Large Rotator Cuff Tears Research Articles

Intramuscular Brown Fat Activation Decreases Muscle Atrophy and Fatty Infiltration and Improves Gait After Delayed Rotator Cuff Repair in Mice

Background: Successful repair of large and massive rotator cuff (RC) tears remains a challenge at least partially because of secondary muscle atrophy and fatty infiltration. β3 Adrenergic agonists are a group of drugs that promote fat resorption through “white fat browning” of intramuscular stem cells. Purpose: To test the role of a β3 adrenergic receptor agonist, amibegron, in improving muscle quality and forelimb function in a delayed RC repair model via promoting brown/beige adipose tissue activation. Study Design: Controlled laboratory study. Methods: Three-month-old PDGFRα-GFP reporter mice, wild type C57BL/6J mice, and uncoupling protein 1 (UCP-1) knockout mice underwent unilateral supraspinatus tendon transection with a 6-week delayed tendon repair. Animals with sham surgery served as controls. Amibegron was given either immediately after tendon transection or after repair. Gait analysis was conducted to measure forelimb function at 6 weeks after tendon repair. Animals were sacrificed at 6 weeks after repair. Supraspinatus muscles were harvested and analyzed histologically. Reverse transcription polymerase chain reaction was performed to quantify gene expression related to atrophy, fibrosis, and fatty infiltration. Results: Histology of PDGFRα reporter mice showed significantly increased UCP-1 expression, suggesting white fat browning in muscle after RC repair. As administered either immediately after tendon transection or after tendon repair, amibegron significantly reduced muscle atrophy and fatty infiltration and resumed normal upper extremity gait in wild type mice. However, the effect of amibegron was not present in UCP-1 knockout mice, suggesting that the effect of amibegron in treating RC muscle atrophy and fatty infiltration is through a UCP 1–dependent mechanism. Conclusion: Amibegron reduced muscle atrophy and fatty infiltration and improved forelimb function after delayed RC repair through a UCP 1–dependent mechanism. This may be an effective clinical treatment strategy for patients to improve muscle quality after RC repair. Clinical Relevance: β3 Adrenergic agonists may serve as a new pharmacologic modality to treat RC muscle atrophy and fatty infiltration to improve clinical outcome of RC repair.

The use of a synthetic shoulder patch for large and massive rotator cuff tears \u2013 a feasibility study

BackgroundThe aim of this study was to explore the feasibility of using a non-absorbable biocompatible polyester patch to augment open repair of massive rotator cuff tears (Patch group) and compare outcomes with other treatment options (Non-patch group).MethodsParticipants referred to orthopaedic clinics for rotator cuff surgery were recruited. Choice of intervention (Patch or Non-patch) was based on patient preference and intra-operative findings. Oxford Shoulder Score (OSS), Shoulder Pain and Disability Index (SPADI), and Constant score were completed at baseline and 6 months. Shoulder MRI was performed at baseline and 6 months to assess fat fraction and Goutallier classification pre- and post- treatment. Feasibility outcomes (including retention, consent and missing data) were assessed.ResultsSixty-eight participants (29 in the Patch group, 39 in Non-patch group) were included (mean age 65.3 years). Conversion to consent (92.6%), missing data (0% at baseline), and attrition rate (16%) were deemed successful feasibility endpoints. There was significant improvement in the Patch group compared to Non-patch at 6 months in OSS (difference in medians 9.76 (95% CI 2.25, 17.29) and SPADI: 22.97 (95% CI 3.02, 42.92), with no substantive differences in Constant score. The patch group had a higher proportion of participants improving greater than MCID for OSS (78% vs 62%) and SPADI (63% vs 50%) respectively. Analysis of the 48 paired MRIs demonstrated a slight increase in the fat fraction for supraspinatus (53 to 55%), and infraspinatus (26 to 29%) at 6 months. These differences were similar and in the same direction when the participants were analysed by treatment group. The Goutallier score remained the same or worsened one grade in both groups equally.ConclusionsThis study indicates that a definitive clinical trial investigating the use of a non-absorbable patch to augment repair of massive rotator cuff tears is feasible. In such patients, the patch has the potential to improve shoulder symptoms at 6 months.Trial registrationISRCTN, ISRCTN79844053, Registered 15th October 2014 (retrospectively registered).

