Outcomes Of Rotator Cuff Tears Research Articles

Natural History of Quantitative Fatty Infiltration and 3D Muscle Volume After Nonoperative Treatment of Symptomatic Rotator Cuff Tears: A Prospective MRI Study of 79 Patients.

The severity of fatty infiltration (FI) predicts the treatment outcome of rotator cuff tears. The purpose of this investigation was to quantitatively analyze supraspinatus (SSP) muscle FI and volume at the initial presentation and after a 3-month minimum of conservative management. We hypothesized that progression of FI could be predicted with initial tear size, FI, and muscle volume. Seventy-nine shoulders with rotator cuff tears were prospectively enrolled, and 2 magnetic resonance imaging (MRI) scans with 6-point Dixon sequences were acquired. The fat fraction within the SSP muscle was measured on 3 sagittal slices, and the arithmetic mean was calculated (FI SSP ). Advanced FI SSP was defined as ≥8%, pathological FI SSP was defined as ≥13.5%, and relevant progression was defined as a ≥4.5% increase in FI SSP . Furthermore, muscle volume, tear location, size, and Goutallier grade were evaluated. Fifty-seven shoulders (72.2%) had normal FI SSP , 13 (16.5%) had advanced FI SSP , and 9 (11.4%) had pathological FI SSP at the initial MRI scan. Eleven shoulders (13.9%) showed a ≥4.5% increase in FI SSP at 19.5 ± 14.7 months, and 17 shoulders (21.5%) showed a ≥5-mm 3 loss of volume at 17.8 ± 15.3 months. Five tears (7.1%) with initially normal or advanced FI SSP turned pathological. These tears, compared with tears that were not pathological, had significantly higher initial mediolateral tear size (24.8 compared with 14.3 mm; p = 0.05), less volume (23.5 compared with 34.2 mm 3 ; p = 0.024), more FI SSP (9.6% compared with 5.6%; p = 0.026), and increased progression of FI SSP (8.6% compared with 0.5%; p < 0.001). An initial mediolateral tear size of ≥20 mm yielded a relevant FI SSP progression rate of 81.8% (odds ratio [OR], 19.0; p < 0.001). Progression rates of 72.7% were found for both initial FI SSP of ≥9.9% (OR, 17.5; p < 0.001) and an initial anteroposterior tear size of ≥17 mm (OR, 8.0; p = 0.003). Combining these parameters in a logistic regression analysis led to an area under the receiver operating characteristic curve (AUC) of 0.913. The correlation between FI SSP progression and the time between MRI scans was weak positive (ρ = 0.31). Three risk factors for relevant FI progression, quantifiable on the initial MRI, were identified: ≥20-mm mediolateral tear size, ≥9.9% FI SSP , and ≥17-mm anteroposterior tear size. These thresholds were associated with a higher risk of tear progression: 19 times higher for ≥20-mm mediolateral tear size, 17.5 times higher for ≥9.9% FI SSP , and 8 times higher for ≥17-mm anteroposterior tear size. The presence of all 3 yielded a 91% chance of ≥4.5% progression of FI SSP within a mean of 19.5 months. Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Test-retest reliability of isometric shoulder muscle strength during abduction and rotation tasks measured using the Biodex dynamometer.

The Constant score (CS) is often used clinically to assess shoulder function and includes a muscle strength assessment only for abduction. The aim of this study was to evaluate the test-retest reliability of isometric shoulder muscle strength during various positions of abduction and rotation with the Biodex dynamometer and to determine their correlation with the strength assessment of the CS. Ten young healthy subjects participated in this study. Isometric shoulder muscle strength was measured during 3 repetitions for abduction at 10° and 30° abduction in the scapular plane (with extended elbow and hand in neutral position) and for internal and external rotation (with the arm at 15° abduction in the scapular plane and elbow flexed at 90°). Muscle strength tests with the Biodex dynamometer were measured in 2 different sessions. The CS was acquired only in the first session. Intraclass correlation coefficients (ICCs) with 95% confidence interval, limits of agreement, and paired t tests for repeated tests of each abduction and rotation task were calculated. Pearson's correlation between the strength parameter of the CS and isometric muscle strength was investigated. Muscle strength did not differ between tests (P>.05) with good to very good reliabilities for abduction at 10° and 30°, external rotation and internal rotation (ICC >0.7 for all). A moderate correlation of the strength parameter of the CS with all isometric shoulder strength parameters was observed (r>0.5 for all). Shoulder muscle strength for abduction and rotation measured with the Biodex dynamometer are reproducible and correlate with the strength assessment of the CS. Therefore, these isometric muscle strength tests can be further employed to investigate the effect of different shoulder joint pathology on muscle strength. These measurements consider a more comprehensive functionality of the rotator cuff than the single strength evaluation in abduction within the CS as both abduction and rotation are assessed. Potentially, this would allow for a more precise differentiation between the various outcomes of rotator cuff tears.

