were analyzed, group I was 47, and group D was 56, respectively. The retear rate of 51.1% (24/47) in Group I was significantly higher than 14.3% (8/56) in Group D (P < .001). HbA1c levels measured 3-6 months after surgery (mean: 6.9; 95% CI: 6.6-7.3 vs mean: 6.5; 95% CI: 6.3-6.7, P = .034), and the proportion of group I and group D were significantly different (75%/25% vs 32.4%/67.6%, P < .001) between the retear and healing groups. Multivariable logistic regression analysis identified increased HbA1c as an independent risk factor for retear (odds ratio: 5.402; 95% CI: 2.072-14.086; P < .001).

CONCLUSIONS

The glycemic control within 3-6 months after surgery when the healing process of the tendon was in progress had a significant effect on retear rate. In particular, the retear rate was higher when the HbA1c level increased at postoperative 3-6 months compared to before surgery.

LEVEL OF EVIDENCE

Retrospective case-control comparative study, Level III.

Pathological alterations in the expression status of rotator cuff tendon matrix components in hyperlipidemia

Hyperlipidemia is an important risk factor in the development and progression of tendon pathology, however its role in aggravating rotator cuff tendon injury (RCTI) is largely unknown. We aimed to assess the expression status of key extracellular matrix (ECM) components in the tendon tissues and tenocytes under hyperlipidemia. Shoulder rotator cuff (RC) tendon tissues harvested from the swine model of hyperlipidemia displayed alterations in histomorphometry and the expression status of major ECM component proteins including COL-I, COL-III, COL-IV, COL-V, COL-VI, MMP2, and MMP9. Similarly, the LDL- and oxLDL-challenged tenocytes displayed altered expression of the same proteins at both transcriptional and translational levels. In addition, the lipid uptake and cellular reactive oxygen radicals predominated in the lipid-challenged tenocytes compared to the control. Overall, the LDL-treated cells displayed predominant pathological alterations compared to the ox-LDL-treated cells. Further understanding regarding the underlying molecular mechanisms driving the tendon matrisome alteration and subsequent aggravated RCTI pathology in hyperlipidemia could open novel translational avenues in the management of RCTI.

Sports-Related Shoulder Injuries Among Female Athletes

PURPOSE OF REVIEW

The objectives of this review are to explore the recent literature evaluating sports-related shoulder injuries among female athletes.

RECENT FINDINGS

Recent literature has highlighted sex-related differences in injury trends and patterns among athletes. Increased participation of women in both recreational and professional sports has resulted in increased exposure to injury. While men experience greater rates of shoulder injury overall, women tend to experience more overuse-related injuries. Evidence also suggests women are more susceptible to shoulder laxity and rotator cuff tears. In comparison to their male counterparts, women note poorer function, increased pain, and decreased activity level following shoulder injuries. Women may also be more likely to experience worse outcomes following surgical intervention. Sex-related differences in injury patterns and outcomes results from a combination of molecular and environmental influences, including hormone pathways, shoulder morphology, and differing rates of participation in, and athletic regulations among, certain sports. Sex-related differences occur in how athletes sustain, experience, and recover from sports-related injuries. A comprehensive understanding of sex-related injuries enhances clinical decision making, treatment, and recovery. Further research is needed to clarify sex as an independent variable when evaluating sports-related shoulder injuries.

Musculoskeletal complications in patients with diabetes mellitus

Musculoskeletal conditions are common in patients with diabetes. Several musculoskeletal disorders are viewed as chronic complications of diabetes because epidemiological studies have revealed high correlations between such complications and diabetes, but the pathophysiological links with diabetes remains unclear. Genetic predispositions, shared risk factors, microvascular impairments, progressive accumulation of advanced glycation end-products, and diabetic neuropathy may underlie the development of musculoskeletal disorders. Musculoskeletal complications of diabetics have received less attention than life-threatening microvascular or macrovascular complications. Here, we review several diabetic musculoskeletal complications with a focus on the clinical importance of early recognition and management, which would improve quality of life and physical function.

Dyslipidemia is associated with risk for rotator cuff repair failure: a systematic review and meta-analysis

Background

Lipid deposition secondary to dyslipidemia (DLD) is shown to have a significant impact on tendon pathology, including tendon elasticity, fatty infiltration, and healing properties. Rotator cuff repair is a common procedure, susceptible to influence from many tear-related and patient-related characteristics. The purpose of this study was to determine the relationship between DLD and rotator cuff repair outcomes with analysis of retear risk and function.

