Management Of Rotator Cuff Tears Research Articles

Currently Available Large Language Models Do Not Provide Musculoskeletal Treatment Recommendations That are Concordant With Evidence-Based Clinical Practice Guidelines

PurposeTo determine whether leading, commercially-available LLMs provide treatment recommendations concordant with evidenced-based clinical practice guidelines (CPGs) developed by the American Academy of Orthopedic Surgeons (AAOS). MethodsAll CPGs concerning the management of rotator cuff tears(n=33) and anterior cruciate ligament (ACL) injuries(n=15) were extracted from the AAOS. Treatment recommendations from Chat-generative pretrained transformer version-4 [ChatGPT-4; OpenAI], Gemini (Google), Mistral-7B (Mistral AI), and Claude-3 (Anthropic) were graded by two blinded physicians as being “concordant,” “discordant,” or “indeterminate” (i.e., neutral response without definitive recommendation) with respect to AAOS CPGs. The overall concordance between LLM and AAOS recommendations were quantified, while the comparative overall concordance of recommendations amongst the four LLMs was evaluated through the Fischer’s-exact test. ResultsOverall 135(70.3%) responses were concordant, 43(22.4%) indeterminate, and 14(7.3%) discordant. Inter-rater reliability for concordance classification was excellent (Kappa=0.92). Concordance with AAOS CPGs was most frequently observed with ChatGPT-4 (n=38, 79.2%), and least frequently with Mistral-7B (n=28,58.3%). Indeterminate recommendations were most frequently observed with Mistral-7B (n=17,35.4%) and least frequently with Claude-3 (n=8, 6.7%). Discordant recommendations were most frequently observed with Gemini (n=6,12.5%) and least frequently with ChatGPT-4 (n=1,2.1%). Overall, no statistically significant differences in concordant recommendations was observed across LLMs (p=0.12). Only 20 (10.4%) of all recommendations were transparent and provided references with full bibliographic details or links to specific peer-reviewed content to support recommendations. ConclusionAmong leading commercially-available LLMs, more than one-in-four recommendations concerning the evaluation and management of rotator cuff and ACL injuries do not reflect current evidenced-based CPGs. Although ChatGPT-4 demonstrated the highest performance, clinically significant rates of recommendations without concordance or supporting evidence were observed. Only 10% of responses by LLMs were transparent, precluding users from fully interpreting the sources from which recommendations were provided. Clinical RelevanceWhile leading LLMs generally provide recommendations concordant with CPGs, a substantial error-rate exists, and the proportion of recommendations that do not align with these CPGs suggest that LLMs are not trustworthy clinical support tools at this time. Each off-the-shelf, closed-source LLM has strengths and weaknesses. Future research should evaluate and compare multiple LLMs to avoid bias associated with narrow evaluation of few models as observed in current literature.

Machine-learning models for diagnosis of rotator cuff tears in osteoporosis patients based on anteroposterior X-rays of the shoulder joint

ObjectiveThis study aims to diagnose Rotator Cuff Tears (RCT) and classify the severity of RCT in patients with Osteoporosis (OP) through the analysis of shoulder joint anteroposterior (AP) X-ray-based localized proximal humeral bone mineral density (BMD) measurements and clinical information based on machine learning (ML) models. MethodsA retrospective cohort of 89 patients was analyzed, including 63 with both OP and RCT (OPRCT) and 26 with OP only. The study analyzed a series of shoulder radiographs from April 2021 to April 2023. Grayscale values were measured after plotting ROIs based on AP X-rays of shoulder joint. Five kinds of ML models were developed and compared based on their performance in predicting the occurrence and severity of RCT from ROIs' greyscale values and clinical information (age, gender, advantage side, lumbar BMD, and acromion morphology (AM)). Further analysis using SHAP values illustrated the significant impact of selected features on model predictions. ResultsR1-6 had a positive correlation with BMD respectively. The nine variables, including greyscale R1-6, age, BMD, and AM, were used in the prediction models. The RF model was determined to be superior in effectively diagnosing RCT in OP patients, with high AUC scores of 0.998, 0.889, and 0.95 in the training, validation, and testing sets, respectively. SHAP values revealed that the most influential factors on the diagnostic outcomes were the grayscale values of all cancellous bones in ROIs. A column-line graph prediction model based on nine variables was constructed, and DCA curves indicated that RCT prediction in OP patients was favored based on this model. Furthermore, the RF model was also the most superior in predicting the types of RCT within the OPRCT group, with an accuracy of 86.364% and 73.684% in the training and test sets, respectively. SHAP values indicated that the most significant factor affecting the predictive outcomes was the AM, followed by the grayscale values of the greater tubercle, among others. ConclusionsML models, particularly the RF algorithm, show significant promise in diagnosing RCT occurrence and severity in OP patients using conventional shoulder X-rays based on the nine variables. This method presents a cost-effective, accessible, and non-invasive diagnostic strategy that has the potential to substantially enhance the early detection and management of RCT in OP patient population.

