Innovations in Rotator Cuff Repair

A common complication of rotator cuff (RC) repair is a postoperative stiffness. Postoperative stiffness may develop and lead to inferior functional outcomes. Rotator cuff repair with additional rotator interval (RI) capsular release can be done to prevent postoperative stiffness in rotator cuff tears. However, routine rotator interval capsular release in rotator cuff repair is controversial. Therefore, we conducted a systematic review and meta-analysis to compare the postoperative outcomes between RC repair with and without RI capsular release for RC tears with and without concomitant stiffness. We searched all comparative studies that compared postoperative outcomes (VAS, CS, ASES, complications and ROM at 3, 6 and 12months) of RC repair with and without RI capsular release for RC tears with and without concomitant stiffness from PubMed and Scopus databases from inception to the February 1, 2020. Seven of 255 studies (six comparative studies and one RCT) (N = 803 patients) were eligible; 2 and 5 studies were included in the pooling of RC repair and RI release without concomitant stiffness and stiffness, respectively; 2, 6, 3, 6, 3, 5, 7, 7, and 7 studies were included in pooling of VAS, CS, ASES at 6 and 12months and range of motion (internal, external rotation and forward flexion) at 3, 6 and 12months, respectively. The UMD of VAS, CS and ASES scores at 6- and 12-month follow-up for the RC repair and RI release group was 0.48 (95% CI: 0.05, 0.90), 0.93 (-1.70, 3.56), -2.27 (-5.30, 0.76), -0.04 (-0.24, 0.15), 1.66 (0.77, 2.55) and 1.58 (0.21, 2.96) scores when compared to RC repair alone with and without concomitant stiffness. In terms of ROM, forward flexion for the RC repair and RI release group was -4.60 (-10.61, 1.41), -7.11 (-15.47, 1.25) and -0.70 (-2.51, -1.11) degrees at 3, 6 and 12months, respectively, when compared to RC repair alone. For external rotation, RC repair and RI release were -0.12 (-8.27, 8.03), -3.98 (-12.09, 4.14) and -2.65 (-5.35, 0.04) degrees at 3, 6 and 12months, respectively, when compared to RC repair alone. For internal rotation in RC repair and RI release, the values were -1.22 (-1.97, -0.48), -1.01 (-1.79, -0.23) and -0.19 (-1.13, 0.74) degrees at 3, 6 and 12months, respectively, when compared to RC repair alone. There were no differences with a RR of 0.92 (0.46, 1.84) between the two groups in terms of complications. After subgroup analysis, RC repair with RI release had no clinically significant differences for pain, function and ROM when compared to RC repair alone in RC tear patients with and without preoperative stiffness. RC repair with RI release in patients with and without preoperative stiffness had no statistically significant differences for pain, function (CS and ASES) and range of motion (FF, ER and IR) when compared to RC repair alone in RC injury patients. II.

