High Retear Rate Research Articles

Electroconductivity, a regenerative engineering approach to reverse rotator cuff muscle degeneration.

Muscle degeneration is one the main factors that lead to the high rate of retear after a successful repair of rotator cuff (RC) tears. The current surgical practices have failed to treat patients with chronic massive rotator cuff tears (RCTs). Therefore, regenerative engineering approaches are being studied to address the challenges. Recent studies showed the promising outcomes of electroactive materials (EAMs) on the regeneration of electrically excitable tissues such as skeletal muscle. Here, we review the most important biological mechanism of RC muscle degeneration. Further, the review covers the recent studies on EAMs for muscle regeneration including RC muscle. Finally, we will discuss the future direction toward the application of EAMs for the augmentation of RCTs.

Humeral head coverage in arthroscopic partial repair of massive rotator cuff tears improves functional outcomes: an analysis of influential factors.

Although partial rotator cuff repair has shown good outcomes, differences in clinical outcomes remain concerns. This study was performed to determine whether patients with humeral head coverage would show better functional outcomes than patients without humeral head coverage and to identify the factors for humeral head coverage after arthroscopic partial repair of massive tears. We performed a retrospective study of 63 patients with massive rotator cuff tears who underwent arthroscopic partial repair between 2012 and 2018. Two to four margin convergences were first performed; then, the Mason-Allen technique was performed. The patients were divided into 2 groups: those with humeral head coverage (38 cases) and those without humeral head coverage (25 cases). The following factors were evaluated: age; sex; hypertension; diabetes; osteoporosis; preoperative and postoperative pseudoparalysis, visual analog scale (VAS) pain score, Constant score, acromiohumeral distance, and subacromial bony spur; and subscapularis tear and repair. Muscle atrophy and fatty degeneration were evaluated by magnetic resonance imaging preoperatively, and the integrity of the repaired cuff was evaluated by ultrasonography at a minimum of 2 years after surgery. Compared with preoperative values, significant improvements in VAS pain scores (from 6.27 to 2.32 in patients with humeral head coverage and from 7.00 to 2.81 in those without humeral head coverage) and Constant scores (from 51.35 to 75.95 and from 44.62 to 69.81, respectively) were observed in both groups (P<.001). Statistical analysis revealed that postoperative VAS pain scores (2.32 vs. 2.81) and Constant scores (75.95 vs. 69.81) in patients with humeral head coverage were superior to those in patients without humeral head coverage (P=.044 and P=.003, respectively). The integrity of the repaired cuff was evaluated by ultrasonography, and partial tears were found in 4 of 37 patients with humeral head coverage and 2 of 26 patients without humeral head coverage (P=.816). Univariable logistic regression analysis revealed that age (P<.001), comorbidity (P=.005), symptom duration (P=.023), preoperative shoulder mobility (P<.001), maintained acromiohumeral distance (P=.006), subscapularis tear (P=.026), and less preoperative supraspinatus and infraspinatus muscle atrophy (P=.001 and P=.010, respectively) had significant correlations with humeral head coverage. Overall satisfactory results were achieved in most patients regardless of high retear rates, but patients with partial repair covering the humeral head were associated with better outcomes than patients without humeral head coverage. Multivariable regression analysis revealed that age (<70 years, P=.003), capability of shoulder mobility (P=.005), maintenance of the acromiohumeral space (>7 mm, P=.016), and less atrophy of the rotator cuff muscles (P=.021) were favorable factors to achieve humeral head coverage during surgical partial repair of massive rotator cuff tears.

Comparative effectiveness of different platelet-rich plasma for arthroscopic rotator cuff repair: A protocol for systematic review and network meta-analysis.

Background:Rotator cuff tears are one of the most common injuries of the shoulder joint in adults. Arthroscopic rotator cuff repair (ARCR) has become the gold standard for the treatment of rotator cuff injuries, but it still has a high rate of retear. Platelet-rich plasma (PRP) has been widely used as an adjunct to ARCR. However, the comparative efficacy of different PRP for ARCR remain unclear. In order to evaluate the relative efficacy of PRP for individuals with ARCR, we will conduct a systematic review and network meta-analysis of randomized controlled trials.Methods:A systematic literature search will be conducted in Embase, PubMed, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang Database, and Chinese Biomedical Literature Database will be searched up to October 2022. The primary outcome will focus on the retear rate at the last follow-up. The secondary outcomes include the Visual Analogue Scale for postoperative pain and functional capacity scores. The risk of bias for individual studies will be assessed according to the revised Cochrane risk-of-bias tool for randomized trials (RoB 2.0). Data analysis will be performed using R 4.1.2. Publication bias will be examined using comparison-adjusted funnel plots and Egger’s test using STATA 15.0. The quality of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach.Results:The results of this study will be submitted to a peer-reviewed journal for publication.Conclusions:The review will compare the efficacy of different PRP for patients with ARCR. The result of the study will provide evidence-based medical evidence for ARCR with PRP augmentation.

