Large Tears Research Articles

Intrasynovial autograft for reconstruction of chronic large rotator cuff tears in a rabbit model: biomechanical, computed tomography, and histological results

BackgroundRotator cuff (RC) tears are a common cause of shoulder dysfunction and pain, posing significant challenges for orthopedic surgeons. Grafts have been proposed as a solution to augment or bridge torn tendons, but optimal clinical outcomes are not always achieved due to poor graft integration, suboptimal mechanical properties, and immunological reactions. The aim of this study was to investigate the biomechanical, CT and histological results of RC reconstruction using an intrasynovial tendon autograft, in a chronic large tear subscapularis rabbit model.MethodsTwenty-six adult male Zealand white rabbits were used in this study. Large defects in the subscapularis tendons were produced bilaterally in 20 rabbits. After 6 weeks, secondary procedures were performed to the right shoulder of the rabbits, which were reconstructed with an intrasynovial interposition autograft (graft group). The left shoulder did not undergo any further treatment (defect group). The specimens were randomly divided into two equal time groups and underwent biomechanical testing, CT analysis, and histological evaluation at 6, and 12 weeks after reconstruction. In addition, 6 rabbits that were not operated, were used as a control group.ResultsAt 12 weeks post-repair, the graft group exhibited a significant increase in ultimate failure load compared to the defect group (p < 0.05). Furthermore, the 12-week graft group demonstrated comparable stiffness to that of the control group. CT analysis indicated no significant progression of intramuscular fat accumulation in both graft groups, in contrast to the 12-week defect group when compared to the control group. Finally, histological evaluation revealed a gradual integration of the graft with the host tissue at 12 weeks.ConclusionOur study suggests that intrasynovial flexor tendon autografts hold promise as an effective interposition graft for the reconstruction of chronic large RC tears, as they improve the biomechanical and biological properties of the repaired tendon. Nonetheless, further investigations in preclinical large animal models are warranted to validate and extrapolate these findings to human studies.

Current concepts in the aetiology, assessment and management of partial distal biceps tendon tears

Partial distal biceps tendon tears encompass a spectrum of disease. They can be either traumatic or degenerative in nature. Traumatic tears usually involve the short head. Degenerative tears can involve either or both short and long head components with the tear affecting the lateral fibres first. Chronic tears may be associated with a narrow radioulnar space, distinct head insertions and radial tuberosity hypertrophy. Patient history and clinical examination findings suggestive of partial tearing of the distal biceps tendon should be confirmed with advanced imaging. Magnetic resonance imaging allows assessment of the tear size, morphology and associated pathologies. Non-surgical management, including physiotherapy and injections, is appropriate in selected cases. Surgical management can involve either endoscopic or open techniques. In small tears or low demand patients, a simple debridement of the bursa, tuberosity and tendon may be indicated. In larger tears in higher functioning patients, release of the remaining fibres, debridement and an anatomical repair is indicated. In this review paper, the authors present current concepts on the pathogenesis and management of partial distal biceps tendon tears.

Dermal Allograft Augmentation for Large and Massive Rotator Cuff Tears and Revisions: A Case Series.

Introduction Arthroscopic advancements have notably improved rotator cuff repair, yet the healing of tendons and retear risks still pose significant challenges, especially with massive and large tears. These larger tears have shown a quadruple increase in retear rate when the tear size grows from 1-3 cm. The prevalent cause of failure, particularly in tears with fatty degeneration, is suture tearing.As such, techniques that enhance tendon healing are pivotal due to their correlation with improved functional outcomes. Dermal allograft augmentation (DAA) is one method that has demonstrated improvements in rotator cuff repair biomechanics, as well as the promotion of vascularization and neotendon formation. This study evaluates the efficacy of DAA in the postoperative healing of large and massive rotator cuff tears, assessed through patient-reported outcomes and functional range of motion. Methods This retrospective study reviewed a single surgeon's database, selecting patients who underwent arthroscopic surgery for full-thickness rotator cuff tears measuring at least 3 cm, or those with maximum stage II fatty infiltration of the supraspinatus or infraspinatus muscle on MRI. We used three validated patient-reported outcome (PRO) measures, American Shoulder and Elbow Surgeon Score (ASES), Single Assessment Numeric Evaluation (SANE), and Simple Shoulder Test (SST), alongside a range of motion metrics, external rotation (ER), and forward flexion (FF). These were recorded pre-operatively and, at minimum, one year post-operatively, with a standard student t-test employed for comparative analysis. Results Out of 18 total patients, the average age was 61 years, and 83% were male. The cause of injury was mostly traumatic in nature (n=11), with the remainder being chronic (n=7). All three PROs (n=11) demonstrated a statistically significant increase in score including ASES (p=0.003), SANE (p=0.004), and SST (p=0.039). External rotation also significantly improved pre- to post-operative function (46 vs 58, p=0.049).Three patients (17%) suffered from a retear within three months of their rotator cuff repair. Two patients (11%) required a reverse shoulder arthroplasty within a year. Conclusion Our study demonstrated that DAA in rotator cuff repair yielded notable functional and clinical advancements, with a moderately low retear rate as confirmed by ultrasound. These outcomes suggest that DAA is a promising intervention for large and historically difficult rotator cuff tears, offering significant implications for future treatment protocols.