Arthroscopic revision of failed rotator cuff repairs: technique and results

Study of Rotator Cuff Repair Techniques: We Really Are Trying

Background: Magnetic resonance imaging (MRI) is the most commonly used imaging modality to assess the rotator cuff. Currently, there are a limited number of studies assessing the interobserver and intraobserver reliability of MRI after rotator cuff repair. Hypothesis: Fellowship-trained orthopaedic shoulder surgeons will have good inter- and intraobserver agreement with regard to features of the repaired rotator cuff (repair integrity, fat content, muscle volume, number of tendons involved, tear size, and retract) on MRI. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Seven fellowship-trained orthopaedic shoulder surgeons reviewed 31 MRI scans from 31 shoulders from patients who had previous rotator cuff repair. The scans were evaluated for the following characteristics: rotator cuff repair status (full-thickness retear vs intact repair), tear location, tendon thickness, fatty infiltration, atrophy, number of tendons involved in retear, tendon retraction, status of the long head of the biceps tendon, and bone marrow edema in the humeral head. Surgeons were asked to review images at 2 separate time points approximately 9 months apart and complete an evaluation form for each scan at each time point. Multirater kappa (κ) statistics were used to assess inter- and intraobserver reliability. Results: The interobserver agreement was highest (80%, κ = 0.60) for identifying full-thickness retears, tendon retear retraction (64%, κ = 0.45), and cysts in the greater tuberosity (72%, κ = 0.43). All other variables were found to have fair to poor agreement. The worst interobserver agreement was associated with identifying rotator cuff footprint coverage (47%, κ = −0.21) and tendon signal intensity (29%, κ = −0.01). The mean intraobserver reproducibility was also highest (77%-90%, κ = 0.71) for full-thickness retears, quality of the supraspinatus (47%-83%, κ = 0.52), tears of the long head of the biceps tendon (58%-94%, κ = 0.49), presence of bone marrow edema in the humeral head (63%-87%, κ = 0.48), cysts in the greater tuberosity (70%-83%, κ = 0.47), signal in the long head of the biceps tendon (60%-80%, κ = 0.43), and quality of the infraspinatus (37-90%, κ = 0.43). The worst intraobserver reproducibility was found in identification of the location of bone marrow edema (22%-83%, κ = −0.03). Conclusion: The results of this study indicate that there is substantial variability when evaluating MRI scans after rotator cuff repair. Intact rotator cuff repairs or full-thickness retears can be identified with moderate reliability. These findings indicate that additional imaging modalities may be needed for accurate assessment of the repaired rotator cuff.

PurposeTo investigate the functional outcomes of patients over 40 years of age who underwent isolated rotator cuff (RC) repair (RCR) for full-thickness RC tears resulting from a primary traumatic anteroinferior shoulder dislocation and to compare these outcomes with a control group of patients who underwent RCR for instability-independent RC tears, with a minimum follow-up of two years.Materials and methodsPatients aged 40 years and older were included for RCR following primary traumatic anteroinferior shoulder dislocation between 01/2012 and 06/2020 with a minimum follow-up of two years. Patients were excluded if they received an additional labral repair or capsular shift. Outcomes were compared to a control group of patients who underwent RCR without history of previous dislocations. Primary outcome measures included passive range of motion (ROM) as well as patient reported outcomes comprising the Western Ontario Shoulder Instability Index (WOSI) and Rowe score. Rates of re-dislocation were evaluated as secondary outcomes.ResultsThirty-six patients were enrolled and divided into 2 groups (n = 18, respectively). Demographic characteristics did not significantly differ (p > 0.05). At final follow-up, patients affected by instability-related RC tears showed comparable functional outcomes in terms of WOSI (427.2 ± 238.9instability group (IG) vs. 431.1 ± 252.1control group (CG); p = 0.962) and Rowe (87.5 ± 12.0IG vs. 91.1 ± 10.2CG; p = 0.339) scores as well as in terms of passive ROM (abduction: 88.1 ± 4.6°IG vs. 86.7 ± 11.5°CG; p = 0.637, forward elevation: 87.8 ± 6.2°IG vs. 88.3 ± 5.1°CG; p = 0.772, external rotation: 55.3 ± 10.5°IG vs. 50.8 ± 15.3°CG; p = 0.312, internal rotation: 65.3 ± 8.5IG vs. 68.8 ± 4.9CG, p = 0.388). No patient experienced a re-dislocation.ConclusionPatients ≥ 40 years who underwent isolated RCR without labral repair or capsular shift for a concurrent RC tear after experiencing a primary traumatic anteroinferior shoulder dislocation, achieved favorable functional outcomes along with absence of re-dislocations.Study designRetrospective case series; Level of Evidence IV.

