Retears and Concomitant Functional Impairments After Rotator Cuff Repair: Shoulder Activity as a Risk Factor

Durable immunomodulatory hierarchical patch for rotator cuff repairing

Degradable rotator cuff patches, followed over five years, have been observed to exhibit high re-tear rates exceeding 50%, which is attributed to the inability of degradable polymers alone to restore the post-rotator cuff tear (RCT) inflammatory niche. Herein, poly(ester-ferulic acid-urethane)urea (PEFUU) was developed, featuring prolonged anti-inflammatory functionality, achieved by the integration of ferulic acid (FA) into the polyurethane repeating units. PEFUU stably releases FA in vitro, reversing the inflammatory niche produced by M1 macrophages and restoring the directed differentiation of stem cells. Utilizing PEFUU, hierarchical composite nanofiber patch (HCNP) was fabricated, simulating the natural microstructure of the tendon-to-bone interface with an aligned-random alignment. The incorporation of enzymatic hydrolysate derived from decellularized Wharton jelly tissue into the random layer could further enhance cartilage regeneration at the tendon-to-bone interface. Via rat RCT repairing model, HCNP possessing prolonged anti-inflammatory properties uniquely facilitated physiological healing at the tendon-to-bone interface's microstructure. The alignment of fibers was restored, and histologically, the characteristic tripartite distribution of collagen I - collagen II - collagen I was achieved. This study offers a universal approach to the functionalization of degradable polymers and provides a foundational reference for their future applications in promoting the in vivo regeneration of musculoskeletal tissues.

Smokers Achieved Minimal Clinically Important Difference for Visual Analog Scale and American Shoulder and Elbow Surgeons Scores at a Lower Rate Than Nonsmokers Even When Repaired Supraspinatus Tendons Were Intact on Postoperative Magnetic Resonance Imaging

Purpose

To investigate the impact of smoking on clinical outcomes after repair of supraspinatus tendon in patients who had an intact repair found on postoperative magnetic resonance imaging.

Methods

Patients who received primary complete repair of supraspinatus tendon tear between 2014 and 2020 were retrospectively identified. Patients were excluded if a postoperative magnetic resonance imaging scan was not available or if the follow-up was less than 2 years. Visual analog score (VAS), American Shoulder and Elbow Surgeons (ASES) score, and active forward flexion were assessed at the 2-year follow-up. The percentage of patients acquiring minimal clinically important difference (MCID) was reported.

Results

One hundred primary supraspinatus tendon repairs were included. The healing rate was 77% in smokers and 90% in nonsmokers. Smoking was the independent predictor of a poorer 2-year VAS (P < .001) and ASES (P < .001) scores. Significant improvement in clinical outcomes was observed between preoperation and the 2-year follow-up, regardless of the integrity of the repair or smoking status (P < .001). When the repaired tendon was intact, nonsmokers had a greater chance of achieving MCID in 2-year VAS and ASES scores than smokers. Ninety-nine percent of nonsmokers, compared with 82% of smokers, achieved MCID in VAS at the 2-year follow-up (P = .023). The corresponding figures for ASES were 98% and 71%, respectively (P = .004).

Conclusions

In this study, smoking was associated with poorer clinical outcomes, including a greater 2-year VAS pain score and a lower 2-year ASES score, when compared with nonsmokers, even in cases in which there was no full-thickness retear of the repaired supraspinatus tendon.

Level of Evidence

Level III, retrospective cohort study.

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.

Differences in Clinical Outcomes Between Patients With Retear After Supraspinatus Tendon Repair and Those With Intact Repair at 5-Year Follow-up

BACKGROUND

It is well known that rotator cuff repair is associated with an overall retear rate of 21% to 26%. However, a cuff retear may not necessarily be associated with poor clinical outcomes.

HYPOTHESIS

There would be no difference in clinical outcomes between patients with a cuff retear and those with an intact repair at a midterm follow-up of 5 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective study was conducted involving patients who received arthroscopic complete repair of the supraspinatus tendon between January 2009 and December 2017. Patients who did not have a postoperative magnetic resonance imaging (MRI) scan or who had a follow-up of <5 years were excluded. Clinical outcomes, including the visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, and active forward flexion (FF) of the involved shoulder were assessed at the 2-year and 5-year follow-up points.

