Biological augmentation in revision surgery: effect of a bioinductive collagen patch (REGENETEN) in patients with rotator cuff retear and a previous arthroscopic rotator cuff repair.

Risk factors affecting rotator cuff retear after arthroscopic repair: a meta-analysis and systematic review.

Paper #27 - Correlation of clinical outcomes of retear and tear progression after arthroscopic rotator cuff repair

Objective To investigate the clinical and MRI outcomes of the arthroscopic rotator cuff repair for massive rotator cuff tear at minimum 2 years after surgery. Methods From October, 2010 to March, 2013, data of 79 shoulders in 77 patients with massive rotator cuff tear who were treated with arthroscopic rotator cuff repair were retrospectively analyzed. There were 42 male (44 shoulders) and 35 female (35 shoulders). The average age before surgery was 57.4 years (43.1-80.4 years). There were 64 right shoulders and 15 left shoulders. The dominate side were involved in 70 cases. A trauma history was documented in 52 shoulders. The symptoms persisted less than 3 months in 42 shoulders, between 3 and 6 months in 11 shoulders, between 6 and 12 months in 11 shoulders and more than 1 year in 15 shoulders. No revision case was included. The clinical results (range of motion, forward elevation strength, external rotation strength and American Shoulder & Elbow Surgeons (ASES) score and MRI results were collected. Results All 77 cases were followed up more than 2 years. The forward elevation (156.9°±20.0° to 103.2°±54.5°), external rotation (40.6°±15.5° to 32.0°±21.4°), internal rotation (L1 to L2), forward elevation strength (9.7±4.7 lb to 4.6±4.9 lb), external rotation strength (11.1±5.1 lb to 8.3±5.4 lb) and ASES score (82.7±14.6 to 45.2±17.4) were all improved significantly at the latest follow-up. During the surgery, complete repair were achieved in 68 shoulders. The forward elevation (146.4°±31.4° to 110.0°±56.7°), external rotation (45.0°±14.8° to 34.1°±20.8°) and ASES score (78.6±14.9 to 54.5±13.9) were all improved significantly at the latest follow-up in patients with partial repair during the surgery. But the forward elevation strength (10.5±4.9 lb to 6.2±3.2 lb) and external rotation strength (11.5±5.1 lb to 8.3±3.8 lb) were significantly better improved in patients who had complete repair. In 68 shoulders with complete repair during the surgery, 20 shoulders were found to have rotator cuff re-tear. The re-tear rate was 29.4%. But none of the patient with postoperative re-tear received revision surgery. The forward elevation (152.0±23.3 to 103.5±60.5), forward elevation strength (8.5±4.7 lb to 5.0±4.7 lb) and ASES score (76.9±16.5 to 40.8±18.6) were all improved significantly at the latest follow-up in patients with postoperative re-tear of the rotator cuff tendon. But the forward elevation (161.4°±13.4° to 152.0°±23.3°), forward elevation strength (11.3±4.7 lb to 8.5±4.7 lb), external rotation strength (12.4±4.8 lb to 9.6±5.3 lb) and ASES score (86.0±13.0 to 76.9±16.5) were significantly better in patients with complete healed rotator cuff tendon comparing with the re-tear group. Conclusion The rotator cuff repair can significantly improve the shoulder function of massive rotator cuff tear even when the rotator cuff tendon can only be partially repaired or re-tear after the surgery. The shoulder function is significantly better in patients with complete healed rotator cuff tendon comparing with the partial repair group and the re-tear group. Key words: Shoulder joint; Arthroscopy; Soft tissue injuries

