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Nunes B, Martins R, Linhares D, Azevedo L, Canadas R, Gutierres M. Effect of Platelet-Rich Plasma Dosing for Healing after Arthroscopic Cuff Repair Compared with Surgery Alone: A Systematic Review and Meta-Analysis. Med Sci Sports Exerc 2024; 56:796-804. [PMID: 38480490 DOI: 10.1249/mss.0000000000003361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Platelet-rich plasma (PRP) has been used for arthroscopic rotator cuff repairs (aRCR), but no studies have addressed the impact of platelet concentration. The primary aim was to evaluate whether the PRP cell concentration has an effect on tendon healing after aRCR compared with surgery alone. The secondary aim was to assess the functional and pain outcomes. MATERIALS AND METHODS A systematic review was performed with searches in the MEDLINE (PubMed), Scopus, Web of Science, and Cochrane (Central) databases according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Metanalytic procedures were performed for randomized controlled trials (RCTs), and a subgroup analysis was used for studies with target (approximately 10 6 cells·μL -1 ) or below-target PRP cellular concentrations (app. 5 × 10 5 cells·μL -1 ) regarding the primary outcome of tendon healing. RESULTS This review included 10 studies (8 RCTs) with 342 patients in the aRCR + PRP group and 344 patients with isolated aRCR. The risk of bias was low to intermediate (6/4, respectively). Meta-analysis of the RCT revealed that the aRCR + high-concentration PRP group had an approximately 3.9-fold higher chance of healing than the non-PRP group (odds ratio, 3.89; 95% confidence interval, 1.78-8.44; P = 0.0007). No significant difference in healing was found between the aRCR + low-concentration PRP and non-PRP groups (odds ratio, 2.21; 95% confidence interval, 0.66-7.45; P = 0.2). The Constant-Murley score and University of California Los Angeles scores were significantly improved in the aRCR + PRP groups with more than 12 months of follow-up, and no significant differences were found consistently for the American Shoulder and Elbow Society and visual analog scale scores. CONCLUSIONS This study highlights that a PRP cell concentration close to the target (10 6 cells·μL -1 ) of patients with aRCR may improve their healing and functional outcomes and that dosing may be potentially useful in therapy.
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Affiliation(s)
| | - Ricardo Martins
- Faculty of Medicine of the University of Porto, Porto, PORTUGAL
| | | | - Luís Azevedo
- CINTESIS@RISE-Center for Health Technology and Services Research at the Health Research Network, MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine of the University of Porto, Porto, PORTUGAL
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Retraction to: Clinical outcome of arthroscopic acromioplasty vs. arthroscopic rotator cuff repair for irreparable rotator cuff tears: A 3-year follow-up. Technol Health Care 2024:THC231589. [PMID: 38393862 DOI: 10.3233/thc-231589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
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Mazuquin B, Moffatt M, Realpe A, Sherman R, Ireland K, Connan Z, Tildsley J, Manca A, Gc VS, Foster NE, Rees J, Drew S, Bateman M, Fakis A, Farnsworth M, Littlewood C. Clinical and cost-effectiveness of individualised (early) patient-directed rehabilitation versus standard rehabilitation after surgical repair of the rotator cuff of the shoulder: protocol for a multicentre, randomised controlled trial with integrated Quintet Recruitment Intervention (RaCeR 2). BMJ Open 2024; 14:e081284. [PMID: 38580365 PMCID: PMC11002397 DOI: 10.1136/bmjopen-2023-081284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/08/2024] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION Despite the high number of operations and surgical advancement, rehabilitation after rotator cuff repair has not progressed for over 20 years. The traditional cautious approach might be contributing to suboptimal outcomes. Our aim is to assess whether individualised (early) patient-directed rehabilitation results in less shoulder pain and disability at 12 weeks after surgical repair of full-thickness tears of the rotator cuff compared with current standard (delayed) rehabilitation. METHODS AND ANALYSIS The rehabilitation after rotator cuff repair (RaCeR 2) study is a pragmatic multicentre, open-label, randomised controlled trial with internal pilot phase. It has a parallel group design with 1:1 allocation ratio, full health economic evaluation and quintet recruitment intervention. Adults awaiting arthroscopic surgical repair of a full-thickness tear are eligible to participate. On completion of surgery, 638 participants will be randomised. The intervention (individualised early patient-directed rehabilitation) includes advice to the patient to remove their sling as soon as they feel able, gradually begin using their arm as they feel able and a specific exercise programme. Sling removal and movement is progressed by the patient over time according to agreed goals and within their own pain and tolerance. The comparator (standard rehabilitation) includes advice to the patient to wear the sling for at least 4 weeks and only to remove while eating, washing, dressing or performing specific exercises. Progression is according to specific timeframes rather than as the patient feels able. The primary outcome measure is the Shoulder Pain and Disability Index total score at 12-week postrandomisation. The trial timeline is 56 months in total, from September 2022. TRIAL REGISTRATION NUMBER ISRCTN11499185.
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Affiliation(s)
- Bruno Mazuquin
- Health Professions, Manchester Metropolitan University, Manchester, UK
| | - Maria Moffatt
- School of Allied Health Professios and Nursing, University of Liverpool, Liverpool, UK
| | - Alba Realpe
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Rachelle Sherman
- Derby Clinical Trials Support Unit, Royal Derby Hospital, Derby, UK
| | - Katie Ireland
- Derby Clinical Trials Support Unit, Royal Derby Hospital, Derby, UK
| | - Zak Connan
- Derby Clinical Trials Support Unit, Royal Derby Hospital, Derby, UK
| | - Jack Tildsley
- Derby Clinical Trials Support Unit, Royal Derby Hospital, Derby, UK
| | - Andrea Manca
- Centre for Health Economics, York University, York, UK
| | - Vijay Singh Gc
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Nadine E Foster
- STARS Education and Research Alliance, Surgical Treatment and Rehabilitation Service (STARS), The University of Queensland and Metro North Health, Saint Lucia, Queensland, Australia
| | - Jonathan Rees
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Steven Drew
- University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Marcus Bateman
- Derby Shoulder Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Apostolos Fakis
- Derby Clinical Trials Support Unit, Royal Derby Hospital, Derby, UK
| | | | - Chris Littlewood
- Allied Health, Social Work & Wellbeing, Faculty of Health Social Care and Medicine, Edge Hill University, Ormskirk, UK
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Bhardwaj AK, Mills L, Doyle M, Sahid A, Montebello M, Monds L, Arunogiri S, Haber P, Lorenzetti V, Lubman DI, Malouf P, Harrod ME, Dunlop A, Freeman T, Lintzeris N. A phase III multisite randomised controlled trial to compare the efficacy of cannabidiol to placebo in the treatment of cannabis use disorder: the CBD-CUD study protocol. BMC Psychiatry 2024; 24:175. [PMID: 38433233 PMCID: PMC10910760 DOI: 10.1186/s12888-024-05616-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/15/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Cannabis use disorder (CUD) is increasingly common and contributes to a range of health and social problems. Cannabidiol (CBD) is a non-intoxicating cannabinoid recognised for its anticonvulsant, anxiolytic and antipsychotic effects with no habit-forming qualities. Results from a Phase IIa randomised clinical trial suggest that treatment with CBD for four weeks reduced non-prescribed cannabis use in people with CUD. This study examines the efficacy, safety and quality of life of longer-term CBD treatment for patients with moderate-to-severe CUD. METHODS/DESIGN A phase III multi-site, randomised, double-blinded, placebo controlled parallel design of a 12-week course of CBD to placebo, with follow-up at 24 weeks after enrolment. Two hundred and fifty adults with moderate-to-severe CUD (target 20% Aboriginal), with no significant medical, psychiatric or other substance use disorders from seven drug and alcohol clinics across NSW and VIC, Australia will be enrolled. Participants will be administered a daily dose of either 4 mL (100 mg/mL) of CBD or a placebo dispensed every 3-weeks. All participants will receive four-sessions of Cognitive Behavioural Therapy (CBT) based counselling. Primary endpoints are self-reported cannabis use days and analysis of cannabis metabolites in urine. Secondary endpoints include severity of CUD, withdrawal severity, cravings, quantity of use, motivation to stop and abstinence, medication safety, quality of life, physical/mental health, cognitive functioning, and patient treatment satisfaction. Qualitative research interviews will be conducted with Aboriginal participants to explore their perspectives on treatment. DISCUSSION Current psychosocial and behavioural treatments for CUD indicate that over 80% of patients relapse within 1-6 months of treatment. Pharmacological treatments are highly effective with other substance use disorders but there are no approved pharmacological treatments for CUD. CBD is a promising candidate for CUD treatment due to its potential efficacy for this indication and excellent safety profile. The anxiolytic, antipsychotic and neuroprotective effects of CBD may have added benefits by reducing many of the mental health and cognitive impairments reported in people with regular cannabis use. TRIAL REGISTRATION Australian and New Zealand Clinical Trial Registry: ACTRN12623000526673 (Registered 19 May 2023).
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Affiliation(s)
- Anjali K Bhardwaj
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia.
- Drug and Alcohol Services, South East Sydney Local Health District, Sydney, NSW, Australia.
| | - Llew Mills
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
- Drug and Alcohol Services, South East Sydney Local Health District, Sydney, NSW, Australia
| | - Michael Doyle
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
| | - Arshman Sahid
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
- Drug and Alcohol Services, South East Sydney Local Health District, Sydney, NSW, Australia
| | - Mark Montebello
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
- Drug and Alcohol Services, North Sydney Local Health District, St Leonards, NSW, Australia
| | - Lauren Monds
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
- Drug and Alcohol Services, North Sydney Local Health District, St Leonards, NSW, Australia
| | - Shalini Arunogiri
- Centre for Addiction and Mental Health, Turning Point, Victoria, Australia
| | - Paul Haber
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
- Drug Health Services, Sydney Local Health District, Sydney, Australia
| | | | - Dan I Lubman
- Centre for Addiction and Mental Health, Turning Point, Victoria, Australia
| | - Peter Malouf
- Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Mary E Harrod
- NSW Users and AIDS Association, Sydney, NSW, Australia
| | - Adrian Dunlop
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Tom Freeman
- Addiction and Mental Health Group, University of Bath, Bath, UK
| | - Nicholas Lintzeris
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
- Drug and Alcohol Services, South East Sydney Local Health District, Sydney, NSW, Australia
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Abhari RE, Snelling SJ, Augustynak E, Davis S, Fischer R, Carr AJ, Mouthuy PA. A Hybrid Electrospun-Extruded Polydioxanone Suture for Tendon Tissue Regeneration. Tissue Eng Part A 2024; 30:214-224. [PMID: 38126344 PMCID: PMC10954604 DOI: 10.1089/ten.tea.2023.0273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 11/13/2023] [Indexed: 12/23/2023] Open
Abstract
Many surgical tendon repairs fail despite advances in surgical materials and techniques. Tendon repair failure can be partially attributed to the tendon's poor intrinsic healing capacity and the repurposing of sutures from other clinical applications. Electrospun materials show promise as a biological scaffold to support endogenous tendon repair, but their relatively low tensile strength has limited their clinical translation. It is hypothesized that combining electrospun fibers with a material with increased tensile strength may improve the suture's mechanical properties while retaining biophysical cues necessary to encourage cell-mediated repair. This article describes the production of a hybrid electrospun-extruded suture with a sheath of submicron electrospun fibers and a core of melt-extruded fibers. The porosity and tensile strength of this hybrid suture is compared with an electrospun-only braided suture and clinically used sutures Vicryl and polydioxanone (PDS). Bioactivity is assessed by measuring the adsorbed serum proteins on electrospun and melt-extruded filaments using mass spectrometry. Human hamstring tendon fibroblast attachment and proliferation were quantified and compared between the hybrid and control sutures. Combining an electrospun sheath with melt-extruded cores created a hybrid braid with increased tensile strength (70.1 ± 0.3N) compared with an electrospun only suture (12.9 ± 1 N, p < 0.0001). The hybrid suture had a similar force at break to clinical sutures, but lower stiffness and stress. The Young's modulus was 772.6 ± 32 MPa for the hybrid suture, 1693.0 ± 69 MPa for PDS, and 3838.0 ± 132 MPa for Vicryl, p < 0.0001. Hybrid sutures had lower overall porosity than electrospun-only sutures (40 ± 4% and 60 ± 7%, respectively, p = 0.0018) but had a significantly larger overall porosity and average pore diameter compared with surgical sutures. There were similar clusters of adsorbed proteins on electrospun and melt-extruded filaments, which were distinct from PDS. Tendon fibroblast attachment and cell proliferation on hybrid and electrospun sutures were significantly higher than on clinical sutures. This study demonstrated that a bioactive suture with increased tensile strength and lower stiffness could be produced by adding a core of 10 μm melt-extruded fibers to a sheath of electrospun fibers. In contrast to currently used sutures, the hybrid sutures promoted a bioactive response: serum proteins adsorbed, and fibroblasts attached, survived, grew along the sutures, and adopted appropriate morphologies.
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Affiliation(s)
- Roxanna E. Abhari
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Sarah J.B. Snelling
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Edyta Augustynak
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Simon Davis
- Nuffield Department of Medicine, Target Discovery Institute, Centre for Medicines Discovery, University of Oxford, Oxford, United Kingdom
- Nuffield Department of Medicine, Chinese Academy for Medical Sciences Oxford Institute, University of Oxford, Oxford, United Kingdom
| | - Roman Fischer
- Nuffield Department of Medicine, Target Discovery Institute, Centre for Medicines Discovery, University of Oxford, Oxford, United Kingdom
- Nuffield Department of Medicine, Chinese Academy for Medical Sciences Oxford Institute, University of Oxford, Oxford, United Kingdom
| | - Andrew J. Carr
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Pierre-Alexis Mouthuy
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
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Littlewood C, Moffatt M, Beckhelling J, Davis D, Burden A, Pitt L, Lalande S, Maddocks C, Stephens G, Tunnicliffe H, Pawson J, Lloyd J, Manca A, Wade J, Foster NE. Physiotherapist-led exercise versus usual care (waiting-list) control for patients awaiting rotator cuff repair surgery: A pilot randomised controlled trial (POWER). Musculoskelet Sci Pract 2023; 68:102874. [PMID: 37926065 DOI: 10.1016/j.msksp.2023.102874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Once a decision to undergo rotator cuff repair surgery is made, patients are placed on the waiting list. It can take weeks or months to receive surgery. There has been a call to move from waiting lists to 'preparation' lists to better prepare patients for surgery and to ensure it remains an appropriate treatment option for them. OBJECTIVE To evaluate the feasibility, as measured by recruitment rates, treatment fidelity and follow-up rates, of a future multi-centre randomised controlled trial to compare the clinical and cost-effectiveness of undertaking a physiotherapist-led exercise programme while waiting for surgery versus usual care (waiting-list control). DESIGN Two-arm, multi-centre pilot randomised controlled trial with feasibility objectives in six NHS hospitals in England. METHOD Adults (n = 76) awaiting rotator cuff repair surgery were recruited and randomly allocated to a programme of physiotherapist-led exercise (n = 38) or usual care control (n = 38). RESULTS Of 302 eligible patients, 76 (25%) were randomised. Of 38 participants randomised to physiotherapist-led exercise, 28 (74%) received the exercise programme as intended. 51/76 (67%) Shoulder Pain and Disability Index questionnaires were returned at 6-months. Of 76 participants, 32 had not received surgery after 6-months (42%). Of those 32, 20 were allocated to physiotherapist-led exercise; 12 to usual care control. CONCLUSIONS A future multi-centre randomised controlled trial is feasible but would require planning for variable recruitment rates between sites, measures to improve treatment fidelity and opportunity for surgical exit, and optimisation of follow-up. A fully powered, randomised controlled trial is now needed to robustly inform clinical decision-making.