The aim of this study was to quantify and compare fat fraction (FF) and muscle volume between patients with failed and intact rotator cuff (RC) repair as well as a control group with nonsurgical conservative treatment to define FF cutoff values for predicting the outcome of RC repair. Patients with full-thickness RC tears who received magnetic resonance imaging (MRI) before and after RC repair including a 2-point Dixon sequence were retrospectively screened. Patients with retear of 1 or more tendons diagnosed on MRI (Sugaya IV-V) were enrolled and matched to patients with intact RC repair (Sugaya I-II) and to a third group with conservatively treated RC tears. Two radiologists evaluated morphological features (Cofield, Patte, and Goutallier), as well as the integrity of the RC after repair (Sugaya). Fat fractions were calculated from the 2-point Dixon sequence, and the RC muscles were segmented semiautomatically to calculate FFs and volume for each muscle. Receiver operator characteristics curves were used to determine FF cutoff values that best predict RC retears. In total, 136 patients were enrolled, consisting of 3 groups: 41 patients had a failed RC repair (58 ± 7 years, 16 women), 50 patients matched into the intact RC repair group, and 45 patients were matched into the conservative treatment group. Receiver operator characteristics curves showed reliable preoperative FF cutoff values for predicting retears at 6.0% for the supraspinatus muscle (0.83 area under the curve [AUC]), 7.4% for the infraspinatus muscle (AUC 0.82), and 8.3% for the subscapularis muscle (0.94 AUC). Preoperative quantitative FF calculated from 2-point Dixon MRI can be used to predict the risk of retear after arthroscopic RC repair with cutoff values between 6% and 8.3%.

Adverse Impact of Corticosteroid Injection on Rotator Cuff Tendon Health and Repair: A Systematic Review

Rotator cuff (RTC) repair is performed using open/mini-open or arthroscopic procedures, and the use of arthroscopic techniques is increasing. The extent to which surgery has transitioned from open to arthroscopic techniques has yet to be elucidated. The purpose of this study was to evaluate trends in open and arthroscopic rotator cuff repair in the USA and describe tendencies in treatment across gender, age, and geographic region. We hypothesized that surgeons would be more likely to perform arthroscopic rotator cuff repair, with similar trends across the USA. A retrospective review of a comprehensive national insurance database (Humana) was performed using the PearlDiver software for all patients who underwent RTC repair between January 2007 and June 2015. Patients were identified by Current Procedural Terminology (CPT) codes. χ 2 tests evaluated the proportion of arthroscopic surgeries by gender and geographic region; logistic regression analysis assessed differences from 2007 to 2015. In the study period, 54,740 patients underwent RTC repair (68% arthroscopic, 52% male), with the highest frequency of RTC repair in patients between 65 and 69years old. The proportion of open RTC repair increased with increasing patient age, with no significant difference between men and women. The proportion of arthroscopic RTC surgeries increased from 56.9% in 2007 to 75.1% in 2015. The overall trend was 188% increase in total RTC repairs. Arthroscopic repair was more frequent than open repair in all US regions, with the highest proportion in the South. Arthroscopic RTC surgery predominates and continues to rise. With increasing patient age, there was an increase in the proportion of open repair. The majority of RTC repairs were performed in patients between 65 and 69years of age.

Background:Redundancies in the rotator cuff tissue, commonly referred to as “dog ear” deformities, are frequently encountered during rotator cuff repair. Knowledge of how these deformities are created and their impact on rotator cuff footprint restoration is limited.Purpose:The goals of this study were to assess the impact of tear size and repair method on the creation and management of dog ear deformities in a human cadaveric model.Study Design:Controlled laboratory study.Methods:Crescent-shaped tears were systematically created in the supraspinatus tendon of 7 cadaveric shoulders with increasing medial to lateral widths (0.5, 1.0, and 1.5 cm). Repair of the 1.5-cm tear was performed on each shoulder with 3 methods in a randomized order: suture bridge, double-row repair with 2-mm fiber tape, and fiber tape with peripheral No. 2 nonabsorbable looped sutures. Resulting dog ear deformities were injected with an acrylic resin mixture, digitized 3-dimensionally (3D), and photographed perpendicular to the footprint with calibration. The volume, height, and width of the rotator cuff tissue not in contact with the greater tuberosity footprint were calculated using the volume injected, 3D reconstructions, and calibrated photographs. Comparisons were made between tear size, dog ear measurement technique, and repair method utilizing 2-way analysis of variance and Student-Newman-Keuls multiple-comparison tests.Results:Utilizing 3D digitized and injection-derived volumes and dimensions, anterior dog ear volume, height, and width were significantly smaller for rotator cuff repair with peripheral looped sutures compared with a suture bridge (P < .05) or double-row repair with 2-mm fiber tape alone (P < .05). Similarly, posterior height and width were significantly smaller for repair with looped peripheral sutures compared with a suture bridge (P < .05). Dog ear volumes and heights trended larger for the 1.5-cm tear, but this was not statistically significant.Conclusion:When combined with a standard transosseous-equivalent repair technique, peripheral No. 2 nonabsorbable looped sutures significantly decreased the volume, height, and width of dog ear deformities, better restoring the anatomic footprint of the rotator cuff.Clinical Relevance:Dog ear deformities are commonly encountered during rotator cuff repair. Knowledge of a repair technique that reliably decreases their size, and thus increases contact at the anatomic footprint of the rotator cuff, will aid sports medicine surgeons in the management of these deformities.