This study aimed to evaluate the differences between mini-open (MO) and arthroscopic (ART) repair procedures for rotator cuff tendon tears in terms of clinical and radiological outcomes. This retrospective study included 59 patients, and data were collected prospectively. Patients with full-thickness rotator cuff tears were randomized to undergo MO or ART repair at 2 centers by 2 surgeons between January 2012 and December 2017. Data were collected 3 weeks before surgery and 6 and 12 months after surgery. Physical function was assessed using the American Shoulder and Elbow Surgeons index, VAS, and Constant scoring system. Radiological outcomes were assessed using the Sugaya classification, adapted for ultrasound. Changes between baseline and follow-up were compared between the 2 groups. Fifty-nine patients who underwent ART or MO rotator cuff repair were included in this study. The 2 groups had similar demographic characteristics and preoperative baseline parameters. Both the MO and ART groups showed statistically significant improvement in outcome parameters (P ≤ .0001); however, cuff repair integrity was significantly better in the ART group (P = .023). All other improvements in the patient-derived parameters were equivalent. None of the patients in either group required revision surgery. According to the results of our retrospective study, MO and ART rotator cuff repair are effective and viable options for surgeons to repair rotator cuff tears. There were no differences in objective and subjective outcomes between the full ART and MO techniques for rotator cuff tears. Surgeons should choose a technique with which they are more familiar.

BackgroundAlthough interest in studies evaluating the outcomes of rotator cuff repair is steadily increasing, the results and tendon integrity after arthroscopic rotator cuff repair in elderly patients have only been minimally investigated. The aim of this study was to evaluate clinical outcomes and repair integrity in patients over 65 years of age who underwent arthroscopic repair of full-thickness rotator cuff tears. MethodsA retrospective study was conducted with the following inclusion criteria (1) elective shoulder arthroscopy for rotator cuff repair for full-thickness postero-superior tears; (2) age over 65 years at surgery; and (3) participation in 24 months follow-up. Preoperatively, the range of motion (ROM) and the Constant-Murley Score (CMS) and at follow-up, the ROM, the SF-12, the American Shoulder and Elbow Surgeons (ASES), and the CMS were evaluated; an ultrasonographic assessment of tendon integrity was performed according to the adapted Sugaya classification. ResultsThe final sample consisted of 110 patients with an average age of 69.2±3.5 years. The mean duration of nonoperative management before surgery was 2.6 ± 0.8 months. The mean period of preoperative physical therapy was 0.6 ± 0.9 months. ROM and CMS showed statistically significant improvement (all p<0.001) after a mean follow-up time of 54.5±22.3 months. The ultrasonographic assessment showed tendon integrity (types I and II) in 75% of cases; 21% were type III repair, and rotator cuff retear (types IV and V) was recorded in 4% of cases. All scores directly correlated with the integrity of the tendon. In the multivariate analysis, higher postoperative CMS was associated with male sex (p<0.001, β=-6.085) and lower age (p=0.004, β=-0.533). Higher postoperative ASES were associated with lower age (p=0.020, β=-0.414). Higher postoperative SF-12 PCS and MCS were associated with lower age (p=0.013, β=-0.550 and p<0.001, β=-0.520, respectively) and shorter preoperative physical therapy period (p=0.013, β =-2.075 and p=0.006, β =-1.093, respectively). ConclusionsA significant ROM and CMS recovery and a rotator cuff integrity rate of 75% can be expected in patients over 65 years of age who undergo arthroscopic repair for full-thickness rotator cuff tears. Better functional, physical and mental health outcomes correlate with rotator cuff integrity and are predicted by male sex and a shorter period of preoperative physical therapy.

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Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness?

