Medium- to long-term clinical and functional outcomes of isolated and combined subscapularis tears repaired arthroscopically

Determining minimal clinically important difference and patient-acceptable symptom state after arthroscopic isolated subscapularis repair

Background

Minimal Clinically Important Difference (MCID) and Patient-Acceptable Symptomatic State (PASS) have emerged as patient-based treatment assessments. However, these have not been investigated in patients undergoing arthroscopic isolated subscapularis repair (AISR). The primary purpose of this study was to determine the MCID and PASS for commonly used patient-reported outcomes in individuals who underwent AISR. The secondary purpose was to assess potential associations between preoperative and intraoperative patient characteristics and the MCID and PASS.

Methods

A retrospective analysis was conducted on prospectively collected data for patients who underwent primary AISR between 2011 and 2021 at a single institution, with minimum 2-year postoperative follow-up. Functional outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), and Visual Analog Scale (VAS) pain scale. The MCID was determined using the distribution-based method, while PASS was evaluated using area under the curve analysis. To investigate the relationship between preoperative variables and the achievement of MCID and PASS thresholds, Pearson and Spearman coefficient analyses were employed for continuous and noncontinuous variables, respectively.

Results

A total of 77 patients with a mean follow-up of 58.1 months were included in the study. The calculated MCID values for VAS pain, ASES, and SSV were 1.2, 10.2, and 13.2, respectively. The PASS values for VAS pain, ASES, and SSV were 2.1, 68.8, and 68, respectively. There was no significant correlation between tear characteristics and the likelihood of achieving a MCID or PASS. Female sex, worker's compensation status, baseline VAS pain score, and baseline ASES score, exhibited weak negative correlations for achieving PASS for VAS pain and ASES.

Conclusion

This study defined the MCID and PASS values for commonly used outcome measures at short-term follow-up in patients undergoing AISR. Tear characteristics do not appear to impact the ability to achieve a MCID or PASS after AISR. Female sex, worker's compensation claim, and low baseline functional scores have weak negative correlations with the achievement of PASS for VAS pain and ASES scores.

Clinical Approach to Inconclusive Subscapularis Tear Diagnosis: a Meta-analysis

To identify factors associated with subscapularis (SSC) tears and provide a theoretical basis for clinical diagnosis, we included studies related to subscapularis tears published before February 1, 2023. We screened for six predictors across previous studies for the meta-analysis. The predictors included age, sex, coracoid overlap (CO), coracohumeral distance (CHD), impairment of the long head of the biceps tendon (LHB), and dominant arm. The Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of the studies. The risk ratios (RRs) and the weighted mean differences (WMDs) were used to evaluate the effect size of categorical variables and continuous variables, respectively. The Egger test was used to assess the publication bias of the studies. Ten studies were included from seven countries. A total of 2 126 patients were enrolled, of whom 1 041 had subscapularis tears and 1 085 did not. The study showed that age (WMD, 4.23 [95% CI, 2.32-6.15]; P<.00001), coracoid overlap (WMD, 1.98 [95% CI, 1.55-2.41]; P<.00001), coracohumeral distance(WMD, -1.03 [95% CI, -1.17- -0.88]; P<.00001), and an injury of the long head of the biceps tendon (RR, 4.98 [95% CI, 3.75-6.61]; P<.00001) were risk factors for subscapularis tears. These risk factors can help clinicians identify subscapularis tears early and select appropriate interventions. The level of evidence is 3.

The effect of arthroscopic coracoplasty on subscapularis strength in cases of subcoracoid impingement in the absence of subscapularis tear

Subcoracoid impingement leads to anterior shoulder pain, and arthroscopic subcoracoid decompression (coracoplasty) is the preferred treatment in recalcitrant cases. The purpose of the present study was to evaluate the effect of coracoplasty on the severity of anterior shoulder pain and the strength of the subscapularis muscle and to correlate it with the preoperative and postoperative coracohumeral distance (CHD) (t:transverse, s:sagittal). Sixteen patients without any subscapularis tendon tears who underwent arthroscopic subcoracoid decompression and rotator cuff repair with 2 years follow-up were included. Preoperative and postoperative 2-year assessments of function and pain were performed using the modified Kennedy-Hawkins test, power grading of various subscapularis muscle tests, and ASES scores. Preoperative and postoperative coracohumeral distance (tCHD, sCHD) and coracoid overlap (CO) were measured using MRIs before and after surgery. The Mean Hawkins pain score and coracoid overlap were decreased. The strength scores for subscapularis strength testing, ASES score, maximum degree of internal rotation, and coracohumeral distance increased (P < .05). Changes in belly press strength were negatively correlated with postoperative tCHD (r = -0.6, P = .04) and postoperative sCHD (r = -0.7, P = .008). A significant increase in the internal rotation range of the shoulder, subscapularis strength, and relief of anterior shoulder pain was observed. However, this increase was inversely proportional to the postoperative CHD, indicating the mechanical effect of the coracoid on subscapularis strength.