AAOS Appropriate Use Criteria: Management of Rotator Cuff Pathology.

AAOS Appropriate Use Criteria: Management of Rotator Cuff Pathology.

Guided versus freehand acromioplasty during rotator cuff repair. A randomized prospective study

IntroductionThere is no consensus on how to perform acromioplasty, particularly regarding the level and extent of bone resection, which depend on scapular and humeral morphologies. HypothesisWe aimed to determine whether computer-assisted acromioplasty planning helps surgeons remove impinging bone, reduce unnecessary resections, and improve short-term outcomes of rotator cuff tears (RCR). Patients and methodsWe randomized 64 patients undergoing RCR of full-thickness supraspinatus tears into two groups: ‘guided acromioplasty’ (GA) and ‘freehand acromioplasty’ (FA). The pre- and post-operative scapula models were reconstructed using computed-tomography scans to quantify impinging bone removal, unnecessary bone resections, and identify zones of acromial bone removal. All patients were evaluated preoperatively and at 6 months to assess their range of motion (ROM), functional scores and tendon integrity using ultrasound. ResultsThe two groups did not differ in demographics, clinical or morphologic characteristics. Compared to FA, GA tended to lower impinging bone removal (55±26% vs. 43±27%, p=0.087) and to increase unnecessary resection of the total bone removed (49±22% vs. 57±27%, p=0.248). GA resulted in significant anterior under-resection, while FA resulted in significant medial over-resection. Clinical outcomes and ROM improved significantly for all patients, except for internal rotation in the GA group. There were no other significant differences between the two groups, neither in terms of post-operative scores nor in terms of clinical net improvements, nor tendon repair integrity. ConclusionsThis computer-assisted planning for acromioplasty during RCR proved no benefits in terms of bone removal, tendon healing, or clinical outcomes. Nonetheless such planning tools could help less experienced surgeons improve the efficacy of acromioplasty. Level of proofI, Randomized controlled trial (Therapeutic study)

Physical therapy versus natural history in outcomes of rotator cuff tears: the Rotator Cuff Outcomes Workgroup (ROW) cohort study

We compared the outcomes of patients who performed physical therapy versus those who did not in a longitudinal cohort of patients undergoing nonoperative treatment of rotator cuff tears. We also assessed whether there was a dose effect in which the pain and functional outcomes in patients performing physical therapy plateaued. From February 2011 to June 2015, a multicenter cohort of patients with rotator cuff tears undergoing nonoperative treatment completed a detailed health and demographic questionnaire and the Shoulder Pain and Disability Index (SPADI) at baseline and 3, 6, 12, and 18 months. Longitudinal mixed models were used to assess whether physical therapy in the first 3 months predicted SPADI scores and dose effect. Among the 55 patients in our cohort, the performance of physical therapy within the first 3 months predicted better SPADI scores versus nonperformance of physical therapy at 3 months (P = .02). Scores were similar between groups at 6, 12, and 18 months. A threshold of 16 physical therapy sessions was observed for pain and functional improvement during follow-up, after which significant improvement was not seen. Patients who performed physical therapy within the first 3 months had statistically significant improvements in pain and function as measured by the SPADI score at 3 months compared with patients who did not report performing physical therapy. Depending on the minimal clinically important difference used for the SPADI score, our results could be interpreted as meeting the minimal clinically important difference threshold or not. Improvement in outcomes was observed up to 16 sessions of physical therapy, after which outcomes plateaued.

Is There an Association Between the “Critical Shoulder Angle” and Clinical Outcome after Rotator Cuff Repair?

