Fatty Degeneration Index Research Articles

Comparative Analysis of Bone Mineral Density of the Lumbar Spine, Hip, and Proximal Humerus in Patients with Unilateral Rotator Cuff Tears.

The proximal humerus, a common site for osteoporotic fractures, is frequently overlooked in osteoporosis evaluations. This study aimed to evaluate the relationship between the conventional bone mineral density (BMD) measurement (at the lumbar spine and femur) and the BMD measurement at both proximal humeri (the asymptomatic side and the side with a rotator cuff tear [RCT]) in patients with unilateral RCT. Furthermore, we investigated clinical features indicative of osteoporosis in RCT patients and assessed the utility of proximal humerus BMD measurements. From April 2020 to September 2020, 87 patients who underwent arthroscopic repairs for unilateral RCTs were examined for age, onset, body mass index, menopause duration, passive range of motion, global fatty degeneration index, and RCT and retraction size. The regions of interest (ROIs) for the conventional BMD included the lumbar spine, femur neck, femur trochanter, and total femur. For the proximal humerus BMD, the ROIs included the head, lesser tuberosity, greater tuberosity (medial, middle, and lateral rows), and total humerus. The conventional BMD of the lumbar spine, femur neck, femur trochanter, and femur total were 1.090, 0.856, 0.781, and 0.945 g/cm2, respectively. The head, lesser tuberosity, greater tuberosity (medial, middle, and lateral rows), and total BMD of the asymptomatic-side proximal humerus were 0.547, 0.544, 0.697, 0.642, 0.554, and 0.610 g/cm2, respectively. The average of proximal humerus BMD was significantly lower than that of conventional BMD (p < 0.001). All ROIs BMD of the RCT-side proximal humerus were 0.497, 0.507, 0.619, 0.598, 0.517, and 0.560 g/cm2. There was no correlation between the conventional BMD and each proximal humerus BMD. All ROI BMD of the RCT-side proximal humerus was not significant in the multiple regression analysis with age, onset, body mass index, passive range of motion, global fatty degeneration index, and RCT and retraction size (p > 0.05). The proximal humerus BMD showed a completely different trend from that of conventional BMD and had no significant association with clinical features. Therefore, the proximal humerus BMD needs to be measured separately from the conventional BMD, as it may provide important information before rotator cuff repair surgery.

Association of Severe Histological Degeneration of the Torn Supraspinatus Tendon and Retear After Arthroscopic Repair of Full-Thickness Rotator Cuff Tears Using the Suture Bridge Technique

Background: Previous studies have demonstrated several prognostic factors for retear after arthroscopic rotator cuff repair (ARCR). However, studies that histologically evaluate the quality of the torn rotator cuff (RC) tendon and its association with postoperative outcomes are limited. Purpose: To investigate factors associated with retear after ARCR using the suture bridge (SB) technique, including the degree of histological degeneration of the RC tendon edge. Study Design: Case-control study; Level of evidence, 3. Methods: The authors retrospectively evaluated 187 patients who underwent ARCR for full-thickness tears using the SB technique; intraoperative biopsy samples were taken to assess the degree of histological degeneration using the Bonar score. The cohort was divided into healed (n = 165) and retear (n = 22) groups according to magnetic resonance imaging results obtained ≥6 months postoperatively. The evaluation included preoperative patient data (age, sex, symptom duration, trauma history, history of heavy manual work, smoking habit, hypertension, diabetes mellitus, and hyperlipidemia) and radiological data (Hamada classification, Patte classification, Goutallier classification, and global fatty degeneration index [GFDI]). Additionally, intraoperative data (anteroposterior tear size, Lafosse classification for concomitant subscapularis tendon tear, and long head of biceps injury) and preoperative and postoperative clinical findings (active range of motion, University of California, Los Angeles [UCLA], score) were evaluated. Results: The retear rate was 11.8%. The retear group had a higher percentage of men (P = .031), higher Bonar score (P < .001), higher mean GFDI value (P = .002), higher rate of tear retraction degree (P = .010), and larger anteroposterior tear size (P = .020) than the healed group. The retear group had lower postoperative internal rotation (P = .031) and lower UCLA score (P < .001). Multivariate logistic regression analysis with a stepwise variable selection revealed anteroposterior tear size (odds ratio [OR], 2.4; 95% CI, 1.3-4.5; P = .004) and Bonar score (OR, 1.7; 95% CI, 1.3-2.4; P < .001) as independent predictors for a retear. Conclusion: The results indicate that end-stage severe tendon degeneration might affect retear. Therefore, further investigation on the progression mechanisms of tendon degeneration and development of methods to assess degenerative tissue might improve clinical outcomes after ARCR.