Comparison of Outcomes between Open and Arthroscopic Rotator Cuff Repair

Objective

The objective of this retrospective cohort study is to evaluate the long-term clinical and functional outcomes of two surgical techniques for rotator cuff repair, namely, open and arthroscopic methods.

Methods

A total of 100 patients diagnosed with rotator cuff tears and treated at Seyhan State Hospital in the past five years were enrolled, considering the same inclusion criteria for both groups. The study groups consisted of 50 patients who underwent open rotator cuff repair and 50 patients who underwent arthroscopic rotator cuff repair. We used the SPSS programme to analyse the data, focusing on parameters such as postoperative recovery time, functional capacity scores, pain levels measured by the VAS scale, quality of life evaluated by the SF-36 scores, and complication rates.

Results

Both methods resulted in similar recovery times and functional capacity scores, but patients treated with the open method reported slightly lower pain levels (average VAS score: 2.8) compared to those treated with the arthroscopic method (average VAS score: 3.1). The study also found slightly better quality of life scores in the arthroscopic group (average SF-36 score: 71.4) compared to the open surgery group (average SF-36 score: 68.7). The complications rates were lower in the arthroscopic group (2%) than in the open surgery group (4%), but these differences were not statistically significant.

Conclusions

The study suggests that, while there are no significant differences in terms of clinical outcomes between the two surgical methods, short-term pain levels may be influenced by the more frequent application of acromioplasty in arthroscopic methods. Therefore, the choice of the surgical method should be made based on the unique characteristics, including the location and size, the patient's overall health status, and the surgeon's experience. These findings should be used as a guide and not as absolute results.

Effect of subscapularis repair on joint contact forces based on degree of posterior-superior rotator cuff tear severity in reverse shoulder arthroplasty

Massive irreparable rotator cuff tears (RCTs) affect the clinical outcomes of reverse shoulder arthroplasty (RSA). However, the effects of subscapularis repair on the outcomes of RSA, based on the degree of posterior-superior RCTs, are unclear. This study aimed to examine the effect of subscapularis repair on three-dimensional joint contact forces (JCFs) based on the degree of posterior-superior RCT severity in RSA. Ten human in vivo experimental data were used as input to the musculoskeletal model. A six-degrees-of-freedom (DOF) anatomical shoulder model was developed and validated against three-dimensional JCFs. The 6-DOF musculoskeletal shoulder model of RSA was then developed by importing the reverse shoulder implant into the validated anatomical shoulder model. Based on the various types of posterior-superior RCT severity, inverse dynamic simulations of subscapularis-torn and subscapularis-repaired models of RSA were performed: from isolated supraspinatus tears to partial or massive tears of the infraspinatus and teres minor. The intact rotator cuff model of RSA was also simulated for comparison with the different types of models. Our results showed that the more posterior-superior RCTs progressed in RSA, the more superior JCFs were observed at 90°, 105°, and 120° abduction in the subscapularis-torn model. However, subscapularis repair decreased the superior JCF at those angles sufficiently. In addition, the teres minor muscle-tendon force increased as infraspinatus bundle tears progressed in both the subscapularis-torn and -repaired models, in order to compensate for the reduced force during abduction. However, the teres minor muscle-tendon force was not as high as that of the infraspinatus muscle-tendon, which could result in muscle force imbalance between repaired subscapularis and teres minor. Therefore, our results suggest that repairing the subscapularis and the repairable infraspinatus during RSA can improve glenohumeral joint stability in the superior-inferior direction by restoring muscle force balance between the anterior cuff (i.e., subscapularis) and posterior cuff (i.e., infraspinatus and teres minor). The findings of this study can help clinician decide whether to repair the rotator cuff during RSA to enhance joint stability.