Objectives:Variations in scapular morphology have been associated with the development of atraumatic rotator cuff tears (RCT). Current theories suggest a morphologic predisposition for altered shoulder biomechanics favoring the development of RCTs. The critical shoulder angle (CSA) is a radiographic measure that accounts for both glenoid inclination and lateral extension of the acromion, and angles >35 degrees are reported to be correlated with the development of degenerative RCTs. The impact of the CSA on outcomes following rotator cuff repair (RCR) has not previously been investigated. The purpose of this study was to investigate the relationship between the CSA and clinical outcomes after rotator cuff repair.Methods:As part of a prospective observational cohort study we obtained CSA measurements for 144 patients with documented full-thickness RCTs who were followed up for a minimum of 48 weeks. Patients were then stratified based on RCT etiology and treatment. Demographic data as well as The Western Ontario Rotator Cuff Index (WORC), American Shoulder and Elbow Surgeons (ASES) score and Visual Analog Scale (VAS) for pain were collected at baseline, four, eight, 16, 32 and 48 weeks. The CSA for all of the patients was measured retrospectively, with all assessors being blinded to the data and we calculated interclass correlation coefficients (ICC) to measure agreement. The statistical analysis included longitudinal multilevel regression modeling to investigate the association of the CSA and the WORC, ASES and VAS for pain.Results:Controlling for demographic and clinical characteristics, patients with CSAs less than 38 degrees reported better outcome scores over time compared to those with CSAs greater than 38 degrees (WORC: B=-106.6, p=0.025, ASES: B=4.83, p=0.0001, VAS: B=-12.99, p=0.0001). Interobserver and intraobserver reliability for CSA measurements resulted in an ICC of 0.969 and 0.982 respectively, indicating excellent agreement.Conclusion:We found that a CSA less than 38 degrees was associated with better outcomes in patients following surgical repair of atraumatic full-thickness rotator cuff tears. This is the first study to examine the relationship between the CSA and outcomes following RCR. These findings suggest that individual scapular morphology may influence both disease development and surgical outcomes of rotator cuff tears. This association warrants further investigation.

Does Smoking Affect Treatment Allocation and Outcomes in Patients with Rotator Cuff Tears?

Objectives:The objectives of this study were (1) to assess the influence of smoking status on treatment allocation (surgical versus non-surgical management) and (2) to compare the short-term functional outcomes of surgical and non-surgical treatment of rotator cuff tears between smokers and non-smokers.Methods:In the context of a prospective pragmatic cohort study we included 196 subjects with known full-thickness rotator cuff tears who were followed prospectively for 48 weeks. The Western Ontario Rotator Cuff Index (WORC), American Shoulder and Elbow Surgeons (ASES) score, and visual analogue pain scores were collected at baseline, 4, 8, 16, 32, and 48 weeks. Multivariate logistic regression was used to determine predictors of treatment allocation. Generalized linear models and t-tests were used to assess the effect of smoking on outcome measures at baseline. Mixed-effects repeated measures regression models were used to assess the effect of smoking on the outcomes after surgical and non-surgical management of rotator cuff tears.Results:The non-smoking group was older than the smoking group (61.4 years vs. 54.2, p=0.0004). Twenty-two percent of the surgical group and 12% of the non-surgical group were smokers. There was no significant difference between smokers and non-smokers in regards to the proportion of patients who were obese, had diabetes, had experienced rotator cuff tear symptoms for more than a year, had utilized physical therapy, had a large RCT, or who had received workers’ compensation. Smoking status was not significantly associated with allocation to surgical versus non-surgical treatment (OR=0.85, p= 0.762). After adjustment for covariates, subjects who smoked reported less favorable baseline adjusted WORC scores (40.9 vs. 54.5, p=0.0008), lower ASES scores (43.0 vs. 59.9, p=0.0001), as well as worse pain scores (59.5 vs. 42.9, p=0.0001). Within the non-surgical management group, smokers reported significantly lower adjusted WORC scores (38.0 vs. 56.8, p=0.0127), lower ASES scores (39.2 vs. 61.6, p=0.0872), and worse pain (61.9 vs. 42.1, p=0.0176) over 48 months. Similarly, in patients who underwent rotator cuff repair, smokers reported significantly lower adjusted WORC scores (31.1 vs. 40.4, p=0.0352), lower ASES scores (37.7 vs. 50.0, p=0.0143), and worse pain scores (63.2 vs. 51.5, p=0.0408) over the 48-week follow-up period.Conclusion:Subjects who smoked reported worse pain and function scores at baseline and over the course of one year, regardless of whether they received surgical or nonsurgical management. Smoking was not a significant predictor of treatment allocation in this cohort. The disparity in reported function and pain in smokers was less pronounced in those who underwent surgical repair than those who received non-surgical management therapy. Further follow up is needed to more clearly elucidate the influence of smoking on the management and outcome of rotator cuff tears.