Methods

PubMed, Embase, and SPORTDiscus were searched for all English-language, peer-reviewed studies between 2000 and the present, which analyzed relationships between patient-related factors and outcomes of rotator cuff repair. Studies that explicitly examined the effect of DLD on rotator cuff repair outcomes were chosen for inclusion. Included studies were assessed for methodological quality, and data were extracted for meta-analysis.

Results

Of the 3087 titles, 424 were screened by abstract, and 67 were reviewed in full. Inclusion criteria were met by 11 studies. Of these studies, 5 studies assessed retear, 2 studies measured function, 3 studies reported both retear and function, and 1 study evaluated the risk of retear necessitating a revision surgery. The studies report no significant difference in functional outcomes. Meta-analysis revealed that DLD patients had a significantly higher risk of retear after primary rotator cuff repair (odds ratio 1.32, 95% confidence interval 1.06-1.64).

Conclusion

DLD leads to an increased risk of retear after rotator cuff repair, although function appears to be unimpaired. DLD should be considered among other risk factors when counseling patients regarding expected rotator cuff repair outcomes.

Descriptive transcriptome analysis of tendon derived fibroblasts following in-vitro exposure to advanced glycation end products

BACKGROUND

Tendon pathologies affect a large portion of people with diabetes. This high rate of tendon pain, injury, and disease appears to manifest independent of well-controlled HbA1c and fasting blood glucose. Advanced glycation end products (AGEs) are elevated in the serum of those with diabetes. In vitro, AGEs severely impact tendon fibroblast proliferation and mitochondrial function. However, the extent that AGEs impact the tendon cell transcriptome has not been evaluated.

OBJECTIVE

The purpose of this study was to investigate transcriptome-wide changes that occur to tendon-derived fibroblasts following treatment with AGEs. We propose to complete a descriptive approach to pathway profiling to broaden our mechanistic understanding of cell signaling events that may contribute to the development of tendon pathology.

METHODS

Rat Achilles tendon fibroblasts were treated with glycolaldehyde-derived AGEs (200μg/ml) for 48 hours in normal glucose (5.5mM) conditions. In addition, total RNA was isolated, and the PolyA+ library was sequenced.

RESULTS

We demonstrate that tendon fibroblasts treated with 200μg/ml of AGEs differentially express 2,159 gene targets compared to fibroblasts treated with an equal amount of BSA-Control. Additionally, we report in a descriptive and ranked fashion 21 implicated cell-signaling pathways.

CONCLUSION

Our findings suggest that AGEs disrupt the tendon fibroblast transcriptome on a large scale and that these pathways may contribute to the development and progression of diabetic tendinopathy. Specifically, pathways related to cell cycle progression and extracellular matrix remodeling were affected in our data set and may play a contributing role in the development of diabetic tendon complications.

Chronic Disease, Allergies, and Increased Years of Running Are Risk Factors Predicting Gradual Onset Running-Related Injuries in Ultramarathon Runners-SAFER XIX Study in 29 585 Race Entrants

OBJECTIVES

To identify risk factors that predict gradual onset running-related injuries (GORRIs) in ultramarathon runners entering a mass community-based event.

DESIGN

Descriptive cross-sectional study.

SETTING

Two Oceans 56 km ultramarathon 2012 to 2015.

PARTICIPANTS

Race entrants (n = 42 003) completed a compulsory pre-race medical history questionnaire; 29 585 (70.4%) of entrants consented.

DEPENDENT/OUTCOME VARIABLE

A history of GORRIs in the past 12 months among race entrants.

MAIN OUTCOME MEASURES

In a multi-variate model, runner demographics, training variables (years of recreational running, weekly running distance, training running speed), history of chronic disease (composite score), and history of allergies were included as factors predicting GORRIs. Prevalence (%) and prevalence ratios (PR, 95% CIs) are reported.

RESULTS

The lifetime prevalence of GORRIs in ultramarathon runners was 24.4%. Independent factors predicting GORRIs were: higher chronic disease composite score (PR = 2.05 times increase risk for every 2 additional chronic diseases; P < 0.0001), history of allergies (PR = 1.66; P < 0.0001), increased years of recreational running (PR = 1.07 times increased risk for every 5 year increase in running; P < 0.0001), lower average weekly running distance (PR = 0.98 times decreased risk for every 15 km increase weekly running distance; P < 0.0001), and slower average training running speed (PR = 0.96 times decreased risk for every km/h increase in training running speed; P < 0.0001).

CONCLUSIONS

Novel risk factors predicting GORRIs are increased number of chronic diseases and a history of allergies. These factors, together with training variables (years of recreational running, weekly running distance, and training running speed) can be targeted to develop and implement injury prevention, treatment, and rehabilitation interventions in ultramarathon runners.

