Effects of 12 Weeks of Progressive Early Active Exercise Therapy After Surgical Rotator Cuff Repair: 12 Weeks and 1-Year Results From the CUT-N-MOVE Randomized Controlled Trial

Supraspinatus Muscle and Tendon Characteristics 1 Year After Surgical Rotator Cuff Repair Compared With Contralateral Shoulder: Data From the CUT-N-MOVE Trial

BACKGROUND

It is necessary to better understand the structural characteristics of the supraspinatus tendon and associated muscle after rotator cuff repair and in the event of retear.

PURPOSE

To study structural differences between the repaired and contralateral shoulders 1 year after rotator cuff repair in patients who received either progressive exercise therapy (PR) or usual care (UC) in a randomized controlled trial and to investigate whether there was interaction with tendon retear and limb dominance.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients with surgically repaired traumatic full-thickness rotator cuff tears involving the supraspinatus tendon were included. After surgery, they were randomized to PR or UC (active from postoperative week 2 or 6, respectively). The subacromial structures (acromiohumeral distance, supraspinatus tendon thickness, and vascularity) and the supraspinatus muscle thickness were examined with ultrasound at the 1-year follow-up.

RESULTS

A total of 79 patients were included. The characteristics of the 2 intervention groups (PR and UC) were comparable, including the Western Ontario Rotator Cuff Index score and number of retears. The authors found significantly thinner supraspinatus tendon (PR, P < .001; UC, P = .003) and reduced acromiohumeral distance (PR, P = .023; UC, P = .025) in the repaired versus the contralateral shoulders in both intervention groups. For neovascularization, there was no interlimb difference in either of the groups or between groups (PR vs UC). In patients with intact tendons, there was no interlimb difference in the muscle thickness, but in patients with tendon retear the muscle was significantly thinner on the repaired side (P = .024 and P < .001, respectively). When the dominant supraspinatus tendon was repaired (both groups), it was significantly thinner than the nondominant healthy tendon, but this difference was not seen when the nondominant supraspinatus tendon was repaired (P = .006).

CONCLUSION

One year after rotator cuff surgery, the repaired supraspinatus tendon was significantly thinner and the corresponding acromiohumeral distance was reduced. In patients with retear, the supraspinatus muscle was significantly thinner on the repaired side and early initiation of tendon-loading exercises did not affect these findings.

REGISTRATION

NCT02969135 (ClinicalTrials.gov identifier).

Biocomposite Anchors Have Greater Yield Load and Energy Compared With All-Suture Anchors in an In Vitro Ovine Infraspinatus Tendon Repair Model

Purpose

To compare tensile fatigue and strength measures of biocomposite and all-suture anchors in an ovine humerus-infraspinatus tendon model of rotator cuff repair.

Methods

Infraspinatus tendons on adult ovine humeri were sharply transected at the insertion. One of each pair was assigned randomly for fixation with 2 biocomposite or all-suture anchors. Constructs were tested with 200 cycles of 20 to 70 N tensile load, and gap formation was measured at the incised tendon end every 50 cycles. They were subsequently tested to failure. Outcome measures including fatigue stiffness, hysteresis, creep, and gap formation and tensile stiffness, and yield and failure displacement, load, and energy were compared between anchors.

Results

Biocomposite anchors had greater yield load (134.1 ± 6.5 N, P < .01) and energy (228.6 ± 85.7 J, P < .03) than all-suture anchors (104.7 ± 6.5 N, 169.8 ± 85.7 J). Fatigue properties were not different between anchors, but stiffness and gap formation increased and hysteresis and creep decreased significantly with increasing cycle number.

Conclusions

Although the yield displacement of both anchors was within the range of clinical failure, the tensile yield load and energy of ovine infraspinatus tendons secured to the humerus with 2 single-loaded all-suture anchors in a single row were significantly lower than those secured with 2 biocomposite anchors in the same configuration.

Clinical Relevance

It is important to understand the biomechanical properties for selecting anchors for rotator cuff repair. A direct comparison of fatigue testing followed by failure strength of infraspinatus tendon fixation with all-suture and biocomposite anchors could help guide anchor selection and postoperative mobility recommendations.

