Degenerative Rotator Cuff Tears Research Articles

Shoulder activity level and progression of degenerative cuff disease

This study prospectively examined the relationship of direct and indirect measures of shoulder activity with the risks of tear progression and pain development in subjects with an asymptomatic degenerative rotator cuff tear. A cohort of asymptomatic degenerative rotator cuff tears was prospectively monitored annually, documenting tear size progression with ultrasound imaging and potential shoulder pain development. Shoulder activity level, self-reported occupational and physical demand level, and hand dominance were compared with risks of tear enlargement and future pain development. The study monitored 346 individuals with a mean age of 62.1 years for a median duration of 4.1 years (interquartile range [IQR], 2.4-7.9 years). Tear enlargement was seen in 177 shoulders (51.2%), and pain developed in 161 shoulders (46.5%) over time. Tear presence in the dominant shoulder was associated with a greater risk of tear enlargement (hazard ratio, 1.40; P = .03) and pain development (hazard ratio, 1.63; P = .002). Shoulder activity level (P = .37) and occupational demand level (P = .62) were not predictive of tear enlargement. Occupational demand categories of manual labor (P = .047) and "in between" (P = .045) had greater risks of pain development than sedentary demands. The median shoulder activity score for shoulders that became painful was lower than for shoulders that remained asymptomatic (10.0 [IQR, 7.0-13.0] vs. 11.0 [IQR, 8.0-14.0], P = .02). Tear enlargement and pain development in asymptomatic tears are more common with involvement of the dominant shoulder. Shoulder activity level is not related to tear progression risks. Pain development is associated with a lower shoulder activity level even though patients with higher occupational demands are more likely to develop pain.

Clinical outcomes and cost-effectiveness of sodium hyaluronate treatment and arthroscopic repair of degenerative rotator cuff tears: A randomized controlled trial

Clinical outcomes and cost-effectiveness of sodium hyaluronate treatment and arthroscopic repair of degenerative rotator cuff tears: A randomized controlled trial

Acromion and glenoid shape: Why are they important predictive factors for the future of our shoulders?

The shape of the acromion differs between patients with degenerative rotator cuff tears and individuals without rotator cuff pathology.It can be assessed in the sagittal plane (acromion type, acromion slope) and in the coronal plane (lateral acromion angle, acromion index, critical shoulder angle).The inter-observer reliability is better for the measurements in the coronal plane.A large lateral extension (high acromion index or high critical shoulder angle) and a lateral down-sloping of the acromion (low lateral acromion angle) are associated with full-thickness supraspinatus tears.The significance of glenoid inclination for rotator cuff disease is less clear.The postulated patho-mechanism is the compression of the supraspinatus tendon between the humeral head and the acromion. Bursal side tears might be caused by friction and abrasion of the tendon. Articular side tears could be due to impairment of the gliding mechanism between tendon fibrils leading to local stress concentration. Further research is needed to understand the exact pathomechanism of tendon degeneration and tear.Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160076. Originally published online at www.efortopenreviews.org

Rehabilitation of symptomatic atraumatic degenerative rotator cuff tears: A clinical commentary on assessment and management

Study DesignClinical Commentary. IntroductionAtraumatic rotator cuff (RC) disease, is one of the most common cause of shoulder pain, which encompasses a continuum from tendinopathy to full thickness cuff tears. Extrinsic, intrinsic and environmental factors have been implicated in the pathophysiology of this disorder, affecting the clinical presentation of symptoms including pain and irritability. Successful rehabilitation of symptomatic atraumatic degenerative rotator cuff (SADRC) tears must address the underlying mechanisms causing dysfunction and correct modifiable factors. Purpose of the StudyThe purpose of this paper is to review the shoulder complex anatomy, introduce atraumatic degenerative RC pathology, differentiate between symptomatic and asymptomatic degenerative RC tears, propose an assessment and introduce the Rotator Cuff Protocol 1 (RCP1) designed by the clinical reasoning of one of the lead authors (LW) as a rehabilitation management approach for those clients who present with SADRC tears. Methods/Results/DiscussionN/A for clinical commentary. ConclusionsThe ability to identify SADRC tears should consider shoulder anatomy, extrinsic, intrinsic and environmental factors, and the consideration for the natural history of atraumatic partial and full thickness tears in the general population. A thorough clinical history and examination, which includes shoulder symptom modification tests, allows the examiner to determine at what phase the patient may start their exercise program. The RCP1 is a program that has been used clinically by many therapists and clients over the years and research is underway to test this protocol in atraumatic rotator cuff disease including SADRC tears. Level of Evidence5.

