Arthroscopic rotator cuff repair in patients over 70 years of age: a systematic review

Factors associated with patient satisfaction after arthroscopic rotator cuff repair: do they differ by age?

BACKGROUND

Several studies have investigated factors affecting patient satisfaction after arthroscopic rotator cuff repair (ARCR); however, it is unknown if these factors vary according to age. Therefore, this study aimed to evaluate the factors associated with satisfaction of ARCR in individuals 70 years and older versus younger patients.

METHODS

Among 319 consecutive patients who underwent ARCR, 173 were included. Patients were divided into an old age group (≥70 years) and a young age group (<70 years), and the two age groups were further divided into satisfied and unsatisfied subgroups. Patient satisfaction was evaluated at the final follow-up visit using a binary question (yes or no). Clinical outcomes were assessed preoperatively and at the final follow-up.

RESULTS

Satisfaction rates in the older and younger age groups were 75.41% and 79.47%, respectively. Mean changes in Constant and American Shoulder and Elbow Surgeons scores were significantly different between the satisfied and unsatisfied subgroups (P=0.031 and P=0.012, respectively) in the young patients. In the old patients, there was a significant difference in the mean change in depression subscale of the Hospital Anxiety and Depression Scale (P=0.031) and anxiety subscale of the Hospital Anxiety and Depression Scale (P=0.044) scores between the satisfied and unsatisfied subgroups.

CONCLUSIONS

Factors affecting patient satisfaction after ARCR differed according to age. Psychological improvement was more important to elderly patients, whereas restoration of function was more important to younger patients. Pain relief was important for both age groups. Level of evidence: III.

Factors associated with reparability of rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

To identify and quantify the factors associated with the reparability of rotator cuff tears (RCTs).

METHODS

PubMed, Scopus, and Web of Science databases were searched for clinical studies published in English focusing on RCT reparability by using the keywords "rotator cuff tear" and "reparability". A meta-analysis was conducted if ≥3 studies examined the same factor and provided enough data to assess RCT reparability. Quality assessment was completed using the quality assessment of diagnostic accuracy studies tool.

RESULTS

Eighteen studies (2700 patients) were enrolled and 26 factors were included in the meta-analysis. The dichotomous variables associated with irreparability were Patte stage 3 (odds ratio (OR): 8.0, 95% confidence interval [CI]: 4.3-14.9), massive tear vs. large tear (OR: 3.1, 95% CI: 1.3-7.2), Goutallier stage for each tendon, and tangent sign (OR: 11.1, 95% CI: 4.3-28.4). The continuous variables associated with irreparability were age (mean difference (MD): 3.25, 95% CI: 1.4-5.1), mediolateral tear size (MD: 12.3, 95% CI: 5.8-18.9), anteroposterior tear size (MD: 10.4, 95% CI: 5.2-15.6), acromiohumeral distance on X-ray (MD: -2.3, 95% CI: -3.0 to -1.6) and magnetic resonance imaging (MD: -1.8, 95% CI: -2.8 to -0.9), and inferior glenohumeral distance on magnetic resonance imaging (MD: 2.2, 95% CI: 1.4-3.0).

CONCLUSION

This study revealed that older age, larger tear size, severe fatty infiltration, muscle atrophy, and advanced superior migration of the humeral head were strongly associated with irreparable RCTs. Conversely, clinical symptoms provided limited information for predicting reparability. Additionally, the tangent sign emerged as a powerful and simple tool for individual prediction, and several quantitative scoring systems also proved useful.

Effect of Gabapentin on Tendon-to-Bone Healing in a Rat Model of Rotator Cuff Repair

BACKGROUND

Gabapentin is often used as an analgesic after rotator cuff repair surgery and is recommended as an additional analgesic for arthroscopic rotator cuff repairs. However, evidence of its effects on biological healing mechanisms is lacking. The objective of this study was to investigate the potential of gabapentin in improving tendon-to-bone healing after rotator cuff repair using a rat model.

MATERIALS AND METHODS

A total of 20 male rats were randomly allocated to one of two groups: group 1 (repair only, n=10) or group 2 (gabapentin injection, n=10). The rats in the experimental group (group 2) were administered 80 mg/kg of gabapentin subcutaneously 30 minutes before surgery, followed by 80 mg/kg subcutaneously every 24 hours for 48 hours. We used the left shoulder of every rat, while for biomechanical analysis, we used the right shoulder.

RESULTS

There was no significant difference in the load to failure, ultimate stress, or elongation between the groups. Collagen continuity, orientation, and density were better in group 2 than group 1.

CONCLUSION

In a rat model of rotator cuff repair, gabapentin had a positive impact on the quality of collagen organization at the junction between the tendon and bone, while preserving the biomechanical properties. We propose the use of gabapentin as a supplementary analgesic agent for postoperative pain relief after arthroscopic rotator cuff repair; however, further studies of the effect of gabapentin on biological healing mechanisms are required. [Orthopedics. 2024;47(5):e241-e246.].