Semi–Bone Tunnel Technique Using Double-Row Suture Bridge Combined With Platelet-Rich Plasma Hydrogel for Rotator Cuff Repair in a Rabbit Model

Background: The approach to managing the footprint area and reconstructing the tendon-bone interface (TBI) is critical for optimal healing. Purpose: To evaluate the outcomes of the semi–bone tunnel (SBT) technique using a double-row suture bridge combined with platelet-rich plasma (PRP) hydrogel for rotator cuff repair in a rabbit model. Study Design: Controlled laboratory study. Methods: A total of 48 New Zealand White rabbits were divided into 4 groups. The supraspinatus tendons were severed at the footprint to create a rotator cuff tear model in the surgical groups. Rabbits were treated with the traditional onto-surface repair (control group), SBT technique (SBT group), and SBT technique combined with PRP hydrogel implantation (SBT+PRP group). The rabbits without surgery were the normal group. At 8 weeks after surgery, macroscopic observation, magnetic resonance imaging (MRI) and micro–computed tomography (μCT) examinations, histological evaluations, and biomechanical tests were performed to assess the curative effects of the given treatments. Results: The MRI results showed that the repaired supraspinatus tendon presented a uniform signal, minimal inflammatory response, and the lowest signal-to-noise quotient value in the SBT+PRP group. The μCT results suggested that the SBT technique did not reduce the local bone mineral density in the TBI area compared with the onto-surface repair technique. The histological staining results showed that the regenerated TBI in the SBT+PRP group had a 4-layer structure similar to the natural tissue. The highest values for biomechanical properties were observed in the SBT+PRP group, and there was no significant difference between the SBT+PRP group and normal group. Conclusion: The SBT technique presented a better tendon-bone healing effect for rotator cuff tear in the rabbit model compared with the traditional onto-surface repair technique. The specimens in the SBT+PRP group had a similar TBI structure and biomechanical properties to the natural tissue. Clinical Relevance: The SBT technique can be an alternative surgical approach for rotator cuff repair, especially for moderate to large tears and cases requiring scaffold implantation.

Preoperative factors associated with 180°, 270°, and 360° labral tears

BackgroundLarge, circumferential glenoid labral tears are an uncommon injury affecting young, athletic patients. There is limited data describing the clinical presentation of patients with larger tears, especially 270- and 360-degree labral tears. Additionally, exam and imaging findings have poor reliability in diagnosing these tears. The purpose of this study is to determine the clinical presentation among patients presenting with small (less than 180 degrees), medium (180-270 degrees), and large (270-360 degrees) labral tears. MethodsThis is a retrospective comparative study of consecutive patients surgically managed by a single shoulder surgeon for all glenoid labral tears from 2018-2022. The primary outcome was demographic and preoperative clinical risk factors. Demographic data including age, sex, hand dominance, BMI, as well as clinical presentation (subluxation vs dislocation, instability history, and participation in contact sports) were recorded. ResultsA total of 188 patients met inclusion criteria: 101/188 (53.70%) patients with small tears, 43/188 (22.90%) patients with medium tears, and 44/188 (23.40%) patients with large tears. Individuals with large and medium-sized labral tears were more likely to have participated in contact sports compared to those with smaller labral tears (p=0.003). Medium and smaller tears were more likely to present as dominant side injury (p=0.02). Furthermore, medium and large tears were more likely to present with anterior instability symptoms compared to smaller tears, which more frequently presented with posterior instability and pain (p=0.003). ConclusionMales participating in contact sports were the most common demographic population presenting with large, 270 to 360-degree labral tears. Instability was the primary complaint rather than pain, and compared to small tears, medium and large sized tears were more likely to present with primary anterior instability. While arthroscopic repair of 270 to 360-degree labral tears can yield excellent clinical outcomes similar to smaller tears, identifying factors associated with larger glenoid labral tears may help in surgical planning and patient counseling.