Treatment of distal 1/3 tibia fractures: plating versus intramedullary nailing – A prospective comparative study

Aims and Objectives: This study was undertaken to introduce anterolateral approach for mini-open degenerative rotator cuff tear in elderly and evaluate its outcome and effectiveness. Material and Methods: This study evaluated 25 cases that were repaired by mini-open repair using anterolateral approach. There were 15 men and 10 women with average age of 57.4 years. Average follow up was 12.6 months. There were 2 partial thickness, 4 small, 8 medium, 8 large, and 3 massive tears. An incision around 5-6 cm from anterolateral edge of acromion and dissected to the raphe between anterior and middle deltoid. Subacromial decompression was done by removing anteroinferior part of acromion. The torn tendon was repaired through single or double row technique using bony tunnels drilled in greater tuberosity. The deltoid was sutured back to remaining acromion. Clinical outcomes were evaluated using the American Shoulder and Elbow surgeon (ASES) scoring system. Results: The average visual analogue scale (VAS) and ASES scores improved respectively from 8.88, 83.32 preoperatively to 1.04 and 17.68 postoperatively. There were no statistically significant difference between final ASES scores and age, symptom duration. Men had higher final ASES scores than women (p= 0.012)

Effects of Platelet-Rich Plasma With Concomitant Use of a Corticosteroid on Tenocytes From Degenerative Rotator Cuff Tears in Interleukin 1β–Induced Tendinopathic Conditions

Background: A corticosteroid injection is commonly used to treat tendinopathy, but it has been associated with negative effects on tendon homeostasis. Platelet-rich plasma (PRP) is known to have proliferative and anabolic effects as well as cytoprotective effects against corticosteroids on tenocytes. However, the combined effects of a corticosteroid and PRP on the anti-inflammatory, matrix synthesis, and cytoprotective potential of tenocytes in conditions simulating tendinopathy have not been investigated. Purpose: To assess the effects of PRP on tenocytes from degenerative rotator cuff tears with the concomitant use of a corticosteroid in interleukin 1β (IL-1β)–induced tendinopathic conditions. Study Design: Controlled laboratory study. Methods: Tenocytes were enzymatically isolated and cultured from patients with degenerative rotator cuff tears. PRP was prepared using a plateletpheresis system, and growth factor concentrations were measured. To evaluate the gene expression of proinflammatory and anti-inflammatory cytokines, enzymes and their inhibitors, and matrix molecules, cells were cultured with 1 ng/mL IL-1β, 1 μM dexamethasone, and 10% (vol/vol) platelet-poor plasma (PPP) and PRP of 200, 1000, and 4000 × 103/μL; quantitative real-time reverse transcriptase polymerase chain reaction was also performed. Western blotting was performed to investigate the protein synthesis of degradative enzymes and their inhibitors. Cell viability, apoptosis, and senescence assays were also conducted. Results: PRP did not interfere with the anti-inflammatory effects of dexamethasone on tenocytes pretreated with IL-1β, but it increased the synthesis of tissue inhibitor of metalloproteinase (TIMP)–1 and -3. Meanwhile, PRP did not induce anti-inflammatory cytokines that had been suppressed with a corticosteroid. It did increase the type I/III collagen ratio mainly through the suppression of type III collagen expression. PRP reversed the decreased viability, increased apoptosis, and induced senescence with IL-1β and a corticosteroid. Conclusion: This study shows that the addition of PRP does not interfere with the anti-inflammatory effects of a corticosteroid on IL-1β–treated tenocytes from degenerative rotator cuff tears but that it does avoid the deleterious side effects of a corticosteroid. Clinical Relevance: PRP can be clinically useful with a corticosteroid as a treatment for tendinopathy.