Subscapularis Tendon Tears: How Best to Approach This Issue

Subscapularis tears, either in combination with more extensive rotator cuff pathology or in isolation, are a relatively common cause of shoulder pain and dysfunction which often requires surgical intervention. Similar to the general treatment of most rotator cuff tears, patients may respond to conservative treatment and not require surgical intervention, especially in the elderly or those with partial tears. However, many subscapularis tears require intervention to address complaints of pain, dysfunction, or both. The spectrum of subscapularis tears ranges from low-grade partial requiring simple debridement to full-thickness tears which have become retracted and irreparable necessitating complex repair. Although open repair had been performed with success, most subscapularis repairs can be accomplished with arthroscopic techniques.

Clinical efficacy and tendon integrity of patients with subscapularis tear by the technique of arthroscopic single external row repair

Background

With the development of arthroscopic technology and equipment, arthroscopy can effectively repair the tear of the subscapular muscle. However, it is difficult to expose the subscapular muscle and operate it under a microscope. In this study, the SwiveLock® C external row anchor under arthroscopy was applied to repair the tear of the subscapular muscle in a single row, which is relatively easy to operate with reliable suture and fixation, and its efficacy was evaluated.

Purpose

This study aimed to assess the clinical efficacy and the tendon integrity of patients who had subscapularis tears by adopting the single-row repair technique with a SwiveLock® C external row anchor.

Methods

Patients who had the subscapular muscle tear either with or without retraction were included, and their follow-up time was at least 1 year. The degree of tendon injury was examined by magnetic resonance imaging (MRI) and confirmed by arthroscopy. The tendon was repaired in an arthroscopic manner by utilizing the single-row technique at the medial margin of the lesser tuberosity. One double-loaded suture SwiveLock® C anchor was applied to achieve a strong fixation between the footprint and tendon. The range of motion, pain visual simulation score, American Shoulder and Elbow Surgeons (ASES) score, and Constant score of shoulder joint were evaluated for each patient before the operation, 3 months after the operation, and at least 1 year after the operation.

Results

In total, 110 patients, including 31 males and 79 females, with an average age of 68.28 ± 8.73 years were included. Arthroscopic repair of the subscapular tendon with SwiveLock® C external anchor can effectively improve the range of motion of the shoulder joint. At the last follow-up, the forward flexion of the shoulder joint increased from 88.97 ± 26.33° to 138.38 ± 26.48° (P < 0.05), the abduction range increased from 88.86 ± 25.27° to 137.78 ± 25.64° (P < 0.05), the external rotation range increased from 46.37 ± 14.48° to 66.49 ± 14.15° (P < 0.05), and the internal rotation range increased from 40.03 ± 9.01° to 57.55 ± 7.43° (P < 0.05). The clinical effect is obvious. The constant shoulder joint score increased from 40.14 ± 15.07 to 81.75 ± 11.00 (P < 0.05), the ASES score increased from 37.88 ± 13.24 to 82.01 ± 9.65 (P < 0.05), and the visual analog scale score decreased from 5.05 ± 2.11 to 1.01 ± 0.85 (P < 0.05). In the 6th month after the operation, two cases (1.81%) were confirmed to have re-tears via MRI.

Conclusion

In this study, we repaired the subscapularis muscle with a single-row technique fixed by SwiveLock® C anchor and FiberWire® sutures and evaluated its efficacy. The results showed that the clinical effect of single-row arthroscopic repair was satisfactory and that reliable tendon healing could be achieved.

Subscapularis tendon tear classification and diagnosis: A systemic review and meta-analysis

Background

In the current study, we performed a systematic review and meta-analysis regarding the comparison of accuracy, sensitivity, and specificity of the techniques in diagnosing SSC tendon tears. Also, we performed a systematic review of the classification of SSC tendon tears.

Methods

English language, peer-reviewed journal publications from the first date available to March 2022 were extracted by searching PubMed and Web of Science databases. A forest plot was used to graphically show the results of pooled sensitivity, specificity, and accuracy of different diagnostic modalities.