Arthroscopic repair of large and massive rotator cuff tears-"sandwich augmentation" with the long head of the biceps tendon: a technical note.

For most shoulder surgeons, addressing massive rotator cuff tears that have retracted ends poses a significant challenge. This study introduces a technique, termed the "sandwich augmentation technique," which incorporates the long head of the biceps tendon (LHBT) into a single-row rotator cuff repair. The procedure, performed arthroscopically with the patient in the lateral decubitus position, involves attaching the LHBT and rotator cuff tissues together to the greater tuberosity. This effectively sandwiches them within the rotator cuff footprint. The goal of this technique is to enhance the thickness of the fully interposed cuff margin, thereby providing better support for the repair. The sandwich augmentation technique, which integrates the biceps into the rotator cuff repair, has demonstrated positive clinical outcomes and moderate anatomical results. It also prevents superior migration of the humeral head in cases of large or massive rotator cuff tears. Further research is required to assess the long-term effectiveness of this procedure.

When is a Reverse Shoulder Arthroplasty Indicated for a Rotator Cuff Tear?

Rotator cuff tears are the most frequent shoulder injury in patients over 50 years old. Treatment of rotator cuff tears is individualized based on the age, demands, and symptoms of the patient. Nonoperative treatment may often be effective, especially in lower-demand or elderly patients. Surgical repair is indicated after failure of nonoperative treatment or in patients whose high-demand lifestyle requires full strength and function of the shoulder. In older patients, larger tears are less likely to heal and rotator cuff repair may not reliable. In cases of failed previous rotator cuff repair, there may not be enough viable tissue for complete repair. If there is underlying arthritis, a rotator cuff repair is unlikely to resolve all symptoms, and treatment to care for the arthritis and rotator cuff tear is indicated. Reverse shoulder arthroplasty provides the surgical answer for these scenarios and is now being used for numerous indications of shoulder pathology.

Role of tear size and tendon degeneration for development of pain in rat models of rotator cuff tear

BackgroundRotator cuff tear (RCT) is a frequent etiology of shoulder pain and disability; however, the triggers for the onset and aggravation of pain remain obscure. In this study, we established novel rat RCT models to examine the impact of tear size and tendon degeneration on pain. MethodsFifty-five adult male Sprague-Dawley rats were allocated into 4 study groups: large tear (L group, n=10); small tear (S group, n=15); small tear with scratching (S+ group n=15); sham surgery (sham group, n=15). Pain-related behaviors were evaluated by weight distribution of forelimbs during a 5-minute free gait using a dynamic weight-bearing apparatus at 2, 4, 6 and 8 weeks. Calcitonin gene-related peptide (CGRP) expressions in ipsilateral dorsal root ganglion (DRG) neurons of C4/5/6 were evaluated at 4 and 8 weeks. The area of scar tissues around the torn tendon, infiltration of inflammatory cells, and severity of tendon degeneration (modified Bonar score) were histologically assessed at 4 and 8 weeks. Additionally, enzyme-linked immunosorbent assay (ELISA) was conducted to evaluate the levels of cyclooxygenase-2 (COX-2) and nerve growth factor (NGF) expression in torn tendons and surrounding tissues at 4 weeks. ResultsThe weight distribution ratio (ipsilateral /contralateral side) was significantly decreased in the L and S+ group compared with its baseline and sham group (P<0.05), but the S group showed no significant difference compared with the Sham. The ratio of CGRP-immunoreactive neurons in the DRGs was significantly higher in the L and S+ groups than in the S and sham groups. The histological assessment indicated that scar tissue formation was more extensive in the L group than in the S and S+ groups. Still, there was no significant difference between the S and S+ groups. The Modified Bonar Score was considerably higher in the S+ group than in the S group. Furthermore, ELISA analysis demonstrated no significant disparity in COX-2 levels between the groups; however, NGF levels were substantially higher in the S+ group than in the S and sham groups. ConclusionThe present study provides compelling evidence that large RCT is strongly associated with heightened pain severity in a rat mode. Nevertheless, even a small tear can significantly aggravate pain when the torn tendon is degenerated. CGRP upregulation driven by peripheral NGF possibly played a pivotal role in the genesis and exacerbation of pain in small RCT.