RESULTS

The study group included 105 patients with a mean follow-up of 85 months. MRI scans were performed at a mean of 20 months. Fourteen full-thickness cuff retears and 91 intact repairs were identified using postoperative MRI scans. Significant improvement in VAS score, ASES score, and FF were found between the preoperative assessment and the 2 designated follow-up points (2 years and 5 years) in both the cuff retear and the intact repair groups (P < .001). The VAS and ASES scores at the 2-year follow-up for the intact repair group were 1.8 ± 2.0 and 80.7 ± 18.1, respectively. The corresponding values for the retear group were 2.3 ± 2.2 and 71.9 ± 19.5, respectively. No significant difference was found between the 2 groups in the VAS and ASES scores at the 2-year follow-up. However, patients with an intact repair had a better VAS score (1.4 ± 1.8; P = .049) and ASES score (81.7 ± 17; P = .019) than those with a cuff retear at the 5-year assessment (3.0 ± 2.8 and 67.1 ± 22.9, respectively). In the intact repair group, 91% of patients achieved the minimal clinically important difference for the 5-year VAS score, compared with 54% in the cuff retear group (P < .001). The corresponding values for the 5-year ASES score were 80% and 54%, respectively (P = .044). FF measurements at the 5-year follow-up in patients with intact repair and those with a cuff retear were 161°± 23° and 144°± 37°, respectively (P = .059). Continuous improvement in VAS score and FF between the 2-year and 5-year follow-up was observed in the intact repair group (P = .005 and P = .04, respectively).

CONCLUSION

The patients with an intact repair had better VAS and ASES scores compared with those who had a cuff retear at a midterm follow-up of 5 years. Between the 2-year and the 5-year follow-up, some further improvement was observed in the VAS score and FF in the intact repair group.

Clinical applications of smart wearable sensors

Smart wearable sensors are electronic devices worn on the body that collect, process, and transmit various physiological data. Compared to traditional devices, their advantages in terms of portability and comfort have made them increasingly important in the medical field. This review takes a unique clinical physician's standpoint, diverging from conventional sensor-type-based classifications, and provides a comprehensive overview of the diverse clinical applications of wearable sensors in recent years. In this review, we categorize these applications according to different diseases, encompassing skin diseases and injuries, cardiovascular diseases, abnormal human motion, as well as endocrine and metabolic disorders. Additionally, we discuss the challenges and perspectives hindering the development of sensors for clinical use, emphasizing the critical need for interdisciplinary collaboration between medical and engineering professionals. Overall, this review would serve as an important reference for the future direction of sensor devices in clinical use.

Effect of Retear After Arthroscopic Rotator Cuff Repair on Return to Work and Sports in Nonathletes: A Retrospective Cohort Study

Background

The impact of retear after arthroscopic rotator cuff repair (ARCR) on clinical outcomes of patients remains controversial.

Purpose/Hypothesis

The purpose of this study was to determine the effects of retear on strength recovery, return to previous levels of work, and return to sports participation. It was hypothesized that retears (1) would not have a significant effect on patient-reported outcome measures (PROMs) and (2) would significantly inhibit strength recovery and return to previous work and sports.

Study Design

Cohort study; Level of evidence, 3.

Methods

The authors collected data from patients who underwent ARCR between January 2015 and December 2019. All included patients had undergone magnetic resonance imaging (MRI) and strength measurements 1 year postoperatively. Minimum 2-year postoperative PROMs (Constant score, pain visual analog scale, American Shoulder and Elbow Surgeons score, and Single Assessment Numeric Evaluation) and status on work and sports participation were collected, and PROM scores, strength recovery (percentage compared with the contralateral shoulder), return to work, and return to sports were compared between patients with versus without retear on 1-year postoperative MRI. Additionally, factors related to return to work and sports were identified through multivariable regression analysis.

Results

A total of 159 patients were included, of whom 19 (11.9%) had evidence of retear. Return-to-work and return-to-sports status was evaluated in 134 (84.3%) and 93 (58.5%) patients, respectively. There were no significant differences in PROM scores between patients with and without retears; however, patients with retears exhibited significantly worse supraspinatus strength recovery (73% vs 86%; P = .018) and external rotation strength recovery (78% vs 88%; P = .030) compared with patients with intact shoulders. There were no between-group differences in return to work or sports. Active workload was associated with unsuccessful return to work, whereas preoperative participation in shoulder sports was associated with successful return to work.

Conclusion

Patients with postoperative retears had significantly worse postoperative strength recovery than patients with intact shoulders. Active workload and preoperative shoulder sports participation were factors associated with ability to return to work.

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

Background

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

Purpose

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

Study Design

Cohort study; Level of evidence, 3.