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Affiliation(s)
- Chris Littlewood
- Faculty of Health, Social Care & Medicine, Edge Hill University, St Helen's Road, Ormskirk, Lancashire, L39 4QP, UK.
| | - Maria Moffatt
- Faculty of Health, Social Care & Medicine, Edge Hill University, St Helen's Road, Ormskirk, Lancashire, L39 4QP, UK
| | - Jacqueline Beckhelling
- Derby Clinical Trials Support Unit, University Hospitals Derby & Burton NHS Foundation Trust, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - Daniel Davis
- Derby Clinical Trials Support Unit, University Hospitals Derby & Burton NHS Foundation Trust, Royal Derby Hospital, Derby, DE22 3NE, UK
| | | | - Lisa Pitt
- University Hospitals Derby & Burton NHS Foundation Trust, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - Stacey Lalande
- Airedale NHS Foundation Trust, Airedale General Hospital, Skipton Rd, Steeton, Keighley, BD20 6TD, UK
| | - Catrin Maddocks
- Robert Jones & Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - Gareth Stephens
- The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK
| | - Helen Tunnicliffe
- University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, LE1 5WW, UK
| | - Jessica Pawson
- Barts Health NHS Trust, Royal London Hospital, Whitechapel, E1 1FR, UK
| | - James Lloyd
- Barts Health NHS Trust, Royal London Hospital, Whitechapel, E1 1FR, UK
| | - Andrea Manca
- Centre for Health Economics, University of York, York, YO10 5DD, UK
| | - Julia Wade
- Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Nadine E Foster
- STARS Education and Research Alliance, Surgical, Treatment and Rehabilitation Service (STARS), The University of Queensland and Metro North Health, Queensland, QLD 4029, Australia
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Man versus Machine: Surgeon versus elastography assessment of the quality of the rotator cuff. JSES Int 2023. [DOI: 10.1016/j.jseint.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
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Resorbable Bioinductive Collagen Implant Is Cost Effective in the Treatment of Rotator Cuff Tears. Arthrosc Sports Med Rehabil 2023; 5:e367-e374. [PMID: 37101868 PMCID: PMC10123441 DOI: 10.1016/j.asmr.2023.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 01/04/2023] [Indexed: 02/13/2023] Open
Abstract
Purpose This study was conducted to investigate whether the use of resorbable bioinductive collagen implant (RBI) in addition to conventional rotator cuff repair (conventional RCR) is cost-effective when compared to conventional RCR alone, in the treatment of full-thickness rotator cuff tears (FT RCT). Methods We developed a decision analytic model to compare the expected incremental cost and clinical consequences for a cohort of patients with FT RCT. The probabilities for healing or failure to heal (retear) were estimated from the published literature. Implant and healthcare costs were estimated from a payor's perspective in 2021 U.S. prices. An additional analysis included indirect cost estimations (e.g., productivity losses). Sensitivity analyses explored the effect of tear size, as well as the impact of risk factors. Results The base case analysis demonstrated that resorbable bioinductive collagen implant + conventional rotator cuff repair results in incremental costs of $232,468 and an additional 18 healed RCTs per 100 treated patients over 1 year. The estimated incremental cost-effectiveness ratio (ICER) is $13,061/healed RCT compared to conventional RCR alone. When return to work was included in the model, RBI + conventional RCR was found to be cost saving. Cost-effectiveness improved with tear size with the largest benefit seen in massive tears compared to large tears, as well as patients at higher risk of retearing. Conclusions This economic analysis demonstrated that RBI + conventional RCR delivered improved healing rates at a marginal increase in costs when compared to conventional RCR alone and is, therefore, cost-effective in this patient population. Considering indirect costs, RBI + conventional RCR resulted in lower costs compared to conventional RCR alone and is, therefore, deemed to be cost saving. Level of Evidence Level IV, economic analysis.
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Arthroscopic rotator cuff repair: patients with physically demanding work have significantly worse time to return to work, level of employment, and job loss. Knee Surg Sports Traumatol Arthrosc 2023; 31:153-160. [PMID: 36163511 DOI: 10.1007/s00167-022-07172-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 09/14/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE The purpose of this study was to determine the results of arthroscopic rotator cuff repair (ARCR) in terms of return to work (RTW). METHODS Inclusion criteria were working patients who underwent ARCR for rotator cuff rupture at the study site between 2008 and 2020 and minimum 12 months of follow-up. Patients were stratified based on the physical demand of their work according to the Canadian Classification and Dictionary of Occupations. The primary outcomes were time to RTW, level of employment (LoE), change of tasks, and work loss. Secondary outcomes included the return to sports activities, EQ-VAS, EQ-5D-5L, DASH, and Oxford Shoulder Score. RESULTS Three-hundred and eighty-three patients were enrolled; at the follow-up evaluation, fifty-three patients (13.8%) lost their job, with a percentage of 34.4% (eleven patients) in the heavy-work category, and five patients (1.3%) chose early retirement. Other twenty-six patients (6.8%) had to lower their level of employment, and twenty patients (5.2%) changing their tasks, with 279 patients (72.9%) returning to their previous work activity. RTW was obtained at a mean time of 4.7 ± 4.6 months, ranging from 3.8 ± 3.1 months in the sedentary work vs 5.8 ± 2.8 months in the very heavy-work category (p = 0.015). The mean EQ-VAS score was 77.3 ± 18 points, the mean Oxford Shoulder Score was 43.4 ± 7.2 points, and the mean DASH score was 9.9 ± 14.5 points; 75.3% returned to their previous level of sport activity. CONCLUSIONS The success of ARCR in terms of RTW is not always complete and varies significantly based on the physical demand of the patient's job. Patients with physically demanding work have a significantly higher time to RTW, reduction of the LoE, and job loss rate, thus affecting the possibility to have a satisfactory return to their previous life. The findings are of clinical relevance since they can help the surgeons to give their patients reliable expectations and to correctly plan the post-operative management. LEVEL OF EVIDENCE IV.
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Lawson O, Nicholson JA, Clement ND, Rudge W, MacDonald DJ, McBirnie J. Tear size, general health status and smoking influence functional outcome at 5 years following arthroscopic rotator cuff repair. Shoulder Elbow 2022; 14:625-634. [PMID: 36479013 PMCID: PMC9720867 DOI: 10.1177/17585732211041637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 08/04/2021] [Accepted: 08/04/2021] [Indexed: 11/17/2022]
Abstract
Introduction There is limited medium-term outcome data regarding the predictors of functional outcome and patient satisfaction after arthroscopic rotator cuff repair. Methods 287 patients that underwent arthroscopic rotator cuff repair under a high-volume single surgeon were contacted at a minimum of 4 years following surgery. Patient demographics, tear size and co-morbidities were pre-operatively recorded. The Oxford shoulder score, EuroQol 5-dimensional score and patient satisfaction were recorded at final follow-up. Results 234 (81.5%) patients completed follow-up at a mean of 5.5 (4-9) years. There were 126 males and 108 females with a mean age of 60 (range 25-83) years. The majority of patients (n = 211, 90%) were satisfied with their final outcome. Multivariate linear regression analysis (R 2 = 0.64) identified that increasing tear size (p = 0.04), worsening general health assessed by the EuroQol 5-Dimensional (p < 0.001), and smoking (p = 0.049) were associated with a worse Oxford shoulder score. Logistic regression analysis (R 2 = 0.13) identified that worsening general health assessed by the EuroQol 5-Dimensional (p < 0.001), and smoking (p = 0.01) were associated with an increased risk of patient dissatisfaction. Conclusion General health status and smoking are independent predictors of functional outcome and patient satisfaction at medium-term follow-up following arthroscopic rotator cuff repair.
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Affiliation(s)
- Olivia Lawson
- Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, UK
| | | | | | - Will Rudge
- Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, UK
| | | | - Julie McBirnie
- Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, UK
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Alkaissy R, Richard M, Morris H, Snelling S, Pinchbeck H, Carr A, Mouthuy PA. Manufacture of Soft-Hard Implants from Electrospun Filaments Embedded in 3D Printed Structures. Macromol Biosci 2022; 22:e2200156. [PMID: 36048528 DOI: 10.1002/mabi.202200156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 08/14/2022] [Indexed: 01/15/2023]
Abstract
Rotator cuff tendon tears are common injuries of the musculoskeletal system that often require surgical repair. However, re-tearing following repair is a significant clinical problem, with a failure rate of up to 40%, notably at the transition from bone to tendon. The development of biphasic materials consisting of soft and hard components, which can mimic this interface, is therefore promising. Here, a simple manufacturing approach is proposed that combines electrospun filaments and 3D printing to achieve scaffolds made of a soft polydioxanone cuff embedded in a porous polycaprolactone block. The insertion area of the cuff is based on the supraspinatus tendon footprint and the size of the cuff is scaled up from 9 to 270 electrospun filaments to reach a clinically relevant strength of 227N on average. The biological evaluation shows that the biphasic scaffold components are noncytotoxic, and that tendon and bone cells can be grown on the cuff and block, respectively. Overall, these results indicate that combining electrospinning and 3D printing is a feasible and promising approach to create soft-to-hard biphasic scaffolds that can improve the outcomes of rotator cuff repair.
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Affiliation(s)
- Rand Alkaissy
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Michael Richard
- 3D LifePrints UK Ltd, Nuffield Orthopaedic Centre, Old Road, Oxford, OX3 7LD, United Kingdom
| | - Hayley Morris
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah Snelling
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Henry Pinchbeck
- 3D LifePrints UK Ltd, Nuffield Orthopaedic Centre, Old Road, Oxford, OX3 7LD, United Kingdom
| | - Andrew Carr
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Pierre-Alexis Mouthuy
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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12
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Mazuquin B, Bateman M, Realpe A, Drew S, Rees J, Littlewood C. Rehabilitation following rotator cuff repair: A survey exploring clinical equipoise among surgical members of the British Elbow and Shoulder Society. Shoulder Elbow 2022; 14:568-573. [PMID: 36199512 PMCID: PMC9527485 DOI: 10.1177/17585732211059804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND We investigated clinical equipoise across surgical members of the British Elbow and Shoulder Society (BESS) in relation to rehabilitation following rotator cuff repair. METHOD An online survey explored clinical equipoise regarding early patient-directed versus standard rehabilitation after rotator cuff repair to inform the design of a national randomised controlled trial (RCT). It described different clinical scenarios relating to patient age, tear size, location and whether other patient-related and intra-operative factors would influence equipoise. RESULTS 76 surgeons completed the survey. 81% agreed/ strongly agreed that early mobilisation might benefit recovery; 57% were neutral/ disagreed that this approach risks re-tear. 87% agreed/ strongly agreed that there is clinical uncertainty about the effectiveness of different approaches to rehabilitation. As age of the patient and tear size increased, the proportion of respondents who would agree to recruit and accept the outcome of randomisation reduced, and this was compounded if subscapularis was torn. Other factors that influenced equipoise were diabetes and non-secure repair. CONCLUSION Surgical members of BESS recognise uncertainty about the effectiveness of different approaches to rehabilitation following rotator cuff repair. We identified a range of factors that influence clinical equipoise that will be considered in the design of a new RCT.
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Affiliation(s)
- Bruno Mazuquin
- Department of Health professions, Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK,Bruno Mazuquin, Faculty of Health and Education, Brooks Building, 53 Bonsall street, Manchester, M15 6GX, UK.
| | - Marcus Bateman
- Derby Shoulder Unit, University Hospitals Derby & Burton NHS Foundation Trust, Derby, UK
| | - Alba Realpe
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Steve Drew
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Jonathan Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Chris Littlewood
- Department of Health professions, Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK
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13
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Sander IL, Dvorak N, Stebbins JA, Carr AJ, Mouthuy PA. Advanced Robotics to Address the Translational Gap in Tendon Engineering. CYBORG AND BIONIC SYSTEMS 2022; 2022:9842169. [PMID: 36285305 PMCID: PMC9508494 DOI: 10.34133/2022/9842169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/25/2022] [Indexed: 12/02/2022] Open
Abstract
Tendon disease is a significant and growing burden to healthcare systems. One strategy to address this challenge is tissue engineering. A widely held view in this field is that mechanical stimulation provided to constructs should replicate the mechanical environment of native tissue as closely as possible. We review recent tendon tissue engineering studies in this article and highlight limitations of conventional uniaxial tensile bioreactors used in current literature. Advanced robotic platforms such as musculoskeletal humanoid robots and soft robotic actuators are promising technologies which may help address translational gaps in tendon tissue engineering. We suggest the proposed benefits of these technologies and identify recent studies which have worked to implement these technologies in tissue engineering. Lastly, key challenges to address in adapting these robotic technologies and proposed future research directions for tendon tissue engineering are discussed.