Does the critical shoulder angle influence retear and functional outcome after arthroscopic rotator cuff repair? A systematic review and meta-analysis.

This systematic review and meta-analysis aimed to evaluate the correlation between increased critical shoulder angle (CSA) and higher retear rates and functional outcomes after arthroscopic rotator cuff repair (ARCR). PubMed, Embase, Web of Science, and Cochrane Library databases published before January 2022 were comprehensively searched. Two reviewers independently reviewed the titles and abstracts using the specified criteria. Studies were included if the authors clearly described the correlation between the CSA and rotator cuff repair. Data on patient characteristics, mean CSA, retear rate, and the functional score was pooled from the selected articles. A meta-analysis was performed using Review Manager (RevMan) 5.4.1 software, 2020 (Cochrane Collaboration, Copenhagen, Denmark). Eleven articles involving 1449 patients from 7 countries were included. The ages of the patients ranged from 45 to 75years. The follow-up period ranged from 6 to 96months. The mean CSA was greater in the retear group than in the non-retear group after ARCR (mean difference 2.73°; 95% confidence interval [CI] 0.69-4.77) (p = 0.009). Three studies evaluated the association between increased CSA and the postoperative retear rate. All three studies showed a higher postoperative retear rate in patients with an increased CSA (odds ratio 5.35; 95% CI 2.02-14.15; p = 0.0007). No association was found between CSA and Constant-Murley (Constant), the University of California at Los Angeles (UCLA), or Visual Analog Scale (VAS) scores during the follow-up period of 24-96months (p > 0.05). This systematic review and meta-analysis showed that CSA correlates highly with rotator cuff retear after ARCR. In addition, the postoperative retear rate of the rotator cuff increased with increased CSA. CSA appeared to not affect worse functional outcomes in patients after ARCR.

Association of Preoperative Vitamin D Deficiency With Retear Rate and Early Pain After Arthroscopic Rotator Cuff Repair: A Retrospective Cohort Study.

Background:Although the function of vitamin D in bone metabolism has been well studied, the question remains whether vitamin D deficiency impairs tendon healing after rotator cuff repair.Purpose:To investigate the correlation between preoperative vitamin D deficiency and the retear rate and pain after arthroscopic rotator cuff repair.Study Design:Cohort study; Level of evidence, 3.Methods:Patients with full-thickness rotator cuff tears who underwent arthroscopic rotator cuff repair between January 2018 and August 2019 were enrolled. Included patients were divided into a control group (vitamin D level ≥20 μg/L) and a deficiency group (vitamin D level <20 μg/L). We investigated the association between preoperative vitamin D level and patient characteristics, MRI findings, pain and function scores (visual analog scale [VAS] for pain; Constant-Murley; University of California, Los Angeles; and American Shoulder and Elbow Surgeons scores), and healing status using the Pearson or Spearman correlation coefficient. The clinical characteristics were compared between the groups using the chi-square test or Fisher exact test.Results:Included were 89 patients (control group, 44 patients; deficiency group, 45 patients). The mean vitamin D levels were 25.07 ± 5.38 and 14.61 ± 3.43 μg/L in the control and deficiency groups, respectively (P < .001); otherwise, there were no significant differences between the groups in the variables under study. Vitamin D levels were not related to age, symptom duration, tear size, extent of retraction, VAS pain score preoperatively and at 6 and 24 months postoperatively, or any function scores. Supraspinatus fatty infiltration and VAS scores at 1 and 3 months postoperatively were significantly associated with vitamin D level (r = –0.360, –0.362, and –0.316, respectively; P < .05 for all). VAS scores were significantly lower in the control group than in the deficiency group at postoperative 1 month (1.09 ± 0.56 vs 1.47 ± 0.66, respectively) and 3 months (1.14 ± 0.77 vs 1.44 ± 0.66) (P < .05 for both). The retear rate was significantly lower in the control group than in the deficiency group (9.09% vs 26.67%, respectively; P < .05).Conclusion:Our study revealed that preoperative vitamin D deficiency was associated with a higher retear rate and early pain (1 and 3 months) after arthroscopic rotator cuff repair.

