Rotator cuff repair vs. reverse arthroplasty for massive tears: A patient-centered outcome analysis.

BackgroundThe failure rate following primary arthroscopic rotator cuff repair (RCR) is high. There is little existing literature reporting on failure rates in the context of the histological degree of fatty accumulation, fibrosis, and atrophy of the rotator cuff (RC) muscles. The objective of this study was to examine the association between histological fatty accumulation, fibrosis, and myofiber size of the RC muscles and re-tear and revision rates in patients who underwent primary arthroscopic RCR at a minimum of 1-year follow-up.MethodsThis is a prospective study of patients who underwent primary arthroscopic RCR by a single surgeon at an academic tertiary institution between September 2020 and November 2023. All patients were indicated for RCR with a diagnosis of supraspinatus tear and had no prior RC surgery. Pre-operatively, RC tear size and RC muscle fatty degeneration using the Goutallier classification were graded on magnetic resonance imaging. Supraspinatus muscle biopsies were obtained at the time of surgery. Biopsy specimens were cross-sectioned and stained with LipidTOX and LAMININ to visualize lipid accumulation and quantify myofiber cross-sectional area at a histological level, respectively. FIBRONECTIN staining was performed to quantify histological fibrosis. Medical records were reviewed for RC re-tear, re-operation, or revision surgery. Patients were included if they had a minimum follow-up of at least 1 year, either by phone call or chart review of the latest visit with an orthopedic provider confirming survivorship.ResultsA total of 53 patients (53 shoulders) underwent primary arthroscopic RCR and met inclusion criteria. Nineteen tears were partial thickness, and the remaining 34 full-thickness tears were roughly evenly distributed between small, medium, large, and massive sizes. Median Goutallier score was 1. Seven (13%) patients experienced retears confirmed on magnetic resonance imaging. Five patients (9%) had undergone revision (mean time to revision 21.8 months) while 48 patients were revision-free with a minimum follow-up of at least 1 year (mean follow-up 38.8 months). Reasons for revision included RC re-tear in 4 patients and glenohumeral arthritis in 1 patient. Revisions included revision RCR (3) and reverse total shoulder arthroplasty (2). There were no significant differences in demographics, tear size, repair type, Goutallier classification, LipidTOX/region of interest, average myofiber cross-sectional area, and % area FIBRONECTIN between patients with and without re-tear, and with and without revision.ConclusionHistological fatty accumulation, fibrosis, and myofiber sizes of the RC muscles were not associated with increased re-tear or revision rates following primary arthroscopic RCR at a mean 3-year follow-up.

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...

What's New in Shoulder and Elbow Surgery.

A new scale measuring translation of the humeral head as a prognostic factor for the treatment of large and massive rotator cuff tears

Clinical outcomes of reverse shoulder arthroplasty and rotator cuff repair in patients with massive rotator cuff tears without osteoarthritis: comparison using propensity score matching.

PURPOSE: The aim of this study was to determine if the re-rupture rate and post-operative infections differed among patients who received a corticosteroid injection (CSI) and those who did not prior to primary arthroscopic rotator cuff repair (RCR). METHODS: Patients who underwent primary RCR by a single surgeon (1999-2020) were included. Demographics included age at the time of surgery, BMI, comorbidities, and the administration of pre-operative CSIs. Tear thickness, size, and RCR integrity were evaluated pre-and post-operatively, by ultrasound or MRI. Infection was identified through clinical diagnosis and post-operative lab work. RESULTS: 154 shoulders underwent primary arthroscopic RCR and were included. 92 patients were in the no injection group including 66 males and 26 females (age 60.7 ± 13.1 years, BMI 27.3 ± 4.8), and 62 patients were in the injection group including 38 males and 24 females (age 58.1 ± 12.3 years, BMI 27.7 ± 4.9). There were no differences in demographics between groups aside from a greater proportion of males in the no injection group (P < 0.001). There were 22 (23.9%) partial and 70 (76.1%) full thickness tears in the no injection group and 18 (29.0%) partial and 4 (71.0%) full thickness tears in the injection group (P > 0.05). Of the full thickness tears in the no injection group, there were 9 (12.9%) small (<1 cm), 12 (17.1%) medium (1-3 cm), 26 (37.1%) large (3-5 cm), and 23 (32.9%) massive tears (>5 cm). Of the full thickness tears in the injection group, there were 7 (15.9%) small, 7 (15.9%) medium, 19 (43.2%) large, and 11 (25.0%) massive tears. There were no differences in primary tear characteristics. No postoperative infections were reported. The average time from pre-operative CSI to surgery was 9.6 ± 22.3 months in the injection group. There were 16 re-ruptures in the no injection group (17.4%) and 11 in the injection group (17.7%) (P > 0.05). The average time to failure was 2.0 ± 3.0 years in the no injection group and 4.6 ± 4.7 years in the injection group (P > 0.05). CONCLUSION: Preoperative CSI did not lead to infections or increased risk of re-rupture following arthroscopic primary RCR in our cohort suggesting this is a viable treatment option in the management of rotator cuff tears without compromising postoperative outcomes.