Clinical and Radiological Outcomes of Arthroscopic Superior Capsular Reconstruction Versus Primary Rotator Cuff Repair in Massive Rotator Cuff Tears: A Propensity Score–Matched Study

Background: Arthroscopic superior capsular reconstruction (aSCR) has emerged as a treatment option for managing massive rotator cuff tears (MRCTs) given the unpredictable results after an arthroscopic rotator cuff repair (aRCR). Yet, few comparative studies of aSCR and aRCR have been conducted. Purpose: To compare the clinical and radiological outcomes between aRCR and aSCR in patients with MRCT. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 163 cases of MRCT from 2010 to 2020 with follow-up ≥2 years were retrospectively reviewed. Among them, 102 had aRCR and 61 had aSCR using fascia lata autograft. Propensity score matching was used to select controls matched for age, sex, diabetes mellitus, osteoporosis, preoperative American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, Constant score, pain visual analog scale (pVAS) score, range of motion (ROM), tear size, global fatty degeneration index, and acromiohumeral distance (AHD). Last, 33 cases in each group were selected after propensity score matching. Radiological assessment was conducted using serial postoperative magnetic resonance imaging. Pre- and postoperative findings—including American Shoulder and Elbow Surgeons, pVAS, Single Assessment Numeric Evaluation, and Constant scores and ROM—were assessed to compare clinical outcomes. For radiological outcomes, global fatty degeneration index, AHD, and healing rate were evaluated. Healing failure was defined as Sugaya classification IV or V in the aRCR group, as compared with a full-thickness tear of the graft in the aSCR group, which corresponded to Sugaya classification IV or V. Results: Postoperative clinical outcomes were significantly improved at the final follow-up in both groups. In the aSCR group, postoperative forward flexion, pVAS, and AHD were significantly improved as compared with the aRCR group (mean, 161° vs 148° [P = .02]; 1.03 vs 1.64 [P = .047]; 7.00 vs 5.23 mm [P < .001], respectively). The healing rate was 20 of 33 (60.6%) for aRCR and 29 of 33 (87.9%) for aSCR (P = .022). Conclusion: aSCR and aRCR are effective and reliable treatment options for MRCT. However, when compared with aRCR, aSCR showed improved clinical outcomes, including pVAS score, postoperative ROM, and favorable radiological findings, including AHD and a higher healing rate.

Long-term effectiveness of arthroscopic partial repair for massive irreparable rotator cuff tears

To explore the long-term effectiveness of arthroscopic partial repair in treatment of massive irreparable rotator cuff tears from both the radiological and clinical perspectives. A retrospective analysis was conducted on the clinical data of 24 patients (25 sides) with massive irreparable rotator cuff tears who met the inclusion criteria between May 2006 and September 2014. Among them, there were 17 males (18 sides) and 7 females (7 sides) with an age range of 43-67 years (mean, 55.0 years). There were 23 cases of unilateral injury and 1 case of bilateral injuries. All patients were treated with the arthroscopic partial repair. The active range of motion of forward elevation and abduction, external rotation, and internal rotation, as well as the muscle strength for forward flexion and external rotation, were recorded before operation, at the first postoperative follow-up, and at last follow-up. The American Association of Shoulder and Elbow Surgeons (ASES) score, the University of California at Los Angeles (UCLA) shoulder scoring, and Constant score were used to evaluate shoulder joint function. And the visual analogue scale (VAS) score was used to evaluate shoulder joint pain. MRI examination was performed. The signal-to-noise quotient (SNQ) was measured above the anchor point near the footprint area (m area) and above the glenoid (g area) in the oblique coronal T2 fat suppression sequence. The atrophy of the supraspinatus muscle was evaluated using the tangent sign. The global fatty degeneration index (GFDI) was measured to assess fat infiltration in the supraspinatus muscle, infraspinatus muscle, teres minor muscle, upper and lower parts of the subscapularis muscle. The mean GFDI (GFDI-5) of 5 muscles was calculated. The incisions healed by first intention. All patients were followed up with the first follow-up time of 1.0-1.7 years (mean, 1.3 years) and the last follow-up time of 7-11 years (mean, 8.4 years). At last follow-up, the range of motion and muscle strength of forward elevation and abduction, ASES score, Constant score, UCLA score, and VAS score of the patients significantly improved when compared with those before operation ( P<0.05). Compared with the first follow-up, except for a significant increase in ASES score ( P<0.05), there was no significant difference in the other indicators ( P>0.05). Compared with those before operation, the degree of supraspinatus muscle infiltration worsened at last follow-up ( P<0.05), GFDI-5 increased significantly ( P<0.05), and there was significant difference in the tangent sign ( P<0.05); while there was no significant difference in the infiltration degree of infraspinatus muscle, teres minor muscle, and subscapularis muscle, upper and lower parts of the subscapularis muscle ( P>0.05). Compared with the first follow-up, the SNQm and SNQg decreased significantly at last follow-up ( P<0.05). At the first and last follow-up, there was no correlation between the SNQm and SNQg and the ASES score, Constant score, UCLA score, and VAS score of the shoulder ( P>0.05). Arthroscopic partial repair is effective in treating massive irreparable rotator cuff tear and significantly improves long-term shoulder joint function. For patients with severe preoperative fat infiltration involving a large number of tendons and poor quality of repairable tendons, it is suggested to consider other treatment methods.

