Functional outcomes of traumatic and non-traumatic rotator cuff tears after arthroscopic repair

Characteristics of Traumatic Versus Atraumatic Rotator Cuff Tears in Patients Under 50 Years of Age

BACKGROUND

 The prevalence of rotator cuff tears (RCTs) is known to be lower in younger patients compared to older patients. Recent studies in patients less than 50 years of age who sustain an RCT have focused on etiology, pathogenesis, and clinical outcomes following treatment. There are fewer studies that have focused on the demographics and clinical characteristics that may predispose this patient population to develop a tear. The purpose of this study is to evaluate the difference in risk factors for degenerative tears compared to traumatic tears in patients under 50 years of age.

METHODS

This single-center retrospective study utilized an internal registry of patients who had RCT injuries identified by the International Classification of Diseases (ICD)-10 code M75.1x and confirmed by MRI between 2018 and 2023. Patients 50 years of age or younger were included and then classified into traumatic versus atraumatic RCT etiology groups. Demographics, tear characteristics, and clinical comorbidities were compared between the cohorts. Statistical analyses included a two-sided student's t-test, Wilcoxon rank-sum test, Chi-square test, and Fisher's exact test.

RESULTS

A total of 177 patients under 50 years of age were identified. There was a higher prevalence of traumatic tears (59.9% vs. 40.1%; p = 0.008), the majority of whom identified as male (75.5% vs. 49.3%, p<0.001) when compared to the atraumatic cohort. Full-thickness tears were more likely to be traumatic (p = 0.04) and seen in patients insured by workers' compensation (p = 0.05). There was no significant difference in the age or preoperative comorbidities between the two groups.

CONCLUSIONS

Our study reveals a higher incidence of traumatic RCTs in a younger patient group. Sex, severity of tear, and workers' compensation were found to differ between traumatic and atraumatic cohorts. Further research is required to understand the interplay of these factors in younger patients' tear risk.

Comparison of functional outcomes following early and delayed arthroscopic repair for traumatic and non-traumatic rotator cuff injuries

BACKGROUND

The effects of the timing of surgical repair on the outcomes of traumatic and non-traumatic rotator cuff injuries (RCI) remain elusive. Thus, this study aimed to compare differences in outcomes following the repair of traumatic and non-traumatic RCI at varying time points.

METHODS

The study population comprised 87 patients with traumatic and non-traumatic RCI who underwent arthroscopic rotator cuff repair and were followed up for a minimum of 6 months. Next, the trauma and the non-trauma groups were stratified into subgroups according to the time of injury (early repair: occurring within 3 months; delayed repair: occurring after 3 months). Measurements before and after surgical interventions were compared to evaluate the effect of the duration of RCI on the functional status of patients in the trauma and non-trauma groups. Primary evaluation indices included the Visual Analog Scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Constant shoulder function score, and the University of California, Los Angeles (UCLA) shoulder score. Secondary evaluation indices consisted of shoulder range of motion (ROM), postoperative rotator cuff retear rate, and incidence of joint stiffness.

RESULTS

Among the 40 patients in the trauma group, 22 underwent early repair, whereas the remaining 18 underwent delayed repair. In the non-trauma group consisting of 47 patients, 18 underwent early repair, whereas the remaining 29 underwent delayed repair. The minimum clinical follow-up time was 6 months, with an average follow-up time of 10.2 months. During postoperative follow-up, 1 and 6 patients who underwent early and delayed repair experienced re-tear in the trauma group, respectively. Contrastingly, 3 and 8 patients who underwent early and delayed repair presented with re-tear in the non-trauma group, respectively.

CONCLUSION

Early repair of traumatic RCI yielded superior outcomes, including improved range of motion, lower pain symptoms, and lower risk of postoperative re-tears compared to delayed repair. Additionally, non-surgical treatment is recommended as the preferred approach for patients with non-traumatic RCI.

Traumatic and Atraumatic Rotator Cuff Tears Have the Same Rates of Healing

Background

To examine whether traumatic rotator cuff repairs (RCRs) differ in postoperative rotator cuff tendon integrity and functional outcomes from degenerative RCRs.

Methods

RCRs performed by a single surgeon were retrospectively identified. The inclusion criteria were repairable Goutallier grades 0 to 2 full-thickness rotator cuff tears. Demographic and clinical data as well as radiological results were compared. A multivariate logistic regression of the of patient acceptable symptom state for American Shoulder and Elbow Surgeons (ASES) score was performed to evaluate whether the origin of tear led to a different relative risk (RR) independently from tear and surgical characteristics.