Operative Management of Rotator Cuff Tears: Identifying Disparities in Access on a National Level.

The purpose of this study was to identify nationwide disparities in the rates of operative management of rotator cuff tears based on race, ethnicity, insurance type, and socioeconomic status. Patients diagnosed with a full or partial rotator cuff tear from 2006-2014 were identified in the Healthcare Cost and Utilization Project's National Inpatient Sample database using International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes. Bivariate analysis using chi-square tests and adjusted, multivariable logistic regression models were used to evaluate differences in the rates of operative versus non-operative management for rotator cuff tears. This study included 46,167 patients. When compared with white patients, adjusted analysis showed that minority race and ethnicity were associated with lower rates of operative management for Black [adjusted odds ratio (AOR): 0.31, 95% confidence interval (CI): 0.29-0.33; p < 0.001], Hispanic [AOR: 0.49, 95% CI: 0.45-0.52; p < 0.001], Asian or Pacific Islander [AOR: 0.72, 95% CI: 0.61-0.84; p < 0.001], and Native American patients [AOR: 0.65, 95% CI: 0.50-0.86; p = 0.002]. In comparison to privately insured patients, our analysis also found that self-payers [AOR: 0.08, 95% CI: 0.07-0.10; p < 0.001], Medicare beneficiaries [AOR: 0.76, 95% CI: 0.72-0.81; p < 0.001], and Medicaid beneficiaries [AOR: 0.33, 95% CI: 0.30-0.36; p < 0.001] had lower odds of receiving surgical intervention. Additionally, relative to those in the bottom income quartile, patients in all other quartiles experienced nominally higher rates of operative repair; these differences were statistically significant for the second quartile [AOR: 1.09, 95% CI: 1.03-1.16; p = 0.004]. There are significant nationwide disparities in the likelihood of receiving operative management for rotator cuff tear patients of differing race/ethnicity, payer status, and socioeconomic status. Further investigation is needed to fully understand and address causes of these discrepancies to optimize care pathways.

Artificial Intelligence and Machine Learning in Rotator Cuff Tears

Rotator cuff tears (RCTs) negatively impacts patient well-being. Artificial intelligence (AI) is emerging as a promising tool in medical decision-making. Within AI, deep learning allows to autonomously solve complex tasks. This review assesses the current and potential applications of AI in the management of RCT, focusing on diagnostic utility, challenges, and future perspectives. AI demonstrates promise in RCT diagnosis, aiding clinicians in interpreting complex imaging data. Deep learning frameworks, particularly convoluted neural networks architectures, exhibit remarkable diagnostic accuracy in detecting RCTs on magnetic resonance imaging. Advanced segmentation algorithms improve anatomic visualization and surgical planning. AI-assisted radiograph interpretation proves effective in ruling out full-thickness tears. Machine learning models predict RCT diagnosis and postoperative outcomes, enhancing personalized patient care. Challenges include small data sets and classification complexities, especially for partial thickness tears. Current applications of AI in RCT management are promising yet experimental. The potential of AI to revolutionize personalized, efficient, and accurate care for RCT patients is evident. The integration of AI with clinical expertise holds potential to redefine treatment strategies and optimize patient outcomes. Further research, larger data sets, and collaborative efforts are essential to unlock the transformative impact of AI in orthopedic surgery and RCT management.

High degree of consensus on diagnosis and management of rotator cuff tears: a Delphi approach.