Differences in three-dimensional shoulder kinematics between patients with pseudoparalytic massive rotator cuff tears and those with non-pseudoparalytic massive rotator cuff tears

The purpose of this study was to clarify the differences in three-dimensional (3D) shoulder kinematics between patients with pseudoparalytic large and massive rotator cuff tears and those with non-pseudoparalytic large and massive rotator cuff tears.

Beige Fibro-Adipogenic Progenitors Reduce Muscle Degeneration in a Mouse Model of Delayed Repair for Massive Rotator Cuff Tears

Rotator cuff (RC) tears are the most common cause of shoulder disability with large and massive rotator cuff tears accounting for up to 40% of all RC tears. The degree of muscle atrophy and fatty degeneration that develop following RC tears are highly correlated with repair success and functional outcomes. Fibroadipogenic progenitors (FAPs) have been identified as the cellular source of fibrosis and fatty infiltration following RC tears. A subset of FAPs possess the capacity to differentiate into beige adipose tissue (BAT) identified by the brown fat hallmark, UCP1. In addition to its thermogenic potential, beige adipose tissue can act in a paracrine fashion, secreting various growth factors known to positively influence muscle health and function. The trophic capacity of BAT on skeletal muscle has major implications for muscle regeneration following injury. The potential for beige FAPs to prevent and reverse pathological changes particularly after repair has yet to be explored. We hypothesized that transplantation of UCP1 expressing beige FAPs would diminish muscle atrophy and degeneration and promote functional recovery in a mouse model of delayed RC repair.

Evaluation of Deltoid Origin Status Following Open and Arthroscopic Repair of Large Rotator Cuff Tears: A Propensity-Matched Case-Control Study.

BackgroundThe purpose of this study was to evaluate and compare deltoid origin status following large rotator cuff repair carried out using either an open or an arthroscopic method with a propensity score matching technique.MethodsA retrospective review of 112 patients treated for full-thickness, large rotator cuff tear via either a classic open repair (open group) or an arthroscopic repair (arthroscopic group) was conducted. All patients included in the study had undergone postoperative magnetic resonance imaging (MRI) and clinical follow-up for at least 12 and 18 months after surgery, respectively. Propensity score matching was used to select controls matched for age, sex, body mass index, and affected site. There were 56 patients in each group, with a mean age of 63.3 years (range, 50–77 years). The postoperative functional and radiologic outcomes for both groups were compared. Radiologic evaluation for postoperative rotator cuff integrity and deltoid origin status was performed with 3-Tesla MRI.ResultsThe deltoid origin thickness was significantly greater in the arthroscopic group when measured at the anterior acromion (P=0.006), anterior third (P=0.005), and middle third of the lateral border of the acromion level (P=0.005). The deltoid origin thickness at the posterior third of the lateral acromion was not significantly different between the arthroscopic and open groups. The arthroscopic group had significantly higher intact deltoid integrity with less scarring (P=0.04). There were no full-thickness deltoid tears in either the open or arthroscopic group.ConclusionsOpen rotator cuff repair resulted in a thinner deltoid origin, especially from the anterior acromion to the middle third of the lateral border of the acromion, at the 1-year postoperative MRI evaluation. Meticulous reattachment of the deltoid origin is as essential as rotator cuff repair when an open approach is selected.

MRI Findings Predictive of Shoulder Stiffness in Patients With Full-Thickness Rotator Cuff Tears

