Minimum 10-Year Outcomes of Primary Arthroscopic Transosseous-Equivalent Double-Row Rotator Cuff Repair

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.

Arthroscopic Incomplete Rotator Cuff Repair With Patch Augmentation Using Acellular Dermal Matrix Allograft

Arthroscopic rotator cuff repair has been shown promising clinical outcomes. However, large to massive rotator cuff tears are difficult to completely repair with appropriate tension because of their size or poor tissue quality. An incomplete repair using the "hybrid technique" is one of way to solve this problem by maximizing the contact area between the tendon and the footprint of greater tuberosity. Additionally, the acellular dermal matrix patch augmentation has emerged as an adjuvant technique to enhance the biomechanical properties to promote healing of the repaired construct. This Technical Note describes arthroscopic incomplete rotator cuff repair using the "hybrid technique" with acellular dermal matrix patch augmentation.

Impact of surrogate outcomes in randomized controlled trials for shoulder rotator cuff tears

PURPOSE

Surrogate outcomes are clinical endpoints that are used as substitutes for direct measures of how a patient feels, functions, or survives. The present study aims to analyze the impact of surrogate outcomes on the results of randomized controlled trials on shoulder rotator cuff tears disorders.

METHODS

Randomized controlled trials (RCTs) related to rotator cuff tear conditions published up until 2021 were retrieved from the PubMed and ACCESSSS databases. The primary outcome of the article was considered a surrogate outcome when the authors used radiological, physiologic, or functional variables. The result of the article was considered positive when results supported the intervention based on the trial's primary outcome. We recorded the sample size, the mean follow-up, and the type of funding. Statistical significance was set at p < 0.05.

RESULTS

A total of 112 papers were included in the analysis. The mean sample size was 87.6 patients; mean follow-up period was 25.97 months. Thirty-six out of 112 RCTs used a surrogate outcome as a primary endpoint. More than half of papers using surrogate outcomes reported a positive finding (20 out of 36), while 10 out of 71 RCTs using patient-centered outcomes favored the intervention (14.08%, p < 0.001) [RR = 3.94 (95% CI 2.07-7.51)]. The mean sample size was smaller in trials using surrogate endpoints (75.11 vs 92.35 patients, respectively, p = 0.049), while the follow-up was shorter (14.12 m vs. 31.9 m, p < 0.001). Approximately 25% of the papers that reported surrogate endpoints (22.58%) were industry-funded projects.

CONCLUSIONS

The substitution of surrogate endpoints for patient-important outcomes in shoulder rotator cuff trials quadruplicates the chances of obtaining a favorable result that favors the analyzed intervention.

Outcomes of Double-Row Rotator Cuff Repair Using a Novel All-Suture Soft Anchor Medial Row

Background

Few studies have examined the short-term clinical outcomes of rotator cuff repair (RCR) with all-suture anchors for medial row anchor fixation.

Purpose

To evaluate clinical outcomes of double-row suture bridge RCR using a novel all-suture medial row anchor.

Study Design

Case series; Level of evidence, 4.

Methods

We enrolled 179 patients before double-row suture bridge RCR (mean age at surgery, 60.0 years; 63% male patients) at a single institution. All patients underwent RCR with all-suture anchor fixation for the medial row and solid anchor fixation for the lateral row. Preoperative (baseline) and follow-up (minimum follow-up time of 2 years; mean, 2.5 years) clinical outcomes were compared using the American Shoulder and Elbow Surgeons (ASES) score and a 10-point numeric pain rating scale (NPRS). We calculated the proportions of patients meeting previously published Patient Acceptable Symptom State (PASS) thresholds for the ASES (≥78.0) and NPRS (≤1.7). We further compared baseline and follow-up outcome scores and the proportions of patients meeting PASS thresholds using paired t tests and McNemar tests, respectively, and calculated effect size to quantify the magnitude of change from baseline to follow-up.

Results

Values significantly improved from baseline to follow-up for ASES (from 45.3 ± 19.8 to 87.3 ± 17.1) and NPRS (from 5.2 ± 2.5 to 1.4 ± 2.1). The proportion of patients meeting PASS thresholds also significantly improved for the ASES (from 6% to 77%) and the NPRS (from 7% to 72%). The magnitude of baseline to follow-up change for all measures was large (all effect sizes ≥1.5).

Conclusion

Our study demonstrated excellent short-term clinical outcomes and substantial improvements for patients undergoing double-row suture bridge RCR with all-suture anchors for medial row fixation.

Comparison of clinical outcomes of arthroscopic rotator cuff repair utilizing suture-bridge procedures with or without medial knots: a meta-analysis

PURPOSE

This investigation aimed to compare the medical efficacy of the knotted and knotless suture-bridge procedures in rotator cuff repair.