Results

There were six studies on using MRI to diagnose subscapularis tendon tears, five studies on MRI, four studies on clinical examination, one on ultrasonography, and one on CT arthrography. Pooled sensitivity values for MRI, MRA, clinical examination, ultrasonography, and CT arthrography were 0.71 (CI: 0.54; 0.87), 0.83 (0.77; 0.88), 0.49 (0.31; 0.67), 0.39 (0.29; 0.51), and 0.90 (0.72–0.97), respectively. The pooled specificity values for MRI, MRA, clinical examination, ultrasonography, and CT arthrography were 0.93 (CI: 0.89; 0.96), 0.86 (0.75; 0.93), 0.89 (0.73; 0.96), 0.93 (0.88; 0.96), and 0.90 (0.69; 0.98), respectively. The pooled diagnostic accuracy values for MRI, MRA, clinical examination, ultrasonography, and CT arthrography were 0.84 (CI: 0.80; 0.88), 0.85 (0.77; 0.90), 0.76 (0.66; 0.84), 0.76 (0.70; 0.81), and 0.90 (0.78; 0.96), respectively.

Conclusion

According to our systematic review and meta-analysis, MR arthrography was the most accurate in diagnosing subscapularis tears. MR arthrography was the most sensitive, and MRI and ultrasonography were the most specific in detecting subscapularis tears.

Analysis of risk factors for advanced age in patients with frozen shoulder

OBJECTIVE

To explore the risk factors of elderly patients with frozen shoulder.

METHODS

262 cases of scapulohumeral periarthritis treated in our hospital from January 2020 to December 2020 were analyzed retrospectively. According to the age of patients, patients younger than 60 years old were divided into middle-aged group (101 cases), patients between 60 and 75 years old were divided into old-aged group (91 cases), and patients ≥ 75 years old were divided into old-aged group (70 cases). The general demographic data and clinical data of the three groups were compared. Visual analogue scale (VAS) was used to evaluate the degree of pain. Finally, the dependent variable is set as whether the onset age of scapulohumeral periarthritis patients is advanced. Univariate and multivariate Logistic regression was used to analyze the risk factors of frozen shoulder patients at an advanced age.

RESULTS

There were no significant differences in general demographic data, fixed position, hypertension history, smoking history, drinking history, supraspinatus muscular atrophy and physical exercise among the three groups (all P > 0.05). The course of disease, diabetes, surgical treatment, pain degree, operation time, cholecystitis, coronary heart disease, pain degree three months after operation and cervical spondylosis in the elderly group were all higher than those in the middle-aged group and the elderly group, and the differences were statistically significant (all P < 0.05). The course of scapulohumeral periarthritis, the degree of pain and the degree of pain 3 months after operation in the elderly group were higher than those in the middle-aged group, with significant differences (all P < 0.05). Univariate Logistic regression analysis showed that the risk factors of scapulohumeral periarthritis in the elderly included diabetes mellitus (OR = 3.067, 95% CI 1.881-4.587, P < 0.001), operative treatment (OR = 3.076, 95% CI 1.365-6.765, P = 0.006), VAS score (OR = 2.267, 95% CI 1.117-3.887, P = 0.013), operation time (OR = 1.537, 95% CI 1.305-2.579, P < 0.001), cholecystitis (OR = 2.143, 95% CI 1.019-4.876, P = 0.023), coronary heart disease(OR = 3.128, 95% CI 1.428-7.019, P = 0.005), VAS at 3 months after operation (OR = 1.537, 95% CI 0.786-2.635, P = 0.002), and cervical spondylosis(OR = 1.162, 95% CI 1.029-1.321, P = 0.012). Multivariate logistic regression analysis showed that the risk factors for the onset of the disease at advanced age included fatty infiltration (OR = 4.021, 95% CI 2.981-9.682, P < 0.001), surgical treatment (OR = 4.109, 95% CI 1.419-7.832, P = 0.008), VAS score (OR = 3.081, 95% CI 1.042-7.931, P = 0.046) and operation time (OR = 1.537, 95% CI 1.305-2.579, P < 0.001).

CONCLUSION

Risk factors of frozen shoulder at advanced age include fat infiltration, surgical treatment, VAS score and surgical time. In clinical practice, we should refer to the above indicators to help patients with early medical intervention and prevent their onset.

Alteration in coracohumeral ligament and distance in people with symptoms of subcoracoid impingement

BACKGROUND

Differentiation between subacromial impingement versus subcoracoid impingement are important for the treatment target. We evaluated the correlations between coracohumeral ligament (CHL) thickness and distance (CHD) and characterized the CHL and subscapularis (SSC) in subcoracoid impingement subjects.