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

The optimal management for massive rotator cuff tears (MRCTs) without osteoarthritis (OA) remains controversial. The purpose of this study was to evaluate and compare the clinical outcomes of reverse shoulder arthroplasty (RSA) vs. rotator cuff repair (RCR) in patients with MRCTs without OA. We conducted a retrospective data analysis of 68 patients treated for MRCTs via RSA and 215 patients treated for MRCTs via arthroscopic RCR between January 2014 and April 2019. Through propensity score matching, patients were matched for sex, age, tear size, and global fatty degeneration index. Thirty-nine patients in each group were included, and all patients had completed minimal 2-year follow-up. Postoperative radiologic evaluations of healing failure were performed. The visual analog scale score for pain, range of motion, and functional outcome measures including the American Shoulder and Elbow Surgeons score, QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score, Simple Shoulder Test score, and Constant score were assessed and compared between the 2 groups. Healing failure was observed in 10 patients in the RCR group (32.3%). No statistically significant differences in preoperative range of motion and functional scores were found between the RCR and RSA groups. Both groups showed significant pain relief and functional improvement at final follow-up. Patients in the RCR group showed significantly greater forward elevation (156.4°±23.8° vs. 139.7°±22.4°, P<.001) and internal rotation (thoracic vertebra, T8.2±1.2 vs. T9.7±2.6, P=.001). The average American Shoulder and Elbow Surgeons score was 88.3±12.2 in the RCR group and 81.8±16.1 in the RSA group (P=.045). The QuickDASH score was significantly higher in the RCR group (P=.019). A significantly higher Simple Shoulder Test score (9.7±2.8 vs. 8.1±3.0, P=.01) and a significantly higher Constant score (67.2±6.5 vs. 63.2±7.1, P=.011) were seen in the RCR group. Both RSA and RCR are effective and reliable treatment options for MRCTs without OA. However, the RCR group showed better shoulder function improvement than the RSA group. Considering the possible implications of RSA, RCR should be referred to as a first-line treatment option for patients with MRCTs without OA with proper indications.

Importance of Initial Peak Torque of the Supraspinatus Muscle during Shoulder Flexion

BackgroundMost previous studies have evaluated flexion strength to assess recovery after arthroscopic rotator cuff (RC) repair. However, limited data are available regarding peak torque at the initial angle (iPT) because most studies have measured flexion strength for peak torque (PT), particularly in small- and medium-sized supraspinatus tears. The purpose of this study was to compare conventional PT and iPT to evaluate supraspinatus muscle strength after arthroscopic RC repair in patients with small- and medium-sized supraspinatus tears.MethodsIsokinetic muscle performance testing was performed in 42 patients with small tears and in 47 patients with medium-sized tears. PT and iPT were evaluated before and 1 year after surgery and were recorded at an angular velocity of 60°/sec and 180°/sec with an isokinetic test.ResultsPT and iPT were significantly lower in the involved-side shoulders than in the uninvolved-side shoulders (PT: small tear, p < 0.001; medium tear, p < 0.001; iPT: small tear, p < 0.001; medium tear, p < 0.001) in both groups, preoperatively. However, postoperatively, in the involved-side shoulders, PTs were not different in both small- and medium-sized tears (all p > 0.05), but iPTs were significantly lower in the involved-side shoulders (small tear, p < 0.001; medium tear, p < 0.001). iPT was significantly lower in the involved side shoulders in the medium-sized tear group than in the small-sized tear group before and after surgery (p < 0.05). In the small- and medium-sized tear groups, tear size was significantly correlated with preoperative iPT in the involved-side shoulders (small tear: r = −0.304, p = 0.046; medium tear: r = −0.323, p = 0.027). However, pain visual analog scale was significantly correlated with preoperative (small tear: r = −0.455, p = 0.002; medium tear: r = −0.286, p = 0.044) and postoperative (small tear: r = −0.430, p = 0.005; medium tear: r = −0.354, p = 0.021) iPT in the involved-side shoulders. Furthermore, fatty infiltration grade of the supraspinatus muscle and global fatty degeneration index were not associated with preoperative and postoperative PT and iPT in each group (all p > 0.05).ConclusionsiPT is as important as conventional PT in isokinetic testing to assess supraspinatus muscle strength before and after RC repair.

Functional and Structural Outcomes After Retears of Arthroscopically Repaired Large and Massive Rotator Cuff Tears.

Background:Most studies have shown acceptable clinical results in patients with large or massive tears treated by arthroscopic rotator cuff repair (ARCR); however, the effects of retears after surgery in these patients remain unknown.Purpose:To evaluate functional and structural outcomes after retears of large and massive rotator cuff tears treated by ARCR.Study Design:Case series; Level of evidence, 4.Methods:A total of 196 consecutive patients with large to massive rotator cuff tears underwent physical examination and magnetic resonance imaging before and after ARCR at 6, 12, and 24 months. Of these, 9 patients were lost at 6 months after surgery. Therefore, 187 patients were followed up for 24 months after surgery; 148 patients showed no postsurgical ruptures. Consequently, the remaining 39 patients with postsurgical ruptures were included in this study (mean age at surgery, 64.2 ± 8.7 years). Functional outcome measures comprised the University of California, Los Angeles (UCLA) and Japanese Orthopaedic Association (JOA) scores. Structural outcome measures consisted of the global fatty degeneration index (GFDI), mediolateral tear size, and residual tendon attachment area as evaluated by our own scoring system.Results:The mean UCLA and JOA scores significantly improved from 16.3 ± 3.9 and 63.2 ± 10.7 preoperatively to 27.9 ± 5.5 (P < .0001) and 84.5 ± 9.4 (P < .0001) at final follow-up, respectively. The mean mediolateral tear size (P = .03, .02, and .02, respectively) and residual tendon attachment area (P = .04, .03, and .04, respectively) significantly improved from preoperatively to 6, 12, and 24 months postoperatively. The correlation analysis between the functional and structural variables confirmed significant associations between the residual tendon attachment area, the JOA and UCLA scores at 24 months postoperatively, and the preoperative GFDI (r = –0.81 to 0.78).Conclusion:The residual tendon attachment area after a retear was significantly larger at 24 months after surgery than before surgery. In addition, significant associations were confirmed between preoperative fatty degeneration, the residual tendon attachment area, and functional outcomes after a retear. These results may explain why functional outcomes significantly improved even after retears in this series.