In the face of improved radiological and arthroscopic techniques the diagnosis and treatment of SLAP lesions has recently gained much interest. Originally described as an (isolated) injury of the overhead athlete, it was only recently that the association of SLAP and rotator cuff defects was described in up to 40 % of cases. This study addresses the question of the evidence-based treatment of such frequent, combined lesions. Based on a systematic review of the online databases PubMed, EMBASE, CINAHL and Cochrane Library we identified clinical studies on the treatment of combined SLAP and rotator cuff lesions. Study quality was assessed using levels of evidence and a modified Jadad score. Clinical outcome was assessed through scores and range of motion assessments. We included 7 studies of 374 patients with a mean age of 53 ± 11 years followed for 35 ± 13 months. Combined lesions have a significant negative effect on isolated rotator cuff or SLAP repair. Patients older than 45 years of age had a significantly better clinical result after biceps tenotomy than SLAP repair with concomitant rotator cuff repair. Biceps tenotomy plus rotator cuff repair showed significantly better range of motion for flexion and rotation than SLAP plus rotator cuff repair. The frequent combination of SLAP and rotator cuff injury should be considered during assessment and informed consent of shoulder patients. While young patients and isolated SLAP lesions show excellent clinical results after elective repair, combined lesions should be treated with biceps tenotomy and/or debridement plus rotator cuff repair in patients older than 45 years.

Rotator cuff repair surgeries often face high failure rates, particularly in cases involving tendon degeneration. Traditional repair techniques and devices frequently fail to adequately restore a healthy native enthesis and strong tendon-bone integration. This study investigates the efficacy of a novel, fully synthetic, bioresorbable nanofiber scaffold in restoring the native enthesis and enhancing the biomechanical properties and overall success of rotator cuff repairs, particularly in the context of chronically degenerated tendons. This study used an ovine model to simulate chronic tendon degeneration with subsequent rotator cuff transection and repair. All repairs were performed using the standard double-row configuration with suture tape; half of the repairs were augmented with the bioresorbable nanofiber scaffold. Nondestructive biomechanical testing was conducted to assess the strength of the repair constructs, followed by histological analysis of all tendon samples to evaluate tissue regeneration and integration at the repair site. Results demonstrated that the scaffold group achieved significantly improved biomechanical properties (peak force, peak stress, equilibrium force, and equilibrium stress) compared to the suture only group, indicating enhanced repair strength and native enthesis restoration. Scaffold samples exhibited significantly decreased cross-sectional areas (ie, less fibrosis) which were similar to healthy tendons. Histological findings indicated the scaffold did not impede re-establishment of Sharpey-like fibers at the tendon insertion. This study provides compelling evidence that the use of a fully synthetic, bioresorbable nanofiber scaffold in rotator cuff repair significantly improves biomechanical outcomes and enthesis regeneration. These improvements were achieved while retaining close to native tendon thickness. The findings suggest that this scaffold represents a significant advancement in rotator cuff repair technology, offering a promising solution to enhance repair strength and quality of bone-tendon integration, especially in challenging cases of tendon degeneration.