What's New in Shoulder and Elbow Surgery.

Background In recent years, the incidence of rotator cuff injury has been increasing in population. Rotator cuff injury is not only the damage of tendon, but also often associated with different levels of nerve damage.Among them, the suprascapular nerve injury is the most commonone . The suprascapular nerve runs on the fascia between supraspinatus and infraspinatus.The severe retraction and fat infiltration of supraspinatus and infraspinatuscaused by massive rotator cuff tear will pull the suprascapular nerve and result in its dysfunction.The symptomsaremanifested as the posterolateral pain of shoulder joint which radiates toward the back of neck andarm and the disability of shoulder abduction and external rotation. Clinically, the disease can be easily missed.The incidence of massive rotator cuff injury accounts for approximately 10% to 40% of all rotator cuff injuries. According to the size of tear, Cofield divided rotator cuff injury intofour types:small tear ( 5 cm) . However, 30% of rotator cuff injuries are considered to be irreparable due to massive tear, atrophy of rotator cuff and fat infiltration, and the retear of 80% of patientis massive rotator cuff tear.The cause of suprascapular nerve damage after massive rotator cuff injury is unclear, which may be related to the retraction of rotator cuff and in turn the traction of suprascapular nerve around spinoglenoid notch.Some studies pointed out that the suprascapular nerve function can be restored with simple rotator cuff repair. For massive rotator cuff injury, there are traditional double-row repair and suture bridge technology.Transposition of latissimus dorsi muscle, transposition of deltoid muscle, patch repair, reverse shoulder arthroplasty,etc.have good efficacy in the treatment of massive rotator cuff injury with severe retraction and fat infiltration. However, there is a lack of study on the recovery of nerve damage.Objective To investigate the effects of traditional double-row repair and fascia lata transposition on the functional recovery of the patient with massive rotator cuff tear with suprascapular nerve injury. Methods From January 2013 to January 2018, a total of 20 patients with massive rotator cuff tear received arthroscopic rotator cuff repair surgery in our hospital, and the data were retrospectively analyzed. There were 10 cases in traditional double-row repair group (group A) and 10 cases in fascia lata transposition group (group B) . All patients were diagnosed as massive rotator cuff injury with suprascapular nerve injury under MRI and electromyogram.The postoperative follow ups were conducted in the 1st and 6th months. Visual analogue scale (VAS) , University of California at Los Angeles (UCLA) scoring system and Constant-Murley scoring system were applied for comparison between the two groups before and 6 months after operation.The conditions of rotator cuff healing and nerve recovery were assessed by MRI and electromyogram 6 months after operation. Results Twenty patients were followed up for 6 months after surgery, and the average follow up time ranged from 6 to 18 months. Six months after operation: the VAS score of group A decreased from preoperative (7.4±0.8) points to postoperative (2.3±1.7) points with statistical difference (P<0.01) ; the UCLA score of group A increased from preoperative (11.5±1.4) points to postoperative (28.3±5.8) points with statistical difference (P<0.01) ; the Constant-Murley score of group A increased from preoperative (45.6±6.2) points to postoperative (79.0±11.7) points with statistical difference (P<0.01) ; the VAS score of group B decreased from preoperative (7.9±0.6) points to postoperative (2.7±1.8) points with statistical difference (P<0.01) ; the UCLA score of group B increased from preoperative (10.1±1.4) points to postoperative (26.9±6.9) points with statistical difference (P<0.01) ; the Constant-Murley score of group B increased from preoperative (39.0±3.4) points to postoperative (72.9±9.4) points with statistical difference (P<0.01) .Electromyogram was reviewed 6 months after operation.While there was no suprascapular nerve injury in the group A,there were 5 cases of suprascapular nerveinjury in the group B (P<0.01) . Conclusion Both the arthroscopic traditional double-row repair and the fascia lata transposition can improve shoulder function. For the patient with suprascapular nerve injury, it is believed that the traditional double-row repair can better restore suprascapular nerve function than the fascia lata transposition does.However, the risk of retearmay be high. Key words: Massive rotator cuff tear; Arthroscopy; Suprascapular nerve; Rotator cuff repair; Patch graft