Rat rotator cuff muscle responds differently from hindlimb muscle to a combined tendon-nerve injury

Rotator cuff tears (RCTs) are among the most common musculoskeletal injuries seen by orthopaedic surgeons. Clinically, massive cuff tears lead to unique pathophysiological changes in rotator cuff muscle, including atrophy, and massive fatty infiltration, which are rarely seen in other skeletal muscles. Studies in a rodent model for RCT have demonstrated that these histologic findings are accompanied by activation of the Akt/mammalian target of rapamycin (mTOR) and transforming growth factor-β (TGF-β) pathways following combined tendon-nerve injury. The purpose of this study was to compare the histologic and molecular features of rotator cuff muscle and gastrocnemius muscle--a major hindlimb muscle, following combined tendon-nerve injury. Six weeks after injury, the rat gastrocnemius did not exhibit notable fatty infiltration compared to the rotator cuff. Likewise, the adipogenic markers SREBP-1 and PPARγ as well as the TGF-β canonical pathway were upregulated in the rotator cuff, but not the gastrocnemius. Our study suggests that the rat rotator cuff and hindlimb muscles differ significantly in their response to a combined tendon-nerve injury. Clinically, these findings highlight the unique response of the rotator cuff to injury, and may begin to explain the poor outcomes of massive RCTs compared to other muscle-tendon injuries.

Rotator cuff repair using a decellularized tendon slices graft: an in vivo study in a rabbit model

Although varieties of surgical repair techniques and materials have been used to repair rotator cuff defects, re-tearing frequently occurs. The purpose of this study is to evaluate the postoperative outcomes of rotator cuff repairs with a decellularized tendon slices (DTSs) graft in a rabbit model. Large defects in the infraspinatus tendons were created bilaterally in 21 rabbits. The graft group underwent reconstruction of the defects with the DTSs grafts, while the defect group did not undergo any treatment. The specimens underwent histological observation, biomechanical testing, and magnetic resonance imaging (MRI) detection at 4, 8, and 12 weeks after surgery. In addition, 2 rabbits that were not operated on were used for MRI detection as a normal reference. Histological analysis revealed that the graft promoted host cell ingrowth and tissue integration, and a tendon-like structure developed at 12 weeks. The ultimate tensile load had a significant difference between specimens at 4 and 12 weeks in the graft group, but there was no significant difference between the graft group and the defect group. In the graft group, the stiffness at 12 weeks was significantly greater than that at 4 or 8 weeks, and it was also greater than the stiffness in the defect group at 12 weeks. MRI demonstrated that the signal strength of the regenerative tissue from the graft group at 12 weeks was similar to that of normal infraspinatus tendon. The DTSs graft allowed for incorporation of host tendon and improved the biomechanical performance of the regenerative tendon. Therefore, the graft could be a promising bioscaffold to enhance the surgical repair of large rotator cuff defects and consequently improve the clinical outcome of rotator cuff tears.

Role of fatty infiltration in the pathophysiology and outcomes of rotator cuff tears

Role of fatty infiltration in the pathophysiology and outcomes of rotator cuff tears

Clinical Outcome of Rotator Cuff Tears with Axillary Nerve Palsy after Anterior Shoulder Dislocation

Clinical Outcome of Rotator Cuff Tears with Axillary Nerve Palsy after Anterior Shoulder Dislocation

鏡視下けん板修復術の短期成績

Purpose: The purpose of this study was to evaluate the outcome of rotator cuff tears repaired arthroscopically. Methods: Twenty patients underwent arthroscopical rotator cuff repair since 2002. The mean follow-up period was 7.5 months. (range: 3M to 16M) Shoulder functions were assessed before operation and after operation by means of JOA shoulder scoring system. Results: Nine patients had small tears, five had medium tears, two had large tears and four had partial tears. The average score was 58.2 points, before operation and 88.4 points after operation. Conclusions: Arthroscopic rotator cuff repair provides good results.