Editorial Commentary: Platelet-rich plasma (PRP) for rotator cuff repair improves re-tear rate but clinical impact is yet to be seen

Rotator cuff tendon repair has a high failure rate due to the inferior quality of tendon material. Platelet-rich plasma (PRP) is considered a potential solution, though its clinical impact is uncertain. Recent literature indicates that while PRP may reduce re-tear rates radiologically, it does not significantly improve clinical outcomes such as pain and function. Early animal studies showed potential benefits, but initial clinical trials were inconclusive due to small sample sizes and varied PRP methods. Larger, recent studies suggest a possible benefit, yet definitive clinical advantages remain elusive. Advancing PRP research requires a dual approach: deeper understanding of tendon and PRP biology, and larger clinical trials focusing on specific PRP preparations and delivery methods. While current evidence is limited, PRP holds promise for improving rotator cuff repair outcomes, and ongoing research may eventually translate into significant clinical benefits.

Age-dependent decline of B3AR agonist-mediated activation of FAP UCP-1 expression in murine models of chronic rotator cuff repair

Amibegron, a β3-adrenergic receptor (B3AR) agonist, has recently been shown to provide therapeutic effects for chronic rotator cuff (RC) tears by inducing the expression of uncoupling protein 1 (UCP-1), a marker of brown fat, in fibroadipogenic progenitors (FAPs). However, it remains to be seen if these beneficial effects hold true with age and in older, more clinically relevant populations. This study seeks to understand the impacts of aging on the efficacy of amibegron to treat chronic RC tears. Young (4-month-old) and aged (33-month-old) C57BL/6 mice underwent a RC injury procedure with delayed repair (DR). Mice were equally randomized to receive amibegron or dimethyl sulfoxide (DMSO) treatments after repair. Functional ability was measured at baseline and 6-weeks after DR. Wet muscle weight and histology of injured and contralateral supraspinatus were also analyzed 6-weeks post-DR. For in vitro histology and real-time quantitative PCR experiments, FAPs were isolated from young and aged mice via fluorescence-activated cell sorting. Young and aged FAPs were treated with amibegron or DMSO either immediately after seeding (early exposure) or 8-days after seeding (late exposure). In vitro results showed that amibegron-mediated FAP UCP-1 expression decreases with age. In vivo data demonstrated that aged mice have a decreased responsiveness to amibegron and decreased propensity for intramuscular FAP UCP-1 expression. Further, delayed amibegron treatment with RC repair did not lead to improvements in muscle atrophy and functional outcomes. Our findings demonstrate that age and the timing of interventions play a critical role in FAP-targeted therapeutics for chronic injuries.

The impact of social deprivation on rotator cuff repair outcomes

BACKGROUND

Rotator cuff tears are a common orthopedic injury, and the role of social determinants of health (SDoH) in surgical outcomes remains underexplored. The goal of this study was to investigate the correlation between social deprivation, measured by the Area Deprivation Index (ADI), and outcomes following arthroscopic rotator cuff repair.

METHODS

We conducted a retrospective chart review on patients undergoing primary arthroscopic rotator cuff repair at a level 1 academic center between 2006 and 2019. Patient demographics (age, gender, race), comorbidities, ADIs, range of motion, visual analog pain scores, and patient-reported outcomes (Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire [QuickDASH]) were collected. Patients were stratified into terciles based on their relative level of deprivation. Statistical analysis was performed using analysis of variance, t tests, χ2 tests, and univariate or multivariate logistic regression.

RESULTS

A total of 322 patients were included in this study. The most deprived group had a higher prevalence of diabetes compared to the least and intermediately deprived group (P < .001). Massive tear occurrence was greater in the least deprived group (P = .003) compared to the most deprived group. There was no difference in objective outcomes between groups. Patient-reported outcomes (SST, ASES, and QuickDASH scores) were worse in the most deprived group compared with the least and intermediate deprived groups.

CONCLUSION

Social deprivation significantly affects patient-reported outcomes in rotator cuff repair surgery. Although clinician-reported outcomes were consistent, patients' perceptions varied based on social determinants. Integrating SDoH considerations in orthopedic care is a promising next step in securing equitable approaches. However, more research is needed to validate and expand these findings.

ASES and UCLA Are Responsive Patient-Reported Outcome Measures After Rotator Cuff Repair: A Systematic Review and Meta-analysis

BACKGROUND

Multiple patient-reported outcome measures (PROMs) have been used to assess shoulder function, but it is unknown which are the most effective.