Comparison of Bone Mineral Density and Appendicular Lean Body Mass between Osteoporotic Distal Radius Fracture and Degenerative Rotator Cuff Tear in Women Patients.

BackgroundAuthors assessed lean body mass (fat free tissue), upper and lower, and bone mineral density (BMD) in patients of osteoporotic bone distal radius fracture (DRF) and degenerative rotator cuff tear (RCT) patients of shoulder. We predict inferior muscle mass and osteoporosis are more frequent in DRF group than RCT group.MethodsBetween January 2016 and June 2017, overall 38 of DRF and 30 of RCT were eligible for this retrospective comparison study after excluding of patients with compounding factors. BMD and other body composition, fat and lean body mass, were assessed with a single dual energy X-ray absorptiometry in one hospital.ResultsT-score of spine were −2.2 and −1.6 in DRF and RCT patients with significant difference (P=0.040). Final BMD score, lower score of patient between spine and femoral score, of both group also presented difference with significance, −2.4 of DRF and −1.9 of RCT patients (P=0.047). Diagnosis of osteoporosis was confirmed in 19 patients (50%) from DRF compared with 9 patients (30%) from RCT. The mean lean soft tissue mass of the arm was 3.7 kg and 3.8 kg in the DRF and RCT, respectively, without significant difference (P=0.882). The mean lean body mass of the leg was 11.0 kg and 10.5 kg in the DRF and RCT, respectively, without significant difference (P=0.189). The relative overall appendicular lean mass was not significantly different between groups.ConclusionsEven though BMD difference, we did not find muscle mass difference between DRF and RCT patients.

Functional outcome of arthroscopic repair of full-thickness degenerative rotator cuff tears

BackgroundIn the past decade, in spite of the advancement in the clinical knowledge, imaging modalities for precise diagnosis and minimally invasive surgeries, the ideal management for degenerative rotator cuff tears is still a matter of debate. MethodsThis prospective study was conducted from January 2013 to August 2016, involved 16 patients (09 males, 07 females) with the mean age of 62.81±7.24 years (range 54–80 years), who had the full-thickness degenerative tear of the rotator cuff. Arthroscopic repair using single row technique was performed in all the patients. The outcome was assessed using ASES questionnaire; pain score by visual analogue scale (VAS) and range of motion of the shoulder joint at presentation, 24 weeks and at final follow-up. ResultsAt the mean follow-up of 24.68±3.17 months (range 20–29 months), the mean ASES score and pain score (VAS) improved significantly from 31.16±5.57 to 71.79±3.92 (p-value <0.001) and 5.63±0.72 to 1.9±0.92 (p-value <0.001) respectively. There was significant improvement in all the movements of the shoulder joint. 14 patients were satisfied with the final functional outcome. ConclusionArthroscopic repair of a full thickness degenerative tear of the rotator cuff using single row repair technique leads to satisfactory functional outcome in terms of activities of daily living, pain scores and range of motion.