Biomimetic gradient scaffolds for the tissue engineering and regeneration of rotator cuff enthesis

Rotator cuff tear is one of the most common musculoskeletal disorders, which often results in recurrent shoulder pain and limited movement. Enthesis is a structurally complex and functionally critical interface connecting tendon and bone that plays an essential role in maintaining integrity of the shoulder joint. Despite the availability of advanced surgical procedures for rotator cuff repair, there is a high rate of failure following surgery due to suboptimal enthesis healing and regeneration. Novel strategies based on tissue engineering are gaining popularity in improving tendon-bone interface (TBI) regeneration. Through incorporating physical and biochemical cues into scaffold design which mimics the structure and composition of native enthesis is advantageous to guide specific differentiation of seeding cells and facilitate the formation of functional tissues. In this review, we summarize the current state of research in enthesis tissue engineering highlighting the development and application of biomimetic scaffolds that replicate the gradient TBI. We also discuss the latest techniques for fabricating potential translatable scaffolds such as 3D bioprinting and microfluidic device. While preclinical studies have demonstrated encouraging results of biomimetic gradient scaffolds, the translation of these findings into clinical applications necessitates a comprehensive understanding of their safety and long-term efficacy.

When is a Reverse Shoulder Arthroplasty Indicated for a Rotator Cuff Tear?

Rotator cuff tears are the most frequent shoulder injury in patients over 50 years old. Treatment of rotator cuff tears is individualized based on the age, demands, and symptoms of the patient. Nonoperative treatment may often be effective, especially in lower-demand or elderly patients. Surgical repair is indicated after failure of nonoperative treatment or in patients whose high-demand lifestyle requires full strength and function of the shoulder. In older patients, larger tears are less likely to heal and rotator cuff repair may not reliable. In cases of failed previous rotator cuff repair, there may not be enough viable tissue for complete repair. If there is underlying arthritis, a rotator cuff repair is unlikely to resolve all symptoms, and treatment to care for the arthritis and rotator cuff tear is indicated. Reverse shoulder arthroplasty provides the surgical answer for these scenarios and is now being used for numerous indications of shoulder pathology.

Comparison of Arthroscopic Single-row and Double-row Repair for Rotator Cuff Injuries With Different Tear Sizes: A Systematic Review and Meta-analysis

Background

There is no clinical gold standard for the indications for single-row (SR) versus double-row (DR) repair according to small, large, or massive rotator cuff tear size.

Purpose

To conduct a meta-analysis to compare the clinical outcomes and retear rates after arthroscopic SR and DR repair for rotator cuff injuries with different tear sizes.

Study Design

Systematic review; Level of evidence, 3.

Methods

On the basis of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria, the PubMed, Embase, Cochrane Library databases, Web of Science, China National Knowledge Infrastructure, and China BioMedical Literature database were searched for relevant studies published before November 1, 2021, using the following search terms: "Rotator Cuff Injuries," "Rotator Cuff Tears," "Arthroscopy," "Arthroscopic Surgery," "single-row," and "double-row"; a total of 489 articles were retrieved. Quality evaluation was conducted for all the studies that met the inclusion criteria. This study evaluated the Constant-Murley score, American Shoulder and Elbow Surgeons (ASES) score, University of California, Los Angeles (UCLA) score, and range of motion (ROM) as well as retear rate. A fixed-effects or random-effects model was adopted to calculate the results and assess risk.

Results

A total of 10 clinical studies were included, with 404 cases of DR and 387 cases of SR. Regarding overall results, DR had better forward elevation ROM (mean difference [MD] = -4.03° [95% CI, -6.00° to -2.06°]; P < .0001; I 2 = 46%) and a lower retear rate (MD = 2.39 [95% CI, 1.40 to 4.08]; P = .001; I 2 = 0%) compared with SR repair. With regard to small tears (<3 cm), there was no noticeable difference on any of the 3 outcome scores between SR and DR. For large rotator cuff tears (≥3 cm), DR repair showed significantly better ASES scores (MD = -3.09 [95% CI, -6.19 to 0.02]; P = .05; I 2 = 73%) and UCLA scores (MD = -1.47 [95% CI, -2.21 to -0.72]; P = .0001; I 2 = 31%) compared with SR repair.

Conclusion

Our meta-analysis revealed that DR had better UCLA scores, ASES scores, and ROM in forward elevation and lower retear rates. In rotator cuff tears <3 cm, there were no statistical differences in clinical outcome between SR and DR.