To develop a consensus on diagnosis and treatment of rotator cuff tears. The study focused on selected areas: imaging, prognostic factors, treatment options, surgical techniques. Panel was composed of all members of the shoulder committee of the Italian Society of Arthroscopy, Knee, Upper arm, Sport, Cartilage and Orthopedic techniques (SIAGASCOT). Four rounds were performed. The first round consisted of gathering questions which were then divided into seven blocks referring to: imaging, patient-related prognostic factors, treatment options, surgical steps, reparative techniques, surgical predictive factors, advanced techniques. Subsequent rounds consisted of condensation by means of online questionnaire and debates. Consensus was defined as two-thirds agreement on one answer. Descriptive statistic was used to summarize the data. Forty-one shoulder experts were involved. Fifty-six statements were finally formulated. A consensus could be achieved on 51. Experts agreed that preoperative magnetic resonance imaging is strongly recommended because it allows a careful evaluation of tear characteristics, while the role of US remains debatable. Controversial patient-related factors such as age, comorbidities, smoking and stiffness do not contraindicate the repair. From a surgical standpoint, the experts highlighted that pseudo-paralysis is not a contraindication to rotator cuff repair. Consensus on specific surgical steps was also achieved: capsular release should be performed only in stiff shoulders; footprint preparation is mandatory, while debridement of tendon edges is not essential. If necessary, a rotator interval release could be performed without interrupting the continuity between subscapularis and supraspinatus tendon; posterior delamination should be always included in the repair. Advanced techniques such as tendon transfers should be selected based on the main clinical deficit, while the superior capsule reconstruction plays a role only in combination with a functional repair. A consensus was achieved almost on every topic of controversy explored. Particularly, MRI was deemed necessary to determine tear characteristics, while radiographs remain important for differential diagnosis; age should not be considered a contraindication to surgery; pseudo-paralysis does not represent a contraindication to arthroscopic rotator cuff repair, but superior capsule reconstruction plays a role only in combination with a functional repair. Latissimus dorsi transfer plays a role when the main functional deficit is in elevation, while the lower trapezius transfer plays a role when the main functional deficit is the external-rotation. V.

Many patients fail to achieve MCID for PROMIS upper extremity and pain interference following nonoperative management of rotator cuff tears

Many patients fail to achieve MCID for PROMIS upper extremity and pain interference following nonoperative management of rotator cuff tears

A Study on Outcomes of Mini Open Procedures on Rotator Cuff Injuries

Background: Many treatment options exist for the management of rotator cuff tears, varying from non-operative-benign neglect to complex arthroscopic partial repair using an interval slide technique. Although satisfactory results may be obtained with many of these options, it should be remembered that few prospective, randomized trials exist comparing these treatments. Thus, controversy remains as to the absolute indications for each, and individual patient factors may significantly affect the final treatment decision. Methods: Hospital-based observational study. Informed consent was taken from the patients. A total of 30 patients who got admitted to the Department of Orthopaedics, Government General Hospital, Kakinada from November 2018 to September 2020 were included in the study. Results: Twenty five cases showed excellent results four cases showed good results and one showed poor result using University of California LosAngeles shoulder scale. Twenty nine cases showed excellent results and one case showed good result with Constant Murley Score. Conclusion: In the era of arthroscopic rotator cuff surgery the mini open technique with open acromio plasty and rotator cuff repair adds to rural surgeon as an elective procedure and can produce clinically competing results that of other contemporary techniques.

Position statement: management of rotator cuff tears in adults.

We sought to compare success and re-tear rates of surgically treated full-thickness tears of the rotator cuff in men and women older than 18 years of age to develop a guideline intended for orthopedic surgeons and other health care providers who assess, counsel and care for these patients. We searched Medline, Embase and Cochrane databases through to Apr. 20, 2021, and included all English-language randomized trials comparing single-row versus double-row fixation via arthroscopic approaches; latissimus dorsi transfer (LDT) versus partial rotator cuff repair, lower trapezius transfer (LTT), and superior capsular reconstruction (SCR); and early versus late arthroscopic rotator cuff repair for traumatic tears. We also considered observational studies comparing LDT with LTT and partial repair and studies comparing early versus late treatment of traumatic rotator cuff tears. Outcomes of interest were functional outcomes, pain outcomes, and re-tear rates associated with these interventions. We rated the quality of the evidence and strength of recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. This guideline will benefit patients seeking surgical intervention of full thickness rotator cuff tears by improving counselling on surgical treatment options and outcomes. It will also benefit surgical providers by expanding their knowledge of various surgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making.