A systematic review: Of acromion types and its effect on degenerative rotator cuff tear

Background: Shoulder joint pain is commonly seen in primary care. Were many of them diagnosed with rotator cuff disease especially involvement of supraspinatus tendon of rotator cuff. The progression of disease leads to tear of rotator cuff and the etiology is multifactorial. However, characteristic changes of acromion morphology appear as major risk factor for rotator cuff tear. According to an ancient classification of acromion type I (flat), type II (curved), or type III (hooked) introduced by Bigliani et al. also documented that incident of rotator cuff tear highly increased with type III (hooked) acromion. Continue study over acromion shape a rare new type IV (convex) acromion also discovered. Many studies have attempted to correlate acromion characteristic with rotator cuff tears. But result still we attempted to determine the rotator cuff tear in association with different shape of acromion through a systemic review of appropriate studies. Methods: Pubmed, Scopus and Baidu scholar database engine searched, limiting results to those published in the English language without limiting year. The key search terms utilized were “acromion morphology”/”rotator cuff tear” and “shoulder joint” / “impingement syndrome”. Over 150 abstract reviewed and 20 literatures were analyzed for quality and relevance study. Conclusions: On the base of previous published article, the different types of acromion shape distribution is not equally seen in population. The most common type II acromion appears large in number with or without rotator cuff disease. Those with type III acromion more than 70% found with degenerative changes or tear of rotator cuff. Current evidence suggests that pathological changes or tear of rotator cuff arise from a multivariare etiology. It increasingly evident that type III acromion plays greater role to rotator cuff tear than other type I and type II of Bilgiani acromion classification.

Masso-kinésithérapie pour tendinopathie dégénérative de la coiffe des rotateurs de l’épaule

Physiotherapy for degenerative rotator cuff disease includes mobilization, muscle strengthening and prevention of sub-acromial impingement. It is a supervised treatment, organized in programs of 12 to 15 sessions, which are distributed to 2 to 3 per week. Randomized trials for chronic shoulder pain due to degenerative rotator cuff disease are numerous. They indicate therapeutic effect of physiotherapy. They also show particular value of muscle strengthening, dynamic humeral centering, technical combinations, and supervision by a physiotherapist. In the specific indication of degenerative rotator cuff tears, cohort studies show a clinically relevant and persistent improvement at 2 years in 75% of patients which were considered for surgery at baseline. Physiotherapy appears therefore as essential to consider first-line treatment for persistent shoulder pain due to degenerative rotator cuff disease without or with a tendinous tear.

Strength, ROM, and ultrasound-detected healing rate after arthroscopic rotator cuff repair

The aim of this study was to investigate whether the etiology of a rotator cuff tear (RCT) influences structural tendon healing and clinical outcome after arthroscopic rotator cuff repair (RCR). The hypothesis was that there is a difference between patients with a sudden onset of symptoms following a traumatic event and those with degenerative lesions. Out of a group of 50 patients enrolled in a previously published prospective investigation, 48 underwent arthroscopic RCR. The acute trauma group (tGA) consisted of 25 patients diagnosed with RCT immediately after trauma, while the chronic degenerative group (dGB) comprised 23 individuals without trauma. After at least 17 months (mean: 27.2), 42 patients underwent clinical and ultrasound examination. The mean age of the patients was 57.9 years in the tGA and 61.0 years in the dGB. The overall drop-out rate was 9.3 %. Average strength was 67.4 N in the tGA and 54.75 N in the dGB. The rate of nonhealing as detected by ultrasound was 13.6 % in the tGA and 9.5 % in the dGB. Arthroscopic RCR leads to favorable clinical and functional outcomes in both traumatic and degenerative RCT. There were no significant differences in outcome.

Radiographic progression of arthritic changes in shoulders with degenerative rotator cuff tears