Methods

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

Results

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

Conclusion

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

A high acromion-greater tuberosity impingement index increases the risk of retear after arthroscopic rotator cuff repair

BACKGROUND

No evaluation has been done on the relationship of the acromion-greater tuberosity impingement index (ATI) with retear after arthroscopic rotator cuff repair (ARCR). Our purpose was to evaluate whether a higher ATI is associated with retear after ARCR.

METHODS

132 patients received ARCR and underwent MRI scan at a one year follow-up to assess tendon healing, and the findings were graded no retear (NR), partial-thickness retear (PR) or full-thickness retear (FR). The ATI, the critical shoulder angle (CSA), acromion index (AI) and lateral acromial angle (LAA) were measured with postoperative radiographs. Functional scores were obtained preoperatively and at a one year follow-up.

RESULTS

Postoperative Constant scores and ASES scores were significantly different between groups with inferior outcomes in the FR group (p < 0.05 for all). The UCLA score was significantly better in the NR group compared with the PR and FR groups (p < 0.05), and in the PR group compared with the FR group (p < 0.05). For ATI and CSA, the values of the PR and FR groups were larger than the NR group (p < 0.05 for all), but there were no significant differences between the PR and FR groups (p > 0.05 for all). No significant differences were observed with regard to the AI and LAA (p > 0.05, respectively). The repair integrity was positively related to the ATI (0.304, p < 0.05) and CSA (0.252, p < 0.05), but not related to the AI or LAA (p > 0.05 for both). ATI was not related to any functional scores (p > 0.05 for all).

CONCLUSION

This study revealed that the ATI was positively related to rotator cuff retear. Patients with retears had significantly greater ATIs after ARCR. Level of Evidence: III, case-control study.

Quantifying shoulder activity after rotator cuff repair: Technique and preliminary results

Repair tissue healing after rotator cuff repair remains a significant clinical problem, and excessive shoulder activity after surgical repair is believed to contribute to re-tears. In contrast, small animal studies have demonstrated that complete removal of activity impairs tendon healing and have advocated for an "appropriate" level of activity, but in humans the appropriate amount of shoulder activity to enhance healing is not known. As an initial step toward understanding the relationship between postoperative shoulder activity and repair tissue healing, the objectives of this study were to assess the precision, accuracy, and feasibility of a wrist-worn triaxial accelerometer for measuring shoulder activity. Following assessments of precision (±0.002 g) and accuracy (±0.006 g), feasibility was assessed by measuring 1 week of shoulder activity in 14 rotator cuff repair patients and 8 control subjects. Shoulder activity was reported in terms of volume (mean acceleration, activity count, mean activity index, active time) and intensity (intensity gradient). Patients had significantly less volume (p ≤ .03) and intensity (p = .01) than controls. Time post-surgery was significantly associated with the volume (p ≤ .05 for mean acceleration, activity count, and mean activity index) and intensity (p = .03) of shoulder activity, but not active time (p = .08). These findings indicate this approach has the accuracy and precision necessary to continuously monitor shoulder activity with a wrist-worn sensor. The preliminary data demonstrate the ability to discriminate between healthy control subjects and patients recovering from rotator cuff repair and provide support for using a wearable sensor to monitor changes over time in shoulder activity.

Retear bigger than preoperative tear size would lead to treatment failure after rotator cuff repair

BACKGROUND

This study aimed to (1) define treatment failure using the referred patient acceptable symptomatic state (PASS) values for pain visual analog scale (PVAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numeric Evaluation (SANE) clinical scores and (2) identify the factors that lead to patient dissatisfaction after arthroscopic rotator cuff repair (ARCR).

METHODS

We analyzed the arthroscopic rotator cuff surgery registry data from January 2015 to December 2016. Patients were followed for ≥2 years and categorized as dissatisfied or satisfied based on our own definition of treatment failure at 2 years postoperatively. For defining treatment failure, the referred PASS values for the PVAS, ASES, and SANE scores were used. Patients who failed to attain the PASS value for the PVAS, ASES, or SANE score were categorized into the dissatisfied group. Pre- and postoperative imaging and basic demographic data were compared between groups. Univariable and multivariable logistic regression analyses were performed to identify the factors affecting patient satisfaction at 2 years after rotator cuff repair.