Objectives: Sleep disturbance is a significant symptom associated with both rotator cuff tears and arthroscopic rotator cuff repair. Melatonin has been shown to be safe and effective in managing multiple sleep disorders, including secondary sleep disorders, with relatively minor adverse effects, and lack of addictive potential. The purpose of this study was to investigate the effects of oral melatonin on postoperative sleep quality after arthroscopic rotator cuff repair (aRCR). Methods: This was a prospective, randomized, clinical trial evaluating patients undergoing arthroscopic rotator cuff repair. Consecutive patients undergoing arthroscopic rotator cuff repair for rotator cuff tear were included. Exclusion criteria included history of alcohol abuse, current antidepressant or sedative use, revision rotator cuff repair, severe glenohumeral arthritis, and concurrent adhesive capsulitis. Patients were randomly assigned in a 1:1 ratio to one of two groups: 5 mg dose of melatonin 1 hour before bedtime, or standard sleep hygiene (6+ hours per night, avoid caffeine and naps in the evening). Patients in the melatonin group took their assigned melatonin dose for 6 weeks beginning the day of surgery. Patient reported outcome assessments included the Pittsburgh Sleep Quality Index (PSQI), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numerical Evaluation (SANE), and pain medication logs. Outcome measures were collected preoperatively, as well as at 2 weeks, 6 weeks, 3 months, 4 months, and 6 months post-operatively. Numeric variables were analyzed using paired and unpaired t-tests, with significance set at p&lt;0.05. Results: Eighty-three patients were included for final analysis (40 control, 43 melatonin). Patient demographics such as age, sex, race, BMI, and laterality did not differ significantly between groups (p≥0.05). Preoperative ASES, SANE, and PSQI scores did not differ between groups (p≥0.055). PSQI scores were significantly lower (better quality sleep) in the melatonin group at the 6-week postoperative period (p=0.036). There was a positive correlation between how patients rated the intensity of their pain and the PSQI at the 6-week assessment (0.566). The PSQI question regarding sleep quality was found to be significantly greater in the melatonin group at the 3-month, 4 month, and 6 month postoperative time point (p=0.015, p=0.041, and p=0.05, respectively). SANE scores in the melatonin group were significantly lower (p=0.011), then higher (p=0.017) at the 6- week and 6-month time point, respectively. ASES scores were significantly greater in the melatonin group at 4 and 6 months (p=0.022 and p=0.020). Patients who were randomized into the melatonin group were found to use significantly less narcotic medication at the 4 month postoperative time point (p=0.046). There was no difference in complication rates between groups. Conclusions: Melatonin use after aRCR led to improved sleep quality in the early postoperative period and improved functional outcomes and decreased narcotic use in the later postoperative period. Based on this investigation, we recommend the use of melatonin postoperatively after aRCR to reduce sleep disturbance in the early postoperative period and potentially help with longer term functional outcome.

Despite advances in arthroscopic techniques and devices, symptomatic massive contracted rotator cuff tear is still a challenging to most shoulder surgeons. This rotator cuff tissue has all of the f...

Sleep disturbance is a significant symptom associated with both rotator cuff tears and arthroscopic rotator cuff repair. Melatonin has been shown to be safe and effective in managing multiple sleep disorders, including secondary sleep disorders, with relatively minor adverse effects and lack of addictive potential. To investigate the effects of oral melatonin on postoperative sleep quality after arthroscopic rotator cuff repair. Randomized controlled trial; Level of evidence, 1. This was a prospective randomized clinical trial evaluating patients undergoing arthroscopic rotator cuff repair. Exclusion criteria included history of alcohol abuse, current antidepressant or sedative use, revision rotator cuff repair, severe glenohumeral arthritis, and concurrent adhesive capsulitis. Patients were randomly assigned in a 1:1 ratio to 1 of 2 groups: 5-mg dose of melatonin 1 hour before bedtime or standard sleep hygiene (≥6 hours per night, avoiding caffeine and naps in the evening). Patients in the melatonin group took their assigned melatonin dose for 6 weeks beginning the day of surgery. Patient-reported outcome assessments, including the Pittsburgh Sleep Quality Index (PSQI), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and the Single Assessment Numeric Evaluation (SANE), and pain medication charts were collected preoperatively as well as at 2 weeks, 6 weeks, 3 months, 4 months, and 6 months postoperatively. Numeric variables were analyzed using paired and unpaired t tests, with significance set at P < .05. Eighty patients were included for final analysis (40 in the control group, 40 in the melatonin group). Patient characteristics such as age, sex, race, body mass index, and laterality did not differ significantly (P≥ .05). Preoperative ASES, SANE, and PSQI scores did not differ between groups (P≥ .055). PSQI scores were significantly lower (better quality sleep) in the melatonin group at the 6-week postoperative period (P = .036). There was a positive correlation between how patients rated the intensity of their pain and the PSQI at the 6-week postoperative period (0.566). The PSQI question regarding sleep quality was found to be significantly lower in the melatonin group at the 3-month, 4-month, and 6-month postoperative periods (P = .015, P = .041, and P≤ .05, respectively). SANE scores were significantly lower in the melatonin group (P = .011) at 6 weeks and then higher in the melatonin group (P = .017) at 6 months. ASES scores were significantly higher in the melatonin group at 4 and 6 months (P = .022 and P = .020, respectively). Lastly, patients who were randomized into the melatonin group were found to use significantly less narcotic medication at the 4-month postoperative period (P = .046). Melatonin use after arthroscopic rotator cuff repair led to improved sleep quality (PSQI) in the early postoperative period as well as improved functional outcomes (ASES and SANE scores) and decreased narcotic use in the later postoperative period. Patients with significant sleep disturbances associated with rotator cuff repairs may benefit from the use of melatonin. NCT04278677 (ClinicalTrials.gov identifier).