IS MESENCHYMAL STROMAL CELL-BASED CELLULAR THERAPY BENEFICIAL IN THE MANAGEMENT OF ROTATOR CUFF TEARS? A META-ANALYSIS OF COMPARATIVE CLINICAL STUDIES

To analyse the efficacy and safety of cellular therapy utilizing Mesenchymal Stromal Cells (MSCs) in the management of rotator cuff(RC) tears from clinical studies available in the literature.We conducted independent and duplicate electronic database searches including PubMed, Embase, Web of Science, and Cochrane Library on August 2021 for studies analyzing the efficacy and safety of cellular therapy (CT) utilizing MSCs in the management of RC tears. VAS for pain, ASES Score, DASH Score, Constant Score, radiological assessment of healing and complications and adverse events were the outcomes analyzed. Analysis was performed in R-platform using OpenMeta [Analyst] software.RESULTS:6 studies involving 238 patients were included for analysis. We noted a significant reduction in VAS score for pain at 3 months (WMD=-2.234,p&lt;0.001) and 6 months (WMD=-3.078,p&lt;0.001) with the use of CT. Concerning functional outcomes, utilization of CT produced a significant short-term improvement in the ASES score (WMD=17.090,p&lt;0.001) and significant benefit in functional scores such as Constant score (WMD=0.833,p=0.760) at long-term. Moreover, we also observed a significantly improved radiological tendon healing during the long-term follow-up (OR=3.252,p=0.059). We also noted a significant reduction in the retear rate upon utilization of CT in RC tears both at short- (OR=0.079,p=0.032) and long-term (OR=0.434,p=0.027). We did not observe any significant increase in the adverse events as compared with the control group (OR=0.876,p=0.869).Utilization of CT in RC tear is safe and it significantly reduced pain severity, improved functional outcome, enhanced radiological tendon healing, and mitigated retear rates at short- and long-term follow-up.

Artificial Intelligence in the Management of Rotator Cuff Tears

Technological innovation is a key component of orthopedic surgery. Artificial intelligence (AI), which describes the ability of computers to process massive data and "learn" from it to produce outputs that mirror human cognition and problem solving, may become an important tool for orthopedic surgeons in the future. AI may be able to improve decision making, both clinically and surgically, via integrating additional data-driven problem solving into practice. The aim of this article will be to review the current applications of AI in the management of rotator cuff tears. The article will discuss various stages of the clinical course: predictive models and prognosis, diagnosis, intraoperative applications, and postoperative care and rehabilitation. Throughout the article, which is a review in terms of study design, we will introduce the concept of AI in rotator cuff tears and provide examples of how these tools can impact clinical practice and patient care. Though many advancements in AI have been made regarding evaluating rotator cuff tears-particularly in the realm of diagnostic imaging-further advancements are required before they become a regular facet of daily clinical practice.

Pre-Operative Corticosteroid Injections And Rate Of Re-Ruptures And Infections In Primary Arthroscopic Rotator Cuff Repair

PURPOSE: The aim of this study was to determine if the re-rupture rate and post-operative infections differed among patients who received a corticosteroid injection (CSI) and those who did not prior to primary arthroscopic rotator cuff repair (RCR). METHODS: Patients who underwent primary RCR by a single surgeon (1999-2020) were included. Demographics included age at the time of surgery, BMI, comorbidities, and the administration of pre-operative CSIs. Tear thickness, size, and RCR integrity were evaluated pre-and post-operatively, by ultrasound or MRI. Infection was identified through clinical diagnosis and post-operative lab work. RESULTS: 154 shoulders underwent primary arthroscopic RCR and were included. 92 patients were in the no injection group including 66 males and 26 females (age 60.7 ± 13.1 years, BMI 27.3 ± 4.8), and 62 patients were in the injection group including 38 males and 24 females (age 58.1 ± 12.3 years, BMI 27.7 ± 4.9). There were no differences in demographics between groups aside from a greater proportion of males in the no injection group (P < 0.001). There were 22 (23.9%) partial and 70 (76.1%) full thickness tears in the no injection group and 18 (29.0%) partial and 4 (71.0%) full thickness tears in the injection group (P > 0.05). Of the full thickness tears in the no injection group, there were 9 (12.9%) small (<1 cm), 12 (17.1%) medium (1-3 cm), 26 (37.1%) large (3-5 cm), and 23 (32.9%) massive tears (>5 cm). Of the full thickness tears in the injection group, there were 7 (15.9%) small, 7 (15.9%) medium, 19 (43.2%) large, and 11 (25.0%) massive tears. There were no differences in primary tear characteristics. No postoperative infections were reported. The average time from pre-operative CSI to surgery was 9.6 ± 22.3 months in the injection group. There were 16 re-ruptures in the no injection group (17.4%) and 11 in the injection group (17.7%) (P > 0.05). The average time to failure was 2.0 ± 3.0 years in the no injection group and 4.6 ± 4.7 years in the injection group (P > 0.05). CONCLUSION: Preoperative CSI did not lead to infections or increased risk of re-rupture following arthroscopic primary RCR in our cohort suggesting this is a viable treatment option in the management of rotator cuff tears without compromising postoperative outcomes.