Electrospun hydroxyapatite loaded L-polylactic acid aligned nanofibrous membrane patch for rotator cuff repair

Rotator cuff repair remains a challenge clinically due to the high retear rate after surgical intervention. There is a significant need to develop functional biomaterials facilitating tendon-to-bone integration. In this study, hydroxyapatite (HA) incorporated polylactic acid (PLLA) aligned nanofibrous membranes were fabricated by electrospinning as a low-cost sustainable rotator cuff patch. The morphology, physical, mechanical and in vitro cell assays of the nanofibrous membranes were characterized. The results showed that the nanofibrous membrane maintained a rough surface and weakened hydrophobicity. It has excellent cytocompatibility, and the cells were oriented along the direction of fiber arrangement. What's more, the PLLA-HA nanofibrous membrane could increase the alkaline phosphatase (ALP) expression in rat bone marrow mesenchymal stem cells (BMSCs), indicating that the electrospinning PLLA-HA nanofibrous membrane can better induce the bone formation of rat BMSCs cells. When the mass ratio of PLLA to HA exceeds 3: 1, with the increase of the HA content, the patch showed rising induction ability. The results suggested that electrospinning PLLA-HA nanofibrous membranes are an ideal patch for promoting tendon-bone healing and reducing the secondary tear rate. Furthermore, the use of biodegradable polymers and low-cost preparation methods presented the possibility for commercial production of these nanofibrous membranes.

Critical shoulder angle and failure of conservative treatment in patients with atraumatic full thickness rotator cuff tears

BackgroundAtraumatic full thickness rotator cuff tears (AFTRCT) are common lesions whose incidence increases with age. Physical therapy is an effective conservative treatment in these patients with a reported success rate near 85% within 12 weeks of treatment. The critical shoulder angle (CSA) is a radiographic metric that relates the glenoid inclination with the lateral extension of the acromion in the coronal plane. A larger CSA has been associated with higher incidence of AFTRCT and a higher re-tear rate after surgical treatment. However, no study has yet described an association between a larger CSA and failure of conservatory treatment in ARCT. The main objective of this study is to determine whether there is an association between CSA and failure of physical therapy in patients with AFTRCT.MethodsWe reviewed the imaging and clinical records of 48 patients (53 shoulders), 60% female, with a mean age of 63.2 years (95% CI ± 10.4 years); treated for AFTRCT who also underwent a true anteroposterior radiograph of the shoulder within a year of diagnosis of the tear. We recorded demographic (age, sex, type of work), clinical (comorbidities), and imaging data (CSA, size and location of the tear). We divided the patients into two groups according to success or failure of conservative treatment (indication for surgery), so 21 shoulders (39.6%) required surgery and were classified as failure of conservative treatment.Univariate and multivariate analysis was performed to detect predictors of failure of conservative treatment.ResultsThe median CSA was 35.5º with no differences between those with failure (median 35.5º, range 29º to 48.2º) and success of conservative treatment (median 35.45º, range 30.2º to 40.3º), p = 0.978.The multivariate analysis showed a younger age in patients with failure of conservative treatment (56.14 ± 9.2 vs 67.8 ± 8.4, p < 0.001) and that male gender was also associated with failure of conservative treatment (57% of men required surgery vs 28% of women, p = 0.035).ConclusionsIt is still unclear if CSA does predict failure of conservative treatment. A lower age and male gender both could predicted failure of conservative treatment in AFTRCT. Further research is needed to better address this subject.

Arthroscopic Repair of Isolated Subscapularis Tears Show Clinical and Structural Outcome Better for Small Tears Than Larger Tears

PurposeTo retrospectively investigate the mid-term outcomes after arthroscopic repair of isolated subscapularis tears with a relatively large number of patients and to compare them by tear size.MethodsMedical records were reviewed for patients who underwent arthroscopic rotator cuff repair between 2010 and 2017 at our institute. The inclusion criterion was isolated subscapularis tears that underwent arthroscopic rotator cuff repair. The exclusion criteria were (1) previous rotator cuff surgery, (2) lack of imaging studies or clinical evaluation data, (3) neuromuscular diseases, and (4) <2-year follow-up. Range of motion, American Shoulder and Elbow Society score, and bear-hug or belly-press test were assessed pre- and postoperatively. Repair integrity was evaluated with magnetic resonance imaging at postoperative1 year. The clinical and imaging study outcomes were compared between smaller (Lafosse types 1-3) and larger (types 4 and 5) tears.ResultsThe subjects included 38 males and 8 females with a mean age of 59 years (range, 25-77 years). The mean follow-up was 36 months (range, 24-96 months). There were 13 type 1, 10 type 2, 12 type 3, 6 type 4, and 5 type 5 shoulders. Postoperative American Shoulder and Elbow Society scores were significantly better in smaller tears than larger tears: 93 ± 8 and 75 ± 14, respectively (P = .003). Smaller tears showed better postoperative internal rotation than larger tears (P = .004). Significant decrease of positive bear-hug or belly-press test was observed in smaller tears (preoperative, 25; postoperative, 11; P < .001), but there was no significant improvement in larger tears (preoperative, 11; postoperative, 9). The retear rate was significantly greater in larger tears (64%) than smaller tears (6%, P < .001).ConclusionsThe clinical and structural outcomes after arthroscopic repair of isolated subscapularis tears were better in smaller tears than larger tears with a mid-term follow-up. Larger tears showed high retear rates with poorer improvement in active range of internal rotation and subscapularis strength.Level of EvidenceLevel III, retrospective, comparative study.