Statistical Fragility of Randomized Controlled Trials Evaluating Rehabilitation After Arthroscopic Rotator Cuff Repair

Background

Clinical decision-making often relies on evidence-based medicine, derived from objective data with conventional and rigorous statistical tests to evaluate significance. The literature surrounding rehabilitation after rotator cuff repair (RCR) is conflicting, with no defined standard of practice.

Purpose

To determine the fragility index (FI) and the fragility quotient (FQ) of randomized controlled trials (RCTs) evaluating rehabilitation protocols after RCR.

Study Design

Systematic review.

Methods

A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching the PubMed, Cochrane Library, and Embase databases for RCTs evaluating rehabilitation protocols after arthroscopic RCRs from 2000 to June 1, 2022. The FI was determined by manipulating the dichotomous outcome events from each article until a reversal of significance with 2 × 2 contingency tables was achieved. The FQ was determined by dividing the FI by the sample size.

Results

Fourteen RCTs with 48 dichotomous outcomes were ultimately included for analysis. The mean FI for the included dichotomous outcomes was 4 (interquartile range, 3-6), suggesting that the reversal of 4 events is required to change study significance. The mean FQ was 0.048. Of the RCTs that reported data regarding loss to follow-up, most studies (58.5%) indicated that >4 patients had been lost to follow-up.

Conclusion

The results of RCT studies of RCR rehabilitation protocols are moderately fragile, something clinicians should be aware of when implementing study results into practice. We recommend the inclusion of FI and FQ in addition to standard P values when reporting statistical results in future RCTs with dichotomous outcome variables on this topic.

Functional Considerations in Bilateral, Simultaneous Tendon Injuries of the Upper Extremity: A Narrative Review of Current Literature

» Bilateral, simultaneous same-tendon injuries of the upper extremity are rarely encountered, yet their unique complexity poses a substantial challenge for treating orthopaedic surgeons.» In general, extremities with more tendon retraction should be repaired acutely while contralateral injuries can be treated in a staged or simultaneous manner depending on injury morphology, location, and anticipated functional impairment.» Combinations of accelerated and conventional rehabilitation protocols can be used for individual extremities to minimize the length of functional impairment.

Machine learning model successfully identifies important clinical features for predicting outpatients with rotator cuff tears

PURPOSE

The aim of this study is to develop a machine learning model to identify important clinical features related to rotator cuff tears (RCTs) using explainable artificial intelligence (XAI) for efficiently predicting outpatients with RCTs.

METHODS

A retrospective review of a local clinical registry dataset was performed to include patients with shoulder pain and dysfunction who underwent questionnaires and physical examinations between 2019 and 2022. RCTs were diagnosed by shoulder arthroscopy. Six machine-learning algorithms (Stacking, Gradient Boosting Machine, Bagging, Random Forest, Extreme Gradient Boost (XGBoost), and Adaptive Boosting) were developed for the prediction. The performance of the models was assessed by the area under the receiver operating characteristic curve (AUC), Brier scores, and Decision curve. The interpretability of the predicted outcomes was evaluated using Shapley additive explanation (SHAP) values.

RESULTS

A total of 1684 patients who completed questionnaires and clinical tests were included, and 417 patients with RCTs underwent shoulder arthroscopy. In six machining learning algorithms for predicting RCTs, the accuracy, AUC values, and Brier scores were in the range of 0.81-0.86, 0.75-0.92, and 0.15-0.19, respectively. The XGBoost model showed superior performance with accuracy, AUC, and Brier scores of 0.85(95% confidence interval, 0.82-0.87), 0.92 (95% confidence interval,0.90-0.94), and 0.15 (95% confidence interval,0.14-0.16), respectively. The Shapley plot showed the impact of the clinical features on predicting RCTs. The most important variables were Jobe test, Bear hug test, and age for prediction, with mean SHAP values of 1.458, 0.950, and 0.790, respectively.

CONCLUSION

The machine learning model successfully identified important clinical variables for predicting patients with RCTs. In addition, the best algorithm was also integrated into a digital application to provide predictions in outpatient settings. This tool may assist patients in reducing their pain experience and providing prompt treatments.

LEVEL OF EVIDENCE

Level III.