Evidence-based Management of Rotator Cuff Tears (Acute and Chronic)

Evidence-based Management of Rotator Cuff Tears (Acute and Chronic)

Poster 153: Dynamic Radiographic Evaluation of Scapulohumeral Rhythm in Patients with Massive vs Small Rotator Cuff Tears

Objectives:The management of rotator cuff tears varies based on patient age, function, tear size, and chronicity. Treatment of massive tears results in less favorable or predictable outcome, presenting a challenge in determining the optimal intervention. Classification of a tear as “massive” is often based on MRI and confirmed intraoperatively. However, the use of a functional measure of shoulder motion, such as the scapulohumeral rhythm (SHR), offers an alternate, clinically relevant method to help guide diagnosis and surgical management. Defined as the ratio of glenohumeral (GH) to scapulothoracic (ST) motion, SHR is known to be altered in patients with rotator cuff tears. While previously challenging to measure SHR in a clinical setting, a novel technique known as Dynamic Digital Radiography (DDR) provides a safe and cost-effective method to directly compare changes in motion between patients with rotator cuff tears and correlate these changes to tear severity. The purpose of this study was to evaluate patients with massive and small rotator cuff tears using DDR, assessing for differences in SHR and range of motion between the two groups.Methods:Shoulders were prospectively analyzed using DDR via obtaining a series of pulsed radiographs at up to 15 Hz of the joint in motion. Scapulothoracic motion and glenohumeral motion were quantified based on the DDR images (figure 1). Measurements were taken in humeral abduction at 0-30°, 30-60°, 60-90°, and full abduction using the Grashey view. SHR at different points was calculated by dividing the humeral arc of motion by the scapular arc of motion in each of those motion ranges. Pairwise t-tests were performed on the obtained data to compare differences between groups at an α level of 0.05.Results:42 patients with a primary diagnosis of rotator cuff tear matched for age and BMI were analyzed (table 1). Based on clinical presentation and MRI, 29 patients were classified as massive rotator cuff tear (MRCT) and 13 patients were classified as small rotator cuff tear (SRCT). The final angle calculations are displayed in table 2. SRCT patients had a significantly higher average overall SHR of 3.04 ± 1.16 compared to the MRCT SHR of 1.91 ± 0.51 (p=0.003). When analyzed across 30-degree intervals of humeral abduction, MRCT patients had a significantly lower SHR compared to SRCT patients at 30-60° (1.83 ± 0.97 vs 3.39 ± 1.62, p=0.005). MRCT also had a lower SHR between 0-30° (2.63 ± 2.08 vs 4.74 ± 3.83, p=0.08) and 60-90° (2.13± 0.80 vs 2.91 ± 1.41 , p=0.13) of humeral abduction compared to SRCT patients, but these differences were not statistically significant. SHR changes across these intervals of humeral abduction are plotted in figure 2. Scapular range of motion during humeral abduction was lower in SRCT compared to MRCT (29.71 ± 12.91 vs 41.57 ± 10.41, p=0.08). No statistically significant difference was found in humeral range of motion between MRCT (76.02 ± 22.66) and SRCT (80.93 ± 20.71).Conclusions:A dynamic measurement of motion demonstrates that scapulohumeral rhythm is significantly different between patients with small vs. massive rotator cuff tears. Based on DDR analysis, patients had a marked difference in the initiation of motion and through the first 60 degrees of humeral abduction, resulting in a nearly 2x lower SHR in MRCT compared to SRCT. Moreover, evaluation of glenohumeral and scapulothoracic motion during humeral abduction demonstrated that patients with larger tears had an increased reliance on scapular contributions to overall humeral elevation. Dynamic measurement of SHR represents a novel method for evaluating rotator cuff tears, with marked differences noted in the earlier phases of shoulder motion. Further study and validation of the dynamic assessment of SHR has the potential to augment the diagnostic algorithm for rotator cuff tears, and ultimately inform prognostic and functional expectations for both the patient and the physician.Table 1.Patient DemographicsTable 2.Relative contributions by glenohumeral (GH) and scapulotlioracic (ST) joint to shoulder girdle motionFigure 1.Reference lines used for calculation of the humeral and scapular abduction arcs. Measurements were taken in reference to a vertical line. Calculations were made in the neutral position, at initiation of abduction, 30°, 60°, 90° and full abduction.Figure 2.SHR measured at 30-degree intervals of humeral abduction. The * Indicates a statistically significant difference at α = 0.05 in SHR measured between massive rotator cuff tear and small rotator cuff tear patients. P-values from left to right are 0.08 (0-30 °), 0.005 (30-60 °), 0.13 (60-90 °), and 0.003 (total)

Is cellular therapy beneficial in management of rotator cuff tears? Meta-analysis of comparative clinical studies

Is cellular therapy beneficial in management of rotator cuff tears? Meta-analysis of comparative clinical studies

Obesity and sex influence fatty infiltration of the rotator cuff: the Rotator Cuff Outcomes Workgroup (ROW) and Multicenter Orthopaedic Outcomes Network (MOON) cohorts.