Results

A total of 616 consecutive shoulders (304 traumatic and 312 degenerative) were finally included. Traumatic ruptures presented a greater distribution of male (72% vs 51%, P < .001) and younger patients (53 vs 57 years, P < .001), as well as earlier onset of symptoms (3 vs 15 months, P < .001), reduced range of motion in preoperative assessment for forward elevation (130° vs 150°, P < .001), and slightly greater preoperative ASES (46.5 ± 19.7 vs 50.0 ± 18.0, P = .022) and Constant (47.0 ± 20.2 vs 52.0 ± 18.9, P = .001) scores. Degenerative tears presented a lower proportion of grade 3 tendon coronal retraction (11% vs 18%, P = .031). Postoperative tendon integrity at 6 months was comparable for both groups, predominantly Sugaya types 1 and 2 (91% traumatic; 92% degenerative, P = .371). Both groups exhibited favorable outcomes in range of motion and postoperative functional scores at last follow-up. The multivariate regression confirmed that the tear origin was not significantly associated with patient acceptable symptom state achievement (P = .201) but rather with greater preoperative ASES score (RR, 1.01), men (RR, 1.16) and workers' compensation (RR, 0.65) (P < .05).

Conclusions

Traumatic cases were frequent, involved younger patients, more frequently affected the anterior rotator cuff, and were associated with more severe tendon retraction. Traumatic and degenerative RCRs lead to comparable clinical and radiologic results.

Level of Evidence

Level III, retrospective comparative study.

Functional and Radiologic Outcomes of Degenerative Versus Traumatic Full-Thickness Rotator Cuff Tears Involving the Supraspinatus Tendon

BACKGROUND

Arthroscopic rotator cuff repair (ARCR) is among the most commonly performed orthopaedic procedures. Several factors-including age, sex, and tear severity-have been identified as predictors for outcome after repair. The influence of the tear etiology on functional and structural outcome remains controversial.

PURPOSE

To investigate the influence of tear etiology (degenerative vs traumatic) on functional and structural outcomes in patients with supraspinatus tendon tears.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients undergoing ARCR from 19 centers were prospectively enrolled between June 2020 and November 2021. Full-thickness, nonmassive tears involving the supraspinatus tendon were included. Tears were classified as degenerative (chronic shoulder pain, no history of trauma) or traumatic (acute, traumatic onset, no previous shoulder pain). Range of motion, strength, the Subjective Shoulder Value, the Oxford Shoulder Score (OSS), and the Constant-Murley Score (CMS) were assessed before (baseline) and 6 and 12 months after ARCR. The Subjective Shoulder Value and the OSS were also determined at the 24-month follow-up. Repair integrity after 12 months was documented, as well as additional surgeries up to the 24-month follow-up. Tear groups were compared using mixed models adjusted for potential confounding effects.

RESULTS

From a cohort of 973 consecutive patients, 421 patients (degenerative tear, n = 230; traumatic tear, n = 191) met the inclusion criteria. The traumatic tear group had lower mean baseline OSS and CMS scores but significantly greater score changes 12 months after ARCR (OSS, 18 [SD, 8]; CMS, 34 [SD,18] vs degenerative: OSS, 15 [SD, 8]; CMS, 22 [SD, 15]) (P < .001) and significantly higher 12-month overall scores (OSS, 44 [SD, 5]; CMS, 79 [SD, 9] vs degenerative: OSS, 42 [SD, 7]; CMS, 76 [SD, 12]) (P≤ .006). At the 24-month follow-up, neither the OSS (degenerative, 44 [SD, 6]; traumatic, 45 [SD, 6]; P = .346) nor the rates of repair failure (degenerative, 14 [6.1%]; traumatic 12 [6.3%]; P = .934) and additional surgeries (7 [3%]; 7 [3.7%]; P = .723) differed between groups.

CONCLUSION

Patients with degenerative and traumatic full-thickness supraspinatus tendon tears who had ARCR show satisfactory short-term functional results. Although patients with traumatic tears have lower baseline functional scores, they rehabilitate over time and show comparable clinical results 1 year after ARCR. Similarly, degenerative and traumatic rotator cuff tears show comparable structural outcomes, which suggests that degenerated tendons retain healing potential.

Early revision rotator cuff repair: an analysis of outcomes and function

PURPOSE

Rotator cuff repair (RCR) is commonly performed and can have good functional outcomes. However, failure of RCR surgery can be challenging for both patient and surgeon alike. This study examines the outcomes of early revision RCR for the management of clinically failed RCRs.

METHODS

Thirty-six patients undergoing revision RCR within 1 year of primary surgery were evaluated. Range of motion (ROM) and patient-reported outcomes (PROMs) were assessed at baseline, post-primary RCR, and post-revision RCR.