METHODS

An observational, cross-sectional study was carried out. Twenty subcoracoid impingement subjects and age/gender matched controls were assessed in 4 different shoulder positions by ultrasonography.

RESULTS

Moderate correlations between CHL thickness with CHD (r = 0.455 in neutral rotation, p = 0.044; r = 0.483 in interior rotation, p = 0.031) were found in subacromial subjects. Subcoracoid impingement subjects had greater CHL thickness (difference = 0.3 mm, effect size = 0.85, p = 0.006), SSC tendon thickness (difference = 0.7 mm, effect size = 0.92, p = 0.01) and SSC/CHD occupation ratio (difference = 8%, effect size = 0.95, p = 0.005) compared with the control.

CONCLUSIONS

Coracohumeral distance is related to ligament thickness, especially in subacromial impingement subjects. Increased coracohumeral ligament and subscapularis thickness as well as decreased subscapularis/coracohumeral distance occupation ratio are characterized in subcoracoid impingement subjects. These quantitative measurements can be useful in identifying patients at risk of subcoracoid impingement from subacromial impingement.

Collagen and platelet-rich plasma in partial-thickness rotator cuff injuries. Friends or only indifferent neighbours? Randomised controlled trial

BACKGROUND

Partial-thickness rotator cuff injuries (PTRCI) are the sum of degenerative, overload, and microtrauma processes. An external supply of collagen and platelet-rich plasma (PRP) could potentially counteract the deterioration of degenerative tendinopathy. This study aimed to compare the effectiveness of collagen with PRP, PRP alone, and collagen alone in the treatment of PTRCI.

METHODS

Ninety patients with PTRCI were randomised and treated with ultrasound-guided injections into the shoulder bursa every consecutive week: Group A - collagen with PRP (n = 30), Group B - collagen alone (n = 30), and Group C - PRP alone (n = 30). Primary outcomes were pain intensity measured in control points on a numeric rating scale (NRS), QuickDash, and EQ-5D-5L questionnaires at the initial assessment (IA) and control assessments after 6 (T1), 12 (T2), and 24 (T3) weeks, respectively.

RESULTS

No statistical differences were found between groups in primary outcomes, although there was a trend towards improvement in Groups A and C (opposite to Group B) between T2 and T3. The following parameters were also observed: rotator cuff discontinuity (n = 3, one case in each group) and rotator cuff regeneration (n = 22 in Group A, n = 20 in Group B, and n = 23 in Group C).

CONCLUSIONS

Combined therapy of collagen and PRP in PTRCI presents similar effectiveness to monotherapies with collagen or PRP.

TRIAL REGISTRATION

The study was prospectively registered on the NCT Trial Center (identification number: NCT04492748 ) on 30.07.2020.

Artificial Intelligence in the Management of Rotator Cuff Tears

Technological innovation is a key component of orthopedic surgery. Artificial intelligence (AI), which describes the ability of computers to process massive data and "learn" from it to produce outputs that mirror human cognition and problem solving, may become an important tool for orthopedic surgeons in the future. AI may be able to improve decision making, both clinically and surgically, via integrating additional data-driven problem solving into practice. The aim of this article will be to review the current applications of AI in the management of rotator cuff tears. The article will discuss various stages of the clinical course: predictive models and prognosis, diagnosis, intraoperative applications, and postoperative care and rehabilitation. Throughout the article, which is a review in terms of study design, we will introduce the concept of AI in rotator cuff tears and provide examples of how these tools can impact clinical practice and patient care. Though many advancements in AI have been made regarding evaluating rotator cuff tears-particularly in the realm of diagnostic imaging-further advancements are required before they become a regular facet of daily clinical practice.

Effectiveness of combined extracorporeal shock-wave therapy and hyaluronic acid injections for patients with shoulder pain due to rotator cuff tendinopathy: a person-centered approach with a focus on gender differences to treatment response

Background

Rotator cuff (RC) tendinopathy is a common shoulder pain condition. Extracorporeal shockwave therapy (ESWT) and hyaluronic acid peritendinous injection are viable treatment options for RC tendinopathy.

The aim of this study is to evaluate the response in two different therapeutic rehabilitative approaches, the combined treatment ESWT plus hyaluronic acid injections (E + Hy) compared to ESWT alone (ESWT-al), in a cohort of patients with RC tendinopathy according to gender differences.

