Recurrent Tears Research Articles

Biologics in rotator cuff repair.

Rotator cuff tears are common in middle-aged and elderly patients. Despite advances in the surgical repair of rotator cuff tears, the rates of recurrent tear remain high. This may be due to the complexity of the tendons of the rotator cuff, which contributes to an inherently hostile healing environment. During the past 20 years, there has been an increased interest in the use of biologics to complement the healing environment in the shoulder, in order to improve rotator cuff healing and reduce the rate of recurrent tears. The aim of this review is to provide a summary of the current evidence for the use of forms of biological augmentation when repairing rotator cuff tears.

Incidence of Septic Arthritis After Vancomycin Soaking of the Graft During Arthroscopic Anatomic Anterior Talofibular Ligament and Calcaneofibular Ligament Reconstruction

Background: Vancomycin soaking of the graft during arthroscopic anterior cruciate ligament reconstruction has been shown to be effective in reducing the rate of postoperative infection. Purpose/Hypothesis: The present study aimed to (1) analyze the effect of vancomycin-soaked grafts during arthroscopic anatomic reconstruction of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) on the incidence of infection and (2) evaluate the influence of infection on functional outcomes and identify the risk factors of infection. It was hypothesized that vancomycin soaking of the graft would reduce the postoperative infection rate. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients at 2 centers who underwent ATFL/CFL reconstruction between December 2011 and July 2022 were included. All patients had undergone anterolateral arthroscopic debridement of the ankle and anatomic ATFL/CFL reconstruction with a gracilis tendon autograft. Vancomycin soaking of the graft was begun in both centers in January 2021. Complications, functional scores, return to sports (RTS) rates, and the level of return were compared between patients with and without vancomycin-soaked grafts and between patients with and without infection. Results: Overall, 182 patients (48% men; mean age, 34 ± 11.9 years) were included, with a mean follow-up of 23 ± 16.1 months. The rate of postoperative infection was significantly lower in the group with vancomycin soaking versus without (0/92 [0%] vs 8/90 [8.9%]; P = .001). At the final follow-up, there were 26 complications (14.3%): 8 infections, 6 recurrent tears, and 12 peripheral neuropathies. The infections developed after a mean of 17 ± 11 days. The functional scores were excellent at the final follow-up (American Orthopaedic Foot and Ankle Society [AOFAS] Ankle-Hindfoot Score, 86.5 ± 18.7; Karlsson score, 85 ± 18.3). Patients with infection had significantly decreased AOFAS scores (52.8 ± 27.6 vs 83.3 ± 21.5; P = .003), Karlsson scores (57 ± 27.7 vs 83.6 ± 20; P = .006), and RTS rates (25% vs 77%; P = .005) versus patients without infection. Conclusion: Vancomycin-soaked grafts for arthroscopic anatomic ATFL/CFL reconstruction decreased the rate of postoperative infection. Infection led to a deterioration in results. Vancomycin-soaking of the graft did not have a negative effect on functional results.

Outcomes After Meniscal Root Repair in Patients With and Without Advanced Patellofemoral Chondromalacia: Comparison at 2-Year Follow-up.

Meniscal root repair can improve patient outcomes significantly; however, several contraindications exist, including arthritic change to the medial or lateral tibiofemoral compartments. The purpose of this study was to evaluate the outcomes of meniscal root repair in patients with advanced patellofemoral chondromalacia (PFC). It was hypothesized that the presence of advanced PFC would not significantly affect the postoperative outcomes. Cohort study; Level of evidence, 3. A retrospective review was conducted of patients who underwent meniscal root repair with at least 2 years of follow-up data. Patients with chondromalacia as determined by arthroscopic visualization (defined as Outerbridge grade 3 or 4) were placed in the PFC group; patients with Outerbridge grade 0 to 2 chondromalacia were placed in the non-PFC group. Outcomes were measured by the Lysholm knee scoring scale and the International Knee Documentation Committee (IKDC) Subjective Knee Form. Clinical outcomes including complications were also recorded. Quantitative data between the groups were analyzed using the 2-tailed independent-samples t test. Overall, this study included 81 patients (35 in the PFC group, 46 in the non-PFC group). The mean follow-up times were 25.1 months in the PFC group and 24.8 months in the non-PFC group. In both groups, Lysholm and IKDC scores improved significantly with 24-month Lysholm scoresaveraging 85.86 in the PFC group and 86.61 in the non-PFC group (P = .62) and 24-month IKDC scores averaging 77.66 for the PFC group and 79.59 for the non-PFC group (P = .45). The cohorts demonstrated similar rates of retear, arthrofibrosis, infection, and progression to total knee arthroplasty. The presence of advanced PFC was not associated with inferior outcomes in patients who underwent posterior meniscal root repair, and rates of recurrent tears, postoperative infection, arthrofibrosis, and conversion to total knee arthroplasty were similar between the study groups. These findings suggest that PFC may not significantly alter the results of meniscal root repair and should not be considered an absolute contraindication for this procedure.