METHODS

The Pubmed, Embase, and Cochrane Library datasets were searched for all available publications comparing the medical results of arthroscopic rotator cuff repairs utilizing knotted or knotless suture-bridge procedures. Two researchers utilized Newcastle-Ottawa Scale and Cochrane risk-of-bias tool to evaluate the included studies. Employing Revman 5.3 software, meta-analysis was conducted following the PRISMA reporting guideline.

RESULTS

Eleven investigations with 1083 patients were considered suitable for the final meta-analysis. 522 individuals were assigned to the knotted group, whereas 561 were assigned to the knotless group. No statistical difference was found between the knotted and knotless groups, regarding VAS score (WMD, 0.17; 95% CI, - 0.10 to 0.44; P = 0.21); Constant score (WMD, -1.50; 95% CI, - 3.52 to 0.52; P = 0.14); American Shoulder and Elbow Surgeons Shoulder (WMD, -2.02; 95% CI, - 4.53 to 0.49; P = 0.11); University of California Los Angeles score (WMD, -0.13; 95% CI, - 0.89 to 0.63; P = 0.73); ROM of flexion (WMD, 1.57; 95% CI, - 2.11 to 5.60; P = 0.37), abduction (WMD, 1.08; 95% CI, - 4.53 to 6.70; P = 0.71) and external rotation (WMD, 1.90; 95% CI, - 1.36 to 5.16; P = 0.25); re-tear rate (OR, 0.74; 95% CI, 0.50 to 1.08; P = 0.12), and medical complications (OR, 0.90; 95% CI, 0.37 to 2.20; P = 0.82).

CONCLUSION

For arthroscopic rotator cuff repairs, there were no statistical differences in medical results among knotted and knotless suture-bridge procedures. Overall, both techniques showed excellent clinical outcomes and could be safely utilized to treat rotator cuff injuries.

Outcomes and Survivorship 5 Years After Arthroscopic Rotator Cuff Repair in Active Patients 70 Years and Older

Background

Rotator cuff tears are common in the elderly population and are associated with increased pain, decreased function, and decreased enjoyment of recreational activities.

Purpose

To evaluate clinical outcomes at a minimum of 5 years after arthroscopic repair of full-thickness rotator cuff tears in recreational athletes aged ≥70 years at the time of surgery.

Study Design

Case series; Level of evidence, 4.

Methods

Included were recreational athletes aged ≥70 years who underwent arthroscopic rotator cuff repair (RCR) from December 2005 to January 2016. Patient and surgery characteristics were collected prospectively and retrospectively reviewed. Patient-reported outcome (PRO) scores utilized were the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), the shortened version of Disabilities of the Arm, Shoulder and Hand score (QuickDASH), 12-Item Short Form Health survey (SF-12) questionnaire (Physical Component Summary and Mental Component Summary), and patient satisfaction. Kaplan Meier survivorship analysis was performed, with failure defined as revision RCR or retear on magnetic resonance imaging (MRI).

Results

Overall, 71 shoulders (n = 67 patients [44 men, 23 women]; mean age, 73.4 years [range, 70.1-81.3 years]) were included in this study. Follow-up data was obtained for 65 of the 69 available shoulders (94%) at a mean of 7.8 years (range, 5-15.3 years). Mean age at follow-up was 81.2 years (range, 75.7-91.0). One RCR was revised after a traumatic accident, and another had a symptomatic, MRI-confirmed retear. One patient had lysis of adhesions for stiffness 3 months postoperatively. All PRO scores improved from pre- to postoperatively-ASES, from 55.3 to 93.6; SANE, from 62 to 89.6; QuickDASH, from 32.9 to 7.3; and SF-12 Physical Component Summary, from 43.3 to 53 (P < .001 for all)-and the median satisfaction score was 10 out of 10. Postoperatively, 63% of the patients returned to their original fitness program and 33% of patients modified their recreational activity. Survivorship analysis showed a 98% survival rate at 5 years and a 92% rate at 10 years.

Conclusion

Sustained improvement in function, reduced pain, and return to activities was seen after arthroscopic RCR in active patients ≥70 years old. Despite one-third of patients modifying their recreational activity, the cohort reported high levels of satisfaction and general health.

Arthroscopic Rotator Cuff Repair Results in Improved Clinical Outcomes and Low Revision Rates at 10-Year Follow-Up: A Systematic Review

PURPOSE

To study the literature to evaluate the functional outcomes, radiologic outcomes, and revision rates following arthroscopic rotator cuff repair (ARCR) at a minimum of 10-years follow-up.

METHODS

Two independent reviewers performed a literature search of PubMed, Embase, and Scopus using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Only studies reporting on outcomes of ARCR with a minimum 10-year follow-up were considered for inclusion. Patient demographics, satisfaction, and clinical, radiologic, and surgical outcomes were evaluated.