Methods

This is a retrospective longitudinal cohort study of patients with painful RC tendinopathy. Patients that had received a clinical evaluation, a shoulder ultra sound examination, as well as the Shoulder Pain and Disability Index (SPADI) questionnaire, and the Numerical Rating Scale (NRS) for pain at baseline, 1-month (T1) and 2-month follow-ups (T2) were included.

Results

Medical records of 53 patients were analyzed. In the comparison between baseline to T1 and similarly from baseline to T2, a statistically significant reduction has been reported in the NRS (p < 0.001) and in the SPADI (p < 0.001) in the entire study group. At T1, patients in the E + Hy compared to ESWT-al group, showed a slight but statistically significant reductions in both NRS and SPADI score, while these changes were more evident at T2 (p < 0.001). Interestingly, a gender dimorphism in NRS and in SPADI was found, with female patients that apparently responded better to the combined E + Hy compared to ESWT-al approach.

Conclusion

This retrospective cohort study suggests that the combination of ESWT plus HyA injections seems to be more effective than ESWT alone in RC tendinopathy in both genders. Moreover, in ESWT alone treatment, male patients reported better outcomes compared to females. However, further randomized controlled trials should be structured to confirm and enforce these conclusions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05819-3.

[Development of a risk stratification model for subscapularis tendon tear based on patient-specific data from 528 shoulder arthroscopy]

OBJECTIVE

To identify and screen sensitive predictors associated with subscapularis (SSC) tendon tear and develop a web-based dynamic nomogram to assist clinicians in early identification and intervention of SSC tendon tear.

METHODS

Between July 2016 and December 2021, 528 consecutive cases of patients who underwent shoulder arthroscopic surgery with completely MRI and clinical data were retrospectively analyzed. Patients admitted between July 2016 and July 2019 were included in the training cohort, and patients admitted between August 2019 and December 2021 were included in the validation cohort. According to the diagnosis of arthroscopy, the patients were divided into SSC tear group and non-SSC tear group. Univariate analysis, least absolute shrinkage and selection operator (LASSO) method, and 10-fold cross-validation method were used to screen for reliable predictors highly associated with SSC tendon tear in a training set cohort, and R language was used to build a nomogram model for internal and external validation. The prediction performance of the nomogram was evaluated by concordance index (C-index) and calibration curve with 1 000 Bootstrap. Receiver operating curves were drawn to evaluate the diagnostic performance (sensitivity, specificity, predictive value, likelihood ratio) of the predictive model and MRI (based on direct signs), respectively. Decision curve analysis (DCA) was used to evaluate the clinical implications of predictive models and MRI.

RESULTS

The nomogram model showed good discrimination in predicting the risk of SSC tendon tear in patients [C-index=0.878; 95% CI(0.839, 0.918)], and the calibration curve showed that the predicted results were basically consistent with the actual results. The research identified 6 predictors highly associated with SSC tendon tears, including coracohumeral distance (oblique sagittal) reduction, effusion sign (Y-plane), subcoracoid effusion sign, biceps long head tendon displacement (dislocation/subluxation), multiple posterosuperior rotator cuff tears (≥2, supra/infraspinatus), and MRI suspected SSC tear (based on direct sign). Compared with MRI diagnosis based on direct signs of SSC tendon tear, the predictive model had superior sensitivity (80.2% vs. 57.0%), positive predictive value (53.9% vs. 53.3%), negative predictive value (92.7% vs. 86.3%), positive likelihood ratio (3.75 vs. 3.66), and negative likelihood ratio (0.25 vs. 0.51). DCA suggested that the predictive model could produce higher clinical benefit when the risk threshold probability was between 3% and 93%.

CONCLUSION

The nomogram model can reliably predict the risk of SSC tendon tear and can be used as an important tool for auxiliary diagnosis.

Development and Validation of a Web-Based Dynamic Nomogram to Improve the Diagnostic Performance of Subscapularis Tendon Tear

Background

There are still some challenges in diagnosing subscapularis (SSC) tendon tears as accurately as posterosuperior rotator cuff tears on magnetic resonance imaging (MRI). The omission of SSC tendon tears can lead to muscle atrophy, fatty infiltration and increased tear accompanied by aggravated shoulder pain and loss of function. An effective noninvasive evaluation tool will be beneficial to early identification and intervention. The study aims to identify sensitive predictors associated with SSC tendon tears and develop a dynamic nomogram to improve diagnostic performance.