Comparaison entre une réparation partielle et une réparation complète des ruptures massives de la coiffe des rotateurs. Un suivi de cinq ans minimum

BackgroundMassive rotator cuff surgical management can be challenging. Controversy exists in the literature regarding the potential benefit of full head coverage for arthroscopic rotator cuff repair. The purpose of this study was to compare re-tear rate and clinical outcome of arthroscopic repair of massive rotator cuff tears in relation to the achievement of full humeral head footprint coverage or not. HypothesisWe hypothesized that there will be no difference in re-tear rate and clinical outcomes between full and partial coverage rotator cuff repairs. Patients and MethodsA retrospective analysis of all adult patients with a massive rotator cuff tear who underwent arthroscopic repair with a minimum five years follow-up was performed. Outcomes analyzed included re-tear rate, the American Shoulder and Elbow Surgeons (ASES) Shoulder Score, and the Penn Shoulder Score. Correlation and subgroup analyses were performed in order to evaluate whether age, symptom duration, tear size, coverage percentage, and fatty infiltration had any effect in outcome. ResultsThe average ASES score was 76.3±25.2, and average Penn Shoulder Score was 75.8±23.1 at 7.9 years mean follow-up in 27 patients analyzed. Re-tear rate was similar between full and partial footprint coverage repair with 2 versus 4 failures, respectively (p=0.64). ASES and Penn Shoulder scores were 84.2 and 83.7 for full rotator cuff repair versus 70.6 and 71.1, for partial coverage repair (p=0.20 and p=0.22, respectively). The percentage of head coverage and the tear size were both found to be significantly correlated with outcome, with coefficient of determination R2 of 0.40 and 0.217, respectively, while a global fatty degeneration index GFDI <1.5 was associated with improved functional outcome. DiscussionNo difference in failure rate and functional outcome was detected between full and partial coverage rotator cuff repair. The size of the tear and fatty infiltration were inversely correlated with functional score while the percentage of coverage achieved was positively correlated with favorable outcome. Level of evidenceIII; retrospective comparative study.

Comparison between partial and full coverage repair in massive rotator cuff tears. A minimum five year follow-up

BackgroundMassive rotator cuff surgical management can be challenging. Controversy exists in the literature regarding the potential benefit of full head coverage for arthroscopic rotator cuff repair. The purpose of this study was to compare re-tear rate and clinical outcome of arthroscopic repair of massive rotator cuff tears in relation to the achievement of full humeral head footprint coverage or not.Hypothesis We hypothesized that there will be no difference in re-tear rate and clinical outcomes between full and partial coverage rotator cuff repairs. Patients and methodsA retrospective analysis of all adult patients with a massive rotator cuff tear who underwent arthroscopic repair with a minimum five years follow-up was performed. Outcomes analyzed included re-tear rate, the American Shoulder and Elbow Surgeons (ASES) Shoulder Score, and the Penn Shoulder Score. Correlation and subgroup analyses were performed in order to evaluate whether age, symptom duration, tear size, coverage percentage, and fatty infiltration had any effect in outcome. ResultsThe average ASES score was 76.3±25.2, and average Penn Shoulder Score was 75.8±23.1 at 7.9 years mean follow-up in 27 patients analyzed. Re-tear rate was similar between full and partial footprint coverage repair with 2 versus 4 failures, respectively (p=0.64). ASES and Penn Shoulder scores were 84.2 and 83.7 for full rotator cuff repair versus 70.6 and 71.1, for partial coverage repair (p=0.20 and p=0.22, respectively). The percentage of head coverage and the tear size were both found to be significantly correlated with outcome, with coefficient of determination R2 of 0.40 and 0.217, respectively, while a global fatty degeneration index GFDI <1.5 was associated with improved functional outcome. DiscussionNo difference in failure rate and functional outcome was detected between full and partial coverage rotator cuff repair. The size of the tear and fatty infiltration were inversely correlated with functional score while the percentage of coverage achieved was positively correlated with favorable outcome. Level of EvidenceIII; retrospective comparative study.

Relationship between the morphology of the greater tuberosity and radiological and clinical outcomes after arthroscopic rotator cuff repair.