RESULTS

Patients with a documented repair failure after primary RCR failed to improve in both ROM and PROMs compared to before primary RCR. Following early revision, RCR SANE (p = 0.024, p < 0.001), ASES (p = 0.004, p < 0.001), and SST (p < 0.001, p = 0.001) scores improved significantly compared to pre-primary and pre-revision scores, respectively. Documentation of a new traumatic injury did not affect clinical or functional outcomes compared to atraumatic re-tears. Number of tendons torn was positively correlated with higher SANE scores (r = 0.638, p = 0.008) and negatively correlated with SST score (r = -0.475, p = 0.03) and improvement in forward elevation (r = -0.368, p = 0.03) after primary RCR. There were significant correlations between number of tendons torn and improvement in SANE (r = 0.664, p = 0.007) and ASES scores (r = 0.468, p = 0.043) from post-primary RCR to post-revision RCR.

CONCLUSION

Early revision after failed RCR can lead to clinically significant improvement in functional outcomes. The presence of a traumatic re-injury does not appear to affect revision RCR outcomes as it does in the primary setting. Patients with early clinical failures of primary RCR may benefit from early revision RCR.

LEVEL OF EVIDENCE

III: Retrospective Case Series.

RNA-Seq analysis reveals sex-dependent transcriptomic profiles of human subacromial bursa stratified by tear etiology

Rotator cuff tendinopathy, a major cause of shoulder disability, occurs due to trauma or degeneration. Our molecular understanding of traumatic and degenerative tears remains elusive. Here, we probed transcript level differences between traumatic and degenerative tears. Subacromial bursa tissues were collected from patients with traumatic or degenerative tears during arthroscopy (N = 32). Transcripts differentially expressed by tear etiology were detected by RNA-seq. RNA-seq results were validated by real-time quantitative polymerase chain reaction. We identified 334 protein-coding transcripts differentially expressed between traumatic and degenerative tears in females and 167 in males at a fold-change greater than 2. In females, XIRP2, MYL1, MYBPC1, TNNT1, and LMOD2, were highly expressed in traumatic tears whereas TPSD1, CDSN, RCVRN, LTBP4, and PTGS1 were elevated in degen tears. Transcripts elevated in traumatic tears represented muscle cell differentiation and development, and muscle contraction whereas those elevated in degenerative tears represented cell activation and immune response. In males, AZGP1, CNTFR, COL9A1, ZNF98, and EREG were highly elevated in traumatic tears whereas MYL2, HOXD11, SLC6A7, CADM1, and MMP17 were highly expressed in degenerative tears. Transcripts elevated in traumatic tears represented metabolic/catabolic processes, and transmembrane protein transport while processes related to cell cycle were mainly enriched in degenerative tears. Numerous long noncoding RNAs were differentially expressed between traumatic and degenerative tears in both sexes. In summary, this study provides insights into molecular biology of bursa in patients with rotator cuff tendon disease based on tear acuity and novel sex-based transcript differences that could inform clinical decision making in treating patients with traumatic or degenerative shoulder injuries.

Comparison of Functional Outcomes After Arthroscopic Rotator Cuff Repair Between Patients With Traumatic and Atraumatic Tears

Background:

The role of tear etiology in outcomes after rotator cuff repair is not well understood.

Purpose/Hypothesis:

The purpose of this study was to determine the difference in outcomes after rotator cuff repair based on tear etiology. We hypothesized that traumatic rotator cuff tears will have greater improvements in functional outcome measures and range of motion (ROM) than atraumatic tears.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We conducted a chart review of 221 consecutive patients who underwent arthroscopic rotator cuff repair; prospectively collected preoperative and minimum 2-year postoperative data were evaluated. Shoulder ROM, strength, and standard shoulder physical examination findings were recorded pre- and postoperatively. Outcome measures included visual analog scale for pain, Subjective Shoulder Value (SSV), 10-item Patient-Reported Outcomes Measurement Information System (PROMIS-10; physical and mental components), and American Shoulder and Elbow Surgeons (ASES) form.

Results:

Of the 221 patients, 73 had traumatic tears and 148 had atraumatic/degenerative tears. There were no differences in age, body mass index, or Charlson Comorbidity Index between groups. Patients in the atraumatic cohort had significantly longer duration of symptoms before presentation (18 vs 7 months; P < .01). Preoperatively, the traumatic cohort had less motion to forward flexion (mean ± SD; 138° ± 43.7° vs 152° ± 29.8°; P = .02). Postoperatively, both groups experienced significant improvements in visual analog scale and SSV scores (P < .001 each). However, only the traumatic cohort demonstrated improvements in ASES and PROMIS-10 physical component scores. Patients with traumatic rotator cuff tears had lower preoperative SSV and less motion than those with atraumatic tears, but they had greater improvements in SSV (40.6% ± 39.0% vs 29.2% ± 39.7%; P = .005) and forward flexion (21.6° ± 48.6° vs 2.3° ± 48.2°; P < .001), as well as strength in forward flexion, external rotation, and internal rotation (P < .001, P = .003, and P = .002, respectively).