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Affiliation(s)
- Iain L. Sander
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
- Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Tebbit Centre, Windmill Road, Oxford OX3 7HE, UK
| | - Nicole Dvorak
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
| | - Julie A. Stebbins
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
- Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Tebbit Centre, Windmill Road, Oxford OX3 7HE, UK
| | - Andrew J. Carr
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
| | - Pierre-Alexis Mouthuy
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
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14
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Lavoie-Gagne O, Fury MS, Mehta N, Harkin WE, Bernstein DN, Berlinberg EJ, Parvaresh K, O'Donnell E, Forsythe B. Double-Row Repair With Platelet-Rich Plasma Optimizes Retear Rates After Small to Medium Full-Thickness Rotator Cuff Repair: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Arthroscopy 2022; 38:2714-2729. [PMID: 35337958 DOI: 10.1016/j.arthro.2022.03.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the different interventions described in the literature for the surgical treatment of small and medium complete rotator cuff tears. METHODS A systematic review of randomized controlled trials of small-medium, full-thickness rotator cuff tears published since 2000 was performed. Clinical characteristics, re-tear rates, range of motion (ROM), and patient-reported outcomes (PRO) data were collected. Interventions were compared via arm-based Bayesian network meta-analysis in a random-effects model. Interventions were ranked for each domain (re-tear risk, pain, ROM, and PROs) via surface under the cumulative ranking curves. RESULTS A total of 18 studies comprising 2046 shoulders (47% females, mean age 61 ± 3 years, mean follow-up 21 ± 5 months) were included. Interventions that ranked highest for minimizing re-tear risk included arthroscopic single-row repair (A+SR) or double-row repair (A+DR) with or without platelet-rich plasma (PRP). Open repair and A+SR repair with acromioplasty (ACP) ranked highest for pain relief. Interventions that ranked highest for ROM improvement included open repair, PT, and A+DR with or without ACP. Interventions that ranked highest for PROs included arthroscopic footprint microfracture with or without SR, open repair, and A+SR with or without ACP. CONCLUSIONS Based on a network meta-analysis of level 1 studies, arthroscopic rotator cuff repair with a SR or DR construct demonstrates similar retear rates, PROs, and clinical outcomes. The highest-ranking treatment for minimizing retears was arthroscopic repair with DR constructs and PRP augmentation, although open repair and arthroscopic SR remain reliable options with excellent clinical outcomes. Addition of PRP to DR constructs trended toward a 56% decreased risk of retear as compared to DR repair alone. Although no single treatment emerged superior, several interventions offered excellent clinical improvements in pain, ROM, and PROs that exceeded minimal clinically important difference thresholds. LEVEL OF EVIDENCE I, systematic review and meta-analysis of level I studies.
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Affiliation(s)
| | - Matthew S Fury
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts, U.S.A
| | - Nabil Mehta
- Rush University Medical Center, Chicago, Illinois, U.S.A
| | | | - David N Bernstein
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts, U.S.A
| | | | | | - Evan O'Donnell
- Massachusetts General Hospital, Boston, Massachusetts, U.S.A
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15
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Holzer-Fleming C, Tavakkolizadeh A, Sinha J, Casey J, Moxham J, Colegate-Stone TJ. Value-based healthcare analysis of shoulder surgery for patients with symptomatic rotator cuff tears - Calculating the impact of arthroscopic cuff repair. Shoulder Elbow 2022; 14:59-70. [PMID: 35845620 PMCID: PMC9284256 DOI: 10.1177/1758573220928258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/30/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgical repair of full-thickness rotator cuff tears in symptomatic patients is known to offer significant benefits. Despite this there remains a lack of universal appreciation that such surgery offers high clinical value, with some commissioners even limiting access to it. The value-based healthcare agenda provides a means to design, deliver and measure the impact of healthcare to a defined segment of patients. The aim of this study was to measure the value of surgically repairing primary symptomatic full-thickness rotator cuff tears when outcomes and costs were assessed over an entire care pathway. METHODS A prospective study of patients undergoing rotator cuff tears repair was undertaken. Patients were managed using a standardised integrated care pathway. Subsequent outcomes and costs were measured over the whole care pathway. Outcomes were assessed from both traditional and patient centric re-formatted prisms. RESULTS Significant improvement in clinical outcomes where recognised when assessed from either the traditional or re-formatted prisms. Economic review of this approach revealed the pathway generated a sustainable and notable positive margin. DISCUSSION This study evidences how a well-designed value-based healthcare shoulder approach can be delivered and measured. It demonstrates rotator cuff surgery to be a high value treatment for patients with symptomatic rotator cuff tears.
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Affiliation(s)
| | | | | | | | | | - Toby J Colegate-Stone
- Toby J Colegate-Stone, Upper Limb Unit,
King's College Hospital, Denmark Hill, London SE5 9RS, UK.
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16
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Al-Tawil K, Casey J, Thayaparan P, Tavakkolizadeh A, Sinha J, Colegate-Stone T. Do partial glenohumeral degenerative changes in patients undergoing arthroscopic rotator cuff repair influence clinical outcomes? Clin Shoulder Elb 2022; 25:112-120. [PMID: 35698780 PMCID: PMC9185121 DOI: 10.5397/cise.2021.00612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/09/2022] [Indexed: 11/25/2022] Open
Abstract
Background The prognostic factors for patients with full-thickness rotator cuff tears (RCTs) include tear size, muscle atrophy and fatty infiltration. However, the influence of early coexisting degenerative changes on RCT outcomes is unappreciated. The purpose of this study was to calculate the impact that pre-existing partial glenohumeral cartilaginous changes have on patients undergoing arthroscopic RCT repair. Methods A study of 54 patients undergoing arthroscopic RCT repair was undertaken. The presence of co-existing patches of glenohumeral degenerative cartilaginous changes and RCT size was recorded at surgery. Pre- and postoperative outcomes were assessed using traditional (Oxford Shoulder Score [OSS], 5-level EuroQol-5D [EQ-5D-5L] questionnaire and EuroQol visual analog scale [EQ-VAS]) and patient-centric re-formatted prisms. Outcomes were assessed as an entire dataset, and sub-group analysis was performed according to the grade of co-existing arthritis and tear size. Results Significant improvements (p<0.05) in clinical outcomes were recognized when assessed using either the traditional or reformatted prisms (average % improvements in OSS, EQ-5D-5L and EQ-VAS were 47%, 33% and 43%, respectively; average improvements in pain, function, and psychological well-being were 48%, 33% and, 29%, respectively). Positive gain was noted in all sub-groups of arthritic grading and tear size. Conclusions Good clinical outcomes can be achieved following RCT repair even in the presence of local partial degenerative cartilage changes and advancing tear size. These benefits are patient-centered but require RCT repairability.
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17
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Metcalfe A, Parsons H, Parsons N, Brown J, Fox J, Gemperlé Mannion E, Haque A, Hutchinson C, Kearney R, Khan I, Lawrence T, Mason J, Stallard N, Underwood M, Drew S. Subacromial balloon spacer for irreparable rotator cuff tears of the shoulder (START:REACTS): a group-sequential, double-blind, multicentre randomised controlled trial. Lancet 2022; 399:1954-1963. [PMID: 35461618 DOI: 10.1016/s0140-6736(22)00652-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND New surgical procedures can expose patients to harm and should be carefully evaluated before widespread use. The InSpace balloon (Stryker, USA) is an innovative surgical device used to treat people with rotator cuff tears that cannot be repaired. We aimed to determine the effectiveness of the InSpace balloon for people with irreparable rotator cuff tears. METHODS We conducted a double-blind, group-sequential, adaptive randomised controlled trial in 24 hospitals in the UK, comparing arthroscopic debridement of the subacromial space with biceps tenotomy (debridement only group) with the same procedure but including insertion of the InSpace balloon (debridement with device group). Participants had an irreparable rotator cuff tear, which had not resolved with conservative treatment, and they had symptoms warranting surgery. Eligibility was confirmed intraoperatively before randomly assigning (1:1) participants to a treatment group using a remote computer system. Participants and assessors were masked to group assignment. Masking was achieved by using identical incisions for both procedures, blinding the operation note, and a consistent rehabilitation programme was offered regardless of group allocation. The primary outcome was the Oxford Shoulder Score at 12 months. Pre-trial simulations using data from early and late timepoints informed stopping boundaries for two interim analyses. The primary analysis was on a modified intention-to-treat basis, adjusted for the planned interim analysis. The trial was registered with ISRCTN, ISRCTN17825590. FINDINGS Between June 1, 2018, and July 30, 2020, we assessed 385 people for eligibility, of which 317 were eligible. 249 (79%) people consented for inclusion in the study. 117 participants were randomly allocated to a treatment group, 61 participants to the debridement only group and 56 to the debridement with device group. A predefined stopping boundary was met at the first interim analysis and recruitment stopped with 117 participants randomised. 43% of participants were female, 57% were male. We obtained primary outcome data for 114 (97%) participants. The mean Oxford Shoulder Score at 12 months was 34·3 (SD 11·1) in the debridement only group and 30·3 (10·9) in the debridement with device group (mean difference adjusted for adaptive design -4·2 [95% CI -8·2 to -0·26];p=0·037) favouring control. There was no difference in adverse events between the two groups. INTERPRETATION In an efficient, adaptive trial design, our results favoured the debridement only group. We do not recommend the InSpace balloon for the treatment of irreparable rotator cuff tears. FUNDING Efficacy and Mechanism Evaluation Programme, a Medical Research Council and National Institute for Health and Care Research partnership.
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Affiliation(s)
- Andrew Metcalfe
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK.
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Jaclyn Brown
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | | | - Aminul Haque
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Charles Hutchinson
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Rebecca Kearney
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Iftekhar Khan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Tom Lawrence
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - James Mason
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nigel Stallard
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Martin Underwood
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Stephen Drew
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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18
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Wang KY, Agarwal AR, Xu AL, Best MJ, Kreulen RT, Jami M, McFarland EG, Srikumaran U. Increased Risk of Surgical-Site Infection and Need for Manipulation Under Anesthesia for Those Who Undergo Open Versus Arthroscopic Rotator Cuff Repair. Arthrosc Sports Med Rehabil 2022; 4:e527-e533. [PMID: 35494279 PMCID: PMC9042754 DOI: 10.1016/j.asmr.2021.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 11/13/2021] [Indexed: 11/19/2022] Open
Abstract
Purpose Methods Results Conclusions Level of Evidence
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Affiliation(s)
- Kevin Y. Wang
- Department of Orthopaedic Surgery, Johns Hopkins, Columbia, Maryland, U.S.A
| | - Amil R. Agarwal
- Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington DC, U.S.A
| | - Amy L. Xu
- Department of Orthopaedic Surgery, Johns Hopkins, Columbia, Maryland, U.S.A
| | - Matthew J. Best
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - R. Timothy Kreulen
- Department of Orthopaedic Surgery, Johns Hopkins, Columbia, Maryland, U.S.A
| | - Meghana Jami
- Department of Orthopaedic Surgery, Johns Hopkins, Columbia, Maryland, U.S.A
| | | | - Uma Srikumaran
- Department of Orthopaedic Surgery, Johns Hopkins, Columbia, Maryland, U.S.A
- Address correspondence to Uma Srikumaran, M.D., M.B.A., M.P.H., Department of Orthopaedic Surgery, Adult Reconstruction Division, Johns Hopkins, 10700 Charter Dr., Suite 205, Columbia, MD 21044.
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19
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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. Arthroscopy 2022; 38:967-979.e4. [PMID: 34450217 DOI: 10.1016/j.arthro.2021.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 08/03/2021] [Accepted: 08/10/2021] [Indexed: 02/02/2023]
Abstract
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.
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20
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Thangarajah T, Tsuchiya S, Lukenchuk J, Lo IK. Arthroscopic Revision Rotator Cuff Repair of Large and Massive Retears using an Interpositional Bridging Dermal Allograft. JSES Int 2022; 6:643-648. [PMID: 35813153 PMCID: PMC9264011 DOI: 10.1016/j.jseint.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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21
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Yang J, Kang Y, Zhao W, Jiang J, Jiang Y, Zhao B, Jiao M, Yuan B, Zhao J, Ma B. Evaluation of patches for rotator cuff repair: A systematic review and meta-analysis based on animal studies. Bioact Mater 2021; 10:474-491. [PMID: 34901561 PMCID: PMC8633530 DOI: 10.1016/j.bioactmat.2021.08.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/12/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
Based on the published animal studies, we systematically evaluated the outcomes of various materials for rotator cuff repair in animal models and the potentials of their clinical translation. 74 animal studies were finally included, of which naturally derived biomaterials were applied the most widely (50.0%), rats were the most commonly used animal model (47.0%), and autologous tissue demonstrated the best outcomes in all animal models. The biomechanical properties of naturally derived biomaterials (maximum failure load: WMD 18.68 [95%CI 7.71–29.66]; P = 0.001, and stiffness: WMD 1.30 [95%CI 0.01–2.60]; P = 0.048) was statistically significant in the rabbit model. The rabbit model showed better outcomes even though the injury was severer compared with the rat model. The first systematic review & meta-analysis on rotator cuff patch materials. The quality of evidence for repair of rotator cuff injury with patch materials is very low. Evidence-based research is an effective way to study patch materials.
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Affiliation(s)
- Jinwei Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China.,Reproductive Medicine Center, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, 730050, China
| | - Yuhao Kang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
| | - Wanlu Zhao
- College of Biomedical Engineering, Sichuan University, Chengdu, 610064, China.,National Engineering Research Center for Biomaterials, Chengdu, 610064, China
| | - Jia Jiang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
| | - Yanbiao Jiang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Bing Zhao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Mingyue Jiao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Bo Yuan
- College of Biomedical Engineering, Sichuan University, Chengdu, 610064, China.,National Engineering Research Center for Biomaterials, Chengdu, 610064, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
| | - Bin Ma
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China
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22
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Cook JA, Baldwin M, Cooper C, Nagra NS, Crocker JC, Glaze M, Greenall G, Rangan A, Kottam L, Rees JL, Farrar-Hockley D, Merritt N, Hopewell S, Beard D, Thomas M, Dritsaki M, Carr AJ. Findings from the patch augmented rotator cuff surgery (PARCS) feasibility study. Pilot Feasibility Stud 2021; 7:163. [PMID: 34416915 PMCID: PMC8377837 DOI: 10.1186/s40814-021-00899-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 08/06/2021] [Indexed: 01/08/2023] Open
Abstract
Background A rotator cuff tear is a common disabling shoulder problem. Symptoms include pain, weakness, lack of mobility and sleep disturbance. Many patients require surgery to repair the tear; however, there is a high failure rate. There is a pressing need to improve the outcome of rotator cuff surgery. The use of patch augmentation to provide support to the healing process and improve patient outcomes holds new promise. Different materials (e.g. human/animal skin or intestine tissue, and completely synthetic materials) and processes (e.g. woven or a mesh) have been used to produce patches. However, clinical evidence on their use is limited. The patch augmented rotator cuff surgery (PARCS) feasibility study aimed to determine the design of a definitive randomised controlled trial (RCT) assessing the effectiveness and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and feasible. Methods A mixed methods feasibility study of conducing a subsequent RCT. The project involved six stages: a systematic review of clinical evidence; a survey of the British Elbow and Shoulder Society’s (BESS) surgical membership; a survey of surgeon trialists; focus groups and interviews with stakeholders; a two-round Delphi study administered via online questionnaires and a 2-day consensus meeting. Results The BESS surgeons’ survey identified a variety of patches in use (105 (21%) responses received). Twenty-four surgeons (77%) completed the trialist survey relating to trial design. Four focus groups were conducted involving 24 stakeholders. Twenty-nine (67% of invited) individuals took part in the Delphi. Differing views were held on a number of aspects including the appropriate patient population for trial participation. Agreement on the key research questions and the outline of two potential RCTs were achieved through the Delphi study and the consensus meeting. Conclusions Randomised comparisons of on-lay patch use for completed rotator cuff repairs, and bridging patch use for partial rotator cuff repairs were identified as areas for further research. The value of an observational study to assess safety concerns of patch use was also highlighted. The main limitation was that the findings were influenced by the participants, who might not necessarily reflect all stakeholders.