BackgroundDegenerative greater tuberosity (GT) changes are often associated with rotator cuff tears. However, little is known about the impact of GT morphology on surgical outcomes. The aim of this study was to examine the relationship between clinical and radiological outcomes, after rotator cuff repair, and GT morphology.MethodsWe retrospectively investigated shoulders that underwent arthroscopic repair of nontraumatic full-thickness supra-/infraspinatus tears. The exclusion criteria were a lack of either radiographs or magnetic resonance images, revision surgery, partial repair, complications such as infection or dislocation, and follow-up < 2 years. GT morphology on radiographs was classified into 5 groups: normal, sclerosis, bone spur, roughness, and femoralization. The acromiohumeral interval (AHI) was measured on anteroposterior radiographs. Fatty degeneration of the cuff muscles was evaluated using the global fatty degeneration index (GFDI). Postoperative cuff integrity was classified using Sugaya's classification at 2 years after surgery. Clinical outcomes were assessed preoperatively and at postoperative 2 years with the Japanese Orthopaedic Association score and the University of California, Los Angeles shoulder rating scale.ResultsThe study included 220 shoulders in 212 patients (104 men and 108 women), with a mean age of 66 years (range 43-85). The mean follow-up period was 28 months (range, 24-60 months). Seven shoulders (3.2%) were classified as normal, 65 (29.5%) as sclerosis, 55 (25.0%) as bone spur, 78 (34.5%) as roughness, and 15 (6.8%) as femoralization. The preoperative AHI, in the roughness and femoralization groups, was significantly smaller than that in the sclerosis (P < .01) and bone spur groups (P < .001). The roughness and femoralization groups had a greater number of large tears (P = .006). In the roughness and femoralization groups, mean GFDI was significantly higher than that in the sclerosis group (P < .001 for both). Repaired cuff integrity was not different between all groups, respectively. Both Japanese Orthopaedic Association and University of California, Los Angeles scores improved postoperatively from 73.3 to 95.6 points and 18.2 to 34.0 points (P < .001 for both), respectively, and there were no significant differences between all groups, respectively.ConclusionRoughness or femoralization of the GT was related to larger tears, with smaller AHI and higher GFDI. Repaired cuff integrity and clinical outcomes in shoulders with roughness or femoralization of the GT were not inferior to shoulders with the other types of GT morphologies in this study. Arthroscopic repair can be indicated for shoulders with advanced changes of the GT, if fatty degeneration of the cuff muscles is not severe.

Stump classification was correlated with retear in the suture-bridge and double-row repair techniques for arthroscopic rotator cuff repair.

The Stump classification is significantly correlated with a retear after arthroscopic rotator cuff repair. However, no study has evaluated whether or not the stump classification is correlated with retear in the suture-bridge or double-row repair techniques. The aim of this study was to evaluate the relationship between a retear and the stump classification in the suture-bridge and double-row repair techniques. Among 389 patients who underwent arthroscopic repairs of full-thickness rotator cuff tears using suture-bridge or double-row repair techniques, 326 patients (median age 67.0years; range 25-85) were included. There were 51 small, 172 medium, 83 large, and 20 massive tears. Two hundred forty patients were treated with the suture-bridge technique, and 86 patients were treated with the double-row technique. The following variables were analyzed: age, sex, the Cofield classification, anteroposterior and mediolateral tear size on preoperative MRI, global fatty degeneration index, and the stump classification. Cuff integrity was evaluated on magnetic resonance imaging at 6months after surgery. The patients were divided into the intact and retear groups and the relationship between the variables and retear was evaluated by multivariate logistic regression analysis. The overall retear rate was 10.1%. In the multivariate logistic regression analysis, the independent predictors of a retear were the stump classification type 3 (Odds ratio: 4.71, p = 0.0246), global fatty degeneration index (Odds ratio: 3.87, p = 0.0030), and anteroposterior tear size (Odds ratio: 1.07, p = 0.0077) in the suture bridge technique. In the double-row technique, the independent predictors of retear were stump classification type 3 (Odds ratio: 7.82, p = 0.0348), and age (Odds ratio: 1.22, p = 0.0163). The stump classification was significantly correlated with retear in the suture-bridge and double-row repair technique. Stump classification type 3 was indicated to be an important risk factor for predicting retear. III.

Comparison of three suture-bridge techniques for large or massive rotator cuff tear with delamination.

Introduction: Rotator cuff tear with delamination is considered a risk factor for postoperative retear. The purpose of this study was to compare clinical outcomes between three repair procedures for large or massive rotator cuff tears with delamination: conventional en masse suture bridge (EMSB), double-layer suture bridge (DLSB), and the combination of DLSB with modified Debyere-Patte (DLSB + DP). Methods: 53 shoulders of 52 patients who had massive rotator cuff tears with delamination were categorized into three groups: EMSB (18 shoulders), DLSB (24 shoulders), and DLSB + DP (11 shoulders). The mean postoperative follow-up period was 34.6 months. Pre- and postoperative evaluations included a range of motion (ROM), Constant scores, global fatty degeneration (GFDI), and tendon integrity according to Sugaya’s classification by magnetic resonance images (MRI). Results: In all groups, ROM significantly improved after the procedures. Mean constant scores significantly improved: from 45.5 to 77.4 after EMSB, from 45.5 to 87.6 after DLSB, and from 46.3 to 88.0 after DLSB + DP. Significant differences were noted in postoperative Constant scores (p = 0.018: DLSB vs. EMSB, and p = 0.045: DLSB + DP vs. EMSB). The Constant pain scores were better for DLSB + DP than for EMSB (p = 0.012). Global fatty degeneration index (GFDI) with DLSB + DP was significantly higher than that for either EMSB or DLSB, indicating significant preoperative fatty degeneration for DLSB + DP. Retear occurred in 27.8% of the EMSB group, 12.5% of the DLSB group, and 9.1% of the DLSB + DP group. Discussion: Comparisons of the three groups demonstrated that DLSB and DLSB + DP achieved better clinical outcomes than EMSB for the repair of large or massive rotator cuff tears. DLSB + DP is useful for massive rotator cuff tears with severe fatty degeneration or for cases where the presence of excessive tension is anticipated when repairing the torn cuff.