Comparison of the Characteristics of Rotator Cuff Tissue in a Diabetic Rat Model

This study evaluated the biomechanical and histologic characteristics of the rotator cuff tendon and muscle tissue with rat models with diabetes mellitus (DM) (group 1) and 30 male rats without DM (group 2). We conducted a time zero study without any additional procedures or external variables at 9 weeks after induction of the diabetic rat model. Thereafter, quantitative evaluation of advanced glycation end products (AGEs) was accomplished via enzyme-linked immunosorbent assay and immunohistochemistry (IHC). Fatty infiltration was investigated with Oil Red O staining, and the peroxisome proliferator activated receptor-gamma (PPAR-gamma) value was studied with IHC. Grossly, the supraspinatus tendons of the group 1 rats were more friable and discolored (yellowish) than those of group 2. In the biomechanical analysis, group 1 rats showed significantly inferior ultimate failure load (P=.001) and ultimate stress (P=.02). Group 1 was significantly inferior to group 2 in terms of total histologic scoring (P<.001). Mean AGE levels were significantly higher in group 1 (P<.001), as determined by IHC. In evaluating fatty infiltration, the degree of Oil Red O staining was significantly higher in group 1 (P<.001), but there was no significant difference in PPAR-gamma value between the 2 groups (P=.14). The intact rotator cuffs of rats with DM were associated with inferior biomechanics in association with AGE accumulation and increased fatty infiltration, as confirmed by histologic examination The hyperglycemic state caused by DM is associated with rotator cuff tendon degeneration. [Orthopedics. 2022;45(3):e154-e161.].

Predictors of multiple injuries in individual distance runners: A retrospective study of 75,401 entrants in 4 annual races-SAFER XX

BACKGROUND

There are limited data on factors that predict an increased risk of multiple injuries among distance runners. The objective of this study was to determine risk factors that are predictive of individual runners with a high annual multiple injury risk (MIR).

METHODS

A retrospective, cross-sectional study at 4 annual (2012-2015) Two Oceans 21.1 km and 56.0 km races in South Africa with 75,401 consenting race entrants. Running-related injury data were collected retrospectively through an online pre-race medical screening questionnaire. The average number of injuries for each runner every year was calculated by taking a runner's race entry history and injury history into account and categorizing entrants into 4 MIR categories (high, intermediate, low, and very low (reference)). Multiple logistic regression modeling (odds ratios) was used to determine whether the following factors were predictive of a high MIR (average > 1 injury/year): demographics, training and racing, chronic-disease history (composite chronic disease score (CCDS)), and history of allergies.

RESULTS

Of all entrants, 9.2% reported at least 1 injury, and 0.4% of entrants were in the high MIR category; the incidence rate was 2.5 injuries per 10 runner-years (95% confidence interval (95%CI): 2.4-2.7). Significant factors predictive of runners in the high MIR category were: running for > 20 years: OR = 2.0 (95%CI: 1.3-3.1; p = 0.0010); a higher CCDS: OR = 2.2 (95%CI: 2.0-2.4; p < 0.0001); and a history of allergies: OR = 2.8 (95%CI: 2.0-3.8; p < 0.0001).

CONCLUSION

Runners who have been running recreationally for > 20 years and those with multiple chronic diseases or a history of allergies were at higher risk of multiple running-related injuries. This high-risk group can be targeted for further study and possible injury-prevention interventions.

Risk Factor Analysis for Predicting the Onset of Rotator Cuff Calcific Tendinitis Based on Artificial Intelligence

Background

Symptomatic rotator cuff calcific tendinitis (RCCT) is a common shoulder disorder, and approaches combined with artificial intelligence greatly facilitate the development of clinical practice. Current scarce knowledge of the onset suggests that clinicians may need to explore this disease thoroughly.

Methods

Clinical data were retrospectively collected from subjects diagnosed with RCCT at our institution within the period 2008 to 2020. A standardized questionnaire related to shoulder symptoms was completed in all cases, and standardized radiographs of both shoulders were extracted using a human-computer interactive electronic medical system (EMS) to clarify the clinical diagnosis of symptomatic RCCT. Based on the exclusion of asymptomatic subjects, risk factors in the baseline characteristics significantly associated with the onset of symptomatic RCCT were assessed via stepwise logistic regression analysis.

Results

Of the 1,967 consecutive subjects referred to our academic institution for shoulder discomfort, 237 were diagnosed with symptomatic RCCT (12.05%). The proportion of women and the prevalence of clinical comorbidities were significantly higher in the RCCT cohort than those in the non-RCCT cohort. Stepwise logistic regression analysis confirmed that female gender, hyperlipidemia, diabetes mellitus, and hypothyroidism were independent risk factors for the entire cohort. Stratified by gender, the study found a partial overlap of risk factors contributing to morbidity in men and women. Diagnosis of hyperlipidemia, diabetes mellitus, and hypothyroidism in male cases and diabetes mellitus in female cases were significantly associated with symptomatic RCCT.