Conclusion:

Patients with traumatic rotator cuff tears have worse preoperative symptoms and more functional deficits but experience greater improvements in ROM, strength, and perceived shoulder function than those with degenerative/atraumatic tears.

Effects of a Novel Proprioceptive Rehabilitation Device on Shoulder Joint Position Sense, Pain and Function

Background and Objectives: Shoulder disorders are associated with pain, restricted range of motion and muscular strength, moderate disability and diminished proprioception. This study aimed to compare the effectiveness of an innovative technology-supported and a classical therapist-based proprioceptive training program in addition to conventional physiotherapy, on joint position sense (JPS), pain and function, in individuals with different musculoskeletal shoulder disorders, such as rotator cuff tear, subacromial impingement syndrome and superior labrum anterior and posterior tear. The innovative element of the proprioceptive training programme consists of the use of the Kinesimeter, a device created for both training and assessing shoulder JPS. Materials and Methods: The shoulder JPS test and the DASH outcome questionnaire were applied to fifty-five individuals (28 females, 27 males, mean age 56.31 ± 6.75), divided into three groups: 17 in the conventional physiotherapy group (control group); 19 in the conventional physiotherapy + classical proprioceptive training program group (CPT group); and 19 in the conventional physiotherapy + innovative proprioceptive training program group (KPT group). Assessments were performed before and after a four-week rehabilitation program, with five physiotherapy sessions per week. Results: When baseline and post-intervention results were compared, the value of the shoulder JPS and DASH outcome questionnaire improved significantly for the KPT and CPT groups (all p < 0.001). Both KPT and CPT groups showed statistically significant improvements in JPS, pain and function, compared to the control group which received no proprioceptive training (all p < 0.05). However, the KPT group showed no significant benefits compared to the CPT group. Conclusions: Our findings indicate that using the Kinesimeter device as a novel, innovative proprioceptive training tool has similar effects as the classical proprioceptive training programs among individuals with different non-operated musculoskeletal shoulder disorders such as: rotator cuff tear, subacromial impingement syndrome, and superior labrum anterior and posterior tear.

Does early repair of traumatic rotator cuff tears provide better outcomes? A systematic review

Our aim was to systematically review literature of trauma related rotator cuff tears in order to evaluate the outcome and healing integrity in relation to time of surgery. Our research question was whether earlier surgical repair leads to superior functional results. This review was conducted according to PRISMA statement. A literature search of Pubmed, Embase, Cohrane was conducted, with two researchers assessing studies for eligibility and quality. A total of 20 studies, published between 1980 and 2019, met the inclusion criteria and were divided into two groups based on duration of symptoms before surgery. Group A comprised of studies in which duration was < 3 months and Group B > 3 months. Within each group there was a statistically significant improvement in the CS from pre-operative to post-operative outcome, but the improvement for Group A was statistically higher in comparison to Group B (P=0.01). Nevertheless, there was no significant difference in the final outcome for the two groups (P=0.29). The re-tear rate per 100 patients was calculated 28.5(±7.2) for Group A, and 17.2 (±12.56) for Group B (P=0.056). Our results suggest that functional outcome and tendon healing may not be valid arguments for early surgical repair. Therefore, repair of traumatic RCTs could be recommended whenever technically possible.

Evaluation of the Clinical Outcomes of the Arthroscopic Treatment of Rotator Cuff Tears Using the Modified Suture Bridge Technique

Objective  To evaluate the postoperative clinical outcomes of the arthroscopic repair of rotator cuff injuries using a suture configuration we have developed based on a modification of the Suture Bridge (Arthrex, Naples, FL, United States). Methods  A retrospective study with 28 male (41.2%) and 40 female (58.8%) subjects with a mean age of 60 years. All patients underwent rotator cuff repair with the modified Suture Bridge technique and follow-up for a minimum period of 18 months. The clinical assessment was performed using the University of California, Los Angeles (UCLA) Shoulder Score. Results  The mean postoperative range of motion was of 134° (range: 110° to 140°) for elevation, 58° (range: 40° to 70°) for lateral rotation, and T10 (range: L4 to T7) for medial rotation. The mean increase was of 15° for elevation, 14° for lateral rotation, and 2 vertebral levels for medial rotation. The outcomes were excellent in 61 (83.6%) cases, good in 8 (10.9%), and regular in 4 cases (5.5%). Conclusion  The modified Suture Bridge technique for the arthroscopic repair of rotator cuff injuries led to excellent or good postoperative clinical outcomes in most cases (69; 94.5%).