RESULTS

Our search found 9 studies including 455 shoulders in 448 patients (51.6% male patients), with age at time of surgery ranging from 45 to 90 years met our inclusion criteria. Overall follow-up ranged from 10 to 18 years. At final follow-up, the ranges of American Shoulder & Elbow Surgeons, age- and sex-adjusted Constant-Morley, and University of California Los Angeles scores were reported in 5, 6, and 3 studies, respectively, as 79.4 to 93.2, 73.2 to 94, and 26.5 to 33, respectively. Of the included studies, satisfaction rates varied in 6 studies from 85.7% to 100% in the long-term. Additionally, the overall radiologic retear rate ranged from 9.5% to 63.2%. The overall surgical revision rates ranged in 6 studies from 3.8% to 15.4%, with from 0% to 6.7% requiring revision ARCR and from 1.0% to 3.6% requiring revision subacromial decompression in 6 and 2 studies, respectively, at minimum 10-years' follow-up.

CONCLUSIONS

In this study, we found that ARCR results in high rates of patient satisfaction, satisfactory clinical outcomes with respect to patient-reported functional outcomes and range of motion, and low revision rates at minimum 10-years' follow-up. However, an overall 30% retear rate was observed in asymptomatic patients.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

Can the Single Assessment Numeric Evaluation be used as a stand-alone subjective outcome instrument in patients undergoing rotator cuff repair?

BACKGROUND/HYPOTHESIS

There is no consensus to which patient-determined shoulder outcome scores should be considered when analyzing patient outcomes. Use of multiple patient-determined outcomes may be redundant and cause increased responder burden. The Single Assessment Numeric (SANE) has not been widely accepted as a stand-alone shoulder-specific outcome measure. The hypothesis was that SANE will correlate with and be comparable in responsiveness to other subjective outcome measures that have been used in a stand-alone fashion in patients undergoing rotator cuff repair (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], Western Ontario Rotator Cuff Index [WORC], and the Simple Shoulder Test [SST]). In addition, the SANE will be more relevant to each patient compared to the ASES, further supporting its use as a stand-alone shoulder-specific outcomes measure.

METHODS

A retrospective review of a database of patients undergoing rotator cuff repair was reviewed where the SANE was recorded with the ASES, WORC, and/or SST. Correlations were determined using the Pearson coefficient. Subgroup analysis was performed to determine if correlations differed in (1) preoperative and (2) postoperative outcome determinations. Responsiveness was determined by calculating the standardized response mean (SRM) and the effect size (ES) of all scores. Relevance and precision of the SANE and ASES were examined using 150 consecutive patients to determine the number of questions in each score that were not answered.

RESULTS

Correlation was excellent for the SANE and the ASES (n = 1838, r = 0.81, P < .0001), the WORC (n = 1793, r = 0.82, P < .0001), and the SST (n = 1836, r = 0.76, P < .0001). Correlation of preoperative scores was moderate and postoperative scores were excellent when comparing the SANE with all 3 scores. All scores were highly responsive, with the SRM of the SANE = 2.1, ASES = 2.2, WORC = 2.4, and the SST = 1.8. The ES of the SANE = 2.4, ASES = 2.7, WORC = 3.0, and the SST = 2.1. One hundred percent of the SANE scores were answered completely compared with 57% (P < .0001) of the ASES, with significant variability found in the answers to the "work" and "score" questions.

CONCLUSION

In patients undergoing rotator cuff repair, the SANE highly correlated and has equivalent responsiveness with the WORC, ASES, and SST, which have been used as stand-alone shoulder-specific outcomes measures. The SANE may provide the same information as the WORC, ASES, and SST regarding outcome with significant reduction in responder burden. This study supports that the SANE can be used as a subjective, stand-alone instrument for patients undergoing rotator cuff repair.

Decellularized Bovine Pericardial Patch Loaded With Mesenchymal Stromal Cells Enhance the Mechanical Strength and Biological Healing of Large-to-Massive Rotator Cuff Tear in a Rat Model

PURPOSE

The purpose of this study was to determine whether the addition of decellularized bovine pericardial patch loaded with mesenchymal stromal cells enhanced bone-to-tendon healing and improved the biomechanical strength of large-to-massive rotator cuff tears in a small animal model.

METHODS

Adipose-derived mesenchymal stromal cells (MSCs) from rat inguinal fat were isolated, cultured, and loaded onto decellularized bovine pericardium patches. To simulate large-to-massive tears, rats were managed with free cage activity for 6 weeks after tear creation. A total of 18 rats were randomly allocated to repair-only (control), repair with pericardial patch augmentation (patch), or repair with MSC loaded pericardial patch augmentation (patch-MSC). Each group had 6 rats (one shoulder of each rat was used for histological evaluation and another for biomechanical evaluation). MSCs seeded on the pericardial patches were traced on four shoulders from 2 other rats at 4 weeks after surgery. Histological evaluation for bone-to-tendon healing and biomechanical testing was carried out at 8 weeks after repair.