Clinical Outcomes and Tendon Healing After Arthroscopic Isolated Subscapularis Tendon Repair: Results at Midterm Follow-up.

Few studies have reported clinical outcomes and tendon healing rates after arthroscopic isolated subscapularis (SSC) repair (AISR). The primary purpose of this study was to evaluate clinical outcomes and tendon healing after AISR. It was hypothesized that AISR would result in satisfactory clinical outcomes along with a high rate of tendon healing at the midterm follow-up. The secondary purpose was to assess the influence of tear size and muscle atrophy on SSC tendon healing and patient-reported outcomes. It was hypothesized that both would be negatively correlated with healing but would have no effect on clinical outcomes . Case series; Level of evidence, 4. A retrospective analysis was conducted on prospectively collected data for 77 patients who underwent primary AISR between 2011 and 2021 at a single institution, with a minimum 2-year postoperative follow-up for all patients. Functional outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, the Subjective Shoulder Value (SSV), and the visual analog scale for pain. Repair techniques and concomitant procedures were also collected. SSC tendon healing was evaluated via ultrasound at the final follow-up. Linear regression analysis was performed to determine factors affecting SSC healing. The mean follow-up was 58.1 ± 3.3 months. ASES scores significantly improved from 41.5 to 81.6, and the SSV improved from 38.2 to 80.5 (P < .01 for both). Among the 40 patients (51.9%) who underwent postoperative ultrasound, 87.5% showed complete tendon healing. There were no significant differences in outcome scores between healed and unhealed tendons. Increased muscle atrophy and larger tears were correlated with failure of SSC healing (β = -0.285 [P = .015] and β = -0.157 [P = .045], respectively). Improved clinical outcomes and an overall high rate of tendon healing were seen at the midterm follow-up after AISR. Smaller tear sizes with less muscle atrophy were correlated with improved tendon healing. However, even when the tendon incompletely healed, the procedure improved functional outcomes.

Does subscapularis tears combined with supraspinatus tears affect postoperative functional outcomes?

Aims: Roughly 50% of rotator cuff tears includes a tear in the subscapularis tendon. We conducted a comparative analysis of the functional outcomes following arthroscopic repair in patients with a tear in both the supraspinatus and subscapularis tendons, as well as those with a rupture solely in the supraspinatus tendon. Our hypothesis posits that the functional outcomes after surgery for rotator cuff tears, specifically those with tears including subscapularis tendon, are inferior compared to tears that only involve the supraspinatus tendon. Methods: We classified patients who had arthroscopic repair for a rotator cuff tear in our clinic from January 2017 to April 2022 into two groups. The study comprised patients who received arthroscopic surgery for a diagnosed rotator cuff injury. The study excluded individuals who were younger than 18, individuals with large tears that could not be repaired, individuals with paralabral cysts, individuals with glenohumeral arthritis, individuals who had undergone labrum tear repair or slap lesion repair, individuals with concomitant neurovascular damage, and individuals who had a follow-up period of less than 6 months, patients who benefit from physiotherapy and medical treatment for 6 months. Following the application of exclusion criteria, a total of 39 patients were selected to participate in the study. The presence of a rotator cuff injury was verified through arthroscopy after being detected using clinical tests such as Jobe, drop arm test, Neer sign, lift-off and belly-press tests, and radiographic evidence such as magnetic resonance imaging. Patients who received subscapularis repair together with a supraspinatus tear were categorised as Group 1 (n=14), while those who just had supraspinatus surgery without any subscapularis tears were categorized as Group 2 (n=25). We recorded the demographic information. At the last postoperative outpatient clinic follow-up, both groups were compared in terms of mortality, laboratory parameters, radiological findings, visual analogue scale (VAS), Constant-Murley score1, American Shoulder and Elbow Surgeons score (ASES)2, and University of California Los Angeles (UCLA) scores.3 Postoperative satisfaction levels were categorised into four groups: very satisfied, satisfied, undecided, and dissatisfied. Results: The groups did not show any significant differences in terms of age, gender distribution, and follow-up periods (p&amp;gt;0.05). There was no statistically significant disparity observed between the groups in relation to VAS, Constant-Murley score, ASES, and UCLA ratings assessed during the final postoperative outpatient clinic follow-up (p&amp;gt;0.05). There were no instances of re-rupture observed in any patient throughout the postoperative follow-up period. The postoperative satisfaction ratings show no significant difference between the two groups (p&amp;gt;0.05). Conclusion: Our findings indicate that the outcomes of patients who received a surgical repair of rotator cuff tendons including subscapularis were at least as successful as those who underwent surgery for just supraspinatus tendon rupture. There is no basis to believe that arthroscopic repair will have a detrimental impact on the functional outcomes of individuals with rotator cuff tears which includes subscapularis tendon tears.