PURPOSE/HYPOTHESIS

The purpose of this study was to report the multiple PROMs used after rotator cuff repair (RCR) and to compare the responsiveness between them. It was hypothesized that the Western Ontario Rotator Cuff PROM would be the most responsive and commonly used in patients undergoing RCR.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

A systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and PRISMA-Searching extension guidelines via PubMed/MEDLINE, Embase (Elsevier), and Web of Science (Clarivate). Patient and study characteristics were extracted. From the studies that met inclusion criteria for responsiveness analysis (≥2 PROMs reported, 1-year minimum follow-up, and pre- and postoperative PROM means and standard deviations reported), the authors compared the responsiveness between PROM instruments using effect size and relative efficiency (RE) if a PROM could be compared with another in ≥10 articles.

RESULTS

A total of 252 studies met inclusion criteria (32,072 patients; mean age, 59.6 years; mean body mass index, 28.7; mean follow-up time, 27.8 months). Range of motion was reported in 131 (52%) studies and imaging findings were reported in 123 (49%) studies. There were 67 PROM instruments identified; the most commonly used were the American Shoulder and Elbow Surgeon (ASES) (n = 183; 73%), Visual Analog Scale (VAS) (n = 163; 65%), and Constant (n = 118; 47%) scores. The 3 PROMs with the highest effect sizes were the University of California, Los Angeles (UCLA) (2.51), Western Ontario Rotator Cuff (2.42), and ASES (2.00) scores. Overall, UCLA and ASES scores were the most responsive PROMs. The ASES PROM was more responsive than the VAS (RE, 1.70), Constant (RE, 2.76), Simple Shoulder Test (RE, 1.67), and Single Assessment Numeric Evaluation (RE, 2.14) scores. The UCLA PROM was more responsive than the ASES (RE, 1.03), VAS (RE, 3.66), Constant (RE, 1.72), and Simple Shoulder Test (RE, 1.66) scores.

CONCLUSION

ASES and UCLA scores were the most responsive PROMs after RCR. The authors recommend widespread adoption of ASES and UCLA scores for clinical and research standardization; however, the UCLA PROM requires in-person range of motion and strength testing, which is a practical limitation and barrier to long-term follow-up.

Operative management of rotator cuff tears: identifying disparities in access on a national level

BACKGROUND

The purpose of this study was to identify nationwide disparities in the rates of operative management of rotator cuff tears based on race, ethnicity, insurance type, and socioeconomic status.

METHODS

Patients diagnosed with a full or partial rotator cuff tear from 2006 to 2014 were identified in the Healthcare Cost and Utilization Project's National Inpatient Sample database using International Classification of Diseases, Ninth Revision diagnosis codes. Bivariate analysis using chi-square tests and adjusted, multivariable logistic regression models were used to evaluate differences in the rates of operative vs. nonoperative management for rotator cuff tears.

RESULTS

This study included 46,167 patients. When compared with white patients, adjusted analysis showed that minority race and ethnicity were associated with lower rates of operative management for Black (adjusted odds ratio [AOR]: 0.31, 95% confidence interval [CI]: 0.29-0.33; P < .001), Hispanic (AOR: 0.49, 95% CI: 0.45-0.52; P < .001), Asian or Pacific Islander (AOR: 0.72, 95% CI: 0.61-0.84; P < .001), and Native American patients (AOR: 0.65, 95% CI: 0.50-0.86; P = .002). In comparison to privately insured patients, our analysis also found that self-payers (AOR: 0.08, 95% CI: 0.07-0.10; P < .001), Medicare beneficiaries (AOR: 0.76, 95% CI: 0.72-0.81; P < .001), and Medicaid beneficiaries (AOR: 0.33, 95% CI: 0.30-0.36; P < .001) had lower odds of receiving surgical intervention. Additionally, relative to those in the bottom income quartile, patients in all other quartiles experienced nominally higher rates of operative repair; these differences were statistically significant for the second quartile (AOR: 1.09, 95% CI: 1.03-1.16; P = .004).

CONCLUSION

There are significant nationwide disparities in the likelihood of receiving operative management for rotator cuff tear patients of differing race/ethnicity, payer status, and socioeconomic status. Further investigation is needed to fully understand and address causes of these discrepancies to optimize care pathways.