Conclusion

Independent predictors of symptomatic RCCT are female, hyperlipidemia, diabetes mellitus, and hypothyroidism. Men diagnosed with hyperlipidemia, diabetes mellitus, and hypothyroidism are at high risk for symptomatic RCCT, while more medical attention is required for women with diabetes mellitus. Artificial intelligence offers pioneering innovations in the diagnosis and treatment of musculoskeletal disorders, and careful assessment through individualized risk stratification can help predict onset and targeted early stage treatment.

Influence of Diabetes-Induced Glycation and Oxidative Stress on the Human Rotator Cuff

Most shoulder rotator cuff tears (RCTs) are caused by non-traumatic age-related rotator cuff degeneration, of which hyperglycemia is a risk factor due to its glycation reaction and oxidative stress. We aimed to identify the influence of diabetes-induced glycation and oxidative stress in patients with non-traumatic shoulder RCTs. Twenty patients, aged over 50 years, with non-traumatic shoulder RCTs participated in this study. Patients with a history of diabetes mellitus or preoperative HbA1c ≥ 6.5% were assigned to the diabetic group (n = 10), and the rest to the non-diabetic group (n = 10). Cell proliferation; expression of genes related to oxidative stress, glycation reaction, inflammation, and collagen; intracellular reactive oxygen species (ROS) levels; and apoptosis rates were analyzed. The diabetic group had significantly lower cell proliferation than the non-diabetic group. In the diabetic group, the mRNA expression levels of NOX1, NOX4, IL6, RAGE, type III collagen, MMP2, TIMP1, and TIMP2 were significantly higher; type I collagen expression was significantly lower; and the rate of ROS-positive cells and apoptotic cells, as well as the expression of advanced glycation end-products (AGEs) and the receptor for AGEs (RAGE), was significantly higher. In conclusion, hyperglycemia caused by diabetes mellitus increased AGE and RAGE expression, and led to increased NOX expression, ROS production, and apoptosis in the human rotator cuff. This provides scope to find a preventive treatment for non-traumatic RCTs by inhibiting glycation and oxidative stress.

The Relationship of Aging and Smoking With Rotator Cuff Disease: A Systematic Review and Meta-analysis

OBJECTIVE

Despite rotator cuff disease being one of the most common causes of shoulder pain, its pathogenesis and biology are poorly understood. In this study, we synthesized evidence from studies reporting associations for aging and smoking status in relation to rotator cuff disease.

DESIGN

A systematic review was performed using multiple databases (PubMed, Embase, Cochrane, CINAHL, and Science Direct). Articles that met our eligibility criteria and presented data on the association between aging and/or smoking status and rotator cuff disease were included. We performed meta-analyses and reported cumulative effects using odds ratios and corresponding 95% confidence intervals.

RESULTS

Of the 212 articles eligible for full-text review, seven studies reported on the relationship between aging and rotator cuff disease, and 10 studies reported on the relationship between smoking and rotator cuff disease. Aging was consistently associated with increased odds of having rotator cuff disease when assessed continuously (per 10-yr increase: odds ratio = 1.20, 95% confidence interval = 1.18-1.21) or categorically (ages <40 yrs vs: [a] 40-44 yrs [odds ratio = 2.71, 95% confidence interval = 1.78-4.13], [b] 45-49 yrs [odds ratio = 4.33, 95% confidence interval = 2.88-6.55], and [c] ≥50 yrs [odds ratio = 6.97, 95% confidence interval = 4.85-10.01]). Assessing studies that reported smoking status as current smokers versus nonsmokers, current smokers were more likely to have rotator cuff disease (odds ratio = 1.94, 95% confidence interval = 1.52-2.48). However, a statistically significant association was not found when never smokers were compared with former smokers (odds ratio = 1.08, 95% confidence interval = 0.97-1.20) and to current smokers (odds ratio = 0.97, 95% confidence interval = 0.87-1.07).

CONCLUSIONS

In this systematic review and meta-analysis, increasing age was a strong risk factor for rotator cuff disease. The finding that current smokers are more likely to have rotator cuff disease as compared with nonsmokers implies that cessation of smoking can potentially lead to mitigation of this risk factor.

Is there a relation between plantar fasciitis and total cholesterol levels?

BACKGROUND

The main objective of this study is to investigate the relationship between hypercholesterolemia and Plantar Fasciitis (PF).

