Outcomes After Combined Remnant Preservation and Bone Marrow Stimulation for Acute Rotator Cuff Tears

Bone Marrow Stimulation for Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Bone marrow stimulation (BMS) has been proposed to augment healing at the time of arthroscopic rotator cuff repair (ARCR) by creating several bone marrow vents in the footprint of the rotator cuff, allowing mesenchymal stem cells, platelets, and growth factors to cover the area as a "crimson duvet."

PURPOSE

To perform a meta-analysis of randomized controlled trials (RCTs) to compare the outcomes after BMS and a control for those undergoing ARCR.

STUDY DESIGN

Meta-analysis; Level of evidence, 1.

METHODS

A literature search of 3 databases was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RCTs comparing BMS and a control for ARCR were included. Clinical outcomes were compared, and a P value <.05 was considered to be statistically significant.

RESULTS

A total of 7 RCTs with 576 patients were included. Overall, 18.8% of patients treated with BMS and 21.0% of patients treated with a control had a retear (I2 = 43%; P = .61). With BMS, the mean Constant score was 88.2, and with the control, the mean Constant score was 86.7 (P = .12). Additionally, there was no significant difference in the American Shoulder and Elbow Surgeons score (94.3 vs 93.2, respectively; P = .31) or visual analog scale score (0.9 vs 0.9, respectively; P = .89).

CONCLUSION

The level 1 evidence in the literature did not support BMS as a modality to improve retear rates or clinical outcomes after ARCR.

High degree of consensus on diagnosis and management of rotator cuff tears: a Delphi approach

PURPOSE

To develop a consensus on diagnosis and treatment of rotator cuff tears. The study focused on selected areas: imaging, prognostic factors, treatment options, surgical techniques.

METHODS

Panel was composed of all members of the shoulder committee of the Italian Society of Arthroscopy, Knee, Upper arm, Sport, Cartilage and Orthopedic techniques (SIAGASCOT). Four rounds were performed. The first round consisted of gathering questions which were then divided into seven blocks referring to: imaging, patient-related prognostic factors, treatment options, surgical steps, reparative techniques, surgical predictive factors, advanced techniques. Subsequent rounds consisted of condensation by means of online questionnaire and debates. Consensus was defined as two-thirds agreement on one answer. Descriptive statistic was used to summarize the data.

RESULTS

Forty-one shoulder experts were involved. Fifty-six statements were finally formulated. A consensus could be achieved on 51. Experts agreed that preoperative magnetic resonance imaging is strongly recommended because it allows a careful evaluation of tear characteristics, while the role of US remains debatable. Controversial patient-related factors such as age, comorbidities, smoking and stiffness do not contraindicate the repair. From a surgical standpoint, the experts highlighted that pseudo-paralysis is not a contraindication to rotator cuff repair. Consensus on specific surgical steps was also achieved: capsular release should be performed only in stiff shoulders; footprint preparation is mandatory, while debridement of tendon edges is not essential. If necessary, a rotator interval release could be performed without interrupting the continuity between subscapularis and supraspinatus tendon; posterior delamination should be always included in the repair. Advanced techniques such as tendon transfers should be selected based on the main clinical deficit, while the superior capsule reconstruction plays a role only in combination with a functional repair.

CONCLUSION

A consensus was achieved almost on every topic of controversy explored. Particularly, MRI was deemed necessary to determine tear characteristics, while radiographs remain important for differential diagnosis; age should not be considered a contraindication to surgery; pseudo-paralysis does not represent a contraindication to arthroscopic rotator cuff repair, but superior capsule reconstruction plays a role only in combination with a functional repair. Latissimus dorsi transfer plays a role when the main functional deficit is in elevation, while the lower trapezius transfer plays a role when the main functional deficit is the external-rotation.

LEVEL OF EVIDENCE

V.