Immunomodulation of Pluripotent Stem Cell-Derived Mesenchymal Stem Cells in Rotator Cuff Tears Model

Background: Rotator cuff tears (RCTs) induce chronic muscle weakness and shoulder pain. Treatment of RCT using surgery or drugs causes lipid infiltration and fibrosis, which hampers tissue regeneration and complete recovery. The pluripotent stem cell-derived multipotent mesenchymal stem cells (M-MSCs) represent potential candidate next-generation therapies for RCT. Methods: The difference between M-MSCs and adult-MSCs was compared and analyzed using next-generation sequencing (NGS). In addition, using a rat model of RCT, the muscle recovery ability of M-MSCs and adult-MSCs was evaluated by conducting a histological analysis and monitoring the cytokine expression level. Results: Using NGS, it was confirmed that M-MSC was suitable for transplantation because of its excellent ability to regulate inflammation that promotes tissue repair and reduced apoptosis and rejection during transplantation. In addition, while M-MSCs persisted for up to 8 weeks in vivo, they significantly reduced inflammation and adipogenesis-related cytokine levels in rat muscle. Significant differences were also confirmed in histopathological remission. Conclusions: M-MSCs remain in the body longer to modulate immune responses in RCTs and have a greater potential to improve muscle recovery by alleviating acute inflammatory responses. This indicates that M-MSCs could be used in potential next-generation RCT therapies.

Effect of perioperative acetaminophen on pain management in patients undergoing rotator cuff repair: a prospective randomized study

BACKGROUND

Limiting opioid use in perioperative pain management is currently an important focus in orthopedic surgery. The ability of acetaminophen to reduce postoperative opioid consumption while providing acceptable pain management has not been thoroughly investigated in patients undergoing rotator cuff repair (RCR).

METHODS

Patients undergoing primary arthroscopic RCR were prospectively randomized to 1 of 3 treatment groups: Group 1 (control) received both 5 mg of oxycodone every 6 hours as needed and 1000 mg of acetaminophen orally every 6 hours as needed after surgery and had the option to take either medication or both. Group 2 (control) received only 5 mg of oxycodone every 6 hours as needed without any additional acetaminophen after surgery. Group 3 received 1000 mg of acetaminophen orally every 6 hours for 1 day prior to and after surgery, which was subsequently decreased to administration every 8 hours during postoperative days 2-5. Group 3 patients were also allowed to take 5 mg of oxycodone every 6 hours as needed after surgery. All patients received interscalene blocks with liposomal bupivacaine (Exparel). Opioid use, pain scores, side effects, and overall satisfaction were assessed daily for the first week after surgery.

RESULTS

A total of 57 patients (mean age, 57.8 ± 9.55 years) were included in this study. Baseline demographic characteristics including age, sex, and body mass index were similar between the groups (P > .05). Patients in group 3 took significantly fewer narcotics overall (P = .017) and took significantly fewer pills each day compared with group 2. Group 3 also reported significantly better overall pain control compared with the other groups (P = .040). There were no significant differences in overall patient satisfaction between the groups (P > .05). Additionally, there were no significant differences between groups regarding postoperative medication-associated side effects (P > .05).

CONCLUSION

Perioperative acetaminophen represents an important component of multimodal analgesia in appropriately selected patients undergoing shoulder surgery. In this study, the use of perioperative acetaminophen significantly decreased opioid consumption and improved overall pain control after primary arthroscopic RCR.

Comparison of tear characteristics, outcome parameters and healing in traumatic and non-traumatic rotator cuff tear: a prospective cohort study

PURPOSE

Acute traumatic and chronic non-traumatic rotator cuff tears are etiologically distinguishable entities. However, prospective studies comparing tear characteristics and outcomes between these two types of tears are lacking. The purpose of this study was to compare the tear characteristics, clinical and functional outcomes, and tendon healing as assessed on magnetic resonance imaging (MRI), between traumatic and non-traumatic rotator cuff tears.

METHODS

MRI proven rotator cuff tears were allocated into two groups according to the history of injury: Group 1 included 28 patients with traumatic tears and group 2 included 33 patients of non-traumatic cuff tears. Both the groups were compared for preoperative tear characteristics (tear size, muscle atrophy, fatty degeneration), range of motion, strength of shoulder abduction and external rotation, functional outcomes, and tendon integrity on MRI, 2 years after the surgery.

RESULTS

Postoperative mean active range of abduction (p = 0.005), abduction strength (p = 0.013), external rotation strength (p = 0.027), University of California at Los Angeles score (p < 0.001), Constant score (p = 0.002), American Shoulder and Elbow Surgeons scores (p = 0.028) and visual analog scale for pain (p = 0.02) were significantly better in group 1 as compared to group 2. The postoperative structural integrity of the cuff on MRI was better in group 1 as compared to group 2, but the values did not reach statistical significance (p = 0.13).

CONCLUSION

Findings from this study suggest that traumatic tears affect younger patients and while having a larger tear size, they have lesser muscle atrophy, fatty degeneration, and tendon retraction. Functional outcomes are better after treatment of traumatic tears as compared to non-traumatic tears. Chronicity of the tear and tendon retraction negatively affected healing in traumatic cuff tears. Muscle atrophy was found to be associated with poorer healing in non-traumatic tears. However, tear size was not associated with healing.