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Affiliation(s)
- Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Mathew Baldwin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Navraj S Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joanna C Crocker
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.,National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK
| | - Molly Glaze
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Gemma Greenall
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,The James Cook University Hospital, South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | - Lucksy Kottam
- The James Cook University Hospital, South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | - Jonathan L Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Dair Farrar-Hockley
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Naomi Merritt
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Melina Dritsaki
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Thangarajah T, Tsuchiya S, Lo IK. Protocol for a Retrospective Comparative Study to Determine the Effect of Two Different Biocomposite Suture Anchors on the Occurrence of Bony Ingrowth and Implant Reabsorption Following Arthroscopic Rotator Cuff Repair. Int J Surg Protoc 2021; 25:147-153. [PMID: 34395961 PMCID: PMC8323536 DOI: 10.29337/ijsp.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/29/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Surgical treatment of rotator cuff tears commonly entails reattachment of the ruptured tendon to its bony insertion using suture anchors. Suture anchor design has evolved from solid metal anchors to vented biocomposite anchors with potentially biologic consequences. Few studies have investigated the differences between different modern anchor design and materials, making it difficult to justify their use or cost. Objective To compare the rate of bony ingrowth and implant resorption between a coil-type open-architecture biocomposite suture anchor and a vented screw-type biocomposite suture anchor, used for arthroscopic double-row rotator cuff repair. Methods and analysis In this retrospective comparative study, a consecutive series of patients who undergo a double row rotator cuff repair using a coil-type open architecture biocomposite suture anchor in the medial row and a vented screw-type biocomposite suture anchor in the lateral row will be included. A sample size calculation demonstrated that 16 participants are required in each group. Primary outcome measures will be bony ingrowth and reabsorption of the suture anchor as measured on computed tomography (CT). Secondary outcomes will include patient reported outcome measures (The American Shoulder and Elbow Surgeons score and The Western Ontario Rotator Cuff questionnaire), range of motion, postoperative tendon integrity, and cyst formation. Highlights Open-architecture suture anchors facilitate the release of marrow constituents.The rate of bony ingrowth for coil- and screw-type anchors will be assessed.The difference in functional outcome between the two anchors will be assessed.
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Affiliation(s)
- Tanujan Thangarajah
- Department of Surgery, Section of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Saho Tsuchiya
- Department of Surgery, Section of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Ian K Lo
- Department of Surgery, Section of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
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Littlewood C, Bateman M, Butler-Walley S, Bathers S, Bromley K, Lewis M, Funk L, Denton J, Moffatt M, Winstanley R, Mehta S, Stephens G, Dikomitis L, Foster NE. Rehabilitation following rotator cuff repair: A multi-centre pilot & feasibility randomised controlled trial (RaCeR). Clin Rehabil 2021; 35:829-839. [PMID: 33305619 PMCID: PMC8191146 DOI: 10.1177/0269215520978859] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 11/16/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the feasibility of a multi-centre randomised controlled trial to compare the clinical and cost-effectiveness of early patient-directed rehabilitation versus standard rehabilitation following surgical repair of the rotator cuff of the shoulder. DESIGN Two-arm, multi-centre pilot and feasibility randomised controlled trial. SETTING Five National Health Service hospitals in England. PARTICIPANTS Adults (n = 73) with non-traumatic rotator cuff tears scheduled for repair were recruited and randomly allocated remotely prior to surgery. INTERVENTIONS Early patient-directed rehabilitation (n = 37); advised to remove their sling as soon as able and move as symptoms allow. Standard rehabilitation (n = 36); sling immobilisation for four weeks. MEASURES (1) Randomisation of 20% or more eligible patients. (2) Difference in time out of sling of 40% or more between groups. (3) Follow-up greater than 70%. RESULTS 73/185 (39%) potentially eligible patients were randomised. Twenty participants were withdrawn, 11 due to not receiving rotator cuff repair. The between-group difference in proportions of participants who exceeded the cut-off of 222.6 hours out of the sling was 50% (80% CI = 29%, 72%), with the early patient-directed rehabilitation group reporting greater time out of sling. 52/73 (71%) and 52/53 (98%) participants were followed-up at 12 weeks when withdrawals were included and excluded respectively. Eighteen full-thickness re-tears were reported (early patient-directed rehabilitation = 7, standard rehabilitation = 11). Five serious adverse events were reported. CONCLUSION A main randomised controlled trial is feasible but would require allocation of participants following surgery to counter the issue of withdrawal due to not receiving surgery.
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Affiliation(s)
- Chris Littlewood
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Staffordshire, UK
- Department of Health Professions, Faculty of Health, Psychology & Social Care, Manchester Metropolitan University, Manchester, Greater Manchester, UK
| | - Marcus Bateman
- Derby Shoulder Unit, University Hospitals Derby & Burton NHS Foundation Trust, Derby, UK
| | | | - Sarah Bathers
- Keele Clinical Trials Unit, School Medicine, Keele University, Staffordshire, UK
| | - Kieran Bromley
- Keele Clinical Trials Unit, School Medicine, Keele University, Staffordshire, UK
| | - Martyn Lewis
- Keele Clinical Trials Unit, School Medicine, Keele University, Staffordshire, UK
| | - Lennard Funk
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Jean Denton
- The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, Shropshire, UK
| | - Maria Moffatt
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Rachel Winstanley
- Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke, UK
| | - Saurabh Mehta
- Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke, UK
| | - Gareth Stephens
- The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Lisa Dikomitis
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Nadine E Foster
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Staffordshire, UK
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25
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Mazuquin B, Moffatt M, Gill P, Selfe J, Rees J, Drew S, Littlewood C. Effectiveness of early versus delayed rehabilitation following rotator cuff repair: Systematic review and meta-analyses. PLoS One 2021; 16:e0252137. [PMID: 34048450 PMCID: PMC8162656 DOI: 10.1371/journal.pone.0252137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/10/2021] [Indexed: 12/02/2022] Open
Abstract
Objective To investigate the effectiveness of early rehabilitation compared with delayed/standard rehabilitation after rotator cuff repair for pain, function, range of movement, strength, and repair integrity. Design Systematic review and meta-analyses. Methods We searched databases and included randomised controlled trials (RCTs) comparing early with delayed/standard rehabilitation for patients undergoing rotator cuff repair surgery. We assessed risk of bias of the RCTs using the Cochrane RoB 2 tool. Results Twenty RCTs, with 1841 patients, were included. The majority of the RCTs were of high or unclear risk of overall bias. We found substantial variations in the rehabilitation programmes, time in the sling and timing of exercise progression. We found no statistically significant differences for pain and function at any follow-up except for the outcome measure Single Assessment Numeric Evaluation at six months (MD: 6.54; 95%CI: 2.24–10.84) in favour of early rehabilitation. We found statistically significant differences in favour of early rehabilitation for shoulder flexion at six weeks (MD: 7.36; 95%CI: 2.66–12.06), three (MD: 8.45; 95%CI: 3.43–13.47) and six months (MD: 3.57; 95%CI: 0.81–6.32) and one year (MD: 1.42; 95%CI: 0.21–2.64) and similar differences for other planes of movement. In terms of repair integrity, early mobilisation does not seem to increase the risk of re-tears (OR:1.05; 95%CI: 0.64–1.75). Discussion Current approaches to early mobilisation, based largely on early introduction of passive movement, did not demonstrate significant differences in most clinical outcomes, although we found statistically significant differences in favour of early rehabilitation for range of movement. Importantly, there were no differences in repair integrity between early and delayed/standard rehabilitation. Most rehabilitation programmes did not consider early active movement as soon as the patient feels able. With ongoing variation in rehabilitation protocols there remains a need for large high quality RCT to inform the optimal approach to rehabilitation after rotator cuff repair surgery.
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Affiliation(s)
- Bruno Mazuquin
- Department of Health Professions, Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, United Kingdom
- * E-mail:
| | - Maria Moffatt
- Department of Health Professions, Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, United Kingdom
| | - Peter Gill
- Department of Health Professions, Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, United Kingdom
- Northern Care Alliance NHS Group, Manchester, United Kingdom
| | - James Selfe
- Department of Health Professions, Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, United Kingdom
| | - Jonathan Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford and NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Steve Drew
- University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
| | - Chris Littlewood
- Department of Health Professions, Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, United Kingdom
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26
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Prinja A, Sabharwal S, Moshtael S, Dey P, Monga P. Measuring outcomes in rotator cuff disorders. J Clin Orthop Trauma 2021; 19:187-191. [PMID: 34141572 PMCID: PMC8178113 DOI: 10.1016/j.jcot.2021.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022] Open
Abstract
Measuring the outcome of treatment for rotator cuff disorders has evolved over the last three decades. Objective surgeon-derived outcomes such as clinical examination findings and imaging of the rotator cuff have the limitation of marginalising the patients perception of their condition. Patient reported outcome measures (PROMs) have evolved and become popular in an attempt to demonstrate meaningful outcome data. There are a large number in use today and as a result, the heterogeneity of scores used across the literature can make comparison difficult. Patient reported outcome scores can be general health related quality of life scores, joint-specific and disease specific. Qualitative outcomes are also being used now, and these help us to better understand the context of quantitative research scores. In this article, we provide an overview of the outcome measures used in rotator cuff disorders.
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Affiliation(s)
- Aditya Prinja
- Upper Limb Unit, Wrightington Hospital, Wigan, UK,Corresponding author.
| | | | | | - Paola Dey
- Faculty of Health, Social Care & Medicine, Edge Hill University, Lancashire, UK
| | - Puneet Monga
- Upper Limb Unit, Wrightington Hospital, Wigan, UK
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27
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Nezhentsev A, Abhari RE, Baldwin MJ, Mimpen JY, Augustyniak E, Isaacs M, Mouthuy PA, Carr AJ, Snelling SJB. In vitro evaluation of the response of human tendon-derived stromal cells to a novel electrospun suture for tendon repair. TRANSLATIONAL SPORTS MEDICINE 2021; 4:409-418. [PMID: 35571511 PMCID: PMC7612718 DOI: 10.1002/tsm2.233] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Recurrent tears after surgical tendon repair remain common. Repair failures can be partly attributed to the use of sutures not designed for the tendon cellular niche nor for the promotion of repair processes. Synthetic electrospun materials can mechanically support the tendon whilst providing topographical cues that regulate cell behaviour. Here, a novel electrospun suture made from twisted polydioxanone (PDO) polymer filaments is compared to PDS II, a clinically-used PDO suture currently utilised in tendon repair. We evaluated the ability of these sutures to support the attachment and proliferation of human tendon-derived stromal cells using PrestoBlue and Scanning Electron Microscopy. Suture surface chemistry was analysed using X-ray Photoelectron Spectroscopy. Bulk RNA-Seq interrogated the transcriptional response of primary tendon-derived stromal cells to sutures after 14 days. Electrospun suture showed increased initial cell attachment and a stronger transcriptional response compared to PDS II, with relative enrichment of pathways including mTorc1 signalling and depletion of epithelial mesenchymal transition. Neither suture induced transcriptional upregulation of inflammatory pathways compared to baseline. Twisted electrospun sutures therefore show promise in improving outcomes in surgical tendon repair by allowing increased cell attachment whilst maintaining an appropriate tissue response.
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Affiliation(s)
- Andrey Nezhentsev
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Roxanna E Abhari
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mathew J Baldwin
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jolet Y Mimpen
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Edyta Augustyniak
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mark Isaacs
- Department of Chemistry, University College London, 20 Gordon St, Bloomsbury, London WC1H 0AJ
- HarwellXPS, Research Complex at Harwell, Rutherford Appleton Laboratories, Harwell Campus, OX11 0DE
| | - Pierre-Alexis Mouthuy
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah J B Snelling
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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28
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Audigé L, Bucher HCC, Aghlmandi S, Stojanov T, Schwappach D, Hunziker S, Candrian C, Cunningham G, Durchholz H, Eid K, Flury M, Jost B, Lädermann A, Moor BK, Moroder P, Rosso C, Schär M, Scheibel M, Spormann C, Suter T, Wieser K, Zumstein M, Müller AM. Swiss-wide multicentre evaluation and prediction of core outcomes in arthroscopic rotator cuff repair: protocol for the ARCR_Pred cohort study. BMJ Open 2021; 11:e045702. [PMID: 33888530 PMCID: PMC8070866 DOI: 10.1136/bmjopen-2020-045702] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 03/20/2021] [Accepted: 03/22/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION In the field of arthroscopic rotator cuff repair (ARCR), reporting standards of published studies differ dramatically, notably concerning adverse events (AEs). In addition, prognostic studies are overall methodologically poor, based on small data sets and explore only limited numbers of influencing factors. We aim to develop prognostic models for individual ARCR patients, primarily for the patient-reported assessment of shoulder function (Oxford Shoulder Score (OSS)) and the occurrence of shoulder stiffness 6 months after surgery. We also aim to evaluate the use of a consensus core event set (CES) for AEs and validate a severity classification for these events, considering the patient's perspective. METHODS AND ANALYSIS A cohort of 970 primary ARCR patients will be prospectively documented from several Swiss and German orthopaedic clinics up to 24 months postoperatively. Patient clinical examinations at 6 and 12 months will include shoulder range of motion and strength (Constant Score). Tendon repair integrity status will be assessed by ultrasound at 12 months. Patient-reported questionnaires at 6, 12 and 24 months will determine functional scores (subjective shoulder value, OSS), anxiety and depression scores, working status, sports activities, and quality of life (European Quality of Life 5 Dimensions 5 Level questionnaire). AEs will be documented according to a CES. Prognostic models will be developed using an internationally supported regression methodology. Multiple prognostic factors, including patient baseline demographics, psychological, socioeconomic and clinical factors, rotator cuff integrity, concomitant local findings, and (post)operative management factors, will be investigated. ETHICS AND DISSEMINATION This project contributes to the development of personalised risk predictions for supporting the surgical decision process in ARCR. The consensus CES may become an international reference for the reporting of complications in clinical studies and registries. Ethical approval was obtained on 1 April 2020 from the lead ethics committee (EKNZ, Basel, Switzerland; ID: 2019-02076). All participants will provide informed written consent before enrolment in the study. TRIAL REGISTRATION NUMBER NCT04321005. PROTOCOL VERSION Version 2 (13 December 2019).