OBJECTIVE. The objective of our study was to evaluate the relationship between stiff shoulder in patients with a full-thickness rotator cuff tear and MRI findings, especially joint capsule abnormality. MATERIALS AND METHODS. This study included 106 patients with small to large (≤ 5 cm) full-thickness rotator cuff tears. Joint capsule edema and thickness in the axillary recess, obliteration of the subcoracoid fat triangle, fatty degeneration of the torn rotator cuff muscle, and degree of retraction were assessed by two radiologists. The size and location of tears were determined by MRI findings and operative report. Associations between MRI findings and preoperative passive range of motion (ROM) were assessed by simple and multiple linear regression analyses and proportional odds logistic regression analysis. RESULTS. There was a significant, negative linear correlation between limited ROM at forward elevation and thickness of the joint capsule in the glenoid portion of the axillary recess (p = 0.018), external rotation and joint capsule edema in the humeral portion of the axillary recess (p = 0.011), and internal rotation and joint capsule edema in the glenoid portion of the axillary recess (p = 0.007). Male sex (p = 0.041) and posterosuperior rotator cuff tear (p = 0.030) were independent predictors of shoulder ROM on external rotation. Degree of fatty degeneration (p = 0.003) was another independent predictor of shoulder ROM on internal rotation. CONCLUSION. MRI findings-especially joint capsule edema and thickness at the axillary recess-can be useful in predicting shoulder stiffness in patients with rotator cuff tear.

Effect of biceps rerouting technique to restore glenohumeral joint stability for large irreparable rotator cuff tears: a cadaveric biomechanical study

The concept of stabilizing the humerus has taken on an important role in the treatment of irreparable cuff tears, and the biceps rerouting (BR) method is considered one of the most effective treatments in this field. The study aimed to evaluate the biomechanical effects of BR for large irreparable rotator cuff tears (LICTs). A total of 8 cadaveric shoulders were used for testing under 5 conditions: intact shoulder, LICT, partial repair (PR), BR, and biceps rerouting with side-to-side repair (BRSS). Total rotational range of motion was measured at 40°, then 20°, and finally 0° of glenohumeral (GH) abduction. Superior humeral translation and subacromial contact pressure were measured at 0°, 30°, 60°, and 90° of external rotation at each abduction angle. Repeated-measures analyses of variance with Tukey post hoc tests were used for statistical comparisons. Superior humeral translation was significantly decreased in the BR and BRSS conditions compared with the LICT and PR conditions at 0° and 20° of GH abduction (P < .001). BR and BRSS significantly reduced subacromial contact pressure compared with LICT and PR at 0° of GH abduction (P < .001). There was no significant decrease in total rotational range of motion after BR at any abduction angle. BR biomechanically restored shoulder stability without overconstraining range of motion in an LICT model.

Reconstruction of large chronic rotator cuff tear can benefit from the bone-tendon composite autograft to restore the native bone-tendon interface.

PurposeWe designed a paired controlled study to investigate the advantages of using bone–tendon composite autograft to reconstruct chronic rotator cuff tear compared with primary repair and provide some evidence to use the bone–tendon composite autograft.MethodThirty-eight Sprague–Dawley rats were used. The native bone–tendon junctions of supraspinatus and Achilles tendon insertion from two rats were harvested for gross and histological observation. Another thirty-six rats had bilateral supraspinatus tenotomy from the great tuberosity. Three weeks later, primary repair (simple tendon pullout direct repair to bone) was performed on one side and the other side was reconstructed using an Achilles–calcaneus composite autograft from the ipsilateral leg. Nine rats were sacrificed for biomechanical testing and another three were sacrificed for histological evaluation at 3, 6, and 9 weeks after surgery, respectively.ResultsThe Achilles–calcaneus composite autograft group showed significantly better biomechanical characteristics at 3 and 6 weeks in terms of maximum load and stiffness. Tissue histology demonstrated an organised extracellular matrix, a clear tidemark, and distinct fibrocartilage layers in the composite graft group, similar to those of the native bone–tendon interface. Additionally, clear bone-to-bone healing and tendon-to-tendon healing were observed. By contrast, the conventional primary repair could not regenerate the structure of the native bone–tendon interface.ConclusionsBone–tendon autograft for chronic rotator cuff reconstruction is superior to the primary repair regarding biomechanical property and histological structure. Our study may provide some evidence in support of the reconstruction of a chronic rotator cuff tear using bone–tendon composite autografts in clinical practice.The Translational potential of this articleThe current study finds the bone-tendon autograft can restore the normal bone-tendon interface, which can not regenerate after repair and is the key factor affecting re-tear. The bone-tendon autografts from our body can be the candidates for rotator cuff tear reconstruction especially the large to massive rotator cuff tear in the future to reduce the re-tear after rotator cuff tear.