Background: The prevalence of partial-thickness rotator cuff tears (PTRCTs) has been reported to be 13% to 40% within the adult population, accounting for 70% of all rotator cuff tears. Approximately 29% of PTRCTs will progress to full-thickness tears if left untreated. The long-term clinical course after arthroscopic repair of PTRCTs is not well known. Purpose: To investigate minimum 10-year patient-reported outcomes (PROs) after arthroscopic rotator cuff repair (RCR) of the supraspinatus tendon and to report reoperation and complication rates. Study Design: Case series; Level of evidence, 4. Methods: Patients were included who underwent arthroscopic RCR of a PTRCT performed by a single surgeon between October 2005 and October 2011. Arthroscopic RCR was performed with a transtendon repair of partial, articular-sided supraspinatus tendon avulsions, bursal-sided repair, or conversion into a full-thickness tear and repair. PRO data were collected preoperatively and at a minimum 10 years postoperatively. PRO measures included the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, the shortened version of Disabilities of the Arm, Shoulder and Hand score (QuickDASH), the 12-Item Short Form Health Survey Physical Component Summary, and patient satisfaction. Subanalyses were performed to determine if tear location or age was associated with outcomes. Retears, revision surgery, and surgical complications were recorded. Results: In total, 33 patients (21 men, 12 women) at a mean age of 50 years (range, 23-68) met criteria for inclusion. Follow-up was obtained in 28 (87.5%) of the 32 eligible patients ≥10 years out from surgery (mean, 12 years; range, 10-15 years). Of the 33 PTCRTs, 21 were articular sided and 12 were bursal sided. Of the 33 patients, 26 underwent concomitant biceps tenodesis. At follow-up, the mean PROs were significantly improved when compared with preoperative levels: American Shoulder and Elbow Surgeons score from 67.3 to 93.7 (P < .001), Single Assessment Numeric Evaluation from 70.9 to 91.2 (P = .004), QuickDASH from 22.3 to 6.6 (P < .004), and 12-Item Short Form Health Survey Physical Component Summary from 44.8 to 54.2 (P < .001). Median postoperative satisfaction was 10 (range, 5-10). No patient underwent revision surgery. Conclusion: Arthroscopic repair of PTRCTs results in excellent clinical outcomes and high patient satisfaction at minimum 10-year follow-up. Furthermore, the procedure is highly durable, with a clinical survivorship rate of 100% at 10 years.