Histology of tendon and enthesis - suitable techniques for specific research questions.

The musculoskeletal system consists of different components comprising a wide range of tissue types, with tendons being one part. Tendon degeneration or rupture have a high prevalence in all age groups, often with poor outcomes of surgical treatment such as chronic pain and high re-tear rates. Therefore, much effort has been directed to further develop diagnostic and therapeutic methods as well as reconstruction techniques, including using adequate placeholders or implants. Diagnostic approaches and advanced stages of preclinical studies will inevitably include histological examination of the pathologically affected tissue. The present study presents adequate tendon-related, histological techniques, including the embedding of soft- and hard-tissue samples in different media. Consideration is also given to samples containing residual implant materials or having been subjected to standard staining protocols and immunohistochemical procedures. The study further examines cells and tendon structure to detect degenerative, fibrotic or inflammatory conditions and possible foreign-body responses to implanted materials. Infraspinatus tendons from preclinical studies carried on rat and sheep samples, as well as human biceps tendon samples, have been used as example materials.

CEUS-assessed supraspinatus muscle perfusion improves after tendon repair and predicts anatomical and functional outcome: A 1-year prospective pilot study.

Rotator cuff tear including SSP (Supraspinatus) tendon tears are a very common and often painful condition with several therapeutic options such as tendon repair. Reflected by the high retear rates, the preoperative selection of patients suitable for surgery or conservative treatment, which often yields comparable results, remains difficult. Using contrast-enhanced ultrasound (CEUS), it is possible to quantify the SSP muscle perfusion as a surrogate parameter for its vitality and healing capabilities. In this study, we enrolled 20 patients who underwent an SSP repair for a preoperative and two postoperative (6 months and 1 year) clinical and sonographic exams including CEUS. Along with functional improvement (p < 0.001, Constant score), we found a significant increase in CEUS-assessed muscle perfusion after tendon repair (p < 0.001). Furthermore, weak preoperative muscle perfusion was associated with a higher risk of a retear (χ2 = 0.045) and a moderate trend towardlower postoperative shoulder function that did not reach significance (r = 0.435; p = 0.055, DASH score). If confirmed in larger studies, CEUS might be a valuable additional diagnostic method for a precise selection of patients who most likely profit from a tendon repair and those who can be treated conservatively with an equally good outcome.

Paper 04: The Effects of Glenohumeral Osteoarthritis on Early Clinical Outcomes Following Arthroscopic Rotator Cuff Repair