Reduced acromiohumeral distance and increased critical shoulder angle: implications for primary care clinicians

ABSTRACT Objectives: The literature indicates that reduced acromiohumeral distance (AHD) and increased critical shoulder angle (CSA) are associated with large and massive rotator cuff (RC) tears which may not be amenable to a successful repair. The purpose of this study was to examine the overall accuracy of these two radiographic features in diagnosing significant RC pathology. Methods: This was a diagnostic study of patients with shoulder pain. To examine the overall accuracy of the measurements, the area under the Receiver Operating Characteristic curves (AUC) were calculated. The validity indices (sensitivity, specificity and likelihood ratios) examined the predictive value of specific cutoff categories of AHD<6 mm and the CSA >35°. Results: Data of 200 consecutive patients; mean age: 59(11), 117 males were used for analysis. There was a weak inverse correlation (r = 0.46) between the AHD and CSA. The AUCs for presence and size of RC tear and different stages of fatty infiltration of supraspinatus and infraspinatus muscles varied from fair to excellent for AHD and poor to good for CSA. Specificity was high for the cutoff categories of both AHD and CSA (>90%). The positive LRs were large for AHD and small to moderate for CSA. Conclusion: The AHD and CSA were reliably measured in the true AP radiographic view. Both radiographic features (AHD<6mm and CSA>35°) were able to confirm the presence of a major RC pathology. However, the AHD<6 mm, an acquired radiologic abnormality secondary to failure of the RC muscles/tendons had better measurement properties. This information is of value to primary care physicians, sports medicine specialists and advanced practice physiotherapists in their clinical decision making.

Bio-inductive implant for rotator cuff repair: our experience and technical notes.

The treatment of chonic large and partial rotator cuff tears represents a common challenge for orthopedic surgeons. Numerous treatments were suggested but the best is still controversial. Into this field the use of an augment for rotator cuff repair aims to protect the tension of the suture in the postoperative phase and to facilitate the biological healing process. In our institution we treated 4 patients (3 males and 1 female) with rotator cuff tear with bio-inductive implant. All patients presented with a postero-superior rotator cuff tear: 3 patients with a type C-III tear according to Snyder classification and 1 patient with partial articular tear with significant degeneration and poor tendon quality (type A-III tear according to Snyder classification). The final outcome is highly satisfying intraoperatively and the postoperative protocol reflects our normal postoperative protocol following to rotator cuff repair. No complications occurred at 6 months follow-up. The use of the bio-inductive implant in the arthroscopic rotator cuff repair resulted easy, rapid and reproducible. Although no current scientific evidences regarding such implants exist, in selected cases and with the correct indications, the use of bio-inductive implant could represent an effective aid and an option in case of complex rotator cuff tears. (www.actabiomedica.it)

Application Strategy of Staged Nursing Intervention After the Surgery of Huge Rotator Cuff Tears Under the Arthroscopy

Objective: To explore the application of staged nursing intervention after the surgery of huge rotator cuff tear under the arthroscopy, and to evaluate the impact on patients' postoperative rehabilitation. Methods: A total of 25 patients who underwent arthroscopic surgery for large rotator cuff tears in our hospital from January 2018 to December 2019 were selected. The intervention group used a staged nursing program to intervene, and Selected 25 patients who only received routine nursing intervention during the same period as the control group. The constant-murley shoulder function score, UCLA score, SF-36 quality of life score, and nursing satisfaction score were compared between the two groups after 6 months. Results: There was no statistically significant in the difference in the scores of pain, functional activity, shoulder joint mobility, and muscle strength of the constant-murley shoulder function score between the observation group and the control group before surgery (P > 0.05). The pain, functional activities, shoulder joint mobility and muscle strength scores of the observation group were significantly higher than those of the control group 6 months after surgery (P < 0.05), and the UCLA score and SF-36 score of the observation group 6 months after surgery were significantly higher than the control group (P < 0.05), and the nursing satisfaction score of the observation group was significantly higher than that of the control group (P < 0.05). Conclusion: Staged nursing intervention can significantly improve the Shoulder joint functional rehabilitation process and quality of life of patients who post operation of huge rotator cuff tears, and improve nursing satisfaction.