Achilles Tendon Allograft for Superior Capsule Reconstruction in Irreparable Massive Rotator Cuff Tears.

BackgroudTreatment remains a challenge in massive and irreparable rotator cuff tears (RCTs), and superior capsular reconstruction (SCR) has become an increasingly popular choice. The objective of this study was to evaluate clinical and radiological outcomes after SCR using an Achilles tendon allograft in irreparable massive RCTs.MethodsFrom December 2015 to March 2018, 11 patients (mean age, 66.3 ± 5.8 years) with irreparable massive RCTs who underwent SCR using an Achilles tendon allograft were enrolled in this study. The range of motion (ROM), visual analog scale (VAS), clinical scores, muscle strength, and acromiohumeral distance (AHD) were measured preoperatively and at 3, 6, and 12 months, and final follow-up postoperatively. Magnetic resonance imaging (MRI) was performed preoperatively and at 6 months postoperatively to assess the global fatty degeneration index and graft failure. Ultrasonography was also conducted preoperatively and at 3, 6, and 12 months, and final follow-up postoperatively to assess graft continuity.ResultsThe mean follow-up period was 27.6 months (range, 24–32 months). The shoulder ROM at final follow-up increased significantly in forward flexion (p = 0.023), external rotation (p = 0.018), internal rotation (p = 0.016), and abduction (p = 0.011). All patients showed improvement in VAS score (p = 0.005) and clinical scores (p < 0.001) compared with the preoperative state. Pseudoparalysis improved in all patients. The AHD was 3.88 mm (± 1.21 mm) preoperatively, 7.75 mm (± 1.52 mm, p = 0.014) at 6 months postoperatively, and 6.37 mm (± 1.72 mm, p = 0.031) at final follow-up. Graft removal and synovectomy were performed in 1 patient who developed postoperative infections. Radiological failure on follow-up MRI occurred in 2 patients at 6 and 12 months postoperatively, respectively.ConclusionsSCR using an Achilles tendon allograft in irreparable massive RCTs achieved functional and clinical improvement. The use of Achilles tendon allograft also has the advantages of short operation time without donor site morbidity, sufficient thickness, and robustness; therefore, this allograft can be a useful graft for SCR.

Combination of risk factors affecting retear after arthroscopic rotator cuff repair: a decision tree analysis

Several risk factors for postoperative retear after arthroscopic rotator cuff repair (ARCR) have been cited in a large number of reports; various combinations of these seem to be present in the clinical setting. Using a combination model for decision tree analysis, we aimed to investigate the combination of risk factors that affect postoperative retear the most. A total of 286 patients who underwent magnetic resonance (MR) imaging at 6 months after surgery were included in this study. Based on the structural integrity of the MR images taken 6 months after surgery, the patients were divided into a healed group (intact tendon, 254 patients) and a retear group (ruptured tendon, 32 patients). Using univariate and decision tree analyses, we selected a combination of 11 risk factors that drastically affected postoperative retear. The mean age was 64.9 ± 7.1 years, and the mean symptom duration was 9.7 ± 11.6 months. The tear was small/medium in 177 patients and large/massive in 109 patients. The technique for surgical repair was single row in 42 patients, double row in 60 patients, and suture bridging in 216 patients. On univariate analysis, both groups had significant differences in the anteroposterior (AP) tear size (P < .0001), mediolateral tear size (P < .0001), hyperlipidemia (P = .0178), global fatty degeneration index (P < .0001), supraspinatus fatty degeneration stage (P < .0001), and critical shoulder angle (CSA) (P = .0015). All of these 5 risk factors, except for mediolateral tear size, were selected as candidates for the decision tree analysis. Eight combination patterns were determined to have prediction probabilities that ranged from 4.3% to 86.1%. In particular, the combination of an AP tear size of ≥40 mm, hyperlipidemia, and a CSA of ≥37° affected retear after ARCR the most. Decision tree analysis lead to the extraction of different retear factor combinations, which were divided into 5 retear groups. The worst combination was of AP tear size ≥40 mm, hyperlipidemia, and CSA ≥37°, and the prediction probability of this combination was 86.2%. Therefore, our data may offer a new index for the prediction of retear after ARCR.

Comparing Clinical Outcomes After Subacromial Spacer Insertion Versus Other Reconstruction Methods in the Treatment of Irreparable Massive Rotator Cuff Tears.