Objectives:Treatment options for massive irreparable rotator cuff tears, in middle aged adults, consists of tendon transfer or superior capsular reconstruction (SCR). The purpose of this study was to evaluate if transfer of the latissimus dorsi tendon transfer is enhanced with combination of superior capsular reconstruction for treatment of massive irreparable rotator cuff tears.Methods:At a single institution, all consecutive patients undergoing transfer of the latissimus dorsi tendon with or without superior capsular reconstruction, between 2013 and 2016, for treatment of irreparable rotator cuff tears were evaluated. SCR, was indicated, in addition to latissimus transfer, for patients with impaired preoperative active abduction. All clinical notes, diagnostic imaging, and operative reports were reviewed in detail. Demographics, operative techniques, and radiographic parameters were collected and measured. Functional outcome scores were prospectively collected from patients. The primary outcome of the study was the Disability of Arm, Shoulder, Hand (DASH) score. The secondary outcomes of the study were the Visual Analog Scale (VAS) pain score, Single Assessment Numeric Evaluation (SANE) score, and the American Shoulder and Elbow Society (ASES) score.Results:At 3 years, there were a total of 26 latissimus dorsi tendon transfers performed in patients with irreparable rotator cuff tears. Of these, 8 patients underwent only latissimus dorsi tendon transfer and 18 patients underwent latissimus dorsi tendon transfer combined with a superior capsular reconstruction. Average age was 53 years old with the majority of patients being male (88%). The dominant extremity was involved in 22 (85%) of latissimus transfers and 14 (53%) of patients had previous surgery to address a rotator cuff tear. Follow-up, for the entire cohort, was on average 29 months. At final follow-up, there was no significant difference in physical examination or radiographic measurements between patients with latissimus transfer alone and those with latissimus transfer with SCR. All patients, undergoing either technique, showed significant improvement in both the DASH score (preoperative DASH=59.6, postoperative DASH=39.9, P=0.049) and VAS score (preoperative VAS=6.6, postoperative VAS=3.3, P=0.0006). However, those patients undergoing revision surgery, regardless of technique, showed significantly less improvement in the DASH score (P=0.005), VAS score (P=0.002), SANE score (P=0.005), and the ASES score (P=0.001). Transfer of the Latissimus tendon with SCR, in comparison to only tendon transfer, did not show any significant difference in the final DASH score (p-value=0.72). At the same time, there was no significant difference between latissimus transfer, with or without SCR, in the secondary outcomes of the VAS score(P=0.97), the SANE score(P=0.63), or the ASES score (P=0.74).Conclusion:This is the first study to report the outcomes of latissimus dorsi tendon transfer with superior capsular reconstruction in comparison to only latissimus dorsi tendon transfer for treatment of irreparable rotator cuff tears. The study suggests that transfer of the latissimus dorsi tendon in combination with superior capsular reconstruction, at short term follow-up of 2 years, may not significantly influence functional outcome. Rather, patients undergoing revision surgery, regardless of technique, may demonstrate smaller improvements in functional outcomes.Table 2.Range of Motion & Physical Examination in Latissimus Dorsi Tendon Transfer with/without SCR Lat Only (n=8)Lat + SCR (n=18) PreoperativePostoperativeP-ValuePreoperativePostoperativeP-ValueRange of Motion (Active)Abduction135 ± 21.276.4 ± 180.0475.4 ± 26.071.5 ± 220.80Forward Flexion106.9 ± 36.7135.7 ± 32.20.15103.5 ± 32.2110.6 ± 45.40.35External Rotation36 ± 11.442.9 ± 150.8025.3 ± 18.638.5 ± 16.30.04Internal Rotation65 ± 22.959.3 ± 12.40.5554.4 ± 13.363.1 ± 13.00.08Hornblower Sign2 (25%)2 (25%)0.9814 (78%)2 (11%)0.07External Rotation Lag6 (75%)2 (25%)0.3417 (94%)3 (17%)0.01Continuous data are reported as mean ± standard deviation. Categorical data reported as number (%).Table 4.Functional Outcomes at Final Follow-Up of Latissimus Dorsi Tendon Transfer with/without SCR Lat Only (n=8)Lat + SCR (n=18) Mean (Std Dev)Mean (Std Dev)P-ValuePrimary OutcomeDASH47.0 ± 39.842.5 ± 27.50.72Secondary OutcomeVas3.14 ± 3.53.4 ± 3.50.97SANE54.7 ± 38.560.9 ± 22.10.63ASES65.8 ± 36.360.6 ± 30.90.74Constance63.8 ± 31.050.3 ± 23.30.34