LEVEL OF EVIDENCE

II, Prospective cohort study.

Can a simple fall cause a rotator cuff tear? Literature review and biomechanical considerations

PURPOSE

A simple fall on the shoulder is often referred to as minor trauma that cannot cause a tendon tear but at best reveal a pre-existing rotator cuff pathology. We wanted to know whether this statement was true. The purpose of our study was therefore to summarize the causes of acute rotator cuff tears reported in the literature and provide a biomechanical explanation for tendon tears diagnosed after a fall.

METHOD

We searched PubMed and included studies reporting rotator cuff tears occurring due to a trauma. The number of cases, the tendons involved, the age of the patients, and the nature of trauma were summarized. In addition, we noted any information provided by the authors on the pathogenesis of acute tendon ruptures.

RESULTS

Sixty-seven articles with a total of 4061 traumatic rotator cuff tears met the inclusion criteria. A simple fall was the most common cause (725 cases) and the supraspinatus tendon was most frequently affected. The postulated pathomechanism is a sudden stretch of the tendon-muscle unit while contracting (eccentric loading).

CONCLUSION

A simple fall can cause an acute rotator cuff tear and fall-related tears are not restricted to young individuals. They can affect patients of any age. The stresses occurring within the rotator cuff during an attempt to cushion a fall may locally exceed the tensile strength of the tendon fibers and cause a partial or full-thickness tear.

Captured Rotator Cuff: A Poor Prognostic Factor in Rotator Cuff Repair

Objective  To describe a new presentation of tears and retears of the rotator cuff, which we denominate captured rotator cuff (CRC). We also aim to evaluate it clinically and through images.

Methods  We assessed retrospectively 16 patients with intraoperative diagnosis of CRC between March 2005 and September 2017; by means of imaging (radiography and magnetic resonance imaging [MRI]) and functional scores (UCLA and Constant & Murley). In images we analyzed the evolution for rotator cuff arthropathy and presence of retears. Functionally, we compared the affected side with the contralateral side and extensive lesions with nonextensive.

Results  Five (31.25%) patients presented with rotator cuff arthropathy, and 10 (62.5%) with retears. Three (75%) patients with nonextensive lesions had good/excellent UCLA and Constant & Murley scores. In patients with extensive lesions, when the Constant & Murley score was evaluated, 6 (50%) presented good/excellent results, and in the UCLA score, 7 (58.3%). Comparing the affected side (Constant 74.72 points; UCLA 20 points) with the contralateral side (Constant 96.96 points; UCLA 25.63 points), there were worse functional results with statistical significance.

Conclusion  The diagnosis of CRC is suspected by characteristic findings on MRI and confirmed in arthroscopy. The affected shoulders present worse functional postoperative scores.

Definition of the terms "acute" and "traumatic" in rotator cuff injuries: a systematic review and call for standardization in nomenclature

BACKGROUND

Although of high relevance for clinical decision making, there exists no consensus throughout the literature of the terms "acute" and "traumatic" used in the classification of rotator cuff tears. With differing definitions, the comparability of outcome studies may be limited. The aim was to provide a detailed systematic review of the definitions used in the literature and present a suggestion for a standardization in nomenclature based on the findings.

METHODS

Four different internet databases were searched in February 2020 using the terms ("acute" OR "traumatic" OR "trauma" OR "athlete" OR "young") AND ("rotator cuff tears" OR "rotator cuff tear" OR "rotator cuff" OR "rotator cuff rupture" OR "supraspinatus" OR "infraspinatus" OR "subscapularis" OR "teres minor"). Prospective, retrospective, cohort and case-control studies as well as case series were included. Systematic reviews, cadaveric or laboratory studies and studies on non-traumatic or non-acute rotator cuff tears were excluded.

RESULTS

The literature search conducted 10,349 articles of which 10,151 were excluded based on the title, 119 based on the abstract and 33 based on the manuscript. A total of 46 studies were finally included for review and subsequently analyzed. Overall, there exists no consensus neither on the term "acute" nor on "traumatic" in the context of rotator cuff tears in the literature. The time span for acute injuries ranged between 2 weeks and 6 months. For traumatic injuries, only 20% of the selected studies described a specific and adequate injury mechanism in combination with adequate imaging.

CONCLUSION

The term "acute" should be reserved for RCT showing muscle edema, wavelike appearance of the central part of the torn tendon and joint effusion, which typically requires adequate imaging within 2 weeks from trauma. Repair of acute tears should occur within 8 weeks from trauma to benefit from possibly superior biological healing capacities. The term "traumatic" should be used for a sudden onset of symptoms in a previously asymptomatic patient, triggered by an adequate trauma, e.g., a fall on the retroverted arm with an axial cranioventral force or a traumatic shoulder dislocation.