Background:Previous studies on subacromial spacer (SAS) insertion have been limited to case series that did not compare the effectiveness of this technique with other techniques.Hypothesis:Outcomes after SAS insertion for the treatment of irreparable massive rotator cuff tears (IMRCTs) will be similar to those of other techniques.Study Design:Cohort study; Level of evidence, 3.Methods:This retrospective study was based on data collected from patients who underwent correction of IMRCTs between January 2010 and October 2017. Group 1 patients (n = 17) received SAS insertion with or without partial repair; group 2 patients (n = 36) were treated with other techniques (isolated partial repairs or bridging grafts). Preoperative tear size and global fatty degeneration index values were evaluated. Range of motion, visual analog scale for pain, American Shoulder and Elbow Surgeons (ASES) score, Constant score, Simple Shoulder Test (SST), Disabilities of the Arm, Shoulder and Hand score, and acromiohumeral distance (AHD) were assessed preoperatively and at final follow-up at least 2 years after the surgery (range, 24-60 months). In both groups, ultrasonographic examination was performed at 3 and 6 months postoperatively, and magnetic resonance imaging (MRI) was performed at 1 year.Results:Tear size and preoperative global fatty degeneration index were not significantly different between the groups (all P > .05). There were no differences in functional scores between the groups at final follow-up (all P > .05). AHD was maintained at final follow-up in group 1 (mean ± SD: 6.2 ± 2.1 mm [postoperatively] vs 6.7 ± 2.3 mm [final follow-up]; P = .678), and there was no difference compared with group 2 (7.2 ± 3.2 mm; P = .244). Patients with retears in group 2 (23 of 36, 63.9%) had lower ASES (P = .041) and SST (P = .027) scores at final follow-up when compared with patients in group 1. Six patients (35.3%) in group 1 had partial repairs; these patients had better external rotation at 90° (P = .047), better SST scores (P = .036), and higher AHDs at final follow-up (P = .046) than those in group 1 who had no repair. Three patients (50%) showed retears of partially repaired tendons on MRI. Of 13 patients (76.5%) in group 1 with postoperative MRI, 12 (92.3%) showed fibrotic tissue in the subacromial space not seen preoperatively.Conclusion:There was no difference in outcomes between SAS and the other reconstruction methods for treating IMRCTs. However, given the high retear rate associated with other techniques and poor functional outcomes after retear, SAS insertion could be a viable option for treating IMRCTs.

Tendon stump type on magnetic resonance imaging is a predictive factor for retear after arthroscopic rotator cuff repair

Fatty infiltration of the rotator cuff musculature increases in larger tearsand is a factor in retearing. However, tearing may recur even in patients with small original tears and little fatty infiltration of the rotator cuff musculature. We devised a system to classify the rotator cuff tendon stump by magnetic resonance imaging (MRI) signal intensityand investigated prognosis-related factors associated with retear based on other MRI findings. We analyzed and compared the signal intensity of the rotator cuff tendon stump and deltoid on preoperative T2-weighted fat-suppressed MRI in 305 patients who underwent primary arthroscopic rotator cuff repair. We also investigated the tear size, Goutallier stage, and global fatty degeneration index. In a type 1 stump, the tendon stump had a lower (darker) signal intensity than the deltoid. In type 2, the signal intensities of the tendon stump and deltoid were equivalent. In type 3, the signal intensity of the tendon stump was higher (whiter) than that of the deltoid. Multiple regression analysis of the association between retear and other parameters identified stump type (odds ratio [OR], 4.28), global fatty degeneration index (OR, 2.99), and anteroposterior tear size (OR, 1.06) as significant factors. The retear rates were 3.4% for type 1 stumps, 4.9% for type 2, and 17.7% for type3. Type 3 stumps had a significantly higher retear rate, suggesting that stump signal intensity may be an important indicator for assessing the stump's condition. Our stump classification may be useful in choosing suture techniques and postoperative therapies.

Plasma poly-unsatured fatty acids profile in children with inattentive ADHD - preliminary results of an efficacy Italian study with omega 3/6

Symptomatic full-thickness rotator cuff (RC) tears are often recommended for surgical repairs. However, some patients decide not to have surgery. The aim of this study was to see if there was any difference in preoperative variables between the two groups.137 consecutive patients recommended for surgery due to symptomatic full-thickness RC tear were evaluated. At mean 58.1 months after surgery-recommendation, the patients were asked whether they had surgery and their clinical outcome was assessed. Variables at the time of surgery-recommendation including demographics, range-of-motion (ROM), tear size, and fatty infiltration on MRI, and clinical score were compared between the two groups.The 59 men and 78 women had a mean age of 64.4 years. Overall, 104 (75.9%) patients were treated with RC repair and 33 (24.1%) were not. The main three reasons for not having surgery were improvement of symptoms or minimal pain (55%), economic burden (12%), and concern for postoperative long rehabilitation (9%). Demography and ROM measured at the time of surgery-recommendation did not differ. All clinical scores at one year and final follow-up survey showed no difference between the two groups. The Constant and UCLA scores at the time of surgery-recommendation were significantly higher and tear size was smaller in the ‘No-surgery’ group. Fatty infiltration of supraspinatus (2.0 versus 1.2, p < 0.001) and global fatty degeneration index (1.4 versus 0.8, p = 0.011) were statistically lower in ‘No-surgery’ group as well.Patients with relatively preserved function and small size tear tend to select non-surgical treatment and lead to relatively good outcome.