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Affiliation(s)
- Laurent Audigé
- Research and Development, Schulthess Klinik, Zurich, Switzerland
- Orthopaedic Surgery and Traumatology, University Hospital Basel, Basel, Switzerland
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Heiner C C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Soheila Aghlmandi
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Thomas Stojanov
- Research and Development, Schulthess Klinik, Zurich, Switzerland
- Orthopaedic Surgery and Traumatology, University Hospital Basel, Basel, Switzerland
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - David Schwappach
- Swiss Patient Safety Foundation, Zurich, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Sabina Hunziker
- Medical Communication/Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Christian Candrian
- Trauma and Ortho Unit, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Gregory Cunningham
- Shoulder Center, Hirslanden Clinique La Colline, Geneva, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneve, Switzerland
| | | | - Karim Eid
- Clinic for Orthopaedics and Traumatology, Baden Cantonal Hospital, Baden, Switzerland
| | - Matthias Flury
- Center for Orthopaedics and Neurosurgery, In-Motion, Wallisellen, Switzerland
| | - Bernhard Jost
- Clinic for Orthopaedic Surgery and Traumatology of the Musculoskeletal System, Cantonal Hospital of St.Gallen, St Gallen, Switzerland
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneve, Switzerland
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | - Beat Kaspar Moor
- Service for Orthopaedics and Traumatology of the Musculoskeletal System, Hôpital du Valais - Centre Hospitalier du Valais Romand, Martigny, Switzerland
| | - Philipp Moroder
- Department of Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charitè Medicine University, Berlin, Germany
| | - Claudio Rosso
- Shoulder and Elbow Center, Arthro Medics, Basel, Switzerland
| | - Michael Schär
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus Scheibel
- Department of Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charitè Medicine University, Berlin, Germany
- Shoulder and Elbow Surgery, Schulthess Klinik, Zurich, Switzerland
| | - Christophe Spormann
- Center for Endoprosthetics and Joint Surgery, Endoclinic, Zürich, Switzerland
| | - Thomas Suter
- Orthopaedic Shoulder and Elbow, Canton Hospital Baselland, Bruderholz, Switzerland
| | - Karl Wieser
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Matthias Zumstein
- Shoulder, Elbow and Orthopaedic Sports Medicine, Orthopaedics Sonnenhof, Bern, Switzerland
- Campus SLB, Swiss Institute for Translational and Entrepreneurial Medicine, Stiftung Lindenhof, Bern, Switzerland
| | - Andreas M Müller
- Orthopaedic Surgery and Traumatology, University Hospital Basel, Basel, Switzerland
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Mohammed KD, Lloyd RFW, Nagaraj C, Krishnan J. The Relevance of Open Rotator Cuff Repair in 2021. Indian J Orthop 2021; 55:433-442. [PMID: 33927822 PMCID: PMC8046857 DOI: 10.1007/s43465-020-00345-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 12/30/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The last decade has seen a large increase in rotator cuff surgery and arthroscopic surgery. We were asked to define the relevance of open rotator cuff repair in 2021. PURPOSE To define whether there are proven advantages to arthroscopic or open rotator cuff repair surgery. METHOD We reviewed the recent literature regarding recent trends, anaesthetic time, rehabilitation, post-operative pain, complications, economic considerations, the learning curve and outcomes. We outlined the senior authors' technique preferences, rationale and patient reported outcomes. RESULTS There is no clear evidence of proven advantage in arthroscopic rotator cuff repair compared to open rotator cuff repairs, with regard to outcomes or the other aspects reviewed. There were no differences in the outcomes of arthroscopic and open repairs in the senior authors practice with his procedure indications. CONCLUSIONS Open rotator cuff repair surgery remains a valid option and has some appeal in specific indications and in settings where arthroscopic resources are limited. We believe surgeons should learn both techniques and the principles of good patient selection, tissue handling, and fixation techniques are of paramount importance in both arthroscopic and open rotator cuff surgery.
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Affiliation(s)
- Khalid D. Mohammed
- grid.410864.f0000 0001 0040 0934Department of Orthopaedic Surgery, Canterbury District Health Board, Christchurch, New Zealand ,grid.29980.3a0000 0004 1936 7830Department of Orthopaedic Surgery & Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | - Richard F. W. Lloyd
- grid.410864.f0000 0001 0040 0934Department of Orthopaedic Surgery, Canterbury District Health Board, Christchurch, New Zealand ,grid.29980.3a0000 0004 1936 7830Department of Orthopaedic Surgery & Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | | | - Jegan Krishnan
- grid.414925.f0000 0000 9685 0624Department of Orthopaedic Surgery, Flinders Medical Centre and Repatriation General Hospital, Adelaide, SA Australia ,grid.1014.40000 0004 0367 2697Department of Orthopaedic Surgery, Flinders University, Adelaide, SA Australia
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30
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Morris JH, Malik AT, Hatef S, Neviaser AS, Bishop JY, Cvetanovich GL. Cost of Arthroscopic Rotator Cuff Repairs Is Primarily Driven by Procedure-Level Factors: A Single-Institution Analysis of an Ambulatory Surgery Center. Arthroscopy 2021; 37:1075-1083. [PMID: 33242633 DOI: 10.1016/j.arthro.2020.11.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 11/06/2020] [Accepted: 11/06/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To identify intraoperative drivers of cost associated with arthroscopic rotator cuff repairs (RCRs) through analysis of an institutional database. METHODS This was a single-institution retrospective review of arthroscopic RCRs performed at an ambulatory surgical center between November 2016 and July 2019. Patient-level factors analyzed included age, sex, insurance type (private, Medicare, Medicaid, self-pay, and other government), American Society of Anesthesiologists grade (I, II, III, and missing), and Charlson comorbidity index (0, 1, 2, and ≥3). Procedure-level factors included use of biologics (decellularized dermal allograft or bioinductive healing implant), anesthesia type (regional block, monitored anesthesia care, or general), number of anchors and sutures, additional procedures (biceps tenodesis, distal clavicle resection, subacromial decompression), and operative time. Multivariate linear regression analysis was used to identify factors significantly associated with higher or lower charges. RESULTS A total of 712 arthroscopic RCRs were included. The risk-adjusted operative charges were $19,728 (95% confidence interval $16,543 to $22,913). The above factors predicted nearly 65% of the variability in operative charges. The only patient-level factor significantly associated with lower charges was female sex (- $1,339; P = .002). Procedure-level factors significantly associated with higher charges were use of biologics (+ $17,791; P < .001), concurrent open biceps tenodesis (+ $4,027; P < .001), distal clavicle resection (+ $2,266; P = .039), use of regional block (+ $1,256; P = .004), number of anchors (+ $2,245/anchor; P < .001), and increasing operative time ($26/min). Other factors had no significant association. CONCLUSIONS Procedural factors are the most significant drivers of operative cost in arthroscopic RCRs, such as quantity and type of implants; additional procedures such as biceps tenodesis and distal clavicle resection; and perioperative conditions such as type of anesthesia and total operating room time. Overall, patient-level factors were not shown to correlate well with operative costs, other than lower charges with female sex. LEVEL OF EVIDENCE IV, economic study.
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Affiliation(s)
- Jesse H Morris
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Azeem T Malik
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Sarah Hatef
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Andrew S Neviaser
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Julie Y Bishop
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Gregory L Cvetanovich
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A..
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31
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Lu Y, Beletsky A, Chahla J, Patel BH, Verma NN, Cole BJ, Forsythe B. How can we define clinically important improvement in pain scores after biceps tenodesis? J Shoulder Elbow Surg 2021; 30:430-438. [PMID: 32593673 DOI: 10.1016/j.jse.2020.05.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/22/2020] [Accepted: 05/24/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patient postoperative pain is an important consideration following biceps tenodesis. The visual analog scale (VAS) for pain is one of the most commonly used measures for perioperative pain assessment. Currently, there is limited understanding of clinically significant improvement in VAS pain. PURPOSE To define the substantial clinical benefit (SCB), patient acceptable symptomatic state (PASS), and minimal clinically important difference (MCID) for the VAS pain score in patients undergoing open subpectoral (OSPBT) or arthroscopic suprapectoral biceps tenodesis (ASPBT) at 1 year from surgery; and to identify preoperative predictors of achieving each outcome end point. METHODS Data from consecutive patients who underwent isolated biceps tenodesis between January 2014 and March 2017 were collected and analyzed. Baseline data and postoperative patient-reported outcome (PRO) scores were recorded at 1 year postoperatively. In order to quantify the clinical significance of outcome achievement for the VAS pain score, the MCID, PASS, and SCB were calculated. RESULTS A total of 165 patients were included in the final analysis. The VAS pain score threshold for achieving MCID was defined as a decrease of 12.9 (0-100). PASS was defined as achieving a 2-year postoperative score of 27.4 points (0-100), and SCB was defined as a decrease of 25.1 (0-100) at 1-year follow-up. The rates of achieving MCID, PASS, and SCB were 73.3%, 52.8%, and 45.9%, respectively. Multivariate regression analysis demonstrated that ASPBT (P = .01) and a lower preoperative Constant-Murley score were predictive of achieving the MCID (P = .01). In contrast, a lower preoperative score on the SF-12 Physical Component Summary (P = .01) and a higher score on the preoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (P < .001) were predictive of achieving the SCB and PASS, respectively. Preoperative duration of symptoms >6 months was predictive of a reduced likelihood to achieve PASS. CONCLUSION This study identified scores for VAS pain that can be used to define clinically significant outcome after biceps tenodesis. Specifically, a decrease in pain score of 12.9 was a clinically important improvement in VAS pain, whereas a decrease of 25.1 represented the upper threshold of VAS pain improvement. Additionally, there were both modifiable and nonmodifiable factors that predicted achieving clinically significant levels of postoperative pain improvement.
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Affiliation(s)
- Yining Lu
- Department of Orthopaedics and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alexander Beletsky
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Jorge Chahla
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Bhavik H Patel
- Department of Orthopaedics, University of Illinois College of Medicine, Chicago, IL, USA
| | - Nikhil N Verma
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Brian J Cole
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Brian Forsythe
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA.
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Cost-effectiveness analysis of arthroscopic surgery versus open surgery in rotator cuff repair. MARMARA MEDICAL JOURNAL 2021. [DOI: 10.5472/marumj.869051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Littlewood C, Wade J, Butler-Walley S, Lewis M, Beard D, Rangan A, Bhabra G, Kalogrianitis S, Kelly C, Mehta S, Singh HP, Smith M, Tambe A, Tyler J, Foster NE. Protocol for a multi-site pilot and feasibility randomised controlled trial: Surgery versus PhysiothErapist-leD exercise for traumatic tears of the rotator cuff (the SPeEDy study). Pilot Feasibility Stud 2021; 7:17. [PMID: 33413664 PMCID: PMC7788278 DOI: 10.1186/s40814-020-00714-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/27/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Clinically, a distinction is made between types of rotator cuff tear, traumatic and non-traumatic, and this sub-classification currently informs the treatment pathway. It is currently recommended that patients with traumatic rotator cuff tears are fast tracked for surgical opinion. However, there is uncertainty about the most clinically and cost-effective intervention for patients with traumatic rotator cuff tears and further research is required. SPeEDy will assess the feasibility of a fully powered, multi-centre randomised controlled trial (RCT) to test the hypothesis that, compared to surgical repair (and usual post-operative rehabilitation), a programme of physiotherapist-led exercise is not clinically inferior, but is more cost-effective for patients with traumatic rotator cuff tears. METHODS SPeEDy is a two-arm, multi-centre pilot and feasibility RCT with integrated Quintet Recruitment Intervention (QRI) and further qualitative investigation of patient experience. A total of 76 patients with traumatic rotator cuff tears will be recruited from approximately eight UK NHS hospitals and randomly allocated to either surgical repair and usual post-operative rehabilitation or a programme of physiotherapist-led exercise. The QRI is a mixed-methods approach that includes data collection and analysis of screening logs, audio recordings of recruitment consultations, interviews with patients and clinicians involved in recruitment, and review of study documentation as a basis for developing action plans to address identified difficulties whilst recruitment to the RCT is underway. A further sample of patient participants will be purposively sampled from both intervention groups and interviewed to explore reasons for initial participation, treatment acceptability, reasons for non-completion of treatment, where relevant, and any reasons for treatment crossover. DISCUSSION Research to date suggests that there is uncertainty regarding the most clinically and cost-effective interventions for patients with traumatic rotator cuff tears. There is a clear need for a high-quality, fully powered, RCT to better inform clinical practice. Prior to this, we first need to undertake a pilot and feasibility RCT to address current uncertainties about recruitment, retention and number of and reasons for treatment crossover. TRIAL REGISTRATION ClinicalTrials.gov ( NCT04027205 ) - Registered on 19 July 2019. Available via.
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Affiliation(s)
- Chris Littlewood
- School of Primary, Community and Social Care, Keele University, Staffordshire, UK.