A new decellularized tendon scaffold for rotator cuff tears - evaluation in rabbits

Background

Scaffolds have considerably advanced in recent years. In orthopaedic surgery, scaffolds have been used as grafts in procedures involving tendon and ligament reconstruction. This paper aimed to produce and evaluate decellularized tendon scaffolds (DTSs) from biomechanical, microscopic, macroscopic and in vivo perspectives.

Methods

Bilateral gastrocnemius muscle tendons from 18 adult New Zealand rabbits were collected. Of these 36 tendons, 11 were used as controls (Group A - control), and 25 were used in the decellularization protocol (Group B - DTS). The groups were subjected to histological, biomechanical and macroscopic analyses, and Group B - DTS was subjected to an additional in vivo evaluation. In the decellularization protocol, we used a combination of aprotinin, ethylenediamine tetraacetic acid (EDTA), sodium dodecyl sulfate (SDS) and t-octyl-phenoxypolyethoxyethanol (Triton X-100) for six days. During this period, the scaffolds were kept at room temperature on an orbital shaker with constant motion.

Results

The DTSs showed an increased cross-sectional area and inter-fascicular distance and no change in parallelism or matrix organization. The nuclear material was not organized in the DTSs as it was in the control. In the biomechanical analysis, no significant differences were found between the groups after analysing the ultimate tensile load, stiffness, and elongation at the ultimate tensile load. During the in vivo evaluation, mononuclear cell infiltration was noted.

Conclusions

The evaluated decellularization protocol generated a tendon scaffold, maintained the most important biomechanical characteristics and permitted cell infiltration.

The effect of erythropoietin on rat rotator cuff repair model: An experimental study

OBJECTIVES

The aim of this study was to determine whether erythropoietin (EPO) can enhance rotator cuff healing in rats as measured by histological analysis and biomechanical testing.

METHODS

A total of 72 rats were included in this study. In the control group (n = 24), repair was performed without EPO injection. In the local group (n = 24) EPO was injected in the repair site. In the systemic group (n = 24) EPO was administered as an intraperitoneal injection every day for 10 days after repair. Rats were euthanized on day 10 (n = 12 from each group) and day 28 (n = 12 from each group). Histopathological (n = 6) and biomechanical examinations (n = 6) were done.

RESULTS

Biomechanical results reveal that the maximum load to failure values of the early control group were statistically lower than those of the early systemic group (p = 0.006). Comparing the the total Bonar values histopathologically reveal that the early systemic group was statistically higher than those of the early local group (p = 0.043). The late control group was statistically higher than those of the late local group (p = 0.003) and the late systemic group (p = 0.034). The late systemic group was statistically higher than those of the late local group (p = 0.003).

CONCLUSIONS

EPO application had a positive effect biomechanically in the early euthanized group and histopathologically in the late euthanized group.

Common Injuries of the Weekend Athlete

Each year increasing numbers of people participate in a wider variety of athletic endeavors. Unlike previous generations, many patients remain in these activities later into their lives, some well beyond retirement. As the population ages and their activities continue, they are subject to injury of various forms affecting all aspects of their bodies.

Clinical Function Improves After Subacromial Injection of Local Anesthetic in Full-Thickness Rotator Cuff Tears: A Randomized Control Trial

Background:

Rotator cuff pathology is the most common cause of shoulder pain in adults, accounting for nearly 70% of shoulder-related visits to clinicians. However, physical examination findings may be limited because of pain or patient inhibition.

Purpose:

To establish whether a relationship exists between pain, range of motion, and strength in patients with a full-thickness rotator cuff tear.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

A single-blind, randomized controlled study of 40 patients undergoing rotator cuff repair for full-thickness rotator cuff tears was performed. Patients were randomized to receive either a subacromial 10-mL 2% lidocaine injection or a sham injection, with no contents being injected into the subacromial space. Before the injection, patients were assessed using a visual analog scale for pain (VAS-Pain) as well as the Constant-Murley subjective questionnaire and objective physical examination. The examination was repeated 10 minutes after injection and 6 months postoperatively. VAS-Pain after injection was not assessed. The assessment at 6 months was performed to demonstrate improvement of rotator cuff function after operative management. Statistical analysis included Student t and chi-square tests as well as multivariate binomial logistic regression analyses to identify predictors for improvement after injection. Results were considered significant if P < .05.

Results:

Range of motion, strength, and Constant-Murley score significantly improved after a subacromial lidocaine injection (P < .05). Range of motion, strength, Constant-Murley score, and VAS-Pain significantly improved at final follow-up compared with the preinjection assessment for both groups (P < .05); however, there was no difference (P > .05) between groups at 6 months postoperatively.

Conclusion:

After subacromial lidocaine injections, patients exhibited modest but significant improvements in range of motion, strength, and the Constant-Murley score. Pain may limit range of motion and strength in patients with full-thickness rotator cuff tears independent of the mechanical impact of the tear itself.