Rotator Cuff Repair With Autologous Tenocytes and Biodegradable Collagen Scaffold: A Histological and Biomechanical Study in Sheep

Background: Large rotator cuff tears still represent a challenging problem in orthopaedics. The use of tenocytes on biomaterials/scaffolds for the repair of large rotator cuff defects might be a promising approach in the field of tendon regeneration. Hypothesis: Cultivated autologous tenocytes seeded on a collagen scaffold lead to enhanced histological and biomechanical results after rotator cuff repair in a sheep model as compared with unseeded scaffolds in an acute setting. Study Design: Controlled laboratory study. Methods: At the tendon-bone junction of the infraspinatus tendon of the right foreleg of 24 sheep, a 3.5 × 1.5–cm tendon defect was created. Sheep were randomly allocated to group 1, a defect; group 2, where an unseeded collagen scaffold was implanted; or group 3, which received the implantation of a collagen scaffold seeded with autologous tenocytes. Twelve weeks postoperatively, tendon regeneration was examined histologically and biomechanically. Results: The histology of the neotendons of group 3 showed better fiber patterns, a higher production of proteoglycans, and an increased genesis of collagen III in contrast to groups 1 and 2. Immunostaining revealed less tissue dedifferentiation, a more structured cartilage layer, and homogeneous cartilage-bone transition in group 3 in comparison with groups 1 and 2. Biomechanically, the tensile strength of the reconstructed tendons in group 3 (mean load to failure, 2516 N; SD, 407.5 N) was approximately 84% that of the native tendons (mean load to failure, 2995 N; SD, 223.1 N) without statistical significance. A significant difference (P = .0095) was registered between group 1 (66.9% with a mean load to failure of 2004 N; SD, 273.8 N) and the native tendons, as well as between group 2 (69.7% with a mean load to failure of 2088 N; SD, 675.4 N) and the native tendons for mean ultimate tensile strength. In breaking stress, a significant difference (P = .0095) was seen between group 1 (mean breaking stress, 1335 N/mm2; SD, 182.7 N/mm2) and the native tendons, as well as between group 2 (breaking stress, 1392 N/mm2; SD, 450.2 N/mm2) and the native tendons (mean breaking stress, 1996 N/mm2; SD, 148.7 N/mm2). Again, there was no significant difference between group 3 (mean breaking stress, 1677 N/mm2; SD, 271.7 N/mm2) and the native tendons. Conclusion: Autologous tenocytes seeded on collagen scaffolds yield enhanced biomechanical results after tendon-bone reconstruction as compared with unseeded scaffolds in an acute setting. Biomechanical results and histological outcomes were promising, showing that the use of autologous tenocytes with specific carrier matrices could be a novel approach for repairing rotator cuff tears. Clinical Relevance: This study supports the use of tenocytes and scaffolds for improving the quality of tendon-bone regeneration.

Improved Rotator Cuff Footprint Contact Characteristics With an Augmented Repair Construct Using Lateral Edge Fixation

Background: The transosseous-equivalent (TOE) rotator cuff repair construct has become the gold standard for the repair of medium and large rotator cuff tears. Repair failure, however, continues to be a problem. One contributing factor may be the inability of the TOE repair to replicate the native footprint contact characteristics during shoulder movement, especially in rotation. This results in higher strain across the repair, which leads to gapping and predisposes the construct to failure. In an effort to better reproduce the native compression forces throughout the footprint, an augmented TOE construct supplemented with lateral edge fixation is proposed, and the contact characteristics were compared with those of the gold standard TOE construct. Hypothesis: The augmented TOE repair will demonstrate improved footprint contact characteristics when compared with the classic TOE repair. Study Design: Controlled laboratory study. Methods: Ten fresh-frozen cadaveric shoulders underwent supraspinatus repair using both the classic TOE double-row construct and the augmented TOE repair. For the augmented repair, 2 luggage tag sutures were used to secure the lateral edge and incorporated into the lateral row anchors. A Tekscan pressure sensor (Tekscan Inc) placed under the repaired tendon was used to collect footprint contact area, force, peak pressure, and contact pressure data for each construct. Results: The augmented construct demonstrated significantly greater contact forces (average difference, 4.9 N) and significantly greater contact pressures (average difference, 23.1 kPa) at all degrees of abduction and all degrees of rotation. At 30° of internal and 30° of external rotation at both 0° and 30° of shoulder abduction, the augmented construct demonstrated significantly greater peak contact pressures. Conclusion: The augmented construct showed superior contact characteristics when compared with the classic TOE technique. The addition of lateral edge fixation to the classic TOE repair significantly improves bone-tendon contact characteristics with minimal additional surgical effort. Clinical Relevance: The results of this study indicate that lateral augmentation of the classic TOE repair produces a biomechanically superior construct that may optimize tendon healing.

