Radiology Review: Acute Full-Thickness Gluteal Tear.

Epidemiology, Natural History, and Indications for Treatment of Rotator Cuff Tears

This study was undertaken to identify differences in the sonographic appearance of acute and chronic full-thickness rotator cuff tears. The ultrasonograms of 24 patients with an acute rotator cuff tear and 20 with a chronic tear were reviewed for tear size (width), location, and the presence and distribution of fluid. Among these 24 patients, 75% with a midsubstance tear location had an acute tear; 64% of patients with joint or bursal fluid had an acute tear; 80% of patients with a nonvisualized rotator cuff due to a massive tear had a chronic tear; and 73% of patients with no sonographic evidence of bursal or joint fluid had a chronic tear. In conclusion, a midsubstance location and the presence of joint or bursal fluid were more commonly associated with an acute tear. A nonvisualized cuff and the absence of joint and bursal fluid were more commonly observed with a chronic tear.

Background:Apoptosis and autophagy are known to be correlated with the extent of damage in torn rotator cuffs, and there is no biological evidence for self-recovery or healing of the rotator cuff tear.Purpose:To establish in a rat model of partial- and full-thickness rotator cuff tears how a glycogen synthase kinase 3β (GSK-3β) inhibitor affects the expression of apoptotic and autophagic markers.Study Design:Controlled laboratory study.Methods:Twelve-week-old Sprague Dawley rats were divided into 3 groups (n = 16 per group). Group 1 acted as the control, with no treatment; group 2 received partial-thickness (right side) and full-thickness (left side) rotator cuff tears only; and group 3 received the same rotator cuff injuries, with GSK-3β inhibitor injected afterward. The tendons from each group were harvested 42 days after surgery. Evaluation of gene expression, immunohistochemistry, and TUNEL staining (terminal deoxynucleotidyl transferase–mediated dUTP nick end labeling) were performed for the following markers: caspases 3, 8, and 9 as well as Bcl-2 (B-cell lymphoma 2); BAX (Bcl-2-associated X protein); beclin 1; p53; and GSK-3β; which represented apoptotic and autophagic reactions. Statistical analysis was performed using 1-way analysis of variance.Results:In the group 2 rats with partial- and full-thickness tears, there were significant increases in the mRNA levels (fold changes) of all 8 markers as compared with group 1 (control). All these increased markers showed significant downregulation by the GSK-3β inhibitor in partial-thickness tears. However, the response to the GSK-3β inhibitor in full-thickness tears was not as prominent as in partial-thickness tears. The number of TUNEL-positive cells in group 2 (partial, 35.08% ± 1.625% [mean ± SE]; full, 46.92% ± 1.319%) was significantly higher than in group 1 (18.02% ± 1.036%; P < .01) and group 3 (partial, 28.04% ± 2.607% [P < .01]; full, 38.97% ± 2.772% [P < .01]), and immunohistochemistry revealed increased expression of all the markers in group 2 as compared with control.Conclusion:The apoptotic and autophagic activity induced in a rat model of an acute rotator cuff tear was downregulated after treatment with a GSK-3β inhibitor, particularly with partial-thickness rotator cuff tears.Clinical Relevance:A GSK-3β inhibitor may be able to modulate deterioration in a torn rotator cuff.

The Value of Clinical Tests in Acute Full-Thickness Tears of the Supraspinatus Tendon: Does a Subacromial Lidocaine Injection Help in the Clinical Diagnosis? A Prospective Study