Registration:

NCT02693444 (ClinicalTrials.gov identifier).

The Relationship Between the Critical Shoulder Angle and the Incidence of Chronic, Full-Thickness Rotator Cuff Tears and Outcomes After Rotator Cuff Repair: A Systematic Review

PURPOSE

To summarize the available evidence and examine the relationship between the critical shoulder angle (CSA) and (1) the incidence of chronic full-thickness rotator cuff tears (RCTs) and (2) outcomes after rotator cuff repair (RCR).

METHODS

A comprehensive search of MEDLINE, Embase, and CINAHL was completed. Comparative studies were included and the influence of the CSA on either the incidence of chronic, full-thickness RCTs, or outcomes following RCR was evaluated. Demographic variables and outcomes were collected.

RESULTS

Seven comparative studies analyzed the influence of the CSA on the incidence of chronic, full-thickness RCTs (the control group constituted patients with a normal rotator cuff). High heterogeneity limited pooling of studies, but the majority concluded that a greater CSA significantly increased the likelihood of a chronic, full-thickness RCT. Conversely, 5 comparative studies analyzed the influence of CSA on outcomes following RCR, and although a greater CSA was associated with a greater re-tear rate, the majority reported that CSA did not significantly influence postoperative functional outcomes, including patient-reported outcome measures (PROMs), range of motion (ROM), and strength.

CONCLUSIONS

Based on the available evidence, there appears to be a relationship between a greater CSA and the presence of a chronic, full-thickness RCT. Furthermore, a greater CSA may be associated with a greater re-tear rate following RCR; however, CSA does not appear to influence functional outcomes following RCR. Despite these observations, the available evidence is of poor quality, and the clinical utility and role of the CSA in the diagnosis and surgical management of a chronic, full-thickness RCT remains in question.

LEVEL OF EVIDENCE

Level IV: Systematic review of Level II-IV studies.

A Comparative Study to Evaluate the Risk Factors for Medium-Sized Rotator Cuff Tear in Patients Younger Than 50 Years of Age

PURPOSE

The purpose of this study was to evaluate preoperative and intraoperative factors associated with rotator cuff tears (RCTs) among patients younger than 50 years and to compare arthroscopic rotator cuff repair (RCR) results in patients younger than 50 years (group A) and patients older than 70 years (group B). We also analyzed the results after arthroscopic RCR in these 2 age groups.

METHODS

Data were collected from 56 patients allocated to group A and 55 patients allocated to group B who had medium-sized RCTs and had undergone arthroscopic RCR between January 2006 and August 2015. Preoperative variables included demographic data, radiologic data, and surgical procedure. We evaluated fatty degeneration on preoperative magnetic resonance imaging (MRI) and intraoperative variables, including concomitant subscapularis repair, as well as repair technique. Pain visual analog scale, functional visual analog scale, American Shoulder and Elbow Surgeons, and Constant scores were documented to compare functional results in each age group. Postoperative MRI scans were conducted to evaluate the retear rate after RCR after a mean postoperative duration of 5.4 months (range, 2-48 months).

RESULTS

Multivariate regression analysis showed acute-on-chronic injury and a history of hypertension were independent factors for differentiation of the groups. Stepwise regression analysis found sex, hypertension, and fatty infiltration of the supraspinatus and infraspinatus to be comparable factors for each group. All patients showed improved results after arthroscopic RCR, but there was no difference between the 2 groups in functional outcomes. However, cuff retears on postoperative MRI scans were found in only 3.9% of the patients in group A versus 16% of the patients in group B.

CONCLUSIONS

The results of this study showed that sex, acute-on-chronic injury, and preoperative fatty infiltration of the rotator cuff were significant factors affecting medium-sized RCTs in patients younger than 50 years. In addition, there were no significant differences in functional outcomes after arthroscopic RCR in both groups at 2 years, but postoperative MRI showed a lower retear rate in group A.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Expectations Following Rotator Cuff Surgery

PURPOSE OF REVIEW

To outline the radiographic and clinical outcomes after a rotator cuff surgery in order to set the expectations with the patient before the surgery to obtain a better outcome, taking into account the factors that can affect the outcome and the technique used for the repair.

RECENT FINDINGS

The majority of surgeons use arthroscopic repair. The double-row repair has better biomechanical strength, footprint coverage, and radiographic healing rates. The principal factors that can affect the outcome of the surgery are the tendon quality, tear size and retraction, fatty infiltration, chronicity of the tear, and concomitant pathologies. Arthroscopic rotator cuff repair can decrease pain and increase function allowing patients to improve their quality of life; 90% of patients are happy 6 months after the surgery and maintain stability during 5 years. Greater preoperative expectations would show better outcomes and patient satisfaction after the surgery.