Very little longitudinal information has been available regarding the relationship of cuff tears and arthritis. The purpose of this study was to determine the midterm risk of and risk factors for rotator cuff tear arthropathy progression in a cohort of subjects with an asymptomatic rotator cuff tear. Baseline (visit 1), 5-year (visit 2), and most recent follow-up (visit 3) radiographs were reviewed in a cohort of 105 subjects enrolled for longitudinal surveillance of asymptomatic degenerative rotator cuff tears and 33 controls. The radiographs were assessed in a blinded, randomized fashion by 3 observers who graded glenohumeral arthritic changes using the Hamada scores, Samilson-Prieto (SPO) scores, and acromiohumeral interval (AHI). Osteoarthritis (SPO classification), cuff tear arthropathy (Hamada classification), and AHI progressed between visits 1 and 3 (median, 8 years; P < .001 in all cases). SPO progression was not significantly different for partial- vs. full-thickness vs. control baseline tear types (P = .19). Both full-thickness and partial-thickness tears had greater progression in Hamada scores than controls did in the first 5 years of follow-up (P = .02 and P = .03, respectively), but scores did not differ between partial- and full-thickness tears. Tears with and without enlargement did not differ in progression in SPO grade, Hamada grade, or AHI. Glenohumeral arthritic changes progress significantly but remain minimal within an 8-year period in early to moderate degenerative cuff disease. Whereas the presence of a rotator cuff tear influences progression in Hamada grade, the magnitude of radiographic progression is not influenced by tear severity or enlargement at midterm time points.

Candidate gene approach identifies six SNPs in tenascin-C (TNC) associated with degenerative rotator cuff tears.

Evidence for a heritable predisposition to rotator cuff tears (RCTs) is growing. Unrelated Caucasian individuals with surgically diagnosed full thickness RCTs (cases) and elderly Caucasian controls with intact rotator cuffs were screened for differences at the candidate genes: TNC, Col5A1, TIMP-1, MMP-1, MMP-2, MMP-3, MMP-9, and MMP-13. A first cohort (59 cases; 32 controls) was genotyped with the Sequenom MassARRAY iPLEX system. Of 142 SNPs within about 67-kbp of the TNC gene, 30 were tested for differences in proportions between cases and controls. A second, matched cohort (96 patients; 44 controls) was also genotyped for the same 30 SNPs, but with the KASP™ genotyping technology. Combining the two cohorts and after Bonferroni correction, six SNPs were significantly associated with RCT. Compared to controls, RCT patients showed a significantly higher rate of homozygosity at rs72758637, rs7021589, and rs1138545; a significantly higher rate of heterozygosity at rs10759753, rs3789870, and rs7035322 and a higher minor allele frequency at rs3789870. Rs1138545, a missense SNP in exon10 might be of biological significance because it varies the amino acid sequence close to the TNC-FNIII5 domain. The FNIII5 domain binds multiple growth factors and co-ligates with integrins during tendon healing. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:894-901, 2017.

What's New in Sports Medicine.

This update is based on the scientific and investigational activities in the specialty of sports medicine from September 2014 to August 2015. It includes a review of pertinent research and articles published in the three premier journals of our specialty, namely, The Journal of Bone & Joint Surgery, The American Journal of Sports Medicine , and Arthroscopy: The Journal of Arthroscopic and Related Surgery. ### Rotator Cuff #### Degenerative Rotator Cuff Tear History The natural history of degenerative rotator cuff tear progression is still being elucidated. There are many studies that show the prevalence of asymptomatic rotator cuff tears, but few exist that evaluate the long-term prospective patient history. Keener et al. attempted to characterize the amount of rotator cuff tear enlargement and progression of symptoms with initial asymptomatic tears. They studied asymptomatic rotator cuff tears in patients who had a symptomatic contralateral rotator cuff tear. In their study, they showed that tears enlarged in almost one-half of the patients over a median of 3 years and those patients who experienced tear enlargement tended to have an onset of new pain. Progressive degenerative changes within the supraspinatus and infraspinatus muscles were associated with tear enlargement compared with the control group. These findings show that many of these tears may progress and may become symptomatic1. #### Therapy After Rotator Cuff Repair Although therapy after rotator cuff repair is universal, the optimal timing of rehabilitation initiation is still unknown. Studies have suggested that outcome scores are better with early passive motion (<6 weeks after the surgical procedure) than with delayed motion (≥6 weeks), but the association of rehabilitation schedule and retear rate is not fully understood. In a systematic review and meta-analysis, Kluczynski et al. found that, in randomized controlled studies, there was not a significant difference between the 2 rehabilitation schedules with respect to retear rates. With analysis of those studies that did not …

Surgical Repair Did Not Improve Functional Outcomes More Than Conservative Treatment for Degenerative Rotator Cuff Tears.