No difference in clinical outcome after rotator cuff repair performed within or later than 3 months after trauma: a retrospective cohort study

PURPOSE

Rotator cuff (RC) tear is one of the most common injuries of the shoulder. Patients with RC tears often report a trauma initiating shoulder pain and impaired function. The aim of this retrospective analysis of a prospectively registered cohort was to elucidate whether the time interval between the trauma and RC repair, using a cut off of 3 months, affects the functional outcome after 2 years.

METHODS

In a single orthopedic unit, 819 consecutive patients were treated with rotator cuff repair during the period from 2010 to 2014 and 733 of the patients completed the Western Ontario Rotator Cuff (WORC) index preoperatively and at 2-year follow-up. The Constant-Murley (CM) score was completed by trained physiotherapists after a clinical examination both preoperatively and at 2-year follow-up. Preoperative magnetic resonance imaging (MRI) was performed in all patients and postoperatively in 65% of the included patients. Re-tears and partial repairs were excluded, as were patients with pseudoparalysis who were given high priority and underwent surgery during the first 3 weeks after trauma.

RESULTS

Of the 733 treated patients, 437 (60%) reported having had a shoulder trauma in their medical history initiating their shoulder symptoms, and of these, 358 met the inclusion criteria. 296 patients with non-traumatic tears, 9 repairs done within 3 weeks after trauma, 25 partial repairs, 33 re-tears and 12 others were excluded. At 2-year follow-up there was no significant difference in WORC index (n.s.) or CM score (n.s.) between patients who had their RC repaired within or more than 3 months after trauma. In patients where RC repair was performed within 3 months, the WORC index improved by 42.9%, and in the group of patients operated later than 3 months, the increase was 38.7%. This difference between the groups was neither statistically significant (n.s.) nor clinically relevant. On postoperative MRI, 80% of the repairs were healed in both groups.

CONCLUSION

In this retrospective cohort study, no differences in clinical outcome were found when RC repair was performed between 3 weeks and 3 months or later than 3 months after injury in patients describing their onset of symptoms as traumatic.

LEVEL OF EVIDENCE

III.

Enhanced healing outcomes in MRL/MpJ mouse tissues conserved in insertion site following surgical repair

BACKGROUND

Surgical repair of supraspinatus tendons (SSTs) has a high failure rate at the insertion site. A significant hurdle to therapeutic development is that effective intrinsic healing mechanisms are unknown. The MRL/MpJ (MRL) mouse exhibits tissue-specific enhanced healing; however, these tissues exhibit disparate properties from the complex SST. The extent of SST healing in the complex environment of the rotator cuff is unknown. We hypothesized that MRL mice would exhibit enhanced restoration of the structurally complex insertion site, resulting in functional improvements.

METHODS

B6 and MRL mice underwent SST detachment and immediate surgical repair. Mice were analyzed for gait assessment after either 2 or 6 weeks and were then killed humanely for immunohistologic analysis.

RESULTS

MRL SSTs demonstrated enhanced recovery of zonal architecture and bone structure compared with B6 SSTs. MRL SSTs exhibited decreased levels of type III collagen at 2 weeks and increased levels of type I procollagen at 6 weeks compared with B6 SSTs. MRL mice experienced initial gait deficits at 2 weeks that had recovered by 6 weeks.

DISCUSSION

The temporal balance of collagen in MRL mice suggests recovery toward naive composition. Initial gait deficits in MRL mice may provide a protective loading environment that is ultimately beneficial. The mechanisms of enhanced healing observed previously in MRL mice may be conserved in the complex SST, providing a platform to interrogate specific aspects of improved healing.

Self-Reported Outcomes in Early Postoperative Management After Shoulder Surgery Using a Home-Based Strengthening and Stabilization System With Telehealth

BACKGROUND

Multiple rehabilitation protocols after shoulder surgery have been proposed. The coronavirus pandemic adds an extra layer of complexity to postoperative rehabilitation after shoulder surgery.

HYPOTHESIS

The combined use of a home-based rehabilitation system, the Shoulder Strengthening and Stabilization System (SSS), and telehealth visits will lead to acceptable patient self-reported outcomes and satisfaction after shoulder surgery.

STUDY DESIGN

Prospective observational cohort.

LEVEL OF EVIDENCE

Level 4.