Study Design Case Report. Background Abdominal wall muscle injuries have been reported in handball, tennis, and baseball; however, a bilateral full-thickness tear of the rectus abdominis muscle and its rehabilitation have not previously been described. This report aims to describe a case of an acute bilateral full-thickness rectus abdominis tear simulating an acute abdomen that presented to an emergency department. Case Description A 25-year-old male (169 cm, 84 kg) was transferred to the emergency room due to severe lancinating (Numerical Pain Rating 10/10) abdominal pain that occurred during weight training at a gym. An orthopedic surgeon, an internist, and a general surgeon assessed him for internal and surgical emergencies. The magnetic resonance imaging of his abdomen revealed a bilateral full-thickness tear of the rectus abdominis muscle. The patient was given an option of surgical repair of the RA, but he refused. Six weeks later, he attended our sports medicine department. A criteria-based rehabilitation program was planned, with weekly follow-ups. Outcomes The patient could walk pain-free at 4th week and jog at 10th week of rehabilitation. Significant improvements in the range of movement of the trunk, pain levels and functional capacity were noted at discharge and 6 and 12-month follow-ups. Discussion Clinical management of this patient is described in detail, with emphasis on diagnostic ultrasonography. The structured rehabilitation program used for this patient resulted in a return to pre-injury level function.

Results of early operative treatment of rotator cuff tears with acute symptoms

Background and purpose Few authors have considered the outcome after acute traumatic rotator cuff tears in previously asymptomatic patients. We investigated whether delay of surgery, age at repair, and the number of cuff tendons involved affect the structural and clinical outcome.Patients and methods 42 patients with pseudoparalysis after trauma and no previous history of shoulder symptoms were included. A full-thickness tear in at least 1 of the rotator cuff tendons was diagnosed in all patients. Mean time to surgery was 38 (6–91) days. Follow-up at a mean of 39 (12–108) months after surgery included ultrasound, plain radiographs, Constant-Murley score, DASH score, and western Ontario rotator cuff (WORC) score.Results At follow-up, 4 patients had a full-thickness tear and 9 had a partial-thickness tear in the repaired shoulder. No correlation between the structural or clinical outcome and the time to repair within 3 months was found. The patients with a tendon defect at follow-up had a statistically significantly lower Constant-Murley score and WORC index in the injured shoulder and were significantly older than those with intact tendons. The outcomes were similar irrespective of the number of tendons repaired.Interpretation A delay of 3 months to repair had no effect on outcome. The patients with cuff defects at follow-up were older and they had a worse clinical outcome. Multi-tendon injury did not generate worse outcomes than single-tendon tears at follow-up.

Rotator cuff (RTC) disease is a particularly prevalent cause of shoulder pain and weakness presenting to primary care physicians, internists, rheumatologists, and orthopedists. An understanding of the anatomy of the RTC tendons and the underlying pathogenesis aids in the diagnosis, which is based largely on history and specific physical examination tests. Imaging may further define the pathology and aid in the evaluation of other sources of shoulder pain. Injuries to the RTC range from tendonitis to partial thickness tears to full thickness tears. The majority of patients with impingement and some cases of partial thickness tears may be managed effectively with non-operative measures including non-steroidal anti-inflammatory drugs, local injections, and physical therapy. Predictors of a good outcome with non-operative treatment include pre-injury strength, ability to raise the arm to the level of the shoulder, and a more acute presentation. Persistent symptoms may require operative intervention including debridement, subacromial decompression, and/or RTC repair. Acute full thickness tears in younger patients in addition to failed non-operative management of full thickness tears in older patients are the most likely to require surgery, which may be done open or arthroscopically. The majority of tears are amenable to the less invasive arthroscopic method, which yields good success rates and high patient satisfaction.

### What you need to know A 45 year old woman falls on ice and injures her shoulder. Assessment at her local hospital reveals bruising only and no bony injury...