Comparison of Outcomes after Arthroscopic Rotator Cuff Repair between Elderly and Younger Patient Groups: A Systematic Review and Meta-Analysis of Comparative Studies

This study aimed to compare the outcomes of arthroscopic rotator cuff repair (ARCR) surgery between younger and older patients. We performed this systematic review and meta-analysis of cohort studies comparing outcomes between patients older than 65 to 70 years and a younger group following arthroscopic rotator cuff repair surgery. We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and other sources for relevant studies up to 13 September 2022, and then assessed the quality of included studies using the Newcastle-Ottawa Scale (NOS). We used random-effects meta-analysis for data synthesis. The primary outcomes were pain and shoulder functions, while secondary outcomes included re-tear rate, shoulder range of motion (ROM), abduction muscle power, quality of life, and complications. Five non-randomized controlled trials, with 671 participants (197 older and 474 younger patients), were included. The quality of the studies was all fairly good, with NOS scores ≥ 7. The results showed no significant differences between the older and younger groups in terms of Constant score improvement, re-tear rate, or other outcomes such as pain level improvement, muscle power, and shoulder ROM. These findings suggest that ARCR surgery in older patients can achieve a non-inferior healing rate and shoulder function compared to younger patients.

Comparison of Locking-Loop Suture Bridge Repair and Single-Row Suture Anchor Repair in Small to Medium Rotator Cuff Tears: A Prospective Cohort Study With Clinical and Ultrasound Evaluations

Background

Single-row (SR) and double-row repair techniques have been described to treat rotator cuff tears. We present a novel surgical strategy of arthroscopic-assisted mini-open repair in which a locking-loop suture bridge (LLSB) is used.

Purpose

To compare the functional outcomes and repair integrity of LLSB technique to the SR technique for arthroscopic-assisted mini-open repair of small to medium rotator cuff tears.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 39 patients who underwent LLSB repair (LLSB group) and 44 patients who underwent SR suture anchor repair (SR group) from 2015 to 2018. We evaluated all patients preoperatively and at 3, 6, 12, and 24 months postoperatively using the visual analog scale (VAS) for pain, Oxford Shoulder Score (OSS), and American Shoulder and Elbow Surgeons (ASES) score. Also, shoulder sonography was performed at 12 months postoperatively to evaluate repair integrity using the Sugaya classification system. The independent-sample t test was used to analyze functional outcomes (VAS, OSS, and ASES scores), and the Fisher exact test was used to analyze postoperative sonography results.

Results

Patients in both the LLSB and SR groups saw a significant improvement on all 3 outcome measures from preoperatively to 24 months postoperatively (P < .001 for all). However, when comparing scores between groups, only the scores at 3 months postoperatively differed significantly (VAS: P = .002; OSS: P < .001; ASES: P = .005). Shoulder sonography at 12 months postoperatively revealed no significant difference in repair integrity between the LLSB and SR groups (retear rate: 10.26% and 6.82%, respectively; P = .892).

Conclusion

Better outcome scores were seen at 3-month follow-up in the LLSB group, with no difference in retear rates compared with the SR group at 12 months postoperatively. The LLSB technique was found to be a reliable technique for rotator cuff repair of small- to medium-sized tears.

Arthroscopic Repair Benefits Reparable Rotator Cuff Tear Patients Aged 65 Years or Older With a History of Traumatic Events

PURPOSE

To evaluate the clinical outcomes of arthroscopic rotator cuff repair at 2-year follow-up in patients aged 65 years or older with a history of traumatic events divided into groups based on symptom duration (<3 months, 3-6 months, and >6 months from injury to surgery) and to compared patient-reported outcomes among the 3 groups.

METHODS

Between 2015 and 2020, 110 patients who met the inclusion criteria were enrolled in this study; these patients were divided into 3 groups according to symptom duration: less than 3 months (group A), 3 to 6 months (group B) and more than 6 months (group C). Preoperative and 2-year postoperative clinical outcomes were compared, including American Shoulder and Elbow Surgeons, Constant-Murley, University of California, Los Angeles, Simple Shoulder Test, and visual analog scale scores; forward elevation; external rotation; and internal rotation. The minimal clinically important difference (MCID), patient acceptable symptom state, substantial clinical benefit, and maximum outcome improvement were also compared among the groups.

RESULTS

The American Shoulder and Elbow Surgeons score, as the primary outcome, improved significantly from 41.0 ± 18.5 to 85.4 ± 8.1 in group A, from 53.7 ± 14.3 to 86.3 ± 11.7 in group B, and from 49.7 ± 18.5 to 83.9 ± 11.9 in group C. All the other parameters showed statistically significant improvements at 2-year follow-up in each group (all P < .05). There was no significant difference in each parameter among the 3 groups except the visual analog scale score, which did not achieve the MCID. Overall, 86 patients (78.2%) exceeded the MCID, 87 patients (79.1%) achieved the patient acceptable symptom state, 77 patients (70.0%) achieved substantial clinical benefit, and 62 patients (56.4%) achieved maximum outcome improvement without significant differences among the 3 groups.

CONCLUSIONS

In rotator cuff tear patients aged 65 years or older with a history of traumatic events, arthroscopic rotator cuff repair significantly improves clinical outcomes at 2-year follow-up regardless of symptom duration if the tear is fully reparable.

LEVEL OF EVIDENCE

Level III, prognostic retrospective study.