Preoperative Vitamin D Deficiency Is Associated With Higher Postoperative Complications in Arthroscopic Rotator Cuff Repair

Exploring the impact of vitamin D on tendon health: a comprehensive review

Tendons are vital components of the musculoskeletal system, facilitating movement and supporting mechanical loads. Emerging evidence suggests that vitamin D, beyond its well-established role in bone health, exerts significant effects on tendon physiology. The aim of this manuscript is to review the impact of vitamin D on tendons, focusing on its mechanisms of action, clinical implications, and therapeutic applications. A comprehensive search of scientific electronic databases was conducted to identify articles on the effects of vitamin D on tendon health. Fourteen studies were included in this review. Five studies were performed in vitro, and nine studies were conducted in vivo. Despite some conflicting results, the included studies showed that vitamin D regulates collagen synthesis, inflammation, and mineralization within tendons through its interaction with vitamin D receptors. Epidemiological studies link vitamin D deficiency with tendon disorders, including tendinopathy and impaired healing. Supplementation with vitamin D shows promise in improving tendon strength and function, particularly in at-risk populations such as athletes and the elderly. Future research should address optimal supplementation strategies and explore the interplay between vitamin D and other factors influencing tendon health. Integrating vitamin D optimization into clinical practice could enhance tendon integrity and reduce the burden of tendon-related pathologies.

Preoperative thrombocytopenia and thrombocytosis predict complications after arthroscopic rotator cuff repair

Background

The purpose of this study was to investigate the association between preoperative platelet count and 30-day postoperative complications following arthroscopic rotator cuff repair (aRCR).

Methods

The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent aRCR between 2015 and 2021. The study population was divided into 5 groups based on preoperative platelet count: normal (200-450k, reference cohort), low-normal (150-200k), mild thrombocytopenia (100-150k), moderate-to-severe thrombocytopenia (<100k), and thrombocytosis (>450k). Thirty-day postoperative complications following aRCR were collected. Multivariate logistic regression analysis was conducted to investigate the relationship between preoperative platelet counts and postoperative complications.

Results

24,779 patients were included in this study: 18,697 (75.5%) in the normal group, 4730 (19.1%) in the low-normal group, 1012 (4.1%) in the mild thrombocytopenia group, 171 (0.7%) in the moderate-to-severe thrombocytopenia group, and 169 (0.7%) in the thrombocytosis group. Low-normal platelets were an independent predictor of urinary tract infection (odds ratio [OR] 2.06, 95% confidence interval [CI] 1.12-3.77; P = .020). Mild thrombocytopenia was not an independent predictor of any complications. Moderate-to-severe thrombocytopenia was an independent predictor of sepsis (OR 9.39, 95% CI 1.48-59.47; P = .017), pneumonia (OR 6.62, 95% CI 1.32-33.24; P = .022), and nonhome discharge (OR 3.34, 95% CI 1.20-9.25; P = .021). Thrombocytosis was an independent predictor of urinary tract infection (OR 4.91, 95% CI 1.16-20.78; P = .030).

Conclusion

Abnormal preoperative platelet counts, both low and high, were independent risk factors for 30-day postoperative complications following aRCR.

Association of Preoperative Vitamin D Deficiency With Retear Rate and Early Pain After Arthroscopic Rotator Cuff Repair: A Retrospective Cohort Study

Background

Although the function of vitamin D in bone metabolism has been well studied, the question remains whether vitamin D deficiency impairs tendon healing after rotator cuff repair.

Purpose

To investigate the correlation between preoperative vitamin D deficiency and the retear rate and pain after arthroscopic rotator cuff repair.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients with full-thickness rotator cuff tears who underwent arthroscopic rotator cuff repair between January 2018 and August 2019 were enrolled. Included patients were divided into a control group (vitamin D level ≥20 μg/L) and a deficiency group (vitamin D level <20 μg/L). We investigated the association between preoperative vitamin D level and patient characteristics, MRI findings, pain and function scores (visual analog scale [VAS] for pain; Constant-Murley; University of California, Los Angeles; and American Shoulder and Elbow Surgeons scores), and healing status using the Pearson or Spearman correlation coefficient. The clinical characteristics were compared between the groups using the chi-square test or Fisher exact test.