Lambers Heerspink FO, van Raay JJ, Koorevaar RC, van Eerden PJ, Westerbeek RE, van’t Riet E, van den Akker-Scheek I, Diercks RL. Comparing surgical repair with conservative treatment for degenerative rotator cuff tears: a randomized controlled trial. J Shoulder Elbow Surg. 2015 Aug;24(8):1274-81. ### Question: In patients with degenerative rotator cuff tears, how does surgical repair compare with conservative treatment with respect to functional outcomes? ### Design: Randomized (unclear allocation concealment), unblinded, controlled trial with 12 months of follow-up. ### Setting: A university hospital and 2 regional hospitals in the Netherlands. ### Patients: 56 patients (mean age, 61 years; 63% men) with degenerative, nontraumatic full-thickness rotator cuff tears were enrolled. Exclusion criteria included trauma associated with the onset of complaints, previous shoulder surgery, frozen shoulder, osteoarthritis of the glenohumeral or acromioclavicular joint, diabetes, cognitive disorders, and neurologic diseases affecting the upper extremities. 45 patients (80%) were included in the analysis. ### Intervention: Patients were allocated to surgery (n = 25) or conservative treatment (n = …

Patterns of tear progression for asymptomatic degenerative rotator cuff tears

The purpose of this study was to examine patterns of rotator cuff tear size progression in degenerative rotator cuff tears and to compare tear progression risks for tears with and without anterior supraspinatus tendon disruption. Asymptomatic full-thickness rotator cuff tears with minimum 2-year follow-up were examined with annual shoulder ultrasound examinations. Integrity of the anterior 3 mm of the supraspinatus tendon determined classification of cable-intact vs. cable-disrupted tears. Tear enlargement was defined as an increase of 5 mm or more in width. Tear propagation direction was calculated from measured changes in tear width in reference to the biceps tendon on serial ultrasound examinations. The cohort included 139 full-thickness tears with a mean subject age of 63.3 years and follow-up duration of 6.0 years. Ninety-six (69.1%) of the tears were considered cable intact. Cable-disrupted tears were larger at baseline (median, 19.0 mm vs. 10.0 mm; P < .0001) than cable-intact tears. There was no difference in the risk of enlargement (52.1% vs. 67.4%; P = .09) or time to enlargement (3.2 vs. 2.2 years; P = .37) for cable-intact compared with cable-disrupted tears. There was no difference in the magnitude of enlargement for cable-intact and cable-disrupted tears (median, 7.0 mm vs.9.0 mm; P = .18). Cable-intact tears propagated a median of 5 mm anteriorly and 4 mm posteriorly, whereas cable-disrupted tears propagated posteriorly. The majority of degenerative rotator cuff tears spare the anterior supraspinatus tendon. Although tears classified as cable disrupted are larger at baseline than cable-intact tears, tear enlargement risks are similar for each tear type.

Inclination-dependent changes of the critical shoulder angle significantly influence superior glenohumeral joint stability