Background: Symptomatic rotator cuff tears are often treated surgically. However, there is a paucity of information regarding the outcomes of revision arthroscopic rotator cuff repairs. Purpose: To evaluate the outcome of revision arthroscopic rotator cuff surgery when compared with primary arthroscopic rotator cuff surgery in a large cohort of patients. Study Design: Cohort study; Level of evidence, 3. Method: A consecutive series of 50 revision arthroscopic rotator cuff repairs performed by a single surgeon, with minimum 2-year follow-up, were retrospectively reviewed using prospectively collected data. As a comparison, 3 primary arthroscopic rotator cuff repair cases (primary group; n = 310) were chosen immediately before each revision case, and 3 were chosen after. Standardized patient-ranked outcomes, examiner-determined assessments, and ultrasound-determined rotator cuff integrity were assessed preoperatively at 6 months and at a minimum of 2 years after surgery. Results: The revision group was older (mean age, 63 years; range, 43-80 years) compared with the primary group (mean age, 60 years; range, 18-88 years) (P < .05) and had larger tear size (mean ± SEM) (4.1 ± 0.5 cm2) compared with the primary group (3.0 ± 0.2 cm2) (P < .05). Two years after surgery, the primary group reported less pain at rest (P < .02), during sleep (P < .05), and with overhead activity (P < .01) compared with the revision group. The primary group had better passive forward flexion (+13°; P < .05), abduction (+18°; P < .01), internal rotation (+2 vertebral levels; P < .001) and also significantly greater supraspinatus strength (+15 N; P < .001), lift-off strength (+9.3 N; P < .05), and adduction strength (+20 N; P < .01) compared with the revision group at 2 years. When compared with the primary group, the revision group was more satisfied with the overall shoulder function before surgery but was less satisfied with their shoulder function than the primary group at 2 years (P < .005). The retear rate for primary rotator cuff repair was 16% at 6 months and 21% at 2 years, while the retear rate for revision rotator cuff repair was 28% at 6 months and deteriorated to 40% at 2 years (P < .05). Conclusion: The short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to those after primary rotator cuff repair. However, these results did not persist, and by 2 years patients who had revision rotator cuff repair were twice as likely to have retorn compared with those undergoing primary repair. The increase in retear rate in the revision group at 2 years was associated with increased pain, impaired overhead function, less passive motion, weaker strength, and less overall satisfaction with shoulder function.

Cost-Effectiveness of Reverse Total Shoulder Arthroplasty Versus Arthroscopic Rotator Cuff Repair for Symptomatic Large and Massive Rotator Cuff Tears

Rare case of intra-articular biceps incarceration following traumatic massive rotator cuff tear

Perioperative Losartan is Associated with Similar Rates of Additional Surgical Procedures For Postoperative Shoulder Stiffness Following Primary Arthroscopic Rotator Cuff Repair But Lower Rates of Secondary Debridement and Repair