Objectives:It is unclear if concomitant glenohumeral osteoarthritis is protective or detrimental with respect to rotator cuff integrity after arthroscopic repair surgery. We hypothesized that the associated stiffness might protect the repaired tendon. In the alternate, arthritis might reflect a gradual degeneration of the joint including a degenerative tendon and therefore predispose the repair to re-tear. Therefore, the purpose of this study was to investigate whether concomitant osteoarthritic changes found intra-operatively during arthroscopic rotator cuff repairs (RCR) have a beneficial or detrimental effect on post-operative repair integrity.Methods:This study is a post-hoc analysis of prospectively collected data of patients who underwent primary arthroscopic RCR between 2005 and 2019 by a single surgeon. Patients were divided into an osteoarthritic group and a control group based on the presence or absence of intra- operative osteoarthritic changes respectively. The primary outcome measure was cuff integrity detected by post-operative ultrasound at 6-months. The secondary outcomes were patient-reported outcomes including shoulder pain, stiffness, level of activity at work and level of sport, and physician-reported outcomes including shoulder range of motion and strength.Results:A total of 2155 consecutive patients met the inclusion criteria with a mean age of 59 years (SD=0.2) and there were more males as compared to females (56% vs. 44%). 28% of patients undergoing RCR had osteoarthritic changes detected intra- operatively. Intra-operatively, the osteoarthritic group had more full-thickness tears (64% vs. 59%) (p<.001), a larger mean anteroposterior tear length [20mm (SD=0.5) vs. 17mm (SD=0.4)] (p<.001) and a larger mean mediolateral tear length [17mm (SD=0.5) vs. 15mm (SD=0.4)] (p<.001). Ultrasonographic evaluation at 6-months post-surgery demonstrated that the osteoarthritic group had a higher incidence of cuff re-tear rate as compared to the control group (15% vs. 11%) (p=.016) (Figure 1). However, after performing a multiple logistic regression analysis, osteoarthritis was not found to be an independent predictor of re-tear. There were very marginal differences in patient-reported outcomes at 6-months after surgery between the two groups (Table 1). The osteoarthritic group reported lesser post-operative frequency of activity pain [2.0 (SD=1.46) vs. 2.2 (SD=1.43)] (p=.005), frequency of extreme pain [0.8 (SD=1.35) vs. 1.0 (SD=1.41)] (p=.035) and level of pain during overhead activity [1.7 (SD=1.30) vs. 1.9 (SD=1.30)] (p=.021) as compared to controls. As compared to controls, the osteoarthritic group also experienced lesser post-operative stiffness [1.5 (SD=1.32) vs. 1.6 (SD=1.31)] (p=.019) and reported lower intensities of work-related activities [1.1 (SD=0.88) vs. 1.2 (SD=0.85)] (p=.038) and lower level of sport activity [0.4 (SD=0.62) vs. 0.5 (SD=0.70)] (p=.004). In terms of physical examination at 6-months following surgery (Table 2), the osteoarthritic group were found to have lesser range of motion in forward flexion [146° (SD=33.1) vs. 151° (SD=31.2)] (p=.009), abduction [127° (SD=38.8) vs. 131° (SD=38.1)] (p=.034), external rotation [50° (SD=21.4) vs. 52° (SD=21.0)] (p=.024) and internal rotation (L1 vertebrae (SD=4.2) vs. T12 vertebrae (SD=4.2)] (p=.004) as compared to controls. The osteoarthritic group as weaker internal rotation strength [68N (SD=30.5) vs. 73N (SD=32.9)] (p=.004), external rotation strength [57N (SD=25.3) vs. 60N (SD=27.2)] (p=.026), supraspinatus flexion strength [45N (SD=26.8) vs. 50N (SD=27.9)] (p<.001), lift-off [40N (SD=24.3) vs. 44N (SD=25.3)] (p<.001) and adduction strength [76N (SD=36.5) vs. 81N (SD=39.3)] (p=.008) as compared to the control group.Conclusions:Patients with concomitant glenohumeral osteoarthritis who underwent arthroscopic RCR had higher re-tear rates at 6-months after surgery. However, osteoarthritis is not an independent predictor of rotator cuff re-tear at 6-months. Therefore, arthroscopic RCR is a viable surgical option for these patients.Figure 1:Proportion of intract vs. torn rotator cuff repairs between the osteoarthritic group (n=1552) and control group (n=603) at 6-months post-operative follow-up (p=.016).Table 1:6-month post-operative pain scares and shoulder function in the osteoarthritic group vs. control group.Table 2:6-month post-operative shoulder range of motion and strength in the osteoarthritic group vs. control group.

Current Perspectives on Rotator Cuff Disease

Rotator cuff (RC) disease, defined as any pathological state of the rotator cuff, is one of the most common shoulder conditions worldwide. It accounts for 70% of shoulder pain and dysfunction in adults and is the third most prevalent musculoskeletal disorder. Currently, the main issue with rotator cuff disease is that surgery represents the most common treatment performed. However, rotator cuff surgeries have a high failure rate positively correlated with the severity of the tear, and a high re-tear rate. This review will focus on the current research perspectives of rotator cuff repairs as well as new advances in the field. Current research is shifting its focus to target the healing and tendon repair process in an aim to decrease the failure rates. The bulk of research right now is within biologic methods based on growth factors, repair scaffolds, and stem cells that promote healing. Among this, researchers are continuously trying to improve surgical techniques. The complement of both methods should pave the way for much more effective, longer-lasting rotator cuff repairs.

Arthroscopic revision rotator cuff repair of large and massive retears using an interpositional bridging dermal allograft.