Repair of chronic and large rotator cuff tears using extra-synovial autografts: An experimental study in rabbits.

To investigate whether and how extra-synovial autografts can enhance the reconstruction of chronic and large rotator cuff tears in a rabbit subscapularis model. Twenty rabbits were used to create a large subscapularis tear bilaterally. Six weeks later, the right shoulder of each rabbit was operated to repair the tear with an extra-synovial autograft, whereas the left shoulder did not undergo any surgery. At 6 and 12 weeks after the second procedure, the specimens underwent biomechanical and histological evaluation. Six more rabbits were used only as a normal reference. Biomechanical evaluation demonstrated that the ultimate load to failure of the Graft group (184.1 ± 35.7 N) was significantly higher (p = 0.04) than that of the Defect group (144.5 ± 32.2 N) at 12 weeks after repair, rising to 76% of the normal subscapularis tendon tensile strength. Histological analysis revealed an enhanced healing environment with neoangiogenesis and decreased inflammatory response at the repair site. Moreover, the tendon maturing score of the Graft group increased substantially from 6 (15.8 ± 0.9) to 12 (23.1 ± 0.6) weeks after repair (p = 0.01). In vivo data support the efficacy of extra-synovial autograft interposition in repairing chronic and large rotator cuff tears in a rabbit subscapularis model. The autografts were capable of enhancing the biomechanical properties of the repaired tendons, as evidenced by increased tensile strength, and forming new connective tissue simulating a fibrocartilage zone, as revealed by histological evaluation. N/A.

Lower Trapezius Tendon Transfer With Achilles Tendon Allograft: A Technique Video

Background: While small to medium rotator cuff tears demonstrate good outcomes with primary repair, large, irreparable cuff tears pose a significant clinical challenge with high re-tear rates and lower patient satisfaction. Tendon transfers are procedures that can restore motion and strength in the shoulder in the case of irreparable rotator cuff tears. Trapezius tendon transfers are suitable for large posterosuperior cuff tears as the lower trapezius has a vector of pull similar to that of the infraspinatus. Indications: Lower trapezius tendon transfers are indicated for young and active patients with irreparable posterior and posterosuperior rotator cuff tears causing significant weakness and loss of external rotation. Contraindications to the procedure include advanced osteoarthritis of the glenohumeral joint, advanced age, and deficiency of the subscapularis, deltoid, or trapezius muscles. Technique Description: Using a scapular incision, the trapezius muscle body and tendon are dissected from the scapular spine and mobilized. The plane of the infraspinatus into the glenohumeral joint is tunneled using blunt dissection, and the prepared allograft is passed through under arthroscopic visualization. The allograft insertion is stabilized with 3 knotless anchors and reinforced using medial row sutures from a concomitant supraspinatus repair. The proximal graft origin is fixed to the trapezius tendon using a Pulvertaft weave morphology to reconstruct the muscle-tendon unit. Results: Outcomes data from the literature demonstrate improvement in symptoms and patient satisfaction following the procedure. In a retrospective analysis of 41 patients, Elhassan et al demonstrated that 90% of patients experienced significant improvement in visual analog scale (VAS), Subjective Shoulder Value (SSV), and Disabilities of the Arm, Shoulder, and Hand (DASH) score at mean follow-up time of 14 months. Discussion/Conclusion: In appropriately indicated patients, the lower trapezius tendon transfer offers restoration of external rotation strength and range of motion, pain relief, low risk of complications, and reduced risk of revision compared with alternative procedures. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Tulip-bundle technique for suture dehiscence in a Boerhaave syndrome.