Methods

From July 2016 to October 2021, 528 consecutive cases of patients who underwent shoulder arthroscopic surgery with preoperative shoulder MRI were retrospectively analyzed. The least absolute shrinkage and selection operator (LASSO) method was used to identify the sensitive factors associated with SSC tendon tears, which were then incorporated into the nomogram. The prediction performance of the nomogram was evaluated by concordance index (C index) and calibrated with 1,000 bootstrap samples combined with external validation of another cohort.

Results

The LASSO method showed that six items including coracohumeral distance (oblique sagittal plane), effusion (Y-face), effusion (subcoracoid), malposition of the long head tendon of the biceps, multiple posterosuperior rotator cuff tears, and considering SSC tendon tears on MRI (based on direct signs) were determined as sensitive predictors. The nomogram achieved a good C index of 0.878 (95% CI, 0.839–0.918) with a good agreement on the risk estimation of calibration plots. The areas under the receiver operator characteristic (ROC) curves of the two methods showed that dynamic nomograms had better prediction performance than MRI diagnosis based on direct signs (training set 0.878 vs. 0.707, validation set 0.890 vs. 0.704).

Conclusion

The study identified sensitive predictors associated with SSC tendon tears and first developed a web-based dynamic nomogram as a good supplementary evaluation tool for imaging diagnosis that could provide an individualized risk estimate with superior prediction performance, even in patients with small or partial tears.

Factors Associated with Shoulder Range of Motion After Arthroscopic Rotator Cuff Repair: A Hospital‐Based Prospective Study

Objective

To assess the factors associated with outcomes of arthroscopic surgical repair of rotator cuff tears (RCTs).

Method

This prospective study recruited patients, at least 18 years old, who underwent arthroscopic rotator cuff repair for full‐thickness RCTs at the First People's Hospital of Hangzhou Xiaoshan between July 2019 and October 2020. Patient demographics, lifestyle habits, and medical histories were collected preoperatively; RCT sizes and affected tendons were determined intraoperatively. Outcomes were assessed by shoulder range of motion (ROM) determinations 1.5 and 3 months postoperatively. The factors associated with ROM were determined using a binary logistic regression analysis, and the results were expressed as adjusted relative risks (RRs) and 95% confidence intervals (CIs).

Results

A total of 132 patients with RCTs underwent arthroscopic surgery. Five were lost to follow‐up, leaving 127 patients (mean age, 59 years; 58.3% women) who were included in the study analysis. The majority of the patients (54.5%) had RCTs that were classified as large or massive, and approximately 20% had tears involving multiple tendons; 80.3% of the patients had tears involving only a single tendon. Moreover, 29.9% of the patients had hypertension and 11.0% had diabetes. Among the patients, 23.0% were smokers and 34.6% drank alcohol. According to the multivariate analysis, none of the assessed factors were associated with shoulder ROM at the 1.5‐month follow‐up. At the 3‐month follow‐up, RCTs involving a single tendon demonstrated 3‐fold better abduction (RR = 4.00; 95% CI, 1.30–12.33; P = 0.016) and 3.15‐fold better internal rotation (RR = 3.15; 95% CI, 1.19–8.36; P = 0.021) than did RCTs involving multiple tendons. Patients who did not drink alcohol demonstrated 6.08‐fold better anteflexion (RR = 7.08; 95% CI, 2.11–23.73; P = 0.002) and nearly 4‐fold better abduction (RR = 4.97; 95% CI, 1.62–15.23; P = 0.005) than patients who drank alcohol.

Conclusion

To improve outcomes, the results indicate that more targeted measures should be directed toward patients with multiple‐tendon RCTs and that preoperative alcohol abstinence education is needed for patients with RCTs.

Identifying key factors associated with subscapularis tendon tears and developing a risk prediction model to assist diagnosis

Background

There are still some challenges in diagnosing subscapularis (SSC) tendon tears as accurately as posterosuperior rotator cuff tears on MRI. The omission of SSC tendon tear can lead to muscle atrophy, fatty infiltration, and increased tearing accompanied by aggravated shoulder pain and loss of function. An effective non-invasive evaluation tool will be beneficial to early identification and intervention. The study aims to identify sensitive predictors associated with SSC tendon tears and develop a risk prediction model to assist in diagnosis.

