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

Rotator cuff repairs with all-suture tape anchors: no difference in outcomes between with or without all-suture tape anchors

PURPOSE

This study aimed at comparing the outcomes of medium- to large-sized rotator cuff repairs performed using the suture bridge technique either with or without tape-like sutures, and single row techniques with conventional sutures.

METHODS

A total of 135 eligible patients with medium to large rotator cuff tears were identified and analyzed retrospectively, from 2017 to 2019. Only repairs using all-suture anchors were included in the study. Patients were divided into the following three groups: single-row (SR) repair (N = 50), standard double-row suture bridge (DRSB) repair with conventional sutures (N = 35), and DRSB with tape-like sutures (N = 50). The average postoperative follow-up period was 26.3 ± 9.8 months (range, 18-37).

RESULTS

DRSB with tapes had the highest re-tear rate of 16% (8/50), but there was no significant difference with the re-tear rates observed in SR (8%, 4/50) and DRSB with conventional sutures (11.4%, 4/35) (n.s.). DRSB with tapes demonstrated higher rate of type 2 re-tears (10%) compared to type 1 re-tears (6%), but the other two groups showed either similar or higher rates of type 1 re-tears compared to that of type 2. Post-operative functional scores of the three groups improved significantly (all p < 0.05), but the differences between the groups were not statistically significant.

CONCLUSIONS

No clinical difference in functional outcomes and re-tear rates were observed in DRSB with tapes when compared with SR and DRSB using the conventional sutures. Tape-like DRSB suture which was expected to be superior by its biomechanical advantage was clinically non-superior to conventional DRSB suture. There were no significant differences in VAS scores and UCLA scores.

LEVEL OF EVIDENCE

Level III.

The Effect of Pulling Angle on Rotator Cuff Mechanical Properties in a Canine In Vitro Model

The objective of this study was to examine the effect of pulling angle on time-zero mechanical properties of intact infraspinatus tendon or infraspinatus tendon repaired with the modified Mason-Allen technique in a canine model in vitro. Thirty-six canine shoulder samples were used. Twenty intact samples were randomly allocated into functional pull (135°) and anatomic pull (70°) groups (n = 10 per group). The remaining sixteen infraspinatus tendons were transected from the insertion and repaired using the modified Mason-Allen technique before being randomly allocated into functional pull or anatomic pull groups (n = 8 per group). Load to failure testing was performed on all specimens. The ultimate failure load and ultimate stress of the functional pulled intact tendons were significantly lower compared with anatomic pulled tendons (1310.2 ± 167.6 N vs. 1687.4 ± 228.2 N, p = 0.0005: 55.6 ± 8.4 MPa vs. 67.1 ± 13.3 MPa, p = 0.0334). For the tendons repaired with the modified Mason-Allen technique, no significant differences were observed in ultimate failure load, ultimate stress or stiffness between functional pull and anatomic pull groups. The variance of pulling angle had a significant influence on the biomechanical properties of the rotator cuff tendon in a canine shoulder model in vitro. Load to failure of the intact infraspinatus tendon was lower at the functional pulling position compared to the anatomic pulling position. This result indicates that uneven load distribution across tendon fibers under functional pull may predispose the tendon to tear. However, this mechanical character is not presented after rotator cuff repair using the modified Mason-Allen technique.

Better Short-Term Outcomes After Rotator Cuff Repair in Studies With Poorer Mean Shoulder Scores and Predominantly Small to Medium-Sized Tears at Baseline: A Systematic Review and Meta-analysis

PURPOSE

To perform a meta-analysis to explore factors associated with clinical and structural short-term outcomes in randomized and nonrandomized prospective studies of rotator cuff repair.

METHODS

Medline, clinicaltrials.gov, and Mendeley were searched for literature published from January 2000 to December 2020 to identify randomized controlled trials (RCT) and nonrandomized prospective cohort studies (PCS) describing the outcome of surgical repair of full-thickness rotator cuff tears. Study quality was assessed by two independent reviewers. We calculated standardized mean difference (SMD) from baseline to follow-up in each trial arm, preferably at 12 months follow-up. Between-study heterogeneity of outcomes, small-study effects and rates of retear were assessed. Meta-regression was performed to estimate associations between prespecified variables and clinical and structural outcomes.