METHODS

A total of 132 patients were prescribed SSS after shoulder surgery. A virtual clinical specialist monitored patients through telehealth visits as prescribed by the treating physician. Data were collected prospectively during each telehealth visit. Patients completed an exit survey during their last telehealth visit.

RESULTS

The use of SSS with telehealth revealed a positive impact on postoperative shoulder rehabilitation (96%), pain (71%), and stiffness (92%) as reported by patients. Both pain scores and pain medication use decreased from the 1st to 8th postoperative telehealth session (P < 0.01). Nearly all (93%) patients recommended SSS after shoulder surgery upon completing the SSS protocol.

CONCLUSION

Postoperative management of shoulder surgery with SSS combined with telehealth results in a reduction in patient pain levels in the early postoperative period. Patients reported high levels of improvement with SSS in shoulder rehabilitation, pain, and stiffness. The overwhelming majority (93%) of patients recommended SSS for postoperative shoulder rehabilitation and SSS yielded high patient satisfaction scores. Elucidating the impact of SSS on clinical outcomes and function in comparison with traditional rehabilitation protocols is warranted.

CLINICAL RELEVANCE

SSS in combination with telehealth was tolerated well by patients and may represent an alternative or adjunct to traditional rehabilitation protocols.

Effect of Arthroscopic Acromioplasty Combined with Rotator Cuff Repair in the Treatment of Aged Patients with Full-Thickness Rotator Cuff Tear and Rotator Cuff Injury

Full-thickness rotator cuff tear and rotator cuff injury are frequently occurring diseases and widely exist in the social population. Surgical repair is the most effective treatment for rotator cuff tears and injuries. With the continuous development of arthroscopy, more and more surgeons choose arthroscopic acromioplasty plus rotator cuff repair for the treatment of rotator cuff injury. However, previously published systematic reviews or meta-analyses still cast doubt on the efficacy of such concomitant procedures for postoperative patient function and pain recovery. In this study, we analyzed the effects of parameters such as shoulder function and acromion morphology on aged patients with full-thickness rotator cuff tear combined with rotator cuff injury treated with arthroscopic acromion plasty and rotator cuff repair. The results showed that arthroscopic acromion plasty and rotator cuff repair helped to promote the joint function recovery of the aged patients with full-thickness rotator cuff tear combined with rotator cuff injury and alleviate the pain of the patients. Compared with simple rotator cuff repair, this technique can increase the postoperative AT and reduce the ACEA and to some extent reduce the risk of postoperative rotator cuff reinjury, which is worthy of promotion.

Analysis of Functional Recovery and Subjective Well-Being after Arthroscopic Rotator Cuff Repair

Background: Rotator cuff tears are common causes of functional shoulder instability and often lead to arthroscopic rotator cuff repair. A well-programmed rehabilitation leads to successful tendon healing, positive functional recovery and subjective well-being (SWB). Objective: To evaluate the changes in shoulder functioning and SWB pre-, post-outpatient rehabilitation and after one-month follow-up. Materials and Methods: A total of 44 patients were assessed three times: at the beginning (six weeks’ post-surgery), at the end of outpatient rehabilitation (2–3 weeks) and one month after rehabilitation. The outcome measures were the Disabilities of the Arm, Shoulder and Hand score (DASH), active range of motion (ROM), manual muscle testing (MMT), hand dynamometry (HD) and pain level by a Visual Analogue Scale (VAS). SWB was assessed by Rosenberg self-esteem scale (RSES), Positive and Negative Affect Schedule (PANAS) and the Lithuanian Psychological Well-Being Scale (LPWBS). Results are presented as a difference between periods. Results: Affected shoulder motor function (MMT, HD and ROM) significantly improved in three periods (p < 0.05); however, major recovery was observed in the follow-up period. VAS scores meaningfully decreased over all stages and negatively correlated with motor function recovery (p < 0.05). DASH rates exhibited significant retrieval in all phases, especially in follow-up. SWB results demonstrated the larger effects of self-evaluation in follow-up, improved daily functions and psychological wellness, then negative emotions significantly decreased (p < 0.05). Conclusions: The experienced pain and psychosocial factors significantly influence functional recovery of the shoulder during rehabilitation. The improvement in motor function, ability and pain relief during rehabilitation increases level of SWB, psychological wellness and positive emotional affect in long-term context.