BackgroundThe purpose of this study was to report the clinical outcomes and retear rate following arthroscopic interpositional bridging dermal allograft for revision rotator cuff repair of large and massive retears.MethodsTwenty-three patients were retrospectively reviewed at a minimum follow-up of 24 (mean, 47; range, 24-77) months after revision rotator cuff repair using an interpositional bridging dermal allograft. There were 17 males and 6 females with a mean age of 56 (range, 40-74) years. Clinical outcomes were assessed using range of motion, the American Shoulder and Elbow Surgeons score and Western Ontario Rotator Cuff Index. Graft integrity was assessed at 12-months using magnetic resonance imaging.ResultsThe interval between the primary rotator cuff repair and interpositional bridging graft was a mean of 82 (range, 7-192) months. Forward flexion improved from a mean of 145° (range, 60-180°) preoperatively to 152° (range, 135-170°) postoperatively (P = .3561). There was a decrease in external rotation from a mean of 50° (range, 20-80°) preoperatively to 37° (range, 0-45°) postoperatively (P = .0021). The American Shoulder and Elbow Surgeons score improved (P = .0196) from a mean of 50 (range, 10-88) to 69 (range, 22-97), and the Western Ontario Rotator Cuff index improved (P = .0008) from a mean of 34 (range, 3-90) to 57 (range, 14-93). The graft was intact in 39% of patients. No patients underwent further surgery.ConclusionInterpositional bridging grafting for revision rotator cuff repair of large and massive retears leads to a significant improvement in functional outcome but is associated with a high retear rate.

The Regenerative Role of Gelatin in PLLA Electrospun Membranes for the Treatment of Chronic Massive Rotator Cuff Injuries.

Failing to regenerate native tendon tissue in chronic massive rotator cuff tears (CMRCTs) results in high retear rates after surgery. Gelatin is a hydrolyzed form of collagen which is bioactive and biocompatible. This study intends to investigate the suitability of integrating gelatin to poly (l-lactic acid) (PLLA) fibrous membranes for promoting the healing of CMRCTs. PLLA/Gelatin electrospun membranes (PGEM) are fabricated using electrospinning technology. The fourier transform infrared, static contact angles are tested sequentially. Cytocompatibility is evaluated with rat tendon fibroblasts and human umbilical endothelial cells (HUEVCs) lines. CMRCTs rat models are established and assigned into three groups (the sham group, the repaired group, and the augmentation group) to perform histomorphological and biomechanical evaluations. Gelatin is successfully integrated into PLLA fibrous membranes by the electrospinning technique. In vitro studies indicate that PGEM shows a great cytocompatibility for rat tendon fibroblasts and HUEVCs. In vivo studies find that applications of PGEM significantly promote well-aligned collagen I fibers formation and enhance biomechanical properties of the repaired tendon in CMRCTs rat models. In summary, gelatin promotes tendon fibroblasts and HUEVCs adhesion, migration, and proliferation on the PLLA fibrous membranes, and PGEM may provide a great prospect for clinical application.

Bridging Allograft Reconstruction Is Superior to Maximal Repair for the Treatment of Chronic, Massive Rotator Cuff Tears: Results of a Prospective, Randomized Controlled Trial

Background: Despite advances in surgical techniques, the use of maximal repair to treat large or massive rotator cuff tears results in a high retear rate postoperatively. Currently, no randomized controlled trials have compared the outcomes of maximal repair with interposition dermal allograft bridging reconstruction. Hypothesis: We hypothesized that large or massive rotator cuff tendon tears reconstructed using bridging dermal allograft would have better clinical outcomes 2 years postoperatively, as measured using the Western Ontario Rotator Cuff (WORC) index, than would those receiving the current gold standard treatment of debridement and maximal repair alone. We also expected that patients treated via bridging reconstruction using dermal allograft would have fewer postoperative failures as assessed using postoperative magnetic resonance imaging scans. Study Design: Randomized controlled trial; Level of evidence 1. Methods: A sample size of 30 patients (determined using a priori sample size calculation) with massive, retracted rotator cuff tears were randomly allocated to 1 of 2 groups: maximal repair or bridging reconstruction using dermal allograft. All patients completed questionnaires (WORC and Disabilities of the Arm, Shoulder and Hand [DASH]) preoperatively and postoperatively at 3 months, 6 months, 1 year, and 2 years. The primary outcome of this study was the WORC index at 2 years. Secondary outcomes included healing rate, progression of rotator cuff arthropathy, and postoperative acromiohumeral distance in both groups. Results: Patients treated via bridging reconstruction using dermal allograft had better postoperative WORC and DASH scores (23.93 ± 24.55 and 15.77 ± 19.27, respectively) compared with patients who received maximal repair alone (53.36 ± 31.93 and 34.32 ± 23.31, respectively). We also noted increased progression to rotator cuff arthropathy in the maximal repair group with an increased retear rate when compared with the reconstruction group (87% and 21%, respectively; P < .001). The acromiohumeral distance was maintained in the reconstruction group but significantly decreased in the maximal repair group. Conclusion: Rotator cuff bridging reconstruction using a dermal allograft demonstrated improved patient-reported outcomes as measured using the WORC index 2 years postoperatively. This technique also showed favorable structural healing rates and decreased progression to arthropathy compared with maximal repair. Trial Registration: ClinicalTrials.gov (NCT01987973)

Basic Research on Tendon Repair: Strategies, Evaluation, and Development.