Methods

Data on 660 patients who received shoulder arthroscopic surgery with preoperative shoulder MRI were collected retrospectively. Of these, patients with SSC tendon tears were defined as the SSC tear group, and patients with intact SSC tendon were enrolled in the non-SSC tear group. Logistic regression analysis was used to identify the key predictors of SSC tendon tears which were then incorporated into the nomogram.

Results

Among 22 candidate factors, five independent factors including coracohumeral distance (CHD, oblique sagittal plane) (OR, 0.75; 95%CI, [0.67–0.84]), fluid accumulation (Y-face) (OR, 2.29; 95%CI, [1.20–4.38]), long head of biceps tendon (LHB) dislocation/subluxation (OR, 3.62; 95%CI, [1.96–6.68]), number of posterosuperior (PS) rotator cuff tears (OR, 5.36; 95%CI, [3.12–9.22]), and MRI diagnosis (based on direct signs) (OR, 1.88; 95%CI, [1.06–3.32]) were identified as key predictors associated with SSC tendon tears. Incorporating these predictors, the nomogram achieved a good C index with a good agreement on the risk estimation of calibration plots. Higher total points of the nomogram were associated with a greater risk of SSC tendon tears.

Conclusion

When evaluating the severity of SSC tendon injury, the combination of reliable predictors can improve the sensitivity and diagnostic performance of MRI. This model provides an individualized probability of risk prediction, which is convenient for clinicians to identify patients at high risk for SSC tendon tears to avoid missed diagnosis.

Outcomes of Mini-Invasive Arthroscopic Arthrolysis Combined with Locking Screw and/or Intramedullary Nail Extraction after Osteosynthesis of the Proximal Humerus Fracture

Data on the effectiveness of arthroscopic arthrolysis and extraction of osteosynthetic material after osteosynthesis of the proximal humerus in patients with persisting problems are rare and insufficient. In this study, we performed arthroscopic arthrolysis and extraction of fixation screws, and, where protruding, extraction of the nail in 34 patients with problems persisting 12 months after osteosynthesis of the proximal humerus using an intramedullary nail. The effectiveness of the treatment was assessed using the Constant-Murley shoulder score and forward flexion difference between the treated arm and the contralateral one. A median increase of 16 points in CMS score and 30 degrees reduction in the arm forward flexion difference was recorded 12 months after the arthroscopy. The improvement was significantly higher in the patient group with intramedullary nail extraction (however, this group had worse pre-operative values and the screw was only extracted where likely to cause problems). The median time to heal was 11 weeks; no serious peri- or post-procedural complications occurred. Mini-invasive arthroscopic arthrolysis combined with extraction of osteosynthetic material proved to be a safe and effective method for treatment of patients after osteosynthesis of the proximal humerus using an intramedullary nail with persisting pain and/or mobility limitation.

Mid-Term Outcomes after Arthroscopic "Tear Completion Repair" of Partial Thickness Rotator Cuff Tears

Background and Objectives: Different arthroscopic procedures are used for partial-thickness rotator cuff tears (PT-RCTs), but there is still no evidence on the superiority of one procedure over the other. The aim of this study was to evaluate the clinical outcomes and the rate of complications of a tear completion repair (TCR) technique. Materials and Methods: Patients who had undergone arthroscopic TCR technique for PT-RCTs with a follow-up of at least 2-years after surgery were included. The TCR technique involved the removal of the "critical zone" and creating microfractures to biologically support tendon healing. Functional outcomes were assessed prospectively by the Constant score (CS) and active and passive range of movement (ROM). Pain and patient satisfaction were measured using a visual analog scale (VAS). Complication rates were recorded, and tendon integrity was assessed with magnetic resonance imaging (MRI) or ultrasound performed at least 2-years after surgery. Results: Eighty-seven patients with a median age of 57 years were followed-up for a median of 5 years. The CS score improved from 53.5 preoperatively to 94.0 postoperatively (p < 0.001). Median VAS score decreased from 8.6 to 1.0 (p < 0.0001). Median patient satisfaction was 9.3. The overall complication rate was 14.9%. Conclusions: Patients with PT-RCTs of the supraspinatus tendon treated by the TCR technique with "critical zone" removal and biological stimulation by microfractures showed good functional results with excellent strength recovery, a high degree of patient satisfaction, and resolution of painful symptoms at mid-term follow-up.