- Department of Health Professions, Faculty of Health, Psychology & Social Care, Manchester Metropolitan University, Manchester, UK.
| | - Julia Wade
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Stephanie Butler-Walley
- School of Primary, Community and Social Care, Keele University, Staffordshire, UK
- Keele Clinical Trials Unit, Keele University, Keele, UK
| | - Martyn Lewis
- School of Primary, Community and Social Care, Keele University, Staffordshire, UK
- Keele Clinical Trials Unit, Keele University, Keele, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Health Sciences & Hull York Medical School, University of York, York, UK
| | - Gev Bhabra
- University Hospitals Coventry & Warwickshire, Coventry, UK
| | - Socrates Kalogrianitis
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Cormac Kelly
- The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, UK
| | - Saurabh Mehta
- Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke, UK
| | - Harvinder Pal Singh
- Leicester Shoulder Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Matthew Smith
- The Liverpool Upper Limb Unit, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Amol Tambe
- Derby Shoulder Unit, University Hospitals Derby & Burton NHS Foundation Trust, Derby, UK
| | - James Tyler
- Airedale General Hospital, Airedale NHS Foundation Trust, Keighley, UK
| | - Nadine E Foster
- School of Primary, Community and Social Care, Keele University, Staffordshire, UK
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Pierami R, Antonioli E, Oliveira I, Castro IQ, Manente F, Fairbanks P, Carrera EDF, Matsumura BA, Lenza M. Clinical outcomes and cost-utility of rotator cuff repair surgery by open and arthroscopic techniques: study protocol for a randomised clinical trial. BMJ Open 2020; 10:e043126. [PMID: 33372080 PMCID: PMC7772301 DOI: 10.1136/bmjopen-2020-043126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Rotator cuff injuries account for up to 70% of pain in the shoulder. However, there remains no consensus on the best surgical treatment for patients with rotator cuff injuries, in terms of the cost-effectiveness and cost-utility of open and arthroscopic methods for rotator cuff repair. The objective of this trial is to compare the efficacy, cost-effectiveness and cost-utility of open and arthroscopic procedures for rotator cuff repair. METHODS AND ANALYSIS The trial is a two-group, parallel-design, randomised controlled trial. A total of 100 patients with symptomatic rotator cuff lesions will be allocated in either open or arthroscopic technique in a 1:1 ratio, considering smoking (yes or no), lesion size (≤3 cm or >3 cm) and diabetes (present or absent) as stratification factors. All patients will be included in the same rehabilitation programme after the intervention. The primary outcome measure will be the Constant-Murley Score and the EuroQol-5D-3L score at 48 weeks postsurgery. Secondary outcomes include cost-effectiveness, cost-utility, pain, complications and clinical analysis, using the Simple Shoulder Test, Visual Analogue Pain Scale (VAS), integrity of the repair evaluated through MRI, and complications and failures of the proposed methods. For the cost-effectiveness analysis, we will use the VAS and the Constant-Murley Score as measures of effectiveness. For the cost-utility analysis, we will use the EuroQol-5D-3L as a measure of utility in terms of incremental cost per quality-adjusted life-years. ETHICS AND DISSEMINATION The study has been approved by the local research ethics committee of both institutions: Hospital Israelita Albert Einstein and Hospital Alvorada Moema/Hospital Pró-Cardíaco. The results will be published in a peer-reviewed, open access journal. TRIAL REGISTRATION NUMBER NCT04146987.
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Affiliation(s)
- Rafael Pierami
- Departamento de Ortopedia, Grupo de Ombro e Cotovelo do Hospital Alvorada Moema, Sao Paulo, Sao Paulo, Brazil
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Eliane Antonioli
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Isadora Oliveira
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | | | - Felipe Manente
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Sao Paulo, SP, Brazil
| | - Paula Fairbanks
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Sao Paulo, SP, Brazil
| | - Eduardo da Frota Carrera
- Departamento de Ortopedia, Grupo de Ombro e Cotovelo do Hospital Alvorada Moema, Sao Paulo, Sao Paulo, Brazil
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Bruno Akio Matsumura
- Departamento de Ortopedia, Grupo de Ombro e Cotovelo do Hospital Alvorada Moema, Sao Paulo, Sao Paulo, Brazil
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Mario Lenza
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Sao Paulo, SP, Brazil
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Stephens G, Littlewood C, Foster NE, Dikomitis L. Rehabilitation following rotator cuff repair: A nested qualitative study exploring the perceptions and experiences of participants in a randomised controlled trial. Clin Rehabil 2020; 35:911-919. [PMID: 33356517 PMCID: PMC8191163 DOI: 10.1177/0269215520984025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate acceptability, barriers to adherence with the interventions, and which outcome measures best reflect the participants' rehabilitation goals in a pilot and feasibility randomised controlled trial evaluating early patient-directed rehabilitation and standard rehabilitation, including sling immobilisation for four weeks, following surgical repair of the rotator cuff of the shoulder. DESIGN Nested qualitative study. SETTING Five English National Health Service Hospitals. SUBJECTS Nineteen patient participants who had undergone surgical repair of the rotator cuff and 10 healthcare practitioners involved in the trial. METHOD Individual semi-structured interviews. Data were analysed thematically. RESULTS Four themes: (1) Preconceptions of early mobilisation; many participants were motivated to enter the trial for the opportunity of removing their sling and getting moving early. (2) Sling use and movement restrictions; for some, sling use for four weeks was unacceptable and contributed to their pain, rather than relieving it. (3) Tensions associated with early mobilisation; clinical tensions regarding early mobilisation and the perceived risk to the surgical repair were apparent. (4) Processes of running the trial; participants found the trial processes to be largely appropriate and acceptable, but withholding the results of the post-operative research ultrasound scan was contentious. CONCLUSION Trial processes were largely acceptable, except for withholding results of the ultrasound scan. For some participants, use of the shoulder sling for a prolonged period after surgery was a reported barrier to standard rehabilitation whereas the concept of early mobilisation contributed tension for some healthcare practitioners due to concern about the effect on the surgical repair.
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Affiliation(s)
- Gareth Stephens
- The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Chris Littlewood
- Department of Health Professions, Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, UK.,Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Staffordshire, UK
| | - Nadine E Foster
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Staffordshire, UK
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Wang J, Wang L, Gao Y, Zhang Z, Huang X, Han T, Liu B, Zhang Y, Li Y, Zhang L. Synergistic Therapy of Celecoxib-Loaded Magnetism-Responsive Hydrogel for Tendon Tissue Injuries. Front Bioeng Biotechnol 2020; 8:592068. [PMID: 33330423 PMCID: PMC7729092 DOI: 10.3389/fbioe.2020.592068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/12/2020] [Indexed: 11/13/2022] Open
Abstract
Tendon tissue injury is very common and always associated with pain, tissue swelling and even malformation if not treated on time. Traditional therapeutic strategies, such as cryotherapy, electrical therapy, ultrasound therapy and anti-inflammatory drug, are still unsatisfying. In this work, a synergistic therapy, based on the combination of celecoxib drug and pulsed electromagnetic field (PEMF) regimens, was developed for the treatment of tendon injury. This celecoxib-loaded magnetism-responsive hydrogel dressing (gelatin/Fe3O4/celecoxib) showed good biocompatibility and coordinated drug release behavior under the PEMF, which could effectively reduce the inflammatory reaction of macrophage cells with the incremental proportion of M2 macrophages at the injury site. CatWalk gait analysis further verified this synergistic effect of combination therapy for achieving the outstanding recovery of the injured tendon tissue. Thus, this magnetism-responsive hydrogel may represent a promising alternative strategy in clinics for promoting tendon healing.
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Affiliation(s)
- Jingxin Wang
- Department of Rehabilitation, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Likang Wang
- Department of Rehabilitation Medicine, The Third Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yueming Gao
- Department of Rehabilitation Medicine, The Second Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Zhao Zhang
- Graduate School, Chinese PLA General Hospital, Beijing, China
| | - Xiaofeng Huang
- Department of Endocrinology, The Second Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Tong Han
- Department of Rehabilitation, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Biyuan Liu
- Department of Rehabilitation, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Yujie Zhang
- Department of Epidemiology, School of Public Health Southern Medical University, Guangzhou, China
| | - Yilan Li
- Department of Rehabilitation, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Lining Zhang
- Department of Rehabilitation Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
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Brealey S, Northgraves M, Kottam L, Keding A, Corbacho B, Goodchild L, Srikesavan C, Rex S, Charalambous CP, Hanchard N, Armstrong A, Brooksbank A, Carr A, Cooper C, Dias J, Donnelly I, Hewitt C, Lamb SE, McDaid C, Richardson G, Rodgers S, Sharp E, Spencer S, Torgerson D, Toye F, Rangan A. Surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder: the UK FROST three-arm RCT. Health Technol Assess 2020; 24:1-162. [PMID: 33292924 PMCID: PMC7750869 DOI: 10.3310/hta24710] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Frozen shoulder causes pain and stiffness. It affects around 10% of people in their fifties and is slightly more common in women. Costly and invasive surgical interventions are used, without high-quality evidence that these are effective. OBJECTIVES To compare the clinical effectiveness and cost-effectiveness of three treatments in secondary care for adults with frozen shoulder; to qualitatively explore the acceptability of these treatments to patients and health-care professionals; and to update a systematic review to explore the trial findings in the context of existing evidence for the three treatments. DESIGN This was a pragmatic, parallel-group, multicentre, open-label, three-arm, randomised superiority trial with unequal allocation (2 : 2 : 1). An economic evaluation and a nested qualitative study were also carried out. SETTING The orthopaedic departments of 35 hospitals across the UK were recruited from April 2015, with final follow-up in December 2018. PARTICIPANTS Participants were adults (aged ≥ 18 years) with unilateral frozen shoulder, characterised by restriction of passive external rotation in the affected shoulder to < 50% of the opposite shoulder, and with plain radiographs excluding other pathology. INTERVENTIONS The inventions were early structured physiotherapy with a steroid injection, manipulation under anaesthesia with a steroid injection and arthroscopic capsular release followed by manipulation. Both of the surgical interventions were followed with post-procedural physiotherapy. MAIN OUTCOME MEASURES The primary outcome and end point was the Oxford Shoulder Score at 12 months post randomisation. A difference of 5 points between early structured physiotherapy and manipulation under anaesthesia or arthroscopic capsular release or of 4 points between manipulation under anaesthesia and arthroscopic capsular release was judged clinically important. RESULTS The mean age of the 503 participants was 54 years; 319 were female (63%) and 150 had diabetes (30%). The primary analyses comprised 473 participants (94%). At the primary end point of 12 months, participants randomised to arthroscopic capsular release had, on average, a statistically significantly higher (better) Oxford Shoulder Score than those randomised to manipulation under anaesthesia (2.01 points, 95% confidence interval 0.10 to 3.91 points; p = 0.04) or early structured physiotherapy (3.06 points, 95% confidence interval 0.71 to 5.41 points; p = 0.01). Manipulation under anaesthesia did not result in statistically significantly better Oxford Shoulder Score than early structured physiotherapy (1.05 points, 95% confidence interval -1.28 to 3.39 points; p = 0.38). No differences were deemed of clinical importance. Serious adverse events were rare but occurred in participants randomised to surgery (arthroscopic capsular release,n = 8; manipulation under anaesthesia,n = 2). There was, however, one serious adverse event in a participant who received non-trial physiotherapy. The base-case economic analysis showed that manipulation under anaesthesia was more expensive than early structured physiotherapy, with slightly better utilities. The incremental cost-effectiveness ratio for manipulation under anaesthesia was £6984 per additional quality-adjusted life-year, and this intervention was probably 86% cost-effective at the threshold of £20,000 per quality-adjusted life-year. Arthroscopic capsular release was more costly than early structured physiotherapy and manipulation under anaesthesia, with no statistically significant benefit in utilities. Participants in the qualitative study wanted early medical help and a quicker pathway to resolve their shoulder problem. Nine studies were identified from the updated systematic review, including UK FROST, of which only two could be pooled, and found that arthroscopic capsular release was more effective than physiotherapy in the long-term shoulder functioning of patients, but not to the clinically important magnitude used in UK FROST. LIMITATIONS Implementing physiotherapy to the trial standard in clinical practice might prove challenging but could avoid theatre use and post-procedural physiotherapy. There are potential confounding effects of waiting times in the trial. CONCLUSIONS None of the three interventions was clearly superior. Early structured physiotherapy with a steroid injection is an accessible and low-cost option. Manipulation under anaesthesia is the most cost-effective option. Arthroscopic capsular release carries higher risks and higher costs. FUTURE WORK Evaluation in a randomised controlled trial is recommended to address the increasing popularity of hydrodilatation despite the paucity of high-quality evidence. TRIAL REGISTRATION Current Controlled Trials ISRCTN48804508. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 71. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Stephen Brealey
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Matthew Northgraves
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Lucksy Kottam
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Belen Corbacho
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Cynthia Srikesavan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Saleema Rex
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Charalambos P Charalambous
- Department of Orthopaedics, Blackpool Victoria Hospital, Blackpool, UK
- School of Medicine, University of Central Lancashire, Preston, UK
| | - Nigel Hanchard
- School of Health & Life Sciences, Teesside University, Middlesbrough, UK
| | | | | | - Andrew Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Joseph Dias
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Catriona McDaid
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Sara Rodgers
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Sally Spencer
- Postgraduate Medical Institute, Edge Hill University, Ormskirk, UK
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Francine Toye
- Physiotherapy Research Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Amar Rangan
- York Trials Unit, Department of Health Sciences, University of York, York, UK
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
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Hasler A, Beeler S, Götschi T, Catanzaro S, Jost B, Gerber C. No difference in long-term outcome between open and arthroscopic rotator cuff repair: a prospective, randomized study. JSES Int 2020; 4:818-825. [PMID: 33345221 PMCID: PMC7738583 DOI: 10.1016/j.jseint.2020.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Arthroscopic rotator cuff repair techniques have almost replaced open repairs. Short- and mid-term studies have shown comparable outcomes, with no clear superiority of either procedure. The aim of this study was to compare the long-term clinical and imaging outcomes following arthroscopic or open rotator cuff repair. Methods Forty patients with magnetic resonance imaging (MRI)–documented, symptomatic supraspinatus or supraspinatus and infraspinatus tears were randomized to undergo arthroscopic or open rotator cuff repair. Clinical and radiographic follow-up was obtained at 6 weeks, 3 months, 1 year, 2 years, and >10 years postoperatively. Clinical assessment included measurement of active range of motion, visual analog scale score for pain, functional scoring according to the Constant-Murley score (CS), and assessment of the Subjective Shoulder Value. Imaging included conventional radiography and MRI for the assessment of cuff integrity and alteration of the deltoid muscle. Results We enrolled 20 patients with a mean age of 60 years (range, 50-71 years; standard deviation [SD], 6 years) in the arthroscopic surgery group and 20 patients with a mean age of 55 years (range, 39-67 years; SD, 8 years) in the open surgery group. More than 10 years’ follow-up was available for 13 patients in the arthroscopic surgery group and 11 patients in the open surgery group, with mean follow-up periods of 13.8 years (range, 11.9-15.2 years; SD, 1.1 years) and 13.1 years (range, 11.7-15 years; SD, 1.1 years), respectively. No statistically significant differences in clinical outcomes were identified between the 2 groups: The median absolute CS was 79 points (range, 14-84 points) in the arthroscopic surgery group and 84 points (range, 56-90 points) in the open surgery group (P = .177). The median relative CS was 94% (range, 20%-99%) and 96% (range, 65%-111%), respectively (P = .429). The median Subjective Shoulder Value was 93% (range, 20%-100%) and 93% (range, 10%-100%), respectively (P = .976). MRI evaluation showed a retear rate of 30% equally distributed between the 2 groups. Neither fatty infiltration of the deltoid muscle, deltoid muscle volume, nor the deltoid origin were different between the 2 groups. Conclusion In a small cohort of patients, we could not document any difference in clinical and radiographic outcomes at long-term follow-up between arthroscopic and open rotator cuff repair. The postulated harm to the deltoid muscle with the open technique could not be confirmed.