Tendon is a fibro-elastic structure that links muscle and bone. Tendon injury can be divided into two types, chronic and acute. Each type of injury or degeneration can cause substantial pain and the loss of tendon function. The natural healing process of tendon injury is complex. According to the anatomical position of tendon tissue, the clinical results are different. The wound healing process includes three overlapping stages: wound healing, proliferation and tissue remodeling. Besides, the healing tendon also faces a high re-tear rate. Faced with the above difficulties, management of tendon injuries remains a clinical problem and needs to be solved urgently. In recent years, there are many new directions and advances in tendon healing. This review introduces tendon injury and sums up the development of tendon healing in recent years, including gene therapy, stem cell therapy, Platelet-rich plasma (PRP) therapy, growth factor and drug therapy and tissue engineering. Although most of these therapies have not yet developed to mature clinical application stage, with the repeated verification by researchers and continuous optimization of curative effect, that day will not be too far away.

Five Year Follow up of Retrospective Cohort Comparing Structural and Functional Outcome of Arthroscopic Single-row ersus Double-row Suture Bridge Repair of Large Posterosuperior Rotator Cuff Tear in Patients Less than or Equal to 70 Years.

High re-tear rates after repairing large-sized posterosuperior rotator cuff tears remain a significant concern which may affect the clinical outcome. The most optimal type of repair (single versus double-row suture bridge) suited for large size tear remains debatable. In a retrospective cohort study with a minimum of five years follow up, the structural and functional outcome of 103 patients with large size cuff tear repaired with single row (SR) or double row suture bridge (DRSB) were evaluated. The structural outcome was assessed with ultrasonography whereas functional outcome was evaluated with Constant Murley (CM) and American shoulder elbow score (ASES). There were 55 patients in the SR group and 48 patients in the DRSB group with a mean follow-up of 74.2 months (range, 60-96 months). While comparing the structural integrity in two groups, we found significantly lower re-tear rates in the DRSB group as compared to the SR group (10.4% vs. 32.7%; P=0.006). Also, there were more focal defects in the SR group (25.4%) than the DRSB group (8.3%). Overall, there was no significant difference in CM and ASES scores when the SR group was compared to DRSB. However, subgroup analysis between those with intact and retorn tendon revealed significant difference (P=0.0001) in the clinical scores. At a minimum of five years follow-up, the DRSB repair of large posterosuperior cuff tear resulted in superior structural healing over SR repair. Nevertheless, overall there was no significant functional difference between both the techniques. However, the functional outcome of the healed tendon subgroup was superior to retear tendon subgroup.

Perioperative Complications and Early Clinical Outcomes Following ACL Reconstruction with Soft Tissue Quadriceps Tendon Autograft in Adolescent Athletes