Fatty infiltration (FI) is one of the most important prognostic factors for outcomes after rotator cuff surgery. Established risk factors include advancing age, larger tear size, and increased tear chronicity. A growing body of evidence suggests that sex and obesity are associated with FI; however, data are limited. We recruited 2 well-characterized multicenter cohorts of patients with rotator cuff tears (Multicenter Orthopaedic Outcomes Network [MOON] cohort [n=80] and Rotator Cuff Outcomes Workgroup [ROW] cohort [n=158]). We used multivariable logistic regression to evaluate the relationship between body mass index (BMI) and the presence of FI while adjusting for the participant's age at magnetic resonance imaging, sex, and duration of shoulder symptoms, as well as the cross-sectional area of the tear. We analyzed the 2 cohorts separately and performed a meta-analysis to combine estimates. A total of 27 patients (33.8%) in the Multicenter Orthopaedic Outcomes Network (MOON) cohort and 57 patients (36.1%) in the Rotator Cuff Outcomes Workgroup (ROW) cohort had FI. When BMI < 25 kg/m2 was used as the reference category, being overweight was associated with a 2.37-fold (95% confidence interval [CI], 0.77-7.29) increased odds of FI and being obese was associated with a 3.28-fold (95% CI, 1.16-9.25) increased odds of FI. Women were 4.9 times (95% CI, 2.06-11.69) as likely to have FI as men. Among patients with rotator cuff tears, obese patients had a substantially higher likelihood of FI. Further research is needed to assess whether modifying BMI can alter FI in patients with rotator cuff tears. This may have significant clinical implications for presurgical surgical management of rotator cuff tears. Sex was also significantly associated with FI, with women having higher odds of FI than men. Higher odds of FI in female patients may also explain previously reported early suboptimal outcomes of rotator cuff surgery and higher pain levels in female patients as compared with male patients.

Patient-Reported Outcomes Measurements Information System (PROMIS) upper extremity and pain interference do not significantly predict rotator cuff tear dimensions.

BackgroundProper diagnosis of rotator cuff tears is typically established with magnetic resonance imaging (MRI); however, studies show that MRI-derived measurements of tear severity may not align with patient-reported pain and shoulder function. The purpose of this study is to investigate the capacity for the Patient-reported Outcomes Measurements Information System (PROMIS) computer adaptive tests to predict rotator cuff tear severity by correlating preoperative tear morphology observed on MRI with PROMIS upper extremity (UE) and pain interference (PI) scores. This is the first study to investigate the relationship between tear characteristics and preoperative patient-reported symptoms using PROMIS. Considering the essential roles MRI and patient-reported outcomes play in the management of rotator cuff tears, the findings of this study have important implications for both treatment planning and outcome reporting.MethodsTwo PROMIS–computer adaptive test forms (PROMIS-UE and PROMIS-PI) were provided to all patients undergoing rotator cuff repair by one of three fellowship-trained surgeons at a single institution. Demographic information including age, sex, race, employment status, body mass index, smoking status, zip code, and preoperative PROMIS-UE and -PI scores was prospectively recorded. A retrospective chart review of small to large full- or partial-thickness rotator cuff tears between May 1, 2017 and February 27, 2019 was used to collect each patient’s MRI-derived tear dimensions and determine tendon involvement.ResultsOur cohort consisted of 180 patients (56.7% male, 43.3% female) with an average age of 58.9 years (standard deviation, 9.0). There was no significant difference in PROMIS-UE or -PI scores based on which rotator cuff tendons were involved in the tear (P > .05). Neither PROMIS-UE nor PROMIS-PI significantly correlated with tear length or retraction length of the supraspinatus tendon (P > .05). The sum of tear lengths in the anterior-posterior and medial-lateral directions was weakly correlated with PROMIS-UE (P = .042; r = -0.152, r2 = 0.031) and PROMIS-PI (P = .027; r = 0.165, r2 = 0.012).ConclusionRotator cuff tear severity does not significantly relate to preoperative PROMIS-UE and -PI scores. This finding underscores the importance of obtaining a balanced preoperative assessment of rotator cuff tears that acknowledges the inconsistent relationship between rotator cuff tear characteristics observed on MRI and patient-reported pain and physical function.