BackgroundThe critical shoulder angle combines the acromion index and glenoid inclination and has potential to discriminate between shoulders at risk for rotator cuff tear or osteoarthritis and those that are asymptomatic. However, its biomechanics, and particularly the role of the glenoid inclination, are not yet fully understood. MethodsA shoulder simulator was used to analyze the independent influence of glenoid inclination during abduction from 0 to 60°. Spindle motors transferred tension forces by a cable-pulley on human cadaveric humeri. A six-degree-of-freedom force transducer was mounted directly behind the polyethylene glenoid to measure shear and compressive joint reaction force and calculate the instability ratio (ratio of shear and compressive joint reaction force) with the different force ratios of the deltoid and supraspinatus muscles (2:1 and 1:1). A stepwise change in the inclination by 5° increments allowed simulation of a critical shoulder angle range of 20° to 45°. FindingsTilting the glenoid to cranial (increasing the critical shoulder angle) increases the shear joint reaction force and therefore the instability ratio. A balanced force ratio (1:1) between the deltoid and the supraspinatus allowed larger critical shoulder angles before cranial subluxation occurred than did the deltoid-dominant ratio (2:1). InterpretationGlenoid inclination-dependent changes of the critical shoulder angle have a significant impact on superior glenohumeral joint stability. The increased compensatory activity of the rotator cuff to keep the humeral head centered may lead to mechanical overload and could explain the clinically observed association between large angles and degenerative rotator cuff tears.

Clinical effectiveness and cost-effectiveness of open and arthroscopic rotator cuff repair [the UK Rotator Cuff Surgery (UKUFF) randomised trial

Uncertainty exists regarding the best management of patients with degenerative tears of the rotator cuff. To evaluate the clinical effectiveness and cost-effectiveness of arthroscopic and open rotator cuff repair in patients aged ≥ 50 years with degenerative rotator cuff tendon tears. Two parallel-group randomised controlled trial. Nineteen teaching and district general hospitals in the UK. Patients (n = 273) aged ≥ 50 years with degenerative rotator cuff tendon tears. Arthroscopic surgery and open rotator cuff repair, with surgeons using their usual and preferred method of arthroscopic or open repair. Follow-up was by telephone questionnaire at 2 and 8 weeks after surgery and by postal questionnaire at 8, 12 and 24 months after randomisation. The Oxford Shoulder Score (OSS) at 24 months was the primary outcome measure. Magnetic resonance imaging evaluation of the shoulder was made at 12 months after surgery to assess the integrity of the repair. The mean OSS improved from 26.3 [standard deviation (SD) 8.2] at baseline to 41.7 (SD 7.9) at 24 months for arthroscopic surgery and from 25.0 (SD 8.0) at baseline to 41.5 (SD 7.9) at 24 months for open surgery. When effect sizes are shown for the intervention, a negative sign indicates that an open procedure is favoured. For the intention-to-treat analysis, there was no statistical difference between the groups, the difference in OSS score at 24 months was -0.76 [95% confidence interval (CI) -2.75 to 1.22; p = 0.452] and the CI excluded the predetermined clinically important difference in the OSS of 3 points. There was also no statistical difference when the groups were compared per protocol (difference in OSS score -0.46, 95% CI -5.30 to 4.39; p = 0.854). The questionnaire response rate was > 86%. At 8 months, 77% of participants reported that shoulder problems were much or slightly better, and at 24 months this increased to 85%. There were no significant differences in mean cost between the arthroscopic group and the open repair group for any of the component resource-use categories, nor for the total follow-up costs at 24 months. The overall treatment cost at 2 years was £2567 (SD £176) for arthroscopic surgery and £2699 (SD £149) for open surgery, according to intention-to-treat analysis. For the per-protocol analysis there was a significant difference in total initial procedure-related costs between the arthroscopic group and the open repair group, with arthroscopic repair being more costly by £371 (95% CI £135 to £607). Total quality-adjusted life-years accrued at 24 months averaged 1.34 (SD 0.05) in the arthroscopic repair group and 1.35 (SD 0.05) in the open repair group, a non-significant difference of 0.01 (95% CI -0.11 to 0.10). The rate of re-tear was not significantly different across the randomised groups (46.4% and 38.6% for arthroscopic and open surgery, respectively). The participants with tears that were impossible to repair had the lowest OSSs, the participants with re-tears had slightly higher OSSs and the participants with healed repairs had the most improved OSSs. These findings were the same when analysed per protocol. In patients aged > 50 years with a degenerative rotator cuff tear there is no difference in clinical effectiveness or cost-effectiveness between open repair and arthroscopic repair at 2 years for the primary outcome (OSS) and all other prespecified secondary outcomes. Future work should explore new methods to improve tendon healing and reduce the high rate of re-tears observed in this trial. Current Controlled Trials ISRCTN97804283. This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 80. See the NIHR Journals Library website for further project information.