Objectives:Rotator cuff repair is associated with an unusually high incidence of osteoarthritic changes and cartilage damage in the glenohumeral joint. Such degeneration may be secondary to improper tensioning of muscular stabilizers during surgical intervention; however, existing studies have not specifically examined changes in joint congruity following rotator cuff repair. Therefore, the purpose of this study was to assess for changes in glenohumeral contact forces following the repair of rotator cuff injury.Methods:Transduction mapping was performed on the glenohumeral joint of ten fresh-frozen cadaveric shoulder specimens. A calibrated pressure-mapping sensor was introduced through the rotator interval and secured along the concavity of the glenoid labrum. Following a baseline force measurements, analysis of force intensity and total glenohumeral contact area was performed in each specimen for 6 simulated injury and treatment conditions: A) A 1 cm supraspinatus lesion; B) 2-suture repair of the 1 cm lesion; C) removal of the 2-suture repair; D) a 2 cm supraspinatus lesion; E) 3-suture repair of the 2 cm lesion and; F) removal of the 3-suture repair. All repairs were performed via bone tunnels in the standard method described. Data were recorded over 60s intervals at a rate of 4 frames per second and included raw force, area, and force per unit area. Values for lesion, repair, and post-repair conditions were expressed as a proportion of initial baseline measurements. Means and standard deviations were then calculated for each condition and compared via Student’s t-tests.Results:For baseline measurements, the mean intact glenohumeral force was 38.55 ± 24.79 N and the mean contact area was 313 ± 84.09 mm2. In comparison to baseline values, 3-suture repair yielded a significant increase in both total glenohumeral force (mean proportion: 2.16 ± 3.26; p=0.046) as well as proportion of force per unit area (1.73 ± 1.86 N/mm2; p=0.024). Both the 2 cm lesion and the 2-suture repair removal yielded significant decreases in contact area when compared to baseline, with the former exhibiting a proportion of 0.76 ± 0.19 (p=0.040) and the latter yielding a proportion of 0.60 ± 0.29 (p=0.004). No other conditions exhibited significant changes from baseline measurements.Conclusion:Rotator cuff injury leads to alterations in glenohumeral forces, with significant increases in articular contact-pressures following repair of larger supraspinatus lesions. These findings offer a possible explanation for the high rate of degenerative changes demonstrated following rotator cuff repair. Further study is warranted to determine how current treatment methods might be improved to result in glenohumeral contact pressures resembling those experienced prior to injury.

Regarding “Delaying Surgery for Rotator Cuff Tears With Concomitant Stiffness”

Recently there have been several evolving trends in the practice of shoulder surgery. Arthroscopic subacromial decompression has been performed with greater frequency by orthopaedic surgeons, and there has been considerable recent interest in arthroscopic rotator cuff repair. The purpose of this study was to identify trends in practice patterns for subacromial decompression and rotator cuff repair over time and in relation to the location of practice, fellowship training, and declared subspecialty of the surgeon. We reviewed the American Board of Orthopaedic Surgery Part II database to identify patterns in the utilization of open and arthroscopic subacromial decompression and rotator cuff repair among candidates for board certification. All procedures involving only arthroscopic or open subacromial decompression and/or rotator cuff repair from 2004 to 2009 were identified. The rates of arthroscopic and open subacromial decompression and/or rotator cuff repair were compared in terms of year, geographic region, fellowship training, and declared subspecialty of the surgeon. Between 2004 and 2009, 12,136 surgical procedures involving only arthroscopic or open subacromial decompression and/or rotator cuff repair were performed. There were significant differences in treatment with respect to year, geographic region of practice, declared subspecialty, and fellowship training (p < 0.001). There was a significant increase over time in the utilization of arthroscopy among all candidates (p < 0.001). Surgeons with sports medicine fellowship training or a sports-medicine-declared subspecialty performed significantly more subacromial decompressions and rotator cuff repairs arthroscopically than all other candidates (p < 0.001). During this time period, there was a significant decrease in the rate of arthroscopic subacromial decompression, both as an isolated procedure and combined with arthroscopic rotator cuff repair (p < 0.001). From 2004 to 2009, there was a significant shift throughout the United States toward arthroscopic rotator cuff repair and subacromial decompression among young orthopaedic surgeons, with sports medicine fellowship-trained surgeons performing more of their procedures arthroscopically than surgeons with other training. However, there was an increasing frequency of arthroscopic rotator cuff repair performed without subacromial decompression, and, overall, there was a decrease in the frequency of isolated arthroscopic subacromial decompression over time.

Arthroscopic Treatment of Rotator Cuff Pathology in Patients with Concurrent Glenohumeral Arthritis (SS-06)