Treatment of Large and Massive Rotator Cuff Tears: Does Infraspinatus Muscle Tear Affect Repair Integrity?

BackgroundClinical outcomes and prognosis of large and massive rotator cuff tears are known to be unpredictable not only in degeneration of the rotator cuff, but also due to a high rate of retear.MethodsTotally, 81 patients who had undergone arthroscopic rotator cuff repair from May 2008 to February 2016 were evaluated in our study. Clinical and functional evaluations were performed with the Constant score and the University of California, Los Angeles (UCLA) score, as well as full physical examination of the shoulder. All patients were confirmed to have magnetic resonance imaging (MRI) of tendon healing at least 1 year postoperatively.ResultsThe average age at the time of surgery was 65 years (range, 47–78 years). The average duration of postoperative time in which a follow-up MRI was performed was 36.1 months (range, 12–110 months). Large tears were present in 48 cases (59.3%) and massive tears in 33 cases (40.7%). Overall, there were 33 retear cases (40.7%). All the average clinical outcome scores were significantly improved at the last follow-up (p<0.001), although repair integrity was not maintained. Compared to type A, types C, and D of the Collin’s classification showed significantly higher retear rates (p=0.036).ConclusionsArthroscopic rotator cuff repair yields improved clinical outcomes and a relatively high degree of patient satisfaction, despite the repair integrity not being maintained. Involvement of the subscapularis muscle or infraspinatus muscle had no effect on the retear rate.

Clinical and Radiological Outcomes of Large and Massive Rotator Cuff Tears Treated With Arthroscopic Augmented Rotator Cuff Repairs Using Extracellular Matrix Patch: Minimum 1-Year Follow Up

Clinical and Radiological Outcomes of Large and Massive Rotator Cuff Tears Treated With Arthroscopic Augmented Rotator Cuff Repairs Using Extracellular Matrix Patch: Minimum 1-Year Follow Up

Réparation des ruptures larges de la coiffe des rotateurs avec renfort au fascia lata

Background Excellent clinical results of arthroscopic surgical repair have been reported for rotator cuff tears, however treatment of large and massive rotator cuff tears remains challenging. We have performed single row repairs with graft augmentation of fascia lata for large and massive rotator cuff tears in order to reduce a tension at the tendon-bone repair site for prevention from retear of the repaired rotator cuff. The purpose of this study was to evaluate clinical outcomes and rotator cuff integrity after arthroscopic rotator cuff repair (ARCR) with graft augmentation of the fascia lata. Material and methods Nineteen patients who underwent ARCR but unable to perform footprint fixation were included. These patients (14 males and 5 females), with an average age of 66.2 years old (range; 52–79 year old), were diagnosed with a large and massive rotator cuff tear. Single row repairs with footprint medialization were performed in 7 cases (SR group) and graft augmentation of fascia lata in addition to single row repairs were done in 12 cases (GA group). MRI was assessed at 6 and 12 months postoperatively and a retear was defined as discontinuity of the repaired supraspinatus tendon. Japanese Orthopaedic Association (JOA) score, UCLA score, and Constant score were assessed as clinical outcomes. Results MRI examinations revealed 6 retears out of 7 SR cases (re-tear rate: 85%) and 2 cases out of 12 GA cases (re-tear rate: 17%) at 6 months postoperatively. There was no additional retear at 12 months. JOA score, UCLA score, and Constant score in both groups significantly improved at the final follow-up, but there was no statistical difference between both groups on each score. The abduction strength significantly improved only in the GA group. Discussion In the present study, ARCR with graft augmentation of fascia lata for large and massive rotator cuff tears showed good clinical scores with a low retear rate and improvement of abduction strength. The low retear rate might be due to reduction of tension at the cuff repair site. Therefore, graft augmentation of fascia lata would be a useful option for large and massive rotator cuff tears.