Bovine bioinductive collagen implants (herein, "bovine collagen implant") can be used to augment rotator cuff repair. Concern exists that these bovine collagen implants may not yield clinical benefits and may actually increase postoperative stiffness and the need for reoperation. Among patients who underwent primary rotator cuff repair with or without a bovine collagen implant, we asked: (1) Did the proportion of patients undergoing reoperation for postoperative stiffness and inflammation differ between the bovine collagen implant and control groups? (2) Did short-term patient-reported outcomes differ between the two groups? (3) Did the proportion of patients receiving postoperative methylprednisolone prescriptions and corticosteroid injections differ between the two groups? We performed a retrospective, matched, comparative study of patients 18 years and older with minimum 2-year follow-up who underwent primary arthroscopic repair of partial or full-thickness rotator cuff tears diagnosed by MRI. All procedures were performed by one surgeon between February 2016 and December 2021. During the period in question, this surgeon broadly offered the bovine collagen implant to all patients who underwent rotator cuff repair and who (1) consented to xenograft use and (2) had surgery at a facility where the bovine collagen implant was available. The bovine collagen implant was used in rotator cuff tears of all sizes per the manufacturer's instructions. A total of 312 patients were considered for this study (243 control, 69 implant). Minimum 2-year clinical follow-up data were available for 83% (201 of 243) of patients in the control group and 90% (62 of 69) of patients in the bovine collagen implant group. After we applied the exclusion criteria, 163 control and 47 implant group patients remained and were eligible for matching. Propensity score matching was conducted to balance cohorts by age, gender, race (Black, White, other), ethnicity (Hispanic, non-Hispanic), health insurance status, Area Deprivation Index, BMI, American Society of Anesthesiologists physical status classification, diabetes, smoking, rotator cuff tear size, concomitant surgical procedures, preoperative American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), VAS score for pain, and shoulder ROM. We included 141 patients (47 in the implant group and 94 in the control group) after matching. Patients were categorized according to whether they received the bovine collagen implant. Before matching, the control cohort was older (mean ± SD 57 ± 10 years versus 52 ± 11 years; p = 0.004), more likely to be White (58% versus 23%; p < 0.001), with a smaller proportion of concomitant distal clavicle excisions (43% versus 21%; p = 0.003), and a smaller proportion of "other" concomitant procedures (17% versus 6%; p = 0.011) compared with the implant cohort. After matching, the cohorts were well matched in all demographic variables. The primary study outcome was reoperation for inflammation and stiffness, defined as a failure of nonoperative treatment for a minimum of 9 months, including physical therapy, NSAIDs, at least one course of oral methylprednisolone, and at least one cortisone injection (reoperations for traumatic retears were excluded). Secondary outcomes were patient-reported outcomes (SSV, ASES score, and VAS score for pain), receipt of methylprednisolone prescriptions, and receipt of corticosteroid injections. Chi-square, Fisher exact tests, and independent-samples t-tests were used to assess relationships between treatment group and study outcomes. A greater proportion of patients in the bovine collagen implant group (9% [4 of 47]) underwent reoperation for inflammation and stiffness than in the control group (0% [0 of 94]; p = 0.01). At minimum 2-year follow-up, the cohorts did not differ by ASES score (mean ± SD 81 ± 24 implant versus 85 ±19 control; p = 0.24), SSV (79 ± 24 implant versus 85 ± 18 control; p = 0.30), or VAS score for pain (2.0 ± 2.9 implant versus 1.5 ± 2.3 control; p = 0.11). The cohorts did not differ in the proportion who received postoperative corticosteroid injections (15% implant versus 11% control; p = 0.46) or methylprednisolone prescriptions (49% implant versus 37% control; p = 0.18). At minimum 2-year follow-up, patients undergoing primary arthroscopic rotator cuff repair with bovine collagen implant augmentation had a greater proportion of reoperation due to inflammation and stiffness compared with patients who did not receive the implant. Furthermore, the implant offered no benefit in patient-reported outcomes or need for postoperative corticosteroid injections or methylprednisolone prescriptions. Because of the lack of clinical benefit and potential increase in postoperative complications, we recommend against the use of these bovine collagen implants unless high-quality randomized controlled trials are able to demonstrate their clinical effectiveness, cost-effectiveness, and overall safety. Level III, therapeutic study.

Arthroscopic revision of failed rotator cuff repairs: technique and results

The number of rotator cuff repairs that are undertaken is increasing. Reverse shoulder arthroplasty (RSA) is the procedure of choice for patients with rotator cuff arthropathy. We sought to determine whether patients who underwent rotator cuff repair and subsequent RSA had different outcomes compared with a matched control group who underwent RSA without a previous rotator cuff repair. All patients with a history of rotator cuff repair who underwent RSA between 2000 and 2015 with a minimum follow-up of two years were eligible for inclusion as the study group. Outcomes, including the American Shoulder and Elbow Surgeons (ASES) scores, were compared with a matched control group of patients who underwent RSA without having previously undergone rotator cuff repair. The study group included 45 patients. Their mean age was 69 years (sd 8.6) and 27 patients (60%) were women. The mean ASES score improved from 43.1 to 76.6 two years postoperatively, and to 66.9 five years postoperatively. There was no significant difference between the outcomes at two years in the two groups (all p ≥ 0.05), although there was significantly more improvement in ASES scores in the control group (44.5 vs 33.4; p = 0.01). However, there was no significant difference between ASES scores at two and five years when baseline ASES scores were matched in the two groups (p = 0.42 at two years; p = 0.35 at five years). Significant improvements in ASES scores were seen following RSA in patients who had previously undergone rotator cuff repair. They had higher baseline ASES scores than those who had not previously undergone this surgery. However, there was no significant difference in outcomes between the two groups, two years postoperatively. Previous rotator cuff repair does not appear to affect the early outcome after RSA adversely.