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Affiliation(s)
- Anita Hasler
- Department of Orthopaedics, Balgrist University Hospital, Zürich, Switzerland
| | - Silvan Beeler
- Department of Orthopaedics, Balgrist University Hospital, Zürich, Switzerland
| | - Tobias Götschi
- Unit for Clinical and Applied Research, Balgrist University Hospital, Zürich, Switzerland.,Institute for Biomechanics, ETH Zürich, Zürich, Switzerland
| | - Sabrina Catanzaro
- Department of Orthopaedics, Balgrist University Hospital, Zürich, Switzerland
| | - Bernhard Jost
- Department of Orthopaedics and Traumatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Christian Gerber
- Department of Orthopaedics, Balgrist University Hospital, Zürich, Switzerland
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Carroll C, Tattersall A. Research and Policy Impact of Trials Published by the UK National Institute of Health Research (2006-2015). VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:727-733. [PMID: 32540230 DOI: 10.1016/j.jval.2020.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/17/2020] [Accepted: 01/25/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Health technology assessment aims to inform and support healthcare decision making, and trials are part of that process. The purpose of this study was to measure the impact of a sample of trials in a meaningful but robust fashion. METHODS All randomized controlled trials funded and published by the UK National Institute of Health Research in the Health Technology Assessment journal series and other peer-reviewed journals were identified for 2006 to 2015. Citation analysis was performed for all trials, and quantitative content analysis was undertaken on a purposive sample to determine whether impact could be categorized as "instrumental" (ie, having a clear influence on key research and policy publications). RESULTS The search identified 133 relevant trials. The citation rate per trial was 102.97. Of the 133 trials, 129 (98%) were cited in 1 or more systematic reviews or meta-analyses (mean per trial = 7.18, range = 0-44). Where they were cited, the trials were used in some form of synthesis 63% of the time. Ninety-one of the 133 (68%) trials were found to be cited in 1 or more guidance or policy document (mean per trial = 2.75, range = 0-26) and had an instrumental influence 41% of the time. The publication of these trials' results in journals other than the Health Technology Assessment journal appears to enhance the discoverability of the trial data. Altmetric.com proved to be very useful in identifying unique policy and guidance documents. CONCLUSION These trials have impressive citation rates, and a sizeable proportion are certainly being used in key publications in a genuinely instrumental manner.
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Affiliation(s)
- Christopher Carroll
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, England, UK.
| | - Andy Tattersall
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, England, UK
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40
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Metcalfe A, Gemperle Mannion E, Parsons H, Brown J, Parsons N, Fox J, Kearney R, Lawrence T, Bush H, McGowan K, Khan I, Mason J, Hutchinson C, Gates S, Stallard N, Underwood M, Drew S. Protocol for a randomised controlled trial of Subacromial spacer for Tears Affecting Rotator cuff Tendons: a Randomised, Efficient, Adaptive Clinical Trial in Surgery (START:REACTS). BMJ Open 2020; 10:e036829. [PMID: 32444433 PMCID: PMC7247380 DOI: 10.1136/bmjopen-2020-036829] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Shoulder pain due to irreparable rotator cuff tears can cause substantial disability, but treatment options are limited. A balloon spacer is a relatively simple addition to a standard arthroscopic debridement procedure, but it is costly and there is no current randomised trial evidence to support its use. This trial will evaluate the clinical and cost-effectiveness of a subacromial balloon spacer for individuals undergoing arthroscopic debridement for irreparable rotator cuff tears.New surgical procedures can provide substantial benefit to patients. Good quality randomised controlled trials (RCTs) are needed, but trials in surgery are typically long and expensive, exposing patients to risk and the healthcare system to substantial costs. One way to improve the efficiency of trials is with an adaptive sample size. Such methods are well established in drug trials but have rarely, if ever, been used in surgical trials. METHODS AND ANALYSIS Subacromial spacer for Tears Affecting Rotator cuff Tendons: a Randomised, Efficient, Adaptive Clinical Trial in Surgery (START:REACTS) is a participant and assessor blinded, adaptive, multicentre RCT comparing arthroscopic debridement with the InSpace balloon (Stryker, USA) to arthroscopic debridement alone for people with a symptomatic irreparable rotator cuff tear. It uses a group sequential adaptive design where interim analyses are performed using all of the 3, 6 and 12-month data that are available at each time point. A maximum of 221 participants will be randomised (1:1 ratio), this will provide 90% power (at the 5% level) for a 6 point difference in the primary outcome; the Oxford Shoulder Score at 12 months. A substudy will use deltoid-active MRI scans in 56 participants to assess the function of the balloon. Analysis will be on an intention-to-treat basis and reported according to principles established in the Consolidated Standards of Reporting Trials statement. ETHICS AND DISSEMINATION NRES number 18/WM/0025. The results will be disseminated via peer-reviewed publications, presentations at conferences, lay summaries and social media. TRIAL REGISTRATION NUMBER ISRCTN17825590.
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Affiliation(s)
- Andrew Metcalfe
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jaclyn Brown
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | | | - Rebecca Kearney
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Tom Lawrence
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Howard Bush
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Kerri McGowan
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Iftekhar Khan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - James Mason
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Simon Gates
- Warwick Medical School, University of Warwick, Coventry, UK
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Nigel Stallard
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Stephen Drew
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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Johnson SM, Cherry JV, Thomas N, Jafri M, Jariwala A, McLeod GG. Clinical outcomes and ultrasonographic viability of GraftJacket® augmented rotator cuff repair: a prospective follow-up study with mean follow-up of forty-one months. J Clin Orthop Trauma 2020; 11:S372-S377. [PMID: 32523296 PMCID: PMC7275267 DOI: 10.1016/j.jcot.2019.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/27/2019] [Accepted: 09/02/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The management of large rotator cuff tears in patients without evidence of glenohumeral arthritis is challenging and controversial. We wished to investigate the viability of Graft Jacket® augmentation and assess the clinical and radiological outcomes in a prospective study with a select cohort of patients. METHODS All procedures were performed by a single shoulder surgeon over a three-year period. Inclusion criteria were patients with large cuff tears (size 3-5 cm) not amenable to end-to-end repair. Patients with radiographic evidence of glenohumeral arthritis or cuff tear arthropathy were excluded. Open rotator cuff repair followed by bridging with GraftJacket® Regenerative Tissue Matrix was performed. Outcome was assessed with Constant scores (CS), QuickDash (QD) and Oxford Shoulder scores (OSS) at minimum twenty-two months and ultrasound assessment at nine months post-operatively. RESULTS Thirteen patients were identified who fit inclusion criteria (one bilateral). No patients were lost to follow up. At final follow-up thirteen shoulders had achieved function range of movement. Mean CS was 83 (range 70-100), mean Quick DASH was 5.4 (range 0-18.2), and mean OSS was 46 (range 41-48). Shoulder ultrasound revealed an intact Graft Jacket® in these patients.One patient had lower functional movement and worse CS (34), QD (34.1) and OSS (25) and ultrasound assessment identified a re-rupture. DISCUSSION This study indicates that augmentation of large rotator cuff repairs with a GraftJacket® scaffold is a viable option and has good functional results and sustained viability. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
| | - Jennifer V. Cherry
- Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
- Corresponding author.
| | - Naveena Thomas
- Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Mansoor Jafri
- Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Arpit Jariwala
- Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
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Tischer T, Lenz R, Breinlinger-O’Reilly J, Lutter C. Cost Analysis in Shoulder Surgery: A Systematic Review. Orthop J Sports Med 2020; 8:2325967120917121. [PMID: 32435659 PMCID: PMC7223215 DOI: 10.1177/2325967120917121] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Cost analysis studies in medicine were uncommon in the past, but with the rising importance of financial considerations, it has become increasingly important to use available resources most efficiently. PURPOSE To analyze the current state of cost-effectiveness analyses in shoulder surgery. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic review of the current literature was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All full economic analyses published since January 1, 2010 and including the terms "cost analysis" and "shoulder" were checked for usability. The methodological quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine levels of evidence and established health economic criteria (Quality of Health Economic Studies [QHES] instrument). RESULTS A total of 34 studies fulfilled the inclusion criteria. Compared with older studies, recent studies were of better quality: one level 1 study and eight level 2 studies were included. The mean QHES score was 87 of 100. The thematic focus of most studies (n = 13) was rotator cuff tears, with the main findings as follows: (1) magnetic resonance imaging is a cost-effective imaging strategy, (2) primary (arthroscopic) rotator cuff repair (RCR) with conversion to reverse total shoulder arthroplasty in case of failure is the most cost-effective strategy, (3) the platelet-rich plasma augmentation of RCR seems not to be cost-effective, and (4) the cost-effectiveness of double-row RCR remains unclear. Other studies included shoulder instability (n = 3), glenohumeral osteoarthritis (n = 3), proximal humeral fractures (n = 4), subacromial impingement (n = 4), and other shoulder conditions (n = 7). CONCLUSION Compared with prior studies, the quality of recently available studies has improved significantly. Current studies could help decision makers to appropriately and adequately allocate resources. The optimal use of financial resources will be of increasing importance to improve medical care for patients. However, further studies are still necessary.
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Affiliation(s)
- Thomas Tischer
- Department of Orthopaedic Surgery, University Medicine Rostock, Rostock, Germany
| | - Robert Lenz
- Department of Orthopaedic Surgery, University Medicine Rostock, Rostock, Germany
| | | | - Christoph Lutter
- Department of Orthopaedic Surgery, University Medicine Rostock, Rostock, Germany
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Grobet C, Audigé L, Eichler K, Meier F, Brunner B, Wieser S, Flury M. Cost-Utility Analysis of Arthroscopic Rotator Cuff Repair: A Prospective Health Economic Study Using Real-World Data. Arthrosc Sports Med Rehabil 2020; 2:e193-e205. [PMID: 32548584 PMCID: PMC7283931 DOI: 10.1016/j.asmr.2020.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 02/04/2020] [Indexed: 02/06/2023] Open
Abstract
Purpose To assess the change in quality of life (QOL) and costs for patients with rotator cuff tears after arthroscopic rotator cuff repair (aRCR) compared with continued nonoperative management, using real-world evidence. Methods Patients indicated for aRCR were included in a prospective study and followed up to 2 years after surgery (postop) for all measurements. QOL (EQ-5D-5L) and shoulder function (Constant Score, Oxford Shoulder Score, subjective shoulder value) were assessed. Sixteen major insurance companies provided all-diagnoses direct medical costs in Swiss francs (CHF; 1 CHF = 1.03 USD). Baseline data at recruitment and costs sustained over 1 year before surgery (preop) served as a proxy for nonoperative management. Total direct medical costs to gain 1 extra quality-adjusted life year (QALY) were calculated as the incremental cost-effectiveness ratio (ICER; mean of 2 years postop compared with 1 year preop) from a societal perspective. Subgroup analyses were separately performed for traumatic (trauma-OP) and degenerative (degen-OP) rotator cuff tear patients. Sensitivity analyses for aRCR patients included more intensive nonoperative treatment with corresponding QOL gain. The relationship between QOL and shoulder function was explored using regression analysis. Results For 153 aRCR patients (mean age 57 years; 63% male), the mean EQ-5D index improved from 0.71 (preop) to 0.94 (1 year postop) and 0.96 (2 years postop). Mean total costs increased from 5,499 CHF (preop) to 17,116 CHF (1 year postop), then decreased to 4,226 CHF (2 years postop). The ICER for all aRCR patients was 24,924 CHF/QALY (95% confidence interval [CI] 16,742 to 33,106) and 17,357 CHF/QALY (95% CI 10,951 to 23,763) and 36,474 CHF/QALY (95% CI 16,301 to 56,648) for the trauma-OP and degen-OP groups, respectively. QOL and shoulder function were significantly associated (P < .001). Conclusions For RC patients treated at a specialized Swiss orthopaedic clinic, aRCR is a cost-effective intervention associated with clinically relevant improvement in QOL up to 2 years after repair compared with prior nonoperative management. Level of Evidence Economic Analyses - Developing an Economic Model, Level II.
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Affiliation(s)
- Cécile Grobet
- Research and Development, Schulthess Klinik, Zurich, Switzerland
- Shoulder and Elbow Surgery, Schulthess Klinik, Zurich, Switzerland
| | - Laurent Audigé
- Research and Development, Schulthess Klinik, Zurich, Switzerland
- Shoulder and Elbow Surgery, Schulthess Klinik, Zurich, Switzerland
- Address correspondence to Laurent Audigé, Ph.D., Schulthess Klinik, Department of Teaching, Research and Development, Lengghalde 2, CH-8008 Zurich, Switzerland.
| | - Klaus Eichler
- Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Flurina Meier
- Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Beatrice Brunner
- Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Simon Wieser
- Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Matthias Flury
- Shoulder and Elbow Surgery, Schulthess Klinik, Zurich, Switzerland
- Center for Orthopedics & Neurosurgery, In-Motion, Wallisellen, Switzerland
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Sandow MJ, Schutz CR. Arthroscopic rotator cuff repair using a transosseous knotless anchor (ATOK). J Shoulder Elbow Surg 2020; 29:527-533. [PMID: 31563504 DOI: 10.1016/j.jse.2019.07.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 07/07/2019] [Accepted: 07/08/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND This article reviews the clinical and radiographic outcomes in a noninferiority trial use of a transosseous knotless anchor to perform arthroscopic rotator cuff repairs in a patient cohort that have an increased incidence of osteoporosis. METHODS Patients aged over 60 with a documented rotator cuff tear and who failed a rehab program underwent repair using an arthroscopic transosseous knotless (ATOK) anchor. Patients were prospectively reviewed using shoulder functional assessments (age-adjusted Constant score, Oxford Shoulder Score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], visual analog scale [VAS] pain scores), and underwent preoperative as well as 1-, 3-, and 12-month postoperative magnetic resonance imaging. RESULTS 15 patients had undergone rotator cuff repair using the ATOK and were followed for a minimum of 24 months (range 24-30 months). From preoperative to 24 months post repair, median scores improved for ASES (61-89), Oxford (26-44), Constant (62-91), and VAS Pain (5-0.5). Four patients developed a partial retear of their repair, but only 1 patient sustained a complete retear: Sugaya type I, 10; type II, 1; type III, 2; type IV, 1; and type V, 1. No anchors were displaced, and there were no osteolysis, neurologic, or technique-related complications. CONCLUSIONS Arthroscopic rotator cuff repairs using a transosseous knotless technique has achieved a satisfactory outcome in this group of patients, who typically have poor bone quality, increasing the risk of antegrade anchor pullout. This approach would appear to combine the potential biomechanical and biological advantages of a transosseous repair technique, with the benefits of the lower morbidity arthroscopic surgical approach.