A 55-year-old-woman was admitted to the emergency department with hematemesis and abdominal pain. Her physical examination was unremarkable. Laboratory results without anemia. The upper gastrointestinal endoscopy revealed a deep large tear between 36 and 39 cm with transmural perforation. A diagnosis of Boerhaave syndrome was made. Thoraco-abdominal CT-scan revealed a laceration in the left posterolateral side of the esophagus, measuring 6.5 cm proximal to the esophagogastric junction (GEJ), associated with a pneumomediastinum, pneumoperitoneum and a mediastinal air fluid collection anteriorly to the GEJ. The patient was submitted to laparoscopic surgery with closure of the perforation, Graham patch confection. Nine days after, the esophago-gastric transit showed luminal contrast leakage to the posterior mediastinum. An endoscopic evaluation showed a 2 cm suture dehiscence. We applied a hemostatic clip in the distal end of the tear to bring the edges closer, but it was impossible to put additional ones. It was decided to perform a tulip-bundle technique with a single-channel endoscope in a sequential two-step maneuver and another two clips were placed in the borders of the tear with an endoloop applied over the clips with success. One month later, an endoscopic revaluation was performed, revealing the clips involved by the endoloop and no signs of leakage. After that, she started oral diet without any complications.

Anatomic factors associated with degeneration and fraying of the coracoacromial ligament.

The coracoacromial ligament (CAL) is frequently observed to be damaged during arthroscopy and it is unclear how demographic, anatomic, and radiographic factors are related to CAL degeneration in full-thickness rotator cuff tears. A prospective study was conducted of patients at a single institution undergoing shoulder arthroscopy for first-time, full-thickness rotator cuff tears. We evaluated preoperative anteroposterior radiographs to obtain critical shoulder angle, glenoid inclination, acromial index, acromiohumeral distance, lateral acromial angle, and acromial morphology. We documented CAL quality, rotator cuff tear size and pattern during arthroscopy. Multiple logistic regression was used to identify predictive factors for encountering severe CAL fraying during arthroscopy. Shoulders had mild CAL degeneration in 58.1% of cases, whereas severe CAL degeneration was present in 41.9% of shoulders. Patients with severe CAL attrition were significantly older (62.0 years vs. 58.0 years, P=0.042). Shoulders with severe CAL attrition had large rotator cuff tears in 54.1% of cases (P<0.001), and tears involving the infraspinatus (63.2% vs. 29.6%, P=0.003). The severe degeneration group was more likely to have a larger critical shoulder angle measurement on preoperative radiographs than those in the mild attrition group (36.1°±3.6° [range, 30°-45°] vs. 34.1°±3.8° [range, 26°-45°], P=0.037). While the clinical impact of CAL degeneration remains uncertain, increased severity of CAL degeneration is associated with older age, larger rotator cuff tear size, presence of infraspinatus tearing, and increased preoperative critical shoulder angle. Level of evidence: III.

Peroneal tendon injuries

The peroneal tendons work to both evert the foot and stabilize the hindfoot on plantarflexion and push off. The tendons are frequently injured as part of sprains and soft tissue injuries to the ankle joint, but diagnosis and treatment are often delayed. Athletes participating in activities with repetitive ankle motion, particularly those involving cutting and twisting movements, as well as those with certain anatomical features, are prone to peroneal tendon injury. Often synovitis and low-grade tendinopathy of the peroneal tendons can be managed with physiotherapy and bracing. Large longitudinal tears, rupture, and subluxation or dislocation of the tendons from the retromalleolar groove are more likely to be treated operatively, although pre-surgical rehabilitation will still be useful in chronic cases. Other surgical procedures can be combined as part of an effective treatment plan such as ankle arthroscopy, ligament stabilization and realignment procedures such as a lateralizing calcaneal osteotomy and Barouk–Rippstein–Toullec first metatarsal elevation osteotomy for non-neurogenic cavus. Persistent weakness in the peroneal tendons post injury may contribute to worsening hindfoot varus deformity: in turn, this leads to further stress on peroneus brevis which can lead to its rupture and consequently further deformity if untreated.

Relationship between the preoperative grip strength and postoperative shoulder strength of patients treated via reverse shoulder arthroplasty.

Systemic disorders including diabetes mellitus, obesity, and depression affect the outcomes of reverse shoulder arthroplasty (RSA). Sarcopenia (a general skeletal muscle disorder) is common in elderly people, but its effect on patients after RSA is not clear. We hypothesized that the preoperative sarcopenia indices of grip strength and general skeletal muscle mass would correlate with the clinical outcomes of RSA. Grip strength and general skeletal muscle mass were measured in patients scheduled (between 2016 and 2021) for primary RSA to treat cuff tear arthropathy, an unrepairable cuff tear, or osteoarthritis with a large cuff tear. Before surgery, grip strength was measured using a hydraulic dynamometer and general skeletal muscle mass was calculated from the appendicular relative skeletal muscle mass index (aRSMI) using dual-energy X-ray absorptiometry. In all, 58 patients were included; the minimal follow-up duration was 12months. The postoperative clinical results (pain, active range of motion, shoulder strength, and functional scores) were evaluated during scheduled outpatient visits. We calculated correlations between the preoperative sarcopenia indices, and the clinical results at the final follow-up. The mean preoperative grip strength and aRSMI were 21.6±4.0kg and 5.98±0.84kg/m2 in females and 30.6±7.5kg and 7.21±0.94kg/m2 in males, respectively; the grip strength and aRSMI were not associated with each other (P=.083). Ten females (25%) and 10 males (56%) met the criteria for sarcopenia. The postoperative abduction shoulder strength and Constant-Murley shoulder score increased significantly with higher preoperative grip strength (R=0.420 and P=.001; and R=0.497 and P<.001, respectively) and the American Shoulder and Elbow Surgeons score was related to the preoperative aRSMI (R=0.320, P=.039). The shoulder strength and functional score after RSA correlated positively with the preoperative grip strength. Measuring grip strength before RSA allows the surgeon to predict shoulder strength after RSA.

Polarized macrophages regulate fibro/adipogenic progenitor (FAP) adipogenesis through exosomes

BackgroundMacrophage polarization has been observed in the process of muscle injuries including rotator cuff (RC) muscle atrophy and fatty infiltration after large tendon tears. In our previous study, we showed that fibrogenesis and white adipogenesis of muscle residential fibro/adipogenic progenitors (FAPs) cause fibrosis and fatty infiltration and that brown/beige adipogenesis of FAPs promotes rotator cuff muscle regeneration. However, how polarized macrophages and their exosomes regulate FAP differentiation remains unknown.MethodsWe cultured FAPs with M0, M1, and M2 macrophages or 2 × 109 exosomes derived from M0, M1 and M2 with and without GW4869, an exosome inhibitor. In vivo, M0, M1, and M2 macrophages were transplanted or purified macrophage exosomes (M0, M1, M2) were injected into supraspinatus muscle (SS) after massive tendon tears in mice (n = 6). SS were harvested at six weeks after surgery to evaluate the level of muscle atrophy and fatty infiltration.ResultsOur results showed that M2 rather than M0 or M1 macrophages stimulates brown/beige fat differentiation of FAPs. However, the effect of GW4869, the exosome inhibitor, diminished this effect. M2 exosomes also promoted FAP Beige differentiation in vitro. The transplantation of M2 macrophages reduced supraspinatus muscle atrophy and fatty infiltration. In vivo injections of M2 exosomes significantly reduced muscle atrophy and fatty infiltration in supraspinatus muscle.ConclusionResults from our study demonstrated that polarized macrophages directly regulated FAP differentiation through their exosomes and M2 macrophage-derived exosomes may serve as a novel treatment option for RC muscle atrophy and fatty infiltration.

Arthroscopic Repair of Retracted Large and Massive Rotator Cuff Tears With and Without Augmentation With a Bio-Inductive Collagen Implant Reveals Substantial and Comparable Clinical Improvement

PurposeThe study objective was to compare clinical and imaging results following repair of retracted large and massive full thickness rotator cuff tears, including revision repairs, with and without augmentation with a bio-inductive collagen implant. MethodsThe study group comprised 24 patients (17 males) with retracted 2-3 tendon rotator cuff tears undergoing arthroscopic repair followed by on-lay augmentation with a bio-inductive collagen implant. The control group comprised 24 patients (19 males) matched by tear size undergoing repair without augmentation. Mean patient age at repair in both groups was 61 years. Active range of motion (ROM) and patient-reported outcomes (PROs) were recorded pre- and post-operatively. Non-contrast high-field MRI was obtained in 20/24 collagen implant patients and 17/24 control patients at minimum 6 months follow-up to assess tendon healing. ResultsASES scores and SST improved from 35 to 86 and 3.6 to 9.3, respectively, in the collagen implant group and from 39 to 87 and 3.9 to 9.7 in the control group. VAS-pain improved from 6.0 to 0.9 and from 5.9 to 0.9 in the collagen implant and control groups, respectively (p<0.001 for all). Overall improvements in ROM and PROs were similar in both groups. MRI revealed intact repairs in 11/20 (55%) patients in the patch group and 9/17 (53%) in the control group. Two patients in each group were revised to reverse shoulder arthroplasty. ConclusionsArthroscopic repair of retracted large and massive rotator cuff tears, including revision repairs, with and without augmentation using a bio-inductive collagen implant results in substantial and comparable early clinical improvement, although predictable healing remains elusive. Further work is needed to optimize patient selection for massive rotator cuff repair and define more precisely the indications for augmentation of these repairs using the collagen implant.

Different types of rotator cuff tear morphology do not affect post-repair clinical outcomes in large to massive tears

ObjectivesThe primary aim of this current study is to evaluate the effects of rotator cuff tear morphology on clinical outcomes in large to massive tears, using a modified version of the existing classification system, with specific focus on tear symmetry and use of margin convergence. MethodsPatients who underwent arthroscopic repair of large to massive, full thickness rotator cuff tears were retrospectively analysed. The tear pattern was classified at the time of surgery as Type IA, Type IB, Type IIA, and Type IIB according to tear symmetry and direction of maximum tear diameter, with Type I being symmetrical and Type II being asymmetrical. Type IA (U-shaped) had greater mediolateral (ML) than anteroposterior (AP) diameter while Type IB (crescent shaped) had greater AP than ML diameter. Type IIA tears have an anterior extension towards the rotator interval while IIB tears have a posterior extension into the infraspinatus, similar to AP L-shaped tears established in the literature. Type I tears were typically repaired from medial to lateral while Type II tears were repaired diagonally. All types were repaired using double row technique, with the addition of margin convergence for Types IA and IIB, which had larger tears in the medial and lateral directions. Primary outcome measures were Oxford Shoulder Score, Constant Shoulder Score, University of California at Los Angeles Shoulder Score followed-up at 6, 12, and 24-months as well as retear rates at latest follow-up. ResultsIn total, 109 patients were included in the study with a mean age of 65.5 ​± ​9.4. The prevalence of each tear morphologies from Type IA to IIB was 22.0 ​%, 34.9 ​%, 27.5 ​%, and 15.6 ​%, respectively. All four groups showed statistically significant improvement from pre-operative scores in all 3 outcome measures at 24 months (p ​< ​0.001 for all). No significant difference in primary outcome measures or retear rates was detected between all 4 groups. ConclusionThis study found that different types of cuff tear morphology, despite affecting surgical repair technique, does not influence clinical outcomes post-arthroscopic rotator cuff repair at mid-term follow-up. Level of evidenceRetrospective Cohort study, Level III.

Hybrid Repair of a Medial Meniscus Mid-Body Radial Tear

Background: Meniscal radial tears are associated with altered contact mechanics, as they have the potential to disrupt the meniscal hoop stress mechanism. In prior studies, radial tears are associated with higher grade of cartilage damage, as well as higher rate and severity of meniscal extrusion in knees with a radial tear relative to other types of tears. Improved understanding of the meniscus biological potential together with modern developments in surgical technique has paved the way for the current emphasis on repairing even radial tears. Indication: Large or complete radial tears of the meniscus without prohibitive joint space narrowing or severe cartilage damage. Technique Description: A hybrid technique of meniscal radial repair is described, combining (1) 2 transtibial pullout cinch-loop sutures, (2) 2 inside-out vertical rip-stop sutures and 2 oblique sutures in a “cross-tag” configuration, and (3) 1 horizontal mattress all-inside suture. The repair is biologically augmented with a notch marrow-venting procedure. Results: Recent evidence has demonstrated significant biomechanical benefit in terms of increased load to failure and construct strength when adding transtibial tunnel augmentation to radial repairs. In addition, rip-stop sutures decrease the chance of cut-out relative to nonreinforced repairs. Those biomechanical advancements are reflected in excellent patient-reported outcomes as well as healing rates following radial repair. Discussion/Conclusion: We present a hybrid technique encompassing the most biomechanically effective novel radial repair techniques, backed by excellent clinical outcomes following radial repair in the current literature. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.