RESULTS

MSCs tagged with a green fluorescent protein were observed in the repair site 4 weeks after the repair. One shoulder each in the control and patch groups showed complete discontinuity between the bone and tendon. One shoulder in the control group showed attenuation with only a tenuous connection. Fibrocartilage and tidemark formation at the bone-to-tendon interface (P = .002) and collagen fiber density (P = .040) and orientation (P = .003) were better in the patch-MSC group than in the control or patch group. Load-to-failure in the patch-MSC and patch groups was higher than that in the control group (P = .001 and .009, respectively).

CONCLUSION

Decellularized bovine pericardial patches loaded with adipose-derived and cultured mesenchymal stromal cells enhanced healing in terms of both histology and mechanical strength at 8 weeks following rotator cuff repair in a rat model.

CLINICAL RELEVANCE

Large-to-massive rotator tears need a strategy to prevent retear and enhance healing. The addition of decellularized bovine pericardial patch loaded with MSCs can enhance bone-to-tendon healing and improve biomechanical healing of large-to-massive rotator cuff tears following repair.

Evaluation of Radiographic Changes 5 Years After Arthroscopic Rotator Cuff Repair

Background:

Radiographic changes in the glenohumeral joint often occur after rotator cuff repair; however, the details of the progression and underlying causes remain unknown.

Purpose:

To retrospectively evaluate the timing and frequency of radiographic changes after arthroscopic rotator cuff repair and to clarify the predictive factors that affect the onset of such changes using multivariate analysis.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

We retrospectively reviewed 100 patients with 5 years of follow-up after arthroscopic rotator cuff repair and evaluated the postoperative shift in radiographic findings on plain radiographs every year during follow-up. Factors related to osteoarthritis, acromial spur re-formation, and greater tuberosity resorption at 5 years after surgery were evaluated using logistic regression analyses. Explanatory variables included preoperative factors, intraoperative factors, and postoperative retear. Baseline variables significant in the univariate analyses were included in the multivariate models.

Results:

Of the 100 patients, 12 developed osteoarthritis, 26 developed acromial spur formation, and 16 developed greater tuberosity resorption at 5 years after surgery. The incidence and grade of osteoarthritis and acromial spur gradually increased over time postoperatively. On the other hand, greater tuberosity resorption developed within 2 years after surgery but did not progress later. Multivariate analysis showed that a larger anteroposterior tear size (odds ratio [OR], 1.09; 95% CI, 1.01-1.17; P = .037) was a risk factor for postoperative osteoarthritis. Early retear (OR, 10.26; 95% CI, 1.03-102.40; P = .047) was a risk factor for acromial spur re-formation. Roughness of the greater tuberosity (OR, 9.07; 95% CI, 1.13-72.82; P = .038) and larger number of suture anchors (OR, 3.34; 95% CI, 1.66-6.74; P = .001) were risk factors for greater tuberosity resorption.

Conclusion:

Our study showed that radiographic changes occurred in 40% of patients within 5 years after arthroscopic rotator cuff repair. While the osteoarthritic changes and acromial spur re-formation gradually progressed postoperatively, the greater tuberosity resorption stopped within 2 years after surgery. Tear size, morphology of the greater tuberosity, and the number of suture anchors can affect radiographic changes. Furthermore, this study suggested that acromial spur re-formation may be an indicator of early retears.

Injection of adipose stem cells in the treatment of rotator cuff disease - a narrative review of current evidence

The purpose of this study is to summarize evidence for the use of adipose stem cell (ASC) injections in the treatment of rotator cuff tears (RCT) and identify future areas of study. A thorough literature search was performed to identify studies investigating the use of ASC injections in the treatment of RCTs. Among animal trials, it is unclear whether ASCs are of benefit for rotator cuff repair. In clinical trials, ASC injection may reduce retear rate with otherwise equivocal clinical outcomes. Although ASC injection may be safe, the literature does not provide a clear consensus as to the efficacy of ASC injections, nor does it delineate which patients would benefit most from this treatment.

The Evolution of Arthroscopic Rotator Cuff Repair

Over the past 30 years, arthroscopic rotator cuff repair (ARCR) has evolved to become the gold standard in treating rotator cuff pathology. As procedural concepts of ARCR continue to improve, it is also continually compared with the open rotator cuff repair as the historical standard of care. This review highlights the evolution of ARCR, including a historical perspective; the anatomic, clinical, and surgical implications of the development of an arthroscopic approach; how arthroscopy improved some of the problems of the open approach; adaptations in techniques and technologies associated with ARCR; future perspectives in orthobiologics as they pertain to ARCR; and lastly, the clinical improvements, or lack of improvements, with all of these adaptations.