RESULTS

Outcomes in 64 RCT and 19 PCS trial arms were analyzed. Median age was 59 years. There was substantial between-study heterogeneity in clinical outcomes (SMD range: .42 to 6.44; I² = 93% in RCT, 88% in PCS) and summary estimates were not calculated. On the basis of multivariate analysis, better clinical outcome was associated with lower (worse) mean outcome value at baseline, smaller tear size, and lower proportion of large-massive tears (R² = 56 and 44%, respectively). Overall retear rate at median 13-month follow-up was 19.9% (interquartile range: 10-30). Higher mean age together with larger tear size and higher proportion of large-massive tears were associated with increased retear rates (R² = 33% and 58%, respectively). Clinical outcome was not significantly related to rate of retear.

CONCLUSIONS

Studies with lower mean outcome values at baseline and predominantly small- to medium-sized tears reported better clinical outcomes. Studies with higher mean age and a predominance of large-massive tears had significantly increased retear rates, but retear rates were not associated with clinical outcome.

LEVEL OF EVIDENCE

Level II, meta-analysis of level I and II studies.

Safety and Efficacy of Autologous Dermal Fibroblast Injection to Enhance Healing After Full-Thickness Rotator Cuff Repair: First-in-Human Pilot Study

Background:

There is growing interest in various biological supplements to improve tendon healing in patients after arthroscopic rotator cuff repair. The ideal biological supplement to strengthen rotator cuff remains unknown.

Purpose:

To assess the safety and efficacy of autologous cultured dermal fibroblast (ADF) injection on tendon-to-bone healing in patients after arthroscopic rotator cuff repair.

Study Design:

Case series; Level of evidence, 4.

Methods:

Included were 6 patients who underwent arthroscopic rotator cuff repair between June 2018 and March 2020; all patients had a full-thickness rotator cuff tear (>2 cm) involving the supraspinatus and infraspinatus tendons. The patients were injected with ADF between the repaired tendon and footprint during arthroscopic rotator cuff repair using the suture bridge technique. The safety of ADFs and the procedure was evaluated at 5 weeks postoperatively, and the anatomical healing of the repaired tendon was accessed at 6 months postoperatively using magnetic resonance imaging and at 12 months using ultrasonography. Outcomes including shoulder range of motion (ROM), visual analog scale (VAS) for pain, and functional scores were measured at 6 and 12 months postoperatively.

Results:

Adverse reactions to ADF injection were not observed at 6 months after surgery. VAS and functional scores at 6 and 12 months postoperatively were significantly improved compared with preoperative scores (all P < .05). However, there was no significant difference on any ROM variable between preoperative and postoperative measurements at 6 and 12 months (all P > .05). No healing failure was found at 6 and 12 months postoperatively.

Conclusion:

There was no adverse reaction to ADF injection, and all patients had successful healing after rotator cuff repair. A simple and easily accessible ADF injection may be a novel treatment option for increasing the healing capacity of torn rotator cuff tendons. Further clinical research is needed to verify the study results.

Current Biological Strategies to Enhance Surgical Treatment for Rotator Cuff Repair

Rotator cuff tear is one of the most common shoulder problems encountered by orthopedic surgeons. Due to the slow healing process and high retear rate, rotator cuff tear has distressed millions of people all around the world every year, especially for the elderly and active athletes. This disease significantly impairs patients' motor ability and reduces their quality of life. Besides conservative treatment, open and arthroscopic surgery contributes a lot to accelerate the healing process of rotator cuff tear. Currently, there are many emerging novel treatment methods to promote rotator cuff repair. A variety of biological stimulus has been utilized in clinical practice. Among them, platelet-rich plasma, growth factors, stem cells, and exosomes are the most popular biologics in laboratory research and clinical trials. This review will focus on the biologics of bioaugmentation methods for rotator cuff repair and tendon healing, including platelet-rich plasma, growth factors, exosomes and stem cells, etc. Relevant studies are summarized in this review and future research perspectives are introduced.