METHODS

The study includes patients who presented to the orthopedics outpatient clinic with heel pain and were diagnosed with PF. The control group was composed of patients who came to the orthopedics outpatient clinic, with complaints other than heel pain. The two groups were compared in terms of epidemiological data, total cholesterol (TC) levels, and hypercholesterolemia prevalence. We also performed an in-group analysis of PF patients in terms of age, sex, body mass index, and duration of symptoms.

RESULTS

There were 238 patients (mean age, 46.7) in the PF group and 240 patients (mean age, 47.9) in the control group. There was a significant difference between the PF group and the control group in TC levels (207.6 ± 47.5 versus 195.1 ± 30.1, p = 0.001). Hypercholesterolemia (TC level > 240 mg/dL) was found in 22.7% (n = 54) of the patients in the PF group whereas in the control group this rate was 10.8% (n = 26) (p < 0.001). It was seen that the TC levels were significantly higher in patients over the age of 45 in the PF group (p = 0.038). We also found that TC levels were higher in PF patients with symptoms for longer than a year (p = 0.026).

CONCLUSION

Significantly higher TC levels were found in PF patients in comparison with other orthopedic outpatients. Besides, being over the age of 45 and having a duration of symptoms longer than a year is associated with higher cholesterol levels for PF patients.

LEVEL OF CLINICAL EVIDENCE

4.

Osteoporosis increases the risk of rotator cuff tears: a population-based cohort study

INTRODUCTION

Osteoporosis has been demonstrated to be a risk factor for rotator cuff retears after surgery; however, no studies have directly investigated the association between osteoporosis and the development of rotator cuff tears. To investigate whether osteoporosis is associated with an increased risk of rotator cuff tears.

MATERIALS AND METHODS

We conducted a population-based, matched-cohort study with a 7-year follow-uTwo matched cohorts (n = 3511 with osteoporosis and 17,555 without osteoporosis) were recruited from Taiwan's Longitudinal Health Insurance Dataset. Person-year data and incidence rates were evaluated. A multivariable Cox model was used to derive an adjusted hazard ratio (aHR) after controlling for age, sex, and various prespecified comorbidities. Age and sex were added in the model to test for interaction with osteoporosis.

RESULTS

Women constituted 88.5% of the cohorts. During follow-up of 17,067 and 100,501 person-years for the osteoporosis and nonosteoporosis cohorts, 166 and 89 rotator cuff tears occurred, respectively. The cumulative incidence of rotator cuff tears was significantly higher in the osteoporosis cohort than in the nonosteoporosis cohort (p < 0.001, log-rank). The Cox model revealed a 1.79-fold increase in rotator cuff tears in the osteoporosis cohort, with an aHR of 1.79 (95% confidence interval, 1.55-2.05). Effect modification of sex and age on rotator cuff tears was not found in patients with osteoporosis.

CONCLUSION

This population-based study supports the hypothesis that compared with individuals without osteoporosis, those with osteoporosis have a higher risk of developing rotator cuff tears.

Reverse shoulder arthroplasty for rotator cuff tears with and without prior failed rotator cuff repair: A large-scale comparative analysis

Background

Large-scale data assessing the effect of a prior failed rotator cuff repair (RCR) on the outcome of reverse shoulder arthroplasty (RSA) is currently lacking. Therefore, this study aimed (1) to assess the course of patients undergoing RCR, specifically focusing on the need for conversion to RSA within two years, and (2) to compare outcomes following RSA performed for rotator cuff tears (RCTs) with and without prior RCR.

Methods

This retrospective cohort study included data from the CMS Data Set (2016-2018). For the first study objective, we included patients undergoing an RCR; these were followed for 24 months to identify a conversion to RSA. For the second study objective, we included RSAs for RCTs, stratified by those with and without a prior RCR (preceding 24 months). Outcomes (hospitalization cost, institutional post-acute care discharge, 90-day readmission and health resource utilization up to 6 months post-RSA) were compared between propensity score-matched groups.

Results

Out of 33,244 RCRs, 433 (1.3%) patients underwent RSA conversion within two years. Among 7534 RSA cases for RCTs, 245 (3.3%) had an RCR in the preceding two years. In the propensity score analysis, except for a minimal increase in the number of physical rehabilitation visits (RR 1.10; p = 0.0009), no differences were observed between those with and without prior RCR in terms of other RSA outcomes. These included hospitalization cost, discharge to institutional post-acute care facility, 90-day readmission and 6-month post-op cost.

Conclusion

Rotator cuff repair in elderly patients, when utilizing currently employed indication criteria, results in low conversion rates to RSA within 2 years postoperatively. Furthermore, large dataset outcomes after RSA for RCT such as cost, post-acute care discharge, physical rehabilitation, and readmission rates appear not to be negatively affected by the presence of a prior RCR.