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Affiliation(s)
- Michael J Sandow
- Wakefield Orthopaedic Clinic, Adelaide, SA, Australia; Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, SA, Australia.
| | - Christine R Schutz
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, SA, Australia
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Abstract
While advances in assessment and management of musculoskeletal conditions have improved care for many people, there have been other, less beneficial developments in the provision of care for people with musculoskeletal pain conditions, one of which is the worrying tendency to provide too much medicine. Too much medicine occurs when the provision of either investigation or intervention (or both) is unjustifiably excessive. Another concern in musculoskeletal health care is medicalizing normality-when a normal human function or condition is labeled as abnormal. In this Viewpoint, the authors argue that medicalizing normality creates health concerns where none exist, while too much medicine involves provision of care where benefits do not outweigh harms, and wastes precious health care resources. The authors (1) list 2 common examples of too much medicine, and 2 examples of medicalizing normality, relevant to physical therapy practice; (2) outline the drivers of too much medicine and medicalizing normality; and (3) make suggestions for change. J Orthop Sports Phys Ther 2020;50(1):1-4. doi:10.2519/jospt.2020.0601.
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Evans J, Dattani R, Ramasamy V, Patel V. Responsiveness of the EQ-5D-3L in elective shoulder surgery: Does it adequately represent patient experience? J Orthop Surg (Hong Kong) 2019; 26:2309499018774922. [PMID: 29764325 DOI: 10.1177/2309499018774922] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
AIM Generic patient-reported outcome measures (PROMs) allow comparison of health-related quality of life across populations and pathologies. For these comparisons to be valid, the PROM must be responsive; the score must change when the patient's quality of life changes. This study aims to assess the responsiveness of the EQ-5D-three level (3L) in elective shoulder surgery. METHODS Pre- and post-operative EQ-5D-3L and Oxford Shoulder Scores (OSS) were prospectively collected across a range of 204 elective shoulder surgeries. Internal responsiveness was assessed through significance testing of mean change scores and standardized response means (SRMs). External responsiveness of the EQ-5D-3L was assessed against the minimal clinically important difference in OSS, using receiver operating characteristic curve and change score correlation. RESULTS Both EQ-5D-3L and OSS scores improved significantly over time ( p < 0.05). The SRM for the EQ-5D was 1.27 (95% CI 1.14-1.41) and for OSS 2.36 (2.22-2.52). Area under the curve for EQ-5D was 0.49. Only a weak correlation was found between EQ-5D and OSS change scores ( r = 0.21). DISCUSSION The EQ-5D-3L is adequately internally responsive to change following elective shoulder surgery but is unable to differentiate patients demonstrating minimal clinically important change. The EQ-5D therefore only partially reflects patient experience.
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Affiliation(s)
- J Evans
- 1 University of Exeter Medical School, Exeter, UK
| | - Rupen Dattani
- 2 Chelsea and Westminster NHS Foundation Trust, London, UK
| | | | - Vipul Patel
- 4 South West London Elective Orthopaedic Centre, Epsom, UK
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Dakin SG, Colas RA, Wheway K, Watkins B, Appleton L, Rees J, Gwilym S, Little C, Dalli J, Carr AJ. Proresolving Mediators LXB4 and RvE1 Regulate Inflammation in Stromal Cells from Patients with Shoulder Tendon Tears. THE AMERICAN JOURNAL OF PATHOLOGY 2019; 189:2258-2268. [PMID: 31437425 PMCID: PMC6876268 DOI: 10.1016/j.ajpath.2019.07.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 07/02/2019] [Accepted: 07/09/2019] [Indexed: 01/25/2023]
Abstract
Tendon stromal cells isolated from patients with chronic shoulder rotator cuff tendon tears have dysregulated resolution responses. Current therapies do not address the biological processes concerned with persistent tendon inflammation; therefore, new therapeutic approaches that target tendon stromal cells are required. We examined whether two specialized proresolving mediators (SPMs), lipoxin B4 (LXB4) and resolvin E1 (RvE1), modulate the bioactive lipid mediator profiles of IL-1β–stimulated tendon cells derived from patients with shoulder tendon tears and healthy volunteers. We also examined whether LXB4 or RvE1 treatments moderated the proinflammatory phenotype of tendon tear stromal cells. Incubation of IL-1β–treated patient-derived tendon cells in LXB4 or RvE1 up-regulated concentrations of SPMs. RvE1 treatment of diseased tendon stromal cells increased 15-epi-LXB4 and regulated postaglandin F2α. LXB4 or RvE1 also induced expression of the SPM biosynthetic enzymes 12-lipoxygenase and 15-lipoxygenase. RvE1 treatment up-regulated the proresolving receptor human resolvin E1 compared with vehicle-treated cells. Incubation in LXB4 or RvE1 moderated the proinflammatory phenotype of patient-derived tendon tear cells, regulating markers of tendon inflammation, including podoplanin, CD90, phosphorylated signal transducer and activator of transcription 1, and IL-6. LXB4 and RvE1 counterregulate inflammatory processes in tendon stromal cells, supporting the role of these molecules as potential therapeutics to resolve tendon inflammation.
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Affiliation(s)
- Stephanie G Dakin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom.
| | - Romain A Colas
- Lipid Mediator Unit, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Kim Wheway
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - Bridget Watkins
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - Louise Appleton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - Jonathan Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - Stephen Gwilym
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - Christopher Little
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - Jesmond Dalli
- Lipid Mediator Unit, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom; Centre for inflammation and Therapeutic Innovation, Queen Mary University of London, London, United Kingdom
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
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Hanchard NCA, Goodchild L, Brealey SD, Lamb SE, Rangan A. Physiotherapy for primary frozen shoulder in secondary care: Developing and implementing stand-alone and post operative protocols for UK FROST and inferences for wider practice. Physiotherapy 2019; 107:150-160. [PMID: 32026815 DOI: 10.1016/j.physio.2019.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The United Kingdom Frozen Shoulder Trial (UK FROST) compares stand-alone physiotherapy and two operative procedures, both with post operative rehabilitation, for primary frozen shoulder in secondary care. We developed physiotherapy protocols for UK FROST, incorporating best evidence but recognizing uncertainty and allowing flexibility. METHODS We screened a UK Department of Health systematic review and UK evidence-based guidelines (Hanchard et al., 2012; Maund et al., 2012) for recommendations, and previous surveys of UK physiotherapists (Hanchard et al., 2011, 2013) for strong consensus. We conducted a two-stage, questionnaire-based, modified Delphi survey of shoulder specialist physiotherapists in the UK National Health Service. This required positive, negative or neutral ratings of possible interventions in four clinical contexts (stand-alone physiotherapy for, respectively, predominantly painful and predominantly stiff frozen shoulder; and post operative physiotherapy for, respectively, predominantly painful and predominantly stiff frozen shoulder). We proposed respectively mandating or recommending interventions with 100% and 90% positive consensus, and respectively disallowing or discouraging interventions with 90% and 80% negative consensus. Other interventions would be optional. RESULTS The systematic review and guideline recommended including steroid injection and manual mobilizations in non-operative care, and we mandated these for stand-alone physiotherapy. Consensus in the pre-existing surveys strongly favoured advice, education and home exercises, which we mandated across contexts. The Delphi survey led to recommendation of some supervised exercise modalities, plus the disallowing or discouragement-in various contexts-of immobilization and some 'higher-tech' electrotherapies and alternative therapies. CONCLUSIONS We developed physiotherapy protocols despite incomplete empirical evidence. Their clear structure enabled implementation in data-sheets designed to facilitate recording, monitoring of fidelity and reporting of interventions. Other trials involving physiotherapy may benefit from this approach.
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Affiliation(s)
- N C A Hanchard
- School of Health and Social Care, Teesside University, Middlesbrough TS1 3BX, United Kingdom
| | - L Goodchild
- Department of Trauma & Orthopaedic Surgery, The James Cook University Hospital, Middlesbrough TS4 3BW, United Kingdom
| | - S D Brealey
- York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, United Kingdom
| | - S E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, United Kingdom
| | - A Rangan
- Department of Trauma & Orthopaedic Surgery, The James Cook University Hospital, Middlesbrough TS4 3BW, United Kingdom; York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, United Kingdom; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, United Kingdom.
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Nicholson JA, Searle HKC, MacDonald D, McBirnie J. Cost-effectiveness and satisfaction following arthroscopic rotator cuff repair: does age matter? Bone Joint J 2019; 101-B:860-866. [PMID: 31256664 DOI: 10.1302/0301-620x.101b7.bjj-2019-0215.r1] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
AIMS The aim of this study was to investigate the influence of age on the cost-effectiveness of arthroscopic rotator cuff repair. PATIENTS AND METHODS A total of 112 patients were prospectively monitored for two years after arthroscopic rotator cuff repair using the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), the Oxford Shoulder Score (OSS), and the EuroQol five-dimension questionnaire (EQ-5D). Complications and use of healthcare resources were recorded. The incremental cost-effectiveness ratio (ICER) was used to express the cost per quality-adjusted life-year (QALY). Propensity score-matching was used to compare those aged below and above 65 years of age. Satisfaction was determined using the Net Promoter Score (NPS). Linear regression was used to identify variables that influenced the outcome at two years postoperatively. RESULTS A total of 92 patients (82.1%) completed the follow-up. Their mean age was 59.5 years (sd 9.7, 41 to 78). There were significant improvements in the mean DASH (preoperative 47.6 vs one-year 15.3; p < 0.001) and OSS scores (26.5 vs 40.5; p < 0.001). Functional improvements were maintained with no significant change between one and two years postoperatively. The mean preoperative EQ-5D was 0.54 increasing to 0.81 at one year (p < 0.001) and maintained at 0.86, two years postoperatively. There was no significant difference between those aged below or above 65 years of age with regards to postoperative shoulder function or EQ-5D gains. Smoking was the only characteristic that significantly adversely influenced the EQ-5D at two years postoperatively (p = 0.005). A total of 87 were promoters and five were passive, giving a mean NPS of 95 (87/92). The total mean cost per patient was £3646.94 and the mean EQ-5D difference at one year was 0.2691, giving a mean ICER of £13 552.36/QALY. At two years, this decreased further to £5694.78/QALY. This was comparable for those aged below or above 65 years of age (£5209.91 vs £5525.67). Smokers had an ICER that was four times more expensive. CONCLUSION Arthroscopic rotator cuff repair results in excellent patient satisfaction and cost-effectiveness, regardless of age. Cite this article: Bone Joint J 2019;101-B:860-866.
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Affiliation(s)
- J A Nicholson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - H K C Searle
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - D MacDonald
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - J McBirnie
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
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Littlewood C, Bateman M, Cooke K, Hennnings S, Cookson T, Bromley K, Lewis M, Funk L, Denton J, Moffatt M, Winstanley R, Mehta S, Stephens G, Dikomitis L, Chesterton L, Foster NE. Protocol for a multi-centre pilot and feasibility randomised controlled trial with a nested qualitative study: rehabilitation following rotator cuff repair (the RaCeR study). Trials 2019; 20:328. [PMID: 31171031 PMCID: PMC6554931 DOI: 10.1186/s13063-019-3407-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/06/2019] [Indexed: 01/28/2023] Open
Abstract
Background Shoulder pain is a highly prevalent complaint and disorders of the rotator cuff, including tears, are thought to be the most common cause. The number of operations repair the torn rotator cuff has risen significantly in recent years. While surgical techniques have progressed, becoming less invasive and more secure, rehabilitation programmes have remained largely like those initially developed when surgical techniques were less advanced and more invasive. Uncertainty remains in relation to the length of post-surgical immobilisation and the amount of early load permitted at the repair site. In the context of this uncertainty, current practice is to follow a generally cautious approach, including long periods of immobilisation in a sling and avoidance of early active rehabilitation. Systematic review evidence suggests early mobilisation might be beneficial but further high-quality studies are required to evaluate this. Methods/design RaCeR is a two-arm, multi-centre pilot and feasibility randomised controlled trial with nested qualitative interviews. A total of 76 patients with non-traumatic rotator cuff tears who are scheduled to have a surgical repair will be recruited from up to five UK NHS hospitals and randomly allocated to either early patient-directed rehabilitation or standard rehabilitation that incorporates sling immobilisation. RaCeR will assess the feasibility of a future, substantive, multi-centre randomised controlled trial to test the hypothesis that, compared to standard rehabilitation incorporating sling immobilisation, early patient-directed rehabilitation is both more clinically effective and more cost-effective. In addition, a sample of patients and clinicians will be interviewed to understand the acceptability of the interventions and the barriers and enablers to adherence to the interventions. Discussion Research to date suggests that there is the possibility of reducing the patient burden associated with post-operative immobilisation following surgery to repair the torn rotator cuff and improve clinical outcomes. There is a clear need for a high-quality, adequately powered, randomised trial to better inform clinical practice. Prior to a large-scale trial, we first need to undertake a pilot and feasibility trial to address current uncertainties about recruitment, retention and barriers to adherence to the interventions, particularly in relation to whether patients will be willing to begin moving their arm early after their operation. Trial registration ISRCTN Registry, 18357968. Registered on 10 August 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3407-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chris Littlewood
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences and Keele Clinical Trials Unit, Keele University, Staffordshire, UK.
| | - Marcus Bateman
- Derby Shoulder Unit, University Hospitals Derby & Burton NHS Foundation Trust, Derby, UK
| | - Kendra Cooke
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences and Keele Clinical Trials Unit, Keele University, Staffordshire, UK
| | - Susie Hennnings
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences and Keele Clinical Trials Unit, Keele University, Staffordshire, UK
| | | | - Kieran Bromley
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences and Keele Clinical Trials Unit, Keele University, Staffordshire, UK
| | - Martyn Lewis
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences and Keele Clinical Trials Unit, Keele University, Staffordshire, UK
| | - Lennard Funk
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Jean Denton
- The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, UK
| | - Maria Moffatt
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Rachel Winstanley
- Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke, UK
| | - Saurabh Mehta
- Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke, UK
| | - Gareth Stephens
- The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Lisa Dikomitis
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences and School of Medicine, Keele University, Staffordshire, UK
| | - Linda Chesterton
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences and School of Medicine, Keele University, Staffordshire, UK
| | - Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences and Keele Clinical Trials Unit, Keele University, Staffordshire, UK
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