Objectives: The minimum clinically important difference (MCID) is a commonly used measure to aid in determining significant improvements for patient-reported outcomes (PROs). As MCID and PROs continue to be implemented in shoulder procedures, MCID can greatly differ depending upon the specific patient population, follow-up time, and methodology. In the setting of rotator cuff repair (RCR), there are few studies that discuss the effect of tendon involvement on MCID achievement. Other orthopaedic conditions have calculated separate MCIDs depending on the severity of the fracture or pathology. The purpose of this study was to calculate an MCID for one-, two-, and three-tendon RCR. They hypothesis was that MICD values would be lower for larger repairs compared to smaller repairs. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) score. Secondary outcomes included evaluating what patient and surgical characteristics affect MCID achievement for each MCID. Methods: A prospectively collected PRO database was queried for patients who underwent primary RCR from 2018 to 2022. Revision procedures, patients with a history of prior shoulder surgery, or patients lacking PROs at any time point were excluded. Demographic and surgery characteristics were extracted through chart review. The primary outcome was the ASES score. ASES is a validated instrument scored on a 100-point scale with 0 indicating the” worst outcome” and 100 being the “best outcome.” MCID was calculated using the anchor-based method as has been done in previous works. The anchor question from PROMIS-10 asks, “In general, how would you rate your physical health?” scored on a 5-point Likert scale. An increase of one point was deemed to be a significant improvement in the anchor to calculate the MCID. An MCID was calculated for the three sizes of RCRs in this sample. Statistical analysis included descriptive statistics, as well as independent sample t-tests, chi-square tests, and fisher exact tests. Results: A total of 799 patients met inclusion criteria. Most patients were male (n=474, 59.3%) and were 61.2 years old. There were 61.5% of patients who had their dominant shoulder treated with RCR. Patients typically presented with at least one tendon that had a full thickness tear (n=643, 80.5%). Many underwent various concomitant procedures including subacromial decompression (83.9%), biceps tendon procedures (tenotomy or tenodesis) (59.0%), distal clavicle excision (24.2%), and arthroscopic debridement (24.0%). The average case length was 130.1 minutes. There were 36 symptomatic retears (4.5%), 10 revisions (1.3%), and 14 other reoperations (1.8%) within one year. ASES scores at baseline and one-year were 48.1 and 84.6, respectively, with an average one-year change of +36.6. MCIDs by number of tendons involved were 40.5, 36.3, and 39.3 for single-, two-, and three-tendon repairs. The number of patients that achieved MCID by tendon size did not statistically differ between groups (Single: 51.0%; Two: 53.0%; Three: 50.0%, p&gt;0.610, respectively). MCID achievement and biceps tendon procedures trended towards significance for the single-tendon cohort (p=0.085), while patient sex trended towards significance in the two-tendon cohort (p=0.055). More acute tears compared to chronic tears met MCID in the three-tendon cohort although this only trended towards significance (p=0.074). MCID achievement was affected by symptomatic retears in the two-tendon RCR group (p&lt;0.001). While reoperation trended towards significance in the single-tendon RCR group (p=0.058). Conclusions: This study found that MCID value varied by the number of tendons involved in RCR, with two-tendon repairs having the lowest MCID (36.3). The number of patients that met MCID in each cohort was similar. Single-tendon tears appear to be more affected by biceps tendon procedures and reoperations, although both of these findings only trended towards significance. Patients with two-tendon tears were shown to be affected by symptomatic retear (p&lt;0.001), and patient sex, although the later finding was not statistically significant (p=0.055). MCID achievement in three-tendon RCRs appear to be influenced by tear chronicity with those with an acute tear being more likely to attain MCID, although this finding was not significant (p=0.074). Surgeons should consider the size of a cuff repair and what corresponding surgical and patient factors may be more pertinent to each patient to help maximize patient outcomes.