Level of evidence

Level 3 evidence; Retrospective cohort study.

Clinical evaluation and management of calcific tendinopathy: an evidence-based review

Calcific tendinopathy (CT) is an important musculoskeletal condition most commonly seen in the shoulder girdle, accounting for 10-42% of all shoulder pain. Despite the high prevalence within the shoulder region, CT has been demonstrated in many tendons throughout the axial and appendicular skeleton. Unlike degenerative tendinopathies, CT appears to be a self-limiting condition that affects otherwise-healthy tendon with deposition of calcium hydroxyapatite crystals between healthy tenocytes. In patients with functionally limiting symptoms or pain, the clinical course may be accelerated through a multitude of treatments including physical therapy and pain management, extracorporeal shock wave therapy, ultrasound-guided percutaneous lavage (UGPL), and operative debridement. Currently, the most efficacious and frequently utilized treatment for shoulder CT is UGPL due to its ability to effectively reduce calcium burden and pain while limiting soft-tissue damage. However, more evidence regarding the treatment and course of CT is needed before determining the most appropriate treatment at all potential sites of CT.

Does statin-treated hyperlipidemia affect rotator cuff healing or muscle fatty infiltration after rotator cuff repair?

BACKGROUND

Hyperlipidemia is linked to poor tendon-to-bone healing and progression of fatty infiltration after rotator cuff repair. Statins effectively treat hyperlipidemia, but it is unknown if they have any potential detrimental effects following rotator cuff repair. The aim of this study was to evaluate the effect of statins on rotator cuff healing and fatty infiltration following repair.

METHODS

A total of 77 patients undergoing arthroscopic rotator cuff repair were recruited prospectively, 38 patients who were prescribed a statin for hyperlipidemia (statin group) and 39 patients who were not taking a statin (control group). Patients who did not have both preoperative and 1-year postoperative magnetic resonance imaging (MRI) scans were excluded from the study. Patient-reported outcome measures, namely the Western Ontario Rotator Cuff (WORC) index, Constant-Murley score, American Shoulder and Elbow Surgeons (ASES) score, and Disabilities of the Arm, Shoulder and Hand (DASH) score, were collected preoperatively and at 1 year. Fatty infiltration was assessed on MRI according to the Goutallier grade preoperatively and at 12 months; rotator cuff healing was assessed at 12 months according to the Sugaya classification. Following propensity score weighting to adjust for baseline imbalances, 12-month outcomes were compared between the 2 groups.

RESULTS

At 12 months, all patient-reported outcome measures had improved significantly compared with baseline (WORC score, 85.9 vs. 32.5, P < .001; ASES score, 87.3 vs. 37.5, P < .001; Constant-Murley score, 77 vs. 31, P < .001; and DASH score, 13.6 vs. 61.4, P < .001). There was no significant difference in postoperative scores in the statin group vs. the control group (WORC score, 84.9 vs. 89.6, P = .94; ASES score, 87.5 vs. 86.6, P = .40; Constant-Murley score, 77 vs. 81, P = .90; and DASH score, 14.4 vs. 11.4, P = .14), and for 3 of these scores, the 95% confidence intervals excluded a clinically meaningful difference. Similarly, rotator cuff healing at 12 months and Goutallier fatty infiltration grades were comparable between the 2 groups. Retears were seen in 6 patients (15.8%) in the statin group and 8 (20.5%) in the control group. Progression of fatty infiltration was seen in 4 patients (10.5%) in the statin and 4 (10.3%) in the control group. Statin use did not demonstrate a significant association with either retear risk (P = .41) or progression of fatty atrophy (P = .69).

CONCLUSION

Patient-reported outcomes, rotator cuff retear rate, and fatty infiltration on MRI at 12 months after rotator cuff repair in patients with hyperlipidemia treated with statins are similar to those in a control group.

Hypolipidemic Effects and Preliminary Mechanism of Chrysanthemum Flavonoids, Its Main Components Luteolin and Luteoloside in Hyperlipidemia Rats