Evaluation of risk factors for irreparable rotator cuff tear in patients older than age 70 including evaluation of radiologic factors of the shoulder

Rotator cuff tears (RCTs) are generally considered to occur at the age of 40 to 50, but some becomes massive tears at the age of 60 to 70 if neglected. This study evaluated preoperative factors affecting tear size and reparability of rotator cuffs based on magnetic resonance imaging findings among patients older than age 70. We identified 270 patients with full-thickness RCTs (175 reparable tears, group A; 95 irreparable tears, group B) that were confirmed with magnetic resonance imaging findings from January 2009 to March 2016. Irreparable tear was identified if all of the following criteria were met: (1) a large to massive RCT based on the DeOrio and Cofield classification, (2) sum of preoperative global fatty degeneration index of the supraspinatus and infraspinatus ≥6, and (3) positive tangent sign. Preoperative variables included demographic data, medical history, and radiologic data. Acromial index, critical shoulder angle, and acromiohumeral interval (AHI) were evaluated to investigate the relationship between anatomic factors and reparability of RCT. Stepwise multivariated regression analysis revealed older age, longer symptom duration, longer duration of overhead sports activity, lower preoperative forward elevation of the shoulder joint, and shorter AHI as risk factors for irreparable RCTs. This study suggests that older age at surgery, longer duration of symptoms, longer duration of overhead sports activity, lower preoperative forward elevation of the shoulder joint, and shorter AHI are independent risk factors for irreparable RCT.

No difference in flexion power despite iliopsoas fatty degeneration in healed hip fractures with large lesser trochanter displacement

ObjectiveTo evaluate iliopsoas atrophy and loss of function after displaced lesser trochanter fracture of the hip.DesignCohort study.SettingDistrict hospital.PatientsTwenty consecutive patients with pertrochanteric fracture and displacement of the lesser trochanter of > 20 mm.InterventionFracture fixation with either an intramedullary nail or a plate.Outcome measurementsClinical scores (Harris hip, WOMAC), hip flexion strength measurements, and magnetic resonance imaging findings.ResultsCompared with the contralateral non-operated side, the affected side showed no difference in hip flexion force in the supine upright neutral position and at 30° of flexion (205.4 N vs 221.7 N and 178.9 N vs. 192.1 N at 0° and 30° flexion, respectively). However, the affected side showed a significantly greater degree of fatty infiltration compared with the contralateral side (global fatty degeneration index 1.085 vs 0.784), predominantly within the psoas and iliacus muscles.ConclusionSevere displacement of the lesser trochanter (> 20 mm) in pertrochanteric fractures did not reduce hip flexion strength compared with the contralateral side. Displacement of the lesser trochanter in such cases can lead to fatty infiltration of the iliopsoas muscle unit. The amount of displacement of the lesser trochanter did not affect the degree of fatty infiltration.Level of evidenceII.

Influence of Muscle Fatty Degeneration on Functional Outcomes After Endoscopic Gluteus Medius Repair

To report the early outcomes of endoscopic repair of tears of the gluteus medius tendon and to determine whether the fatty degeneration had an influence on clinical results. Between October 2012 and June 2014, data were prospectively collected and retrospectively reviewed for all patients who underwent endoscopic gluteus medius repair. Patients were assessed pre- and postoperatively using the modified Harris hip score, the nonarthritic hip score, and visual analog scale for pain. The gluteus minimus and the 3 distinct parts of the gluteus medius (anterior, middle, and posterior) were assigned a grade of fatty degeneration on preoperative magnetic resonance imaging scans. Twenty-two hips (in 20 patients) were assessed with the mean follow-up of 31.7months (range: 24 to 47months). There were 15 partial-thickness and 7 full-thickness tears. No patient was lost to follow-up. The mean age at the time of surgery was 66years (range: 45 to 82years). Of the 20 magnetic resonance imaging-assessed hips included in the study, 14 had fatty degeneration of the gluteus medius (partial-thickness tears: n= 8, full-thickness tears: n= 6). The mean gluteus medius fatty degeneration index was 1.57 (range: 0.33 to 3.33). Postoperative improvement was seen in modified Harris hip score (33.7 points vs 80.2 points, P= .0001), nonarthritic hip score (47.7 points vs 76.8 points, P=.0001), and in the visual analog scale for pain (7.2 vs 3.2, P < .05). Increasing preoperative fatty degeneration index of the gluteus medius correlated with decreased postoperative functional hip score values (regression coefficient, 0.5839; P<.0001). Tear characteristics (partial or full-thickness) did not correlate with fatty degeneration or muscular atrophy and did not affect postoperative outcomes. Endoscopic surgical repair can be an effective treatment of gluteus medius tears in the short term. Fatty degeneration of the gluteus medius and minimus has a negative impact on clinical outcomes of endoscopic gluteus medius repair. Level IV, therapeutic case series (no control group).