Graft Augmentation of Repairable Rotator Cuff Tears: An Algorithmic Approach Based on Healing Rates

We provide our algorithm for tissue augmentation of rotator cuff repairs based on the current available evidence regarding rotator cuff healing. A variety of factors are associated with healing following rotator cuff repair. Increasing tear size and retraction as well as severe fatty degeneration have been associated with worsening rates of tendon healing. Given the correlation between tendon healing and postoperative outcomes, it is important to identify patients at high risk for failure and to modify their treatment accordingly to minimize the risk of early biomechanical failure and maximize the potential for structural healing. One approach that may be used to improve healing is tissue augmentation. Tissue augmentation is the use of tissue patches and scaffolds to provide rotator cuff reinforcement. Surgical management for rotator cuff tears (RCTs) continues to be a challenging task in orthopaedic surgery today. Appropriate treatment measures require an in depth understanding and consideration of the patient’s prognostic factors such as age, fatty infiltration of the rotator cuff muscles, bone mineral density, rotator cuff retraction, anteroposterior tear size, work activity, and degenerative changes of the joint. Using these factors within the Rotator Cuff Healing Index, we can determine a patient’s surgical treatment that will yield the maximum healing rate. For nonarthritic RCTs, joint-preserving strategies should be first-line treatment options. For young, active patients with a reparable RCT and minimal fatty infiltration, a complete repair can be effective. For young patients with irreparable RCTs, superior capsular reconstructions, and tendon transfers are viable options. For elderly patients with low work activity, an irreparable RCT and significant fatty infiltration, a partial repair with or without graft augmentation can be attempted if minimal to no arthritic changes are seen. Level of EvidenceLevel V, expert opinion.

The Evolving Roles of MRI and Ultrasound in First-Line Imaging of Rotator Cuff Injuries.

Rotator cuff tears are the most likely source of shoulder pain in adults and may cause protracted disability. Management of rotator cuff tears is associated with considerable costs. Accurate diagnosis can guide surgical planning and help achieve a favorable clinical outcome. Although radiography remains the initial imaging test for shoulder injury, the roles of MRI and ultrasound (US) as first-line imaging after radiography are evolving. This article leverages current literature and the practical experience of subspecialty musculoskeletal radiologists from different institutions in describing a practical approach to imaging rotator cuff pathology. Both MRI and US are accurate for identifying rotator cuff tears, but each has advantages and shortcomings. As both modalities currently represent reasonable first-line approaches, considerable practice variation has evolved. Given the low cost of US, imagers should strive to optimize the quality of shoulder US examinations and to build referrer confidence in this modality. The roles of direct CT and MR arthrography as well as imaging evaluation of the postoperative rotator cuff are also considered. Through careful selection among the available imaging modalities and optimal performance and interpretation of such examinations, radiologists can positively contribute to the diagnosis and treatment of patients with rotator cuff injuries.

Return to Play After Arthroscopic Management of Rotator Cuff Tears in Professional Contact Athletes (245)