This study aimed to investigate the key constituents and preliminary mechanism for the hypolipidemic activity of chrysanthemum flavonoids. Hyperlipidemia (HPL) rats were divided into five groups: the model control group (MC); Chrysanthemum flavone intervention group (CF); luteolin intervention group; luteoloside intervention group and simvastatin intervention group. The body weight, organ coefficient, serum lipids, antioxidant activity, and lipid metabolism enzymes were detected. Hematoxylin and eosin (H&E) staining was used to observe the liver and adipose tissue. Chrysanthemum flavonoids, luteolin, and luteoloside can reduce the weight and levels of total cholesterol (TC), triglycerides (TG), and LDL-C, and increase the level of HDL-C in the blood and reduce liver steatosis. Indicators of liver function (AST, ALT, and ALP) improved. The antioxidant activity (GSH-Px, CAT, SOD) and enzymes associated with lipid catabolism (FAβO, CYP7A1, and HL) increased, while lipid peroxidation products (MDA) and enzymes associated with lipid synthesis (FAS, HMG-CoA, and DGAT) decreased. Chrysanthemum flavonoids had a better effect on the antioxidant level and lipid metabolism-related enzyme activity. There was no significant difference in the effects of the chrysanthemum flavonoids, luteolin, and Luteoloside on improving blood lipids and hepatic steatosis—mechanisms that may be related to antioxidant levels and regulating enzymes involved in the metabolism of fatty acids, cholesterol, and triglycerides in the liver. However, chrysanthemum flavonoids had a stronger antioxidant and lipid metabolism regulation ability, and the long-term effects may be better.

Phloridzin Ameliorates Lipid Deposition in High-Fat-Diet-Fed Mice with Nonalcoholic Fatty Liver Disease via Inhibiting the mTORC1/SREBP-1c Pathway

We aimed to investigate whether phloridzin could alleviate nonalcoholic fatty liver disease (NAFLD) in mice, which was induced by feeding a high-fat diet (HFD). We initially analyzed the effect of phloridzin on alleviating HFD-induced NAFLD in C57BL/6J mice and oleic acid (OA)-stimulated human normal liver L-02 cells (L02). Then, we investigated the mechanism of phloridzin on the mTORC1/sterol-regulatory element-binding protein-1c (SREBP-1c) signaling pathway by siRNA analysis, qRT-PCR, flow cytometry, and western blot analysis in vivo and in vitro. The results revealed that phloridzin significantly inhibited the increase in body weight, alleviated abnormal lipid metabolism, and decreased lipid biosynthesis and insulin resistance. Moreover, phloridzin augmented the number of CD8⁺CD122⁺PD-1⁺ Tregs and CD4⁺FoxP3⁺ Tregs in HFD-fed C57BL/6J mice and HFD-fed aP2-SREBF1c mice and downregulated the mTORC1/SREBP-1c signaling pathway-related protein expressions in vivo and in vitro. Furthermore, phloridzin reduced the expression of SREBP-1c in SREBP-1c-RNAi-lentivirus-transfected L02 cells and reversed the SREBP-1c expression in HFD-fed aP2-SREBF1c transgenic mice. Phloridzin ameliorates lipid accumulation and insulin resistance via inhibiting the mTORC1/SREBP-1c pathways. These results indicated that phloridzin may actively ameliorate NAFLD.

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.

Diabetes is an independent risk factor for infection after non-arthroplasty shoulder surgery: a national database study

OBJECTIVES

Diabetes has been associated with poor healing and prior literature has shown worse functional outcomes in diabetic patients undergoing both open and arthroscopic shoulder surgery. However, the effects of diabetes on perioperative complications for patients undergoing non-arthroplasty type shoulder procedures are not well defined. The purpose of this study was to analyze the effects of diabetes on 30-day complications following non-arthroplasty shoulder surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent open and arthroscopic shoulder procedures (excluding arthroplasty) from 2011 to 2018. Diabetic patients were identified and compared to a non-diabetic cohort. Demographic data and postoperative complications within 30 days were analyzed. Multivariable regression was used to determine the effect of diabetes on shoulder surgery.

RESULTS

We identified 99,970 patients who underwent shoulder surgery in our cohort and 13.9% (13,857 patients) of these patients were diabetics. Within the diabetic cohort, 4,394 (31.7%) were insulin dependent. Diabetics were more likely to be older, female, and have a higher body mass index (P < 0.01). Diabetics had a higher rate of associated medial comorbidities (P < 0.05). Diabetics were less likely to be smokers and on average had shorter surgeries (P < 0.05). Univariate analysis showed that diabetes was associated with increased risk for infectious and other major and minor complications; however, multivariate regression revealed that diabetes was only independently associated with infection (OR 1.33, P = 0.38).

CONCLUSION

While diabetes is associated with increased likelihood of infection following shoulder surgery, absent commonly associated comorbidities, they are not at increased risk for other 30-day postoperative complications.

Grip and shoulder strength correlation with validated outcome instruments in patients with rotator cuff tears

HYPOTHESIS/BACKGROUND

The ability to better define preoperatively the extent of rotator cuff (RC) dysfunction is desired. The study's purpose was to prospectively examine the relationships between absolute and percentage loss (affected compared to unaffected) of grip and shoulder strength, and RC dysfunction.