To determine the value of sonography in the evaluation of acute traumatic tears of the rotator cuff. Preoperative sonography was performed within 3 weeks of trauma in 184 patients, 98 of whom underwent surgery. The rotator cuff tears were preoperatively classified as partial-thickness tears or as small, large, or massive full-thickness tears. Sonographic findings were correlated with surgical findings (n = 70) and arthroscopic inspection (n = 28). Adequate examination was possible in 163 (88%) of 184 patients. Sonography demonstrated 42 (91%) of 46 full-thickness tears and seven (78%) of nine partial-thickness tears. Sonography showed more extensive tears than were found at surgery in four (4%) of 98 patients and less extensive tears in seven (7%) of 98 patients. Sonographic patterns were a defect (31 [63%] of 49 tears), focal thinning (10 [21%] of 49 tears), and nonvisualization (eight [16%] of 49 tears). Sonography is useful in the evaluation of acute shoulder trauma when a rotator cuff tear is suspected and findings at plain radiography are negative.

Objectives:Rotator cuff tears lead to significant morbidity due to pain and decreased function. Despite the prevalence of cuff repairs, mid-term outcomes have been scarcely reported. The purpose of this study is to report minimum 5-year outcomes and clinical survivorship after double-row rotator cuff repair for full-thickness supraspinatus tendon tears.Methods:Patients at least five years out from arthroscopic double-row repair for a full-thickness cuff tear involving the supraspinatus tendon were included. Pre- and postoperative ASES, SF-12 PCS, QuickDASH, SANE, and satisfaction scores were collected. The relationship between outcomes and (1) tear chronicity, (2) number of tendons involved, (3) type of repair, and (4) primary versus revision procedure, was also evaluated. Kaplan-Meier survivorship analysis was conducted defining failures as progression to revision rotator cuff surgery.Results:From November 2005 to February 2012, a total of 189 shoulders were eligible for inclusion. Fifteen shoulders (7.9%) underwent revision rotator cuff repair and were considered failures. Outcomes data were reported at a mean follow-up of 6.6 (range, 5.0-11.0) years. All outcome scores significantly improved from pre- to postoperative time point, including mean ASES (57.9 to 92.9, P < 0.001), SF-12 PCS (43.4 to 52.0, P < 0.001), QuickDASH (35.2 to 10.5, P < 0.001), and SANE scores (61.5 to 86.5, P < 0.001). Acute tears demonstrated significantly better ASES and SANE scores than chronic tears (ASES 95.1 ± 8.9 versus 91.7 ± 11.2, P = 0.025; SANE 89.6 ± 19.9 versus 85.7 ± 21.3, P = 0.042). No other analyzed variable had a significant association with outcomes scores (P > 0.05). Survivorship analysis demonstrated a postoperative clinical survivorship of the repair of 96.5% at two years and 93.8% at five years (Figure 1).Conclusion:Patients can expect excellent clinical outcomes and a low failure rate following arthroscopic double-row repair of full-thickness supraspinatus tears at mid-term follow-up. The repair of acute tears and primary repairs were associated with better postoperative outcomes.

PurposeAcute trauma-related rotator cuff tears are believed to have better healing potential than chronic tears due to less degenerative changes of the tendons. However, the histopathological condition of tendons from trauma-related tears is not well investigated. The purpose of this study was to explore specific histopathological features in tendons from acute trauma-related full-thickness rotator cuff tears and to compare them to findings in tendons from nontraumatic, chronic tears.MethodsIn a prospective cohort study, 62 previously asymptomatic patients [14 women, median age 61 years (range 42–75)] with trauma-related full-thickness rotator cuff tears were consecutively included. Arthroscopic repair was performed within 30 (median, IQR 25–37) days after the injury. During surgery, tissue biopsies were harvested from the supraspinatus tendons in 53 (86%) of the patients. In addition, similar biopsies were harvested from 10 patients undergoing surgery for chronic tears without history of trauma. All tissue samples were examined by a well-experienced pathologist under light microscope. Tendon degeneration was determined using the Bonar score whereas immunostaining was used for proliferation (Ki67), inflammation (CD45), apoptosis (p53) and haemosiderin staining to study traces of bleeding.ResultsThe median (IQR) Bonar score for the acute trauma-related biopsies was 10.5 (7.5–14.5) compared to 11 (5–12.8) for the control group with no statistically significant difference between the groups. No statistically significant between-group difference was found for the inflammatory index whereas tendons from patients with trauma-related full-thickness rotator cuff tears had statistically significantly higher apoptosis [3.1 (0.5–8.9) vs. 0.1 (0–1.5), p = 0.003] and proliferation [4.0 (1.8–6.9) vs. 0.4 (0–2.0), p = 0.001) indices than those undergoing surgery for chronic tears. Positive haemosiderin staining was found in 34% of tissue samples from patients with trauma-related tears compared to 10% in the control group (n.s).ConclusionThis study suggests that there is no difference with regard to degenerative changes between supraspinatus tendons harvested from patients with acute, trauma-related rotator cuff tears and patients with nontraumatic, chronic tears.Level of evidenceII.