Objectives:To prospectively evaluate the effect of early versus delayed motion on repair integrity on 6-month postoperative magnetic resonance imaging (MRI) scans following rotator cuff repair, and to correlate repair integrity with clinical and functional outcomes. We hypothesized that repair integrity would differ between the early and delayed groups and that patients with repair failures would have worse clinical and functional outcomes.Methods:This was a prospective, randomized, single blinded clinical trial comparing an early motion (post-op day 2-3) to a delayed motion (post-op day 28) rehabilitation protocol following arthroscopic repair of isolated supraspinatus tears. All patients underwent MRI at 6 months post-operatively as part of the study protocol. A blinded board-certified and fellowship-trained orthopaedic surgeon (not part of the surgical team) reviewed operative photos and video to confirm the presence of a full thickness supraspinatus tear and to ensure an adequate and consistent repair. The same surgeon along with a blinded sports medicine fellowship-trained musculoskeletal radiologist independently reviewed all MRIs to determine whether the repair was intact at 6 months. Outcome measures were collected by independent evaluators who were also blinded to group assignment. These included the Western Ontario Rotator Cuff (WORC) index, Single Assessment Numeric Evaluation (SANE) ratings, pain scores, sling use, and physical exam data. Enrolled patients were followed at 6 weeks, 6 months, and 1 year.Results:From October 2008 to April 2012, 73 patients met all inclusion criteria and were willing to participate. 36 patients were randomized to delayed motion and 37 were randomized to early motion. The final study group at 6 months consisted of 58 study participants. Postoperative MRIs were obtained on all of these patients at 6 months regardless of whether or not they were progressing as expected. These MRIs demonstrated an overall failure rate of 29%. This did not differ significantly based on early or late motion, with 9 (26%) tears occurring in the delayed motion group compared to 10 (32%) in the early motion group (p=0.70). When patients with repair failures were compared to those with intact cuffs, no significant differences were detected in range of motion, strength, or WORC, SANE, or pain scores at 6 months or 1 year. Interestingly, however, at 6 weeks, both WORC and SANE scores were significantly better in patients who were later found to have repair failures on MRI (p<0.05). When evaluated irrespective of rehabilitation protocol, non-compliance with sling use was associated with higher failures rates (p<0.05).Conclusion:Repair failure rates do not significantly differ between patients randomized to early and delayed motion protocols following arthroscopic single tendon rotator cuff repair. Repair failure on MRI does not correlate with clinical outcome at 6 months or 1 year. However, better subjective outcome scores at 6 weeks are associated with higher rates of repair failure at 6 months.

The aim of this study was to estimate the incidence of stiffness during the first 6 months after rotator cuff repair and to evaluate postoperative stiffness with respect to its risk factors and its influence on the outcome at 6 months postoperatively. In a prospective cohort of 117 patients (69 women, 48 men; average age 59) from our institutional rotator cuff registry, who underwent either arthroscopic (n = 77) or open (n = 40) rotator cuff repair, we measured shoulder range of motion (ROM) at 3 and 6 months post-surgery. We evaluated the incidence of stiffness and analyzed functional outcomes, comparing various preoperative and intraoperative factors in patients with stiffness to those without at the 6-month mark. Shoulder stiffness was observed in 31% of patients (36/117) at 3 months postoperatively, decreasing to 20% (23/117) at 6 months. No significant link was found between stiffness at 6 months and demographic factors, preoperative stiffness, tear characteristics, or the type of repair. Notably, patients undergoing arthroscopic repair exhibited a 4.3-fold higher risk (OR 4.3; 95% CI 1.2-15.6, p = 0.02) of developing stiffness at 6 months compared to those with mini-open repair. Despite these differences in stiffness rates, no significant variation was seen in the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, or Visual Analog Scale (VAS) scores at 6 months between the groups. The incidence of postoperative shoulder stiffness following rotator cuff repair was substantial at 31% at 3 months, reducing to 20% by 6 months. Mini-open repair was associated with a lower 6-month stiffness incidence than arthroscopic repair, likely due to variations in rehabilitation protocols. However, the presence of stiffness at 6 months post-surgery did not significantly affect functional outcomes or pain levels.

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