METHODS

Forty-seven consecutive patients with proven RC tears participated in this study. Prior to surgery, bilateral strengths of grip, shoulder abduction, and shoulder external rotation (ER) were measured with a handheld dynamometer, and subjective outcome measures were gathered. RC tear size was determined via arthroscopy. Patient-reported outcomes were gathered on the day of the examination or via e-mail following initial evaluation. Descriptive statistics, difference analysis, and correlation coefficients (reported as either direct or negative) were used to analyze data. Grip, abduction and ER strengths, and percentage loss of grip, abduction, and ER strengths (percentage loss affected vs. unaffected), and tear size were analyzed in relation to all of the scores on selected subjective outcome measurement tools. The P value was set at .05.

RESULTS

Fair direct correlations were found between grip strength and the Veterans RAND 12-Item Health Survey (VR-12) mental health scores, ER strength and Simple Shoulder Test (SST), abduction strength, and both the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) function score and SST score. Abduction and ER strengths were also found to possess a fair direct correlation. Fair negative correlations were found between the ASES function score and each of the following: percentage loss of abduction strength, percentage loss of ER strength, and tear size in centimeters. Another fair negative correlation was found between the Single Assessment Numerical Evaluation (SANE) score and tear size in centimeters.

DISCUSSION

Our findings suggest that as shoulder strength decreases, ipsilateral shoulder RC dysfunction increases. Grip strength was not related to shoulder RC dysfunction.

CONCLUSION

Grip strength was not found to correlate with RC tears. Those with decreased abduction and ER strengths and low ASES scores should be considered more likely to have an RC tear.

Proportion and distribution of upper extremity musculoskeletal disorders and its association with disability in type 2 diabetes mellitus

STUDY DESIGN

Cross-sectional INTRODUCTION: Globally, diabetes is a leading cause of disability with an increased prevalence rate in the past three decades. Chronic diabetes has been shown to affect collagenous tissue which often leads to subsequent musculoskeletal complications. Despite increasing prevalence of musculoskeletal disorders, the proportion and distribution of types of upper extremity musculoskeletal disorders resulting in disabilities is poorly understood.

PURPOSE OF THE STUDY

This cross-sectional study aims to gather data on the prevalence, proportion and distribution of upper extremity musculoskeletal disorders among individuals with Type 2 Diabetes Mellitus. Further, this study examines the relationship between common upper extremity disorders and the resulting disability among individuals with Type 2 Diabetes Mellitus.

METHODS

170 individuals diagnosed with Type 2 Diabetes Mellitus were recruited at a tertiary care hospital. Routine upper extremity assessments were performed to identify the presence of Frozen Shoulder (FS), Limited Joint Mobility (LJM), Trigger Finger, Carpal Tunnel Syndrome (CTS), and Dupuytren's Contracture. Disability was measured using the Disabilities of arm, shoulder, and hand (DASH) questionnaire. Descriptive statistics, one-way analysis of variance, Tukey's test, and Pearson's test were used to examine the prevalence, proportion and distribution of musculoskeletal disorders and disabilities among individuals with type 2 Diabetes Mellitus.

RESULTS

83(48.9%) participants had one or a combination of multiple musculoskeletal disorders of the upper extremity. The proportion of LJM, FS, CTS, Trigger Finger, and Dupuytren's Contracture were n = 46(27.1%); n = 43(25.3%); n = 16(9.4%); n = 8(4.7%); n = 5(2.9%) respectively. Disability scores on the DASH were 25.8 ± 14.5, 10.3 ± 11.9, and 10.6 ± 10.4 respectively for individuals with FS, LJM and Trigger Finger. DASH scores were highest in individuals with both CTS and FS, 29.8 ± 19.3. Duration of diabetes was significantly associated (r = 0 .19; P < .01) with the disability scores on DASH.

CONCLUSION

The prevalence of musculoskeletal disorders in people with type 2 Diabetes mellitus remains high despite advances in medical management over the last two decades. The overall prevalence of hand disorders (LJM, CTS, Dupuytren's contracture, Trigger Finger) was higher than shoulder disorders (FS), e.g. frozen shoulder. People with a diabetes that had a diagnosed upper extremity conditon had more upper extremity disability, than those with diabetes but no diagnosed hand condition, Disability was highest for frozen shoulder and lowest for Dupuytren's diagnoses. Carpal tunnel syndrome was the most disabling hand condition. People with diabetes should be screened for upper extremity diagnoses that could limit their function. Poeple with disability resulting from hand disorders was lower than the shoulder disorders. A combination of hand and shoulder disorders resulted in greater disability.