Objectives:Quadriceps tendon (QT) autograft has emerged as an increasingly popular soft tissue graft alternative to the hamstring tendon (HS) autograph for ACL reconstruction (ACLR). However, utilization of the technique is not yet widespread, particularly in the population of adolescent athletes, for whom safety and effectiveness of the technique remains under-investigated, despite this being the most affected epidemiologic sub-population, with regard to primary ACL injury, post-ACLR re-tear, and overall complications. The study hypothesis was that QT-ACLR would have equivalent or lower rates of perioperative complications and early ACL re-tear than historically reported for HS ACLR.Methods:A retrospective review of all 12-19 year-old athletes who underwent primary QT-ACLR by a single surgeon at a tertiary care pediatric hospital were included, with prospective outreach performed at 1 and 2 years to collect PROs and confirm absence of ACL re-tear or revision surgery. Patients with <6 months follow-up were excluded to insure adequate reporting of early perioperative complications. Patients with between 6-12 month follow up were excluded from the ACL re-tear analysis. Concomitant procedures at the time of primary ACL surgery, perioperative and early post-operative complications, and subsequent surgeries were analyzed. A sub-analysis excluding the first 25 knees was performed to eliminate any potential effects of a surgical ‘learning curve’.Results:90 patients (93 knees, 70% female) were included, with a mean age of 16.0 years (±1.85) and mean follow up of 12.6 months (IQR 9.1-21.4). Concomitant meniscal pathology was detected in more than half of patients, with 30% undergoing meniscal repair and 27% partial meniscectomy. There were 51 complications overall in 36 knees (39%, Table 1). Secondary surgery for a complication was performed in 22 knees (24%), most commonly for a cyclops lesion/arthrofibrosis (15%), but also for revision ACLR (5%) and removal of implants (1%). Of note, 6 additional knees (6%) were diagnosed by MRI for a cyclops lesion/arthrofibrosis, but were successfully treated with non-operative measures, including physical therapy, dynamic splinting, and/or intra-articular cortisone injections. ACL graft tear was more common in the first 25 knees for whom QT-ACLR was performed (16% vs. 1%, p=0.02), indicating that initial re-tear could be a function of the surgical learning curve and technique adjustments. Early graft tear rate of 5% is similar to reported rates in HS autograft in adolescents. Arthrosibrosis/cyclops lesions were more frequently observed than historically reported for other graft types, and were not significantly different based on learning curve (20% vs. 22%, p=1.00). Pedi-IKDC (Table 2) showed significant improvement from baseline to 6-month (p<0.001) and 1-year time (p<0.001) period. Patients without complications had a significantly higher Pedi-IKDC score at 1 year follow up (mean, 93.9) compared to those with complications (mean, 85.5; p=0.04).Conclusions:Quad tendon ACLR shows a relatively high overall early post-operative complication and subsequent surgery rate in adolescents, most notably cyclops lesions/arthrofibrosis, most cases of which underwent arthroscopic debridement/LOA. This is consistent with previous adult QT-ACLR studies. Graft tear rates at 1-year post-operatively are similar to historically reported re-tear rates of the HS ACLR for adolescents, with a higher re-tear rate in the earlier sub-cohort, which may relate to surgical learning curve. Continued research into minimizing risks and quantifying longer term ACL re-tear risk will be critical for this young, active population, who are increasingly undergoing ACLR with the QT autograft, which remains relatively understudied, particularly in the adolescent sub-population.

Current Biological Strategies to Enhance Surgical Treatment for Rotator Cuff Repair.

Rotator cuff tear is one of the most common shoulder problems encountered by orthopedic surgeons. Due to the slow healing process and high retear rate, rotator cuff tear has distressed millions of people all around the world every year, especially for the elderly and active athletes. This disease significantly impairs patients’ motor ability and reduces their quality of life. Besides conservative treatment, open and arthroscopic surgery contributes a lot to accelerate the healing process of rotator cuff tear. Currently, there are many emerging novel treatment methods to promote rotator cuff repair. A variety of biological stimulus has been utilized in clinical practice. Among them, platelet-rich plasma, growth factors, stem cells, and exosomes are the most popular biologics in laboratory research and clinical trials. This review will focus on the biologics of bioaugmentation methods for rotator cuff repair and tendon healing, including platelet-rich plasma, growth factors, exosomes and stem cells, etc. Relevant studies are summarized in this review and future research perspectives are introduced.

Association between functional outcome scores and MRI-based structural integrity after rotator cuff repair: a prospective cohort study.

Natural history of rotator cuff tears is poorly understood. Repair of rotator cuff tears has shown to improve functional outcomes in full-thickness tears. However, high re-tear rates have been reported in literature, which does not correlate with poorer outcomes. Primary aim of this study was to explore association between functional outcome scores and structural integrity of rotator cuff, using magnetic resonance imaging (MRI)-based grading. Patients with MRI-proven full-thickness rotator cuff tears, undergoing mini-open rotator cuff repair, were assessed for shoulder abduction strength and functional outcome scores before the surgery and 2 years after the procedure. Association between functional outcome scores and MRI grading for rotator cuff healing (Sugaya grading) was analyzed. A total of 38 patients (18 females and 20 males), with a mean age of 50.6 years (SD: 10.9), were included in the study. Mean duration of symptoms was 6.05 months (SD: 4.2). On postoperative MRI, healing of the cuff was categorized as Sugaya grade 1 in 12 patients, grade 2 in 20 patients and grade 3 in 6 patients. Higher Sugaya grades (T: 13.48, p: 0.001) and grades of fatty degeneration (T: 14.05, p: 0.001) were found to be associated with longer duration of symptoms. Improvement in shoulder abduction strength correlated negatively with the duration of symptoms (r: -0.39, p: 0.01). There was a significant improvement in functional outcome scores after the surgery. There was no association between postoperative structural integrity of the repaired tendon (Sugaya grading) and functional outcome scores. Early repair of rotator cuff results in better functional outcomes and shoulder strength. The findings from this study suggest there is a dissociation between MRI-based grades of healing of repaired rotator cuff and function of the shoulder. Level II, Prospective cohort study.