RESULTS

Of 117 patients, 30 (25.6%) were defined as the dissatisfied group (mean follow-up period, 37.5 months). Seventeen patients (14.5%) had confirmed retear on follow-up magnetic resonance imaging. In the univariate analysis, sex significantly differed between the groups (female, satisfied vs. dissatisfied groups: 39 [44.8%] vs. 22 [73.3%]; P = .010). Retear alone did not affect patient satisfaction in the univariate analysis (P = .11). Progressed retear size featured a significantly higher risk of patient dissatisfaction (P = .024; odds ratio 6.430, 95% confidence interval 1.270-32.541) in the multivariable analysis using symptom duration, sex, preoperative ASES score, preoperative tear size, retear, and progressed retear size as variables. Moreover, female sex had an increased odds for dissatisfaction (odds ratio 4.646, 95% confidence interval 1.590-13.578; P = .005).

CONCLUSION

Two years after ARCR, most patients (74.4%) reported satisfaction with their outcomes. However, satisfaction levels can be altered by female sex or progressed retear size compared with the preoperative state.

Relationship between preoperative size of rotator cuff tears measured using radial-slice magnetic resonance images and postoperative rotator cuff integrity: a prospective case-control study

Background

Magnetic resonance imaging (MRI) is useful for diagnosing shoulder diseases preoperatively. However, preoperative risk factors for retears have not been previously reported using a radial-slice MRI. Here, we investigated the relationship between the preoperative tear area of the rotator cuff evaluated using radial-slice MRI and the postoperative rotator cuff integrity. Our hypothesis is that larger tear area of the rotator cuff measured using radial-slice MRI would be associated with increased retear rates.

Methods

From June 2010 to October 2015, we treated 102 consecutive patients who underwent shoulder arthroscopy for reparable rotator cuff tears. The patient demographics, medical comorbidities, radiologic factors, tear size, fatty infiltration, muscle atrophy measured using oblique coronal and oblique sagittal MRI, and the tear area calculated using radial-slice MRI were assessed to compare the intact and retear groups in univariate and multivariate logistic regression analyses. The cutoff values of the independent factors were obtained using the receiver operating characteristic curve.

Results

Retears occurred in 15 of 102 (14.7%) patients. In the univariate analysis, significant differences were found between the two groups for tear size, fatty infiltration of the supraspinatus and infraspinatus, muscle atrophy, and tear area. In the multivariate analysis, the tear area was the independent factor that significantly affected the rate of retear. A tear area of 6.3 cm² was the strongest predictor of retear with an area under the curve of 0.965, sensitivity of 86.7%, and specificity of 96.6%.

Conclusion

The tear area was the independent factor that most significantly affected the rate of retear and showed excellent accuracy with a cutoff value of 6.3 cm². Radial-slice MRI may be a valuable diagnostic tool for assessing the postoperative rotator cuff integrity.

The role of scapular dyskinesis on rotator cuff tears: a narrative review of the current knowledge

Scapular dyskinesis can be present in healthy individuals as in patients with shoulder pathology.Altered patterns of scapular kinematics can cause or exacerbate rotator cuff tear pathology. However, more research is needed.Regardless of the cause or the consequence of rotator cuff tear, scapular dyskinesis impairs shoulder function, worsens the symptoms, and compromises the success of clinical intervention.The available literature suggests physical therapy as the first treatment for degenerative cuff tears, and scapular dyskinesis should be addressed if present. Non-responsive cases or traumatic tears may require surgery.Postsurgical physical therapy protocols after rotator cuff repair must consider scapular dyskinesia to improve the outcomes. Cite this article: EFORT Open Rev 2021;6:932-940. DOI: 10.1302/2058-5241.6.210043.

Editorial Commentary: Causes of Failure After Arthroscopic Rotator Cuff Repair

Causes of failure after arthroscopic rotator cuff repair include patient factors, tear factors, and surgical factors. Failure may occur at the suture-tendon interface, the bone-tendon interface, or the bone-anchor interface. Low bone mineral density (BMD) in the greater tuberosity has been reported as a prognostic factor for recurrent tears following rotator cuff repair, and although most studies suggest the tendon-to-suture interface as the "weakest link," patients with low BMD may have lower suture anchor pull-out strength. A potential alternative cause of failure is the suture cutting through the greater tuberosity bone in patients with low BMD. Knotless suture bridge constructs or single-row constructs may be more susceptible to a suture cutting through the bone. The knotted suture bridge technique, wherein the medial mattress sutures are tied, may to some extent "shield" against complete cut-through. When bone quality appears poor, a common response is to change the type of anchor, size of anchor, or the location of the anchor. Other factors, such as bone preparation, suture type, suture tensioning, and anchor type (e.g., internal vs external locking), may all potentially affect suture cutting through weak bone.