Objectives:Rotator cuff tears are rare injuries in professional contact athletes and there is limited data to help guide players and team physicians regarding outcomes after surgical management. The purpose of this study was to report on the clinical outcomes and return to play rates of professional contact athletes that underwent arthroscopic management of rotator cuff tears at our institution.Methods:A retrospective review was performed on 10 rotator cuff tears in 9 professional contact athletes that underwent arthroscopic management of a rotator cuff tear from 2002-2019 at our institution. 8 tears occurred in elite American football players, 7 from the NFL and 1 from the CFL. The remaining 2 rotator cuff tears were identified in professional hockey players from the NHL. The average age of the players was 28.7 ± 4.8 years. Patient information included age, sport, position played, date of injury, date of surgery and length of time from surgery to return to play. Surgical data included tear size, acuity and pattern as well as procedure performed (debridement vs repair). Both intra and post-operative complications were documented.The primary outcome measure was the ability to return to play and the number of games played after surgery was documented. As in other similar studies, return to play was defined as the ability to participate in at least 1 full regular-season game after surgery. Return to play and career length data were collected through publicly available internet sources (NFL, CFL and NHL statistical websites) as well as from the team’s medical staff.Results:80% of the professional contact athletes that underwent arthroscopic management of a rotator cuff tear in this study were able to return to play at the same professional. The average age of the players that returned to play was 27.3 ± 4.2 years and the average time to return to play was 7.9 ± 1.9 months. 8 of the 10 tears occurred in professional football players and the majority of these injuries (6 of 8) occurred in defensive players. 2 of the 10 tears occurred in professional hockey players from the NHL and both were offensive players. All of these players regained sufficient range of motion, strength and function to pass a pre-participation physical performed by their team’s medical staff and all participated in at least one regular season game. For the football players, the average playing experience after surgery was 32 ± 25 games played. For the hockey players, the average playing experience after surgery was 22 ± 11games played.9 of the 10 tears were full thickness tears that underwent arthroscopic single row repair while 1 was a partial tear that was debrided. The average tear size was 1.95 ±0.9 cm. The average number of suture anchors used was 1.35 ± 0.7. All tears involved the supraspinatus rotator cuff tendon and 4 were classified as small tears (<1cm), 3 as medium tears (1-3cm) and 2 as large tears (3-5cm). 7 of the 10 tears underwent acute surgical repair (<2 weeks from date of injury), while 3 players underwent delayed surgical intervention at the end of the season. The delay in surgical intervention did not appear to negatively impact healing rates or the ability to return to play. Other factors that did not appear to influence return to play included type of sport, position, type of procedure (debridement vs repair) or the number of suture anchors used in the repair. Post-operative imaging was available in 8 of the 10 tears and 7 of 8 (88%) demonstrated a healed repair. No intra-operative complications were noted.2 veteran players with large (3-5cm) full thickness tears did not return to play. The average age of these players was 34.5 years and both had > 10 years of professional playing experience. One of these players was an NFL player that demonstrated a repair failure at 6 months on post-operative imaging and elected to retire rather than undergo revision surgery. The second was an NHL player that retired for reasons unrelated to his shoulder, despite a good clinical outcome and a healed repair on post-operative imaging. To our knowledge, none of the remaining players have undergone subsequent surgical intervention or revision surgery on their injured shoulder.Conclusions:This is one of only a few studies since 1996 to report on the clinical outcomes after operative management of rotator cuff tears in elite professional contact athletes. The majority (80%) of the professional contact athletes in this series were able to return to play at the same professional level after arthroscopic management of a symptomatic rotator cuff tear. Older players with > 10 years of professional experience and large rotator cuff tears were less likely to return to play after surgical intervention.

A 5-Year Follow-up of Patients Treated for Full-Thickness Rotator Cuff Tears: A Prospective Cohort Study

Background:The evidence in support of operative versus nonoperative management of rotator cuff tears (RCTs) is limited, based primarily on observational studies of lower scientific merit.Purpose:To (1) compare the efficacy of operative versus nonoperative management of full-thickness RCTs across time and (2) detect variables that predict success within each group.Study Design:Cohort study; Level of evidence, 2.Methods:We included patients with symptomatic full-thickness RCTs who were enrolled in an institutional shoulder registry. Patient enrollment began in 2009 and continued until early 2018. The following outcome measures were collected at baseline, then 6 months, 1 year, and annually up to 5 years postoperatively: Western Ontario Rotator Cuff Index (WORC), American Shoulder and Elbow Surgeons (ASES) score, Veterans RAND 12-Item Health Survey (VR-12) mental and physical component subscales (MCS and PCS, respectively), 100-point Single Assessment Numeric Evaluation (SANE) rating, and 100-point visual analog scale (VAS) for pain and for patient satisfaction. We performed regression models for all outcome variables across all 5 years of follow-up and included the following predictor variables: treatment type (operative vs nonoperative), sex, age, symptom duration, smoking status, diabetes status, injury side, and obesity status.Results:A total of 595 patients were included. Longitudinal mixed-effects regression revealed that patients who received operative treatment did better across time on all outcomes. Women (n = 242; 40.7%) did not fare as well as did men on the ASES, WORC, or VR-12 PCS. Older patients tended to improve less on the VR-12 PCS and more on the VR12-MCS. Patients with longer symptom duration at baseline had better scores across time on the ASES, WORC, VAS for pain, and SANE. Current or recent smokers and patients with diabetes tended to have lower scores on all measures across time. For changes in scores from baseline, patients in the operative group improved to a larger degree out to 3 years compared with those in the nonoperative group.Conclusion:Patients with RCTs tended to improve regardless of whether they received operative or nonoperative treatment, but patients who underwent operative treatment improved faster. There appear to be several predictors of improved and worsened outcomes for patients with RCTs undergoing operative or nonoperative treatment.