Acute rotator cuff tear is commonly associated with tearing of the proximal biceps tendon, but has never been reported to occur simultaneously with a distal biceps tendon rupture. A 38-year-old right-hand-dominant strongman competitor attempted a 300-pound overhead axle press and experienced immediate pain in the right shoulder and elbow. He had no known systemic risk factors for tendon ruptures including hyperparathyroidism, hemodialysis, alcoholism, rheumatoid arthritis, statin medications, fluoroquinolones, and steroid use.Right shoulder magnetic resonance imaging (MRI) showed a full-thickness supraspinatus tear with 3 cm of retraction. There was minimal fatty infiltration of the supraspinatus on the sagittal cuts consistent with acute rupture. The subscapularis was intact. The long head of the biceps tendon had mild medial subluxation but was completely within the bicipital groove. Right elbow MRI showed a complete distal biceps tendon rupture. Thirteen days after his injury, the patient underwent arthroscopic supraspinatus repair and proximal biceps tenodesis. Distal biceps tendon repair was performed using the modified 2-incision muscle-splitting technique. At 24-month follow-up, the patient was pain free and had returned to full activity including weightlifting but had not returned to strongman competition.This is the first report of simultaneous acute full thickness ruptures of the rotator cuff and distal biceps tendon. This case report underscores the importance of a complete physical examination and a high index of suspicion for additional concomitant injuries, particularly in athletes with unusually high stresses to the body.

Full-thickness rotator cuff tears (RCTs) represent a musculoskeletal damage that severely affects shoulder function and quality of life. Current surgical interventions are hindered by limited regenerative capacity of rotator cuff repair implants and high retear rates postoperatively. In this study, we investigated a tendon repair matrix (TRM) product prepared from bovine tendon collagen. The TRM was designed as a regenerative scaffold to improve the healing of damaged rotator cuff. In vitro results showed excellent cytocompatibility of TRM, with significantly enhanced adhesion, proliferation, and spreading of bone marrow stromal cells and tenocyte-like mouse tendon precursor cells,mouse tendon-derived cell line, clone D6 (TT-D6) cells (mouse tendon-derived cell line, clone D6). In a rabbit model of acute full-thickness supraspinatus tendon tear, TRM promoted type I collagen deposition, improved interface tissue formation, and enhanced tendon-to-bone integration. Furthermore, biomechanical test results revealed load-bearing capacity of the TRM group compared with both the empty and native tissue control groups. These findings support the clinical potential of TRM as a regenerative scaffold for the functional reconstruction of RCTs. Impact Statement This study addresses a critical clinical need in sports medicine by evaluating a novel bovine collagen-based tendon repair matrix (TRM) for the repair of acute full-thickness rotator cuff tears (RCTs). The TRM exhibited excellent biocompatibility and significantly enhanced tendon-to-bone healing, as demonstrated by improved fibrocartilaginous tissue formation and biomechanical strength in a rabbit model. These promising results underscore TRM's potential to reduce postoperative retear rates by promoting effective regeneration of the tendon-bone interface. Consequently, this research represents an important advancement toward improving clinical outcomes for RCT patients, offering substantial potential for translation into clinical practice.