Superior Capsular Reconstruction for Massive Irreparable Cuff Tears: A Systematic Review for Clinical & Functional & Radiological Outcomes

Background Massive rotator cuff tears (MRCT) are defined as a full-thickness tear of at least two tendons or measuring greater than five centimeters in diameter in the coronal plane. They represent about 20% of all rotator cuff tears and 80% of recurrent tears. Aim of the Work The treatment of massive irreparable cuff tears (MIRCT) is considered a consistent challenge for the orthopedic surgeons regarding the best management and the postoperative outcomes. Patients and Methods Search were conducted using the following databases: MEDLINE database, PubMed, Cochrane Bone and Muscle Trauma Group Specialized Register, Cochrane Register of Controlled Trails (The Cochrane Library). Data will be independently extracted by two reviewers and cross-checked. Results In radiological parameters, this review makes radiological assessment based on acromiohumeral distance and MRI graft integrity. AHD showed significant improvement in mean change postoperatively rather than preoperatively. As regarding MRI graft integrity, despite this high failure rate (20%) most patients still experienced improved functional outcome scores with two studies reporting no significant differences in functional scores between the intact and re-tear group. but on the other hand Denard et al. demonstrated that 100% of patients with healed grafts had a successful outcome compared to 45.5% when the graft did not heal (p = 0.009). Conclusion Not all patients with massive cuff tears are appropriate candidates for complex joint preservation surgery such as SCR because of age, comorbidities, and ability to participate in the lengthy postoperative rehabilitation, so rTSA is an optimal option for elderly, low-demand patients who can benefit from the speed of surgery and rehabilitation with rTSA for massive rotator cuff tears without arthritis.

Sirtuin 6 Overexpression Improves Rotator Cuff Tendon-to-Bone Healing in the Aged.

Aging is an independent risk factor for recurrent tearing after surgical repair of rotator cuff ruptures around the tendon-to-bone area. However, aging signature factors and related mechanisms involved in the healing of the rotator cuff are still unknown. We hypothesized that differences in proteins involved in the rotator cuff according to age may affect tendon-to-bone healing. The proteome analysis performed to identify the signature aging proteins of the rotator cuff confirmed the sirtuin signal as an age-specific protein. In particular, the expression of SIRT6 was markedly down-regulated with age. Ingenuity pathway analysis of omics data from age-dependent rat rotator cuffs and linear regression from human rotator cuffs showed SIRT6 to be closely related to the Wnt/β-catenin signal. We confirmed that overexpression of SIRT6 in the rotator cuff and primary tenocyte regulated canonical Wnt signaling by inhibiting the transcriptional expression of sclerostin, a Wnt antagonist. Finally, SIRT6 overexpression promoted tendon-to-bone healing after tenotomy with reconstruction in elderly rats. This approach is considered an effective treatment method for recovery from recurrent rotator cuff tears, which frequently occur in the elderly.

Medial Collateral Ligament Pie-Crusting for Isolated Medial Meniscal Root Repair Is Associated With Improved Clinical Outcomes with Minimum 2-Year Follow-Up

To determine clinical and radiographic outcomes of medial collateral ligament (MCL) pie-crusting during isolated medial meniscal root repair. A retrospective review was conducted between August 2013 and December 2019 in patients undergoing isolated medial meniscal root repair. Outcomes, including International Knee Documentation Committee (IKDC) score, Lysholm score, re-tears, MCL laxity, and conversion to total knee arthroplasty (TKA), were compared between pie crust (PC) and non-pie crust (NPC) cohorts. Other assessments included subjective instability or stiffness, infection, and intra-operative chondromalacia. Additionally, radiographic outcomes were compared to determine progression of medial compartment arthrosis. Final analysis included 97 knees, 45 in the PC, and 52 in the NPC group. IKDC and Lysholm scores were similar between both groups preoperatively and 3 months postoperatively. However, at the 6,12, and 24-month follow up, the PC group had a significantly higher measured IKDC and Lysholm scores than the NPC group. PASS percentages for the IKDC score were significantly higher in the PC group at 6 months, 1 year, and 2 years (96.2%; P= .02) follow-up compared to the NPC group. MCID percentages for the IKDC score were also significantly higher at the 1- and 2-year (100%; P= .05) follow-up in the PC group compared to the NPC group. There was also a significantly higher rate of recurrent medial meniscal root tears in the NPC group (4 [8.9%]) compared to the PC group (0 [P= .03]). No MCL laxity was observed at 6 months follow-up. MCL pie-crusting during isolated medial meniscal root repair can be used as an alternative surgical technique, as it leads to improved clinical and patient outcomes compared to patients who do not undergo MCL pie-crusting in the short term. Additionally, those that underwent MCL pie-crusting had a lower incidence of recurrent tears, and no patients experienced MCL laxity at 6 months. Level III, retrospective cohort/comparative study.