Multiple Treatment Comparisons for Large and Massive Rotator Cuff Tears: A Network Meta-analysis.

There is no consensus about the best choice between all the options available for large and massive rotator cuff tear (mRCTs) management. To determine the comparative effectiveness of current treatment options for management of large and mRCTs. Network meta-analysis. We searched the Cochrane systematic reviews, MEDLINE and EMBASE databases for all trials of adults with large and mRCTs that report preoperative and postoperative functional scores after an intervention option. The network meta-analysis included 20 trials with 1233 patients with 37.24 months follow-up. Eight treatment options for management of large and mRCTs were compared. The primary effectiveness outcome was the functional score. This meta-analysis did not show statistically significant differences between conservative, partial repair, patch or platelet rich plasma (PRP) augmentation, reverse total shoulder arthroplasty, and complete repair. Latissimus dorsi (LD) transfer was ranked first for effectiveness [standardized mean difference (SMD): 2.17, 0.28-4.07] and debridement ranked last (SMD: -2.15, -3.13 to -1.17). Latissimus dorsi transfer seems to be most effective for management of large and mRCTs, although some heterogeneity was observed in this network meta-analysis of full text reports. The choice of the operating technique depends on the patient's general health status and his expectations. When a decision has been reached to perform surgery, a repair, even if partial, should be attempted. Procedures involving biologic augmentation (eg, PRP) seem to convey no additional benefit while introducing more risk. Debridement alone should be avoided.

Arthroscopic Side-to-side Repair for Large U-shaped Full-Thickness Rotator Cuff Tears: Is the Repair Integrity Actually Maintained?

To evaluate the clinical and structural outcomes of arthroscopic side-to-side repair of large U-shaped full-thickness rotator cuff tears (FTRCTs) by assessing the functional score of the patients and the integrity of the tendon repair using magnetic resonance imaging with a minimum follow-up duration of 2years. In this case series, 59 consecutive patients who underwent arthroscopic side-to-side repair of large U-shaped FTRCTs, with a minimum follow-up duration of 2years (range 25 to 72months), were retrospectively enrolled. The mean patient age was 58.6years. Patients' functional scores and integrity of the tendon repairs were evaluated. The mean visual analog scale score improved from 5.7 ± 2.1 preoperatively to 2.4 ± 1.3 postoperatively (P < .001). The mean range of motion (forward flexion) improved from 152.7° ± 11.4° to 164.5° ± 9.5° (P < .001). The mean Constant-Murley score improved from 57.3 ± 7.2 preoperatively to 77.8 ± 6.9 postoperatively (P < .001). Postoperative magnetic resonance imaging examinations demonstrated cuff integrity with a retear rate of 54.2%. The retear rate of patients who underwent anchor fixation to the medial row (45%) was significantly lower than that of patients who underwent simple side-to-side repair (73.7%) (P=.039). The University of California at Los Angeles shoulder rating and Constant-Murley scores were not significantly different between the healed and retear groups (P= .639 and P= .863, respectively). Arthroscopic side-to-side repair of large U-shaped FTRCTs demonstrated satisfactory clinical outcomes. However, the retear rate was higher than expected when simple side-to-side fixation was performed without footprint fixation. Therefore, medial row fixation is recommended if arthroscopic side-to-side repair is performed. III, comparative therapeutic trial.

Open Rotator Cuff Repair: Where Does it Stand Now?

Introduction:With recent improvements to arthroscopic techniques, surgery for rotator cuff tears (RCT) has shifted from open repair to all-arthroscopic repair. Although evidence has not supported improved outcomes with arthroscopic techniques over the open rotator cuff repair, but as expected the incidence of performing open rotator cuff repair decrease from 43.1 to 24.9% from the last decade (USA).1 The all-arthroscopic technique is preferable among shoulder surgeons and has been accepted as the gold standard for the repair of RCT because this approach is minimally invasive and causes less insult to the deltoid muscle, which are believed to reduce postoperative infection and favour rehabilitation. 2, 3 Despite the switch towards all-arthroscopic RCR, open repair is still performed with reliable clinical outcome. In some country setting, the main reason to favor open repair is because of the high cost – utility ratio in which arises from the consumables arthroscopic tools and implants. The second reason is massive retracted RCT or in the case for revision rotator cuff surgery in which non prosthetic arthroplasty is required. We investigated the merit of open versus arthroscopic RCR for large RCT by comparison of the clinical and radiological outcome with propensity matching score technique.Methods:The outcomes of 112 patients who were treated for large, full-thickness, RCT either by open repair or arthroscopic repair were retrospectively reviewed. All patients included in this study were followed-up for at least 18 months and were imaged at a minimum of 12 months after surgery. Propensity score matching was used to select for controls matched by age, sex, body mass index and affected site. The post-operative functional and radiologic outcomes were compared. Radiologic evaluations were performed using 3 T MRI for (1) post-operative rotator cuff integrity, (2) deltoid origin status and, (3) regional acromio-humeral distance which measured at 3 regions of interests of the lateral acromion border (anterior third, middle third and posterior third).Results:The range of motion, muscle strength and functional scores improved postoperatively for both groups. Open group showed higher constant (p=0.012) and ASES score (p=0.047). Arthroscopic group showed better forward elevation (p=0.006) and external rotation (p=0.004) with less postoperative pain compared to open group (p<0.001). Operative time and hospitalization stay were shorter in arthroscopic group (p=0.007 and p<0.001). Re-tear rate was higher in arthroscopic group (25%) than open group (17.9%) without statistical difference (p=0.300).The deltoid origin thickness was significantly greater in the arthroscopic group when measured at the anterior acromion as well as the anterior third and middle third of the lateral border of the acromion. There was no significant difference in deltoid origin thickness at the posterior third of the lateral acromion between groups. Deltoid integrity was significantly better with less scaring in the arthroscopic group. There was no full-thickness deltoid tear in either group.AHD was significantly greater in open group when measured at the anterior third of the lateral acromion border compare to arthroscopic group (p=0.005). Re-tear rate was affected by AHD at the anterior third of lateral border of acromion for arthroscopic and open group (p=0.021, p=0.029). Re-tear rate was affected by AHD at middle third of lateral border of acromion for open group (p=0.046).Conclusions:Open rotator cuff is still warranted at the present day. Both repair technique showed comparable outcome for large size RCT. Open repair has superior functional score with lower re-tear rate while arthroscopic repair has superior ROM improvement, pain relief, shorter operation and hospitalization time. Imaging confirmed that open repair of RCT resulted in less thickness of the deltoid origin, especially at the anterior acromion to the middle third of the lateral acromion border at 12 months after surgery. Careful re-attachment of the deltoid origin is essential for open repair of RCT. Open RCR showed greater AHD at the anterior third of the lateral border of acromion. Regional AHD measured at anterior third of the lateral border of acromion significantly associated with re-tear rate following both open and arthroscopic RCR. Nevertheless, regional AHD measured at middle third of the lateral border of acromion significantly associated only with re-tear rate following open RCR.References Day MA, Westermann RW, Bedard NA, et al. Trends Associated with Open Versus Arthroscopic Rotator Cuff Repair. HSS J 2019; 15: 133-136. 2019/07/23. DOI: 10.1007/s11420-018-9628-2.Snyder SJ. Evaluation and treatment of the rotator cuff. Orthop Clin North Am 1993; 24: 173-192. 1993/01/01.Gartsman GM, Khan M and Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator cuff. J Bone Joint Surg Am 1998; 80: 832-840. 1998/07/09.

Irreparable Massive Rotator Cuff Tear: How do I address

Despite advances in arthroscopic techniques and devices, symptomatic massive contracted rotator cuff tear is still a challenging to most shoulder surgeons. This rotator cuff tissue has all of the f...