Impact of cyclic mechanical stimulation on the expression of extracellular matrix proteins in human primary rotator cuff fibroblasts

Mechanical stimulation plays an important role in the development and remodelling of tendons. The aim of the study was to evaluate the effects of mechanical stimulation on the expression of extracellular matrix proteins in human primary rotator cuff (RC) fibroblasts. RC fibroblasts were isolated from patients with degenerative RC tears and characterized using flow cytometry and immunohistochemistry. Cells were stimulated using the Flexcell FX5K™ Tension System. The stimulation regime was a uniaxial sinusoidal waveform with 10% elongation and a frequency of 0.5Hz, whereby each cycle consists of 10-s strain and 30-s relaxation. Data were normalized to mechanically unstimulated control groups for every experimental condition. RT-qPCR was performed to determine relative mRNA levels, and collagen production was measured by a colorimetric assay. The positive expression of CD91 and CD10, and negativity for CD45 and CD4 confirmed the fibroblast phenotype of RC primary cells. RT-qPCR revealed that 10% continuous cyclic strain for 7 and 14days induced a significant increase in the mRNA expression both on the matrix metalloproteinases MMP1, MMP3, MMP13, and MMP14 and on the extracellular matrix proteins decorin, tenascin-C, and scleraxis. Furthermore, mechanically stimulated groups produced significantly higher amounts of total collagen. These results may contribute to a better understanding of strain-induced tendon remodelling and will form the basis for the correct choice of applied force in rehabilitation after orthopaedic surgery. These findings underline the fact that early passive motion of the joint in order to induce remodelling of the tendon should be included within a rehabilitation protocol for rotator cuff repair.

Return to Sport After Rotator Cuff Tear Repair

Background: One of the most frequent demands from athletes after rotator cuff tear repair is to return to sport, if possible at the same level of play. Purpose: The main goal of this study was to determine the rate of return to sport after treatment of rotator cuff tears. Study Design: Meta-analysis and systematic review. Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to perform this systematic review and meta-analysis of the results in the literature, as well as for the presentation of results. A search of the literature was performed on the electronic databases MEDLINE, Scopus, EMBASE, and the Cochrane Library. The quality of the included studies was evaluated according to the MINORS (Methodological Index for Nonrandomized Studies) checklist. Inclusion criteria were studies in English evaluating return to sport after treatment of traumatic, degenerative, partial or full-thickness rotator cuff tears in patients practicing a sport regularly, whatever the level, all ages and sports included. The main judgment criterion was the number of patients who returned to a sports activity after treatment of a rotator cuff tear. The criterion was analyzed in 2 ways: return to sport (yes/no) and the level of play (identical or higher/lower level). Results: Twenty-five studies were reviewed, including 859 patients (683 athletes), all treated surgically after a mean follow-up of 3.4 years (range, 0.3-13.4 years). The level of sports was recorded in 23 studies or 635 (93%) athletes and included 286 competitive or professional athletes and 349 recreational athletes. The most commonly practiced sports were baseball (224 participants), tennis (104 participants), and golf (54 participants). The overall rate of return to sport was 84.7% (95% CI, 77.6%-89.8%), including 65.9% (95% CI, 54.9%-75.4%) at an equivalent level of play, after 4 to 17 months. Of the professional and competitive athletes, 49.9% (95% CI, 35.3-64.6%) returned to the same level of play. Conclusion: Most recreational athletes return to sports at the same level of play as before their injury, but only half of professional and competitive athletes return to an equivalent level of play.