Poster 239: Advanced Patellofemoral Chondromalacia Does Not Affect Outcomes After Meniscal Root Repair

Objectives: Meniscal root tears have been shown to accelerate cartilage breakdown and increase the risk of total knee arthroplasty (TKA) if left unaddressed. Unfortunately, many patients with meniscal root tears already have associated chondromalacia which can impact surgical outcomes. The presence of advanced chondromalacia in the medial or lateral compartmentsof the knee is a known contraindication to performing meniscal root repair; however, the effect of advanced patellofemoral chondromalacia on meniscal root outcomes is not known. The purpose of this study was to compare the outcomes of meniscal root repair in patients with and without advanced patellofemoral chondromalacia (PFC). Methods: A retrospective review of prospectively collected data of patients undergoing meniscal root repair by a single surgeon was conducted between January 2016 and December 2019. Patients were included if they had undergone an isolated posterior medial or lateral meniscal root repair. The meniscal root repair was performed using a transtibial suture technique. Patients were placed into one of two groups depending on the amount of patellofemoral chondromalacia present at the time of surgery. Patients with Outerbridge grade 0-2 were placed in the Minimal Patellofemoral Chondromalacia (MPFC) Group. Patients with Outerbridge 3-4 changes found the time of surgery were placed in the Patellofemoral Chondromalacia (PFC) Group. Patients with Outerbridge 3-4 changes found in the medial or lateral compartment were excluded from the study. Lysholm Knee Scoring Scale and the International Knee Documentation (IKDC) Subjective Knee Form were collected preoperatively, 6,12 and 24 months after surgery. Clinical outcomes followed included recurrent meniscal tear, conversion to total knee arthroplasty, knee arthrofibrosis requiring manipulation under anesthesia/lysis of adhesions and infection. PASS and MCID were determined using data on meniscal repairs in other literature. Continuous data was compared using two-tailed student-T test while categorical data was compared utilizing chi-square testing. Results: A total of 27 patients made up the PFC group and 54 in the MPFC group. There was no difference between the groups with regards to age, sex, BMI or laterality of the procedure. The PFC group had 26 medial and 1 lateral meniscal root repairs. The MPFC group had 51 medial and 3 lateral repairs. The average Outerbridge score of the patella for the PFC group was 3.2 compared to 1.8 in the MPFC group (p<.001). The Outerbridge score for the trochlea in each group was 3.4 vs. 1.6 for the PFC and MPFC groups respectively (p<.001). No difference was identified between the Outerbridge score for the medial compartment for the PFC and MPFC groups (1.48 vs 1.46 respectively) or the lateral compartments (0.48 vs. 0.61 respectively). Lysholm and IKDC scores rose significantly over the pre- operative value at all time points in the study for both groups. No difference was seen between the two groups for the Lysholm or IKDC scores at any timepoint during study. PASS rates for IKDC between the two groups were similar with 6,12 and 24-month PASS rates being 66.7%, 87.5% and 81.4% respectively for the PFC group and 62.9%, 77.8% and 85.2% for the MPFC group. There was also no difference between the groups with regards to the percentage of patients reaching MCID for IKDC. The PFC group showed the percentage of patients reaching MCID to be 81.5%, 100% and 92.6% at the 6,12, and 24 month time points respectively while the MPFC group showed the percentage of patients reaching MCID to be 75.9%, 88.9% and 94.4% at the 6,12 and 24 month postoperative time points respectively. There was 1 (3.7%) recurrent tear in the PFC group and 3 (5.6%) in the MPFC group (p=.72). One patient (3.7%) in the PFC and none of the MPFC group were converted to TKA by the 2-year follow up (p=.15). Each group had 1 patient develop arthrofibrosis requiring MUA/LOA. There were no infections in the PFC group and one in the MPFC group which was a superficial wound infection that resolved after a course of oral antibiotics. Conclusions: In our series, the presence of advanced patellofemoral chondromalacia did not lead to inferior short-term outcomes in patients undergoing meniscal root repair compared to patients without patellofemoral chondromalacia. IKDC and Lysholm scores were similar between the PFC and MPFC group at all time points while scores for both groups were significantly higher than preoperative levels at all time points. The ability to reach MCID and PASS for IKDC was not significantly different between the two groups. In addition