Results

Included were 89 patients (control group, 44 patients; deficiency group, 45 patients). The mean vitamin D levels were 25.07 ± 5.38 and 14.61 ± 3.43 μg/L in the control and deficiency groups, respectively (P < .001); otherwise, there were no significant differences between the groups in the variables under study. Vitamin D levels were not related to age, symptom duration, tear size, extent of retraction, VAS pain score preoperatively and at 6 and 24 months postoperatively, or any function scores. Supraspinatus fatty infiltration and VAS scores at 1 and 3 months postoperatively were significantly associated with vitamin D level (r = -0.360, -0.362, and -0.316, respectively; P < .05 for all). VAS scores were significantly lower in the control group than in the deficiency group at postoperative 1 month (1.09 ± 0.56 vs 1.47 ± 0.66, respectively) and 3 months (1.14 ± 0.77 vs 1.44 ± 0.66) (P < .05 for both). The retear rate was significantly lower in the control group than in the deficiency group (9.09% vs 26.67%, respectively; P < .05).

Conclusion

Our study revealed that preoperative vitamin D deficiency was associated with a higher retear rate and early pain (1 and 3 months) after arthroscopic rotator cuff repair.

Treatment of partial rotator cuff lesions is associated with a higher frequency of post-operative shoulder stiffness. A prospective investigation on the role of surgery-related risk factors for this complication

PURPOSE

Post-operative shoulder stiffness (SS) is a common complication after arthroscopic rotator cuff (RC) repair. The aim of this prospective study is to evaluate the role of surgical risk factors in the development of this complication, with special focus on the characteristics of the RC tears.

METHODS

Two-hundred and twenty patients who underwent arthroscopic RC repair for degenerative posterosuperior RC tears were included. Surgery-related risk factors for development of post-operative SS belonging to the following five categories were documented and analyzed: previous surgery, RC tear characteristics, hardware and repair type, concomitant procedures, time and duration of surgery. The incidence of post-operative SS was evaluated according to the criteria described by Brislin and colleagues.

RESULTS

The incidence of post-operative SS was 8.64%. The treatment of partial lesions by tear completion and repair technique was significantly associated with development of post-operative SS (p = 0.0083, pc = 0.04). A multivariate analysis revealed that treatment of partial lesions in patients younger than 60 years was associated to a higher risk of developing post-operative SS (p = 0.007). Previously known pre-operative risk factors such as female sex and younger age were confirmed. No other significant associations were documented.

CONCLUSION

The treatment of partial lesions of the RC may lead to a higher risk of post-operative SS than the treatment of complete lesions, in particular in patients younger than 60 years. Possible explanations of this finding are the increased release of pro-inflammatory cytokines caused by the additional surgical trauma needed to complete the lesion and the different pain perception of the subgroup of patients who require surgical treatment already for partial tears.

EVIDENCE

A higher risk of post-operative SS should be expected after tear completion and repair of partial lesions, especially in young patients. Appropriate pre-operative counseling and post-operative rehabilitation should be considered when approaching this subgroup of RC tears.

LEVEL OF EVIDENCE

Prognostic study, level II.

Use of biologics in rotator cuff disorders: Current concept review

Poor tendon to bone healing following rotator cuff repair has led to the continued interest and investigation into biological augmentation. The biology of tendinopathy is not fully understood and consequently the availability of disease modifying therapeutic targets is limited. A ceiling of benefit has been reached by mechanical optimisation of rotator cuff repair and thus, in order to improve healing rates, a biological solution is required. This review focuses on the strategies to biologically augment rotator cuff disorders with an emphasis on rotator cuff repair. Leucocyte rich platelet rich plasma has been shown to improve healing rates without clinically relevant improvements in outcome scores. Similarly, improved healing rates have also been reported with bone marrow stimulation and in long-term follow-up with bone marrow concentrate. Extracellular matrix (ECM) and synthetic scaffolds can increase healing through mechanical and or biological augmentation. A potential third category of scaffold is bio-inductive and has no mechanical support. Studies involving various scaffolds have shown promising results for augmentation of large to massive tears and is likely to be most beneficial when tendon quality is poor, however level I evidence is limited.

The Serum from Patients with Secondary Frozen Shoulder Following Rotator Cuff Repair Induces Shoulder Capsule Fibrosis and Promotes Macrophage Polarization and Fibroblast Activation

PURPOSE

Disorders with systematic inflammation were prognostic for secondary frozen shoulder (sFS) following rotator cuff repair (RCR); however, how systematic inflammation affects sFS remains unclear. The aim of this study was to observe the effect of pre-operative serum from patients with sFS and the serum from those without on shoulder capsule in mice, and on macrophages and fibroblasts in vitro.

METHODS

Serum samples of a consecutive cohort of patients for RCR were collected pre-operatively. Three months after RCR, patients who developed sFS (Group S) were identified. Serum samples from gender- and age-matched controls without sFS (group NS) were also picked out. Firstly, the effect of serum on shoulder capsule fibrosis was observed histologically and biomechanically in a mouse model of RCR. Secondly, the roles of the serum on macrophage polarization and fibroblast activation were investigated, and the potentially involved signaling pathways were identified. Finally, inflammation and fibrosis-related cytokines in serum were quantified.

RESULTS

In our cohort, all patients had free pre-operative shoulder range of motion. Seven patients developed sFS at 3 months after surgery. Seven matched patients without sFS were selected as control. The inter-group difference of basic characteristics was not significant. Compared to the serum of group NS, the serum of group S significantly induced hypercellularity, capsular thickening, and range of motion deficiency in mice shoulders after RCR. Compared to the serum of group NS, samples of group S significantly promoted M2 polarization of THP-1 human macrophages and the activation of human capsule-derived fibroblasts. Meanwhile, Smad3 and p-Smad3 in macrophages and fibroblasts were significantly up-regulated. On the other hand, levels of inflammation and fibrosis-related cytokines were not significantly different between serum in group S and group NS.

CONCLUSION

Although all patients in this cohort had free range of motion pre-operatively, the pre-operative serum from patients with sFS at 3 months after RCR could act as a trigger of shoulder capsule fibrosis post-operatively. This effect may be related to its promotion on macrophage polarization to M2 phenotype and fibroblast activation.

Malnutrition in Orthopaedic Sports Medicine: A Review of the Current Literature

CONTEXT

Malnutrition is well-studied in various aspects of the orthopaedic literature, most commonly in relation to arthroplasty, spine surgery, and trauma. However, the management of nutritional deficiencies is commonly overlooked among orthopaedic sports medicine providers. The purpose of this article is to analyze the available sports medicine literature to review the associations between malnutrition and the management of orthopaedic sports medicine patients from a treatment and performance standpoint.

EVIDENCE ACQUISITION

PubMed was searched for relevant articles published from 1979 to 2019.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Few studies exist on the implications of macronutrient deficiencies specific to orthopaedic sports medicine procedures. Interestingly, micronutrient disorders-namely, hypovitaminosis D and iron deficiency-have been well studied and may lead to worse postoperative outcomes, injury rates, and athletic performance. Nutritional supplementation to correct such deficiencies has been shown to mitigate these effects, though further study is required.

CONCLUSION

Nutritional deficiencies are highly prevalent in orthopaedic sports medicine patients, and practitioners should be aware of their potential effects on treatment and performance outcomes. Management of such deficiencies and their effect on surgical patients remain an area of potential future research. Future studies are warranted in order to explore the potential therapeutic role of nutritional supplementation to prevent complications after common orthopaedic sports medicine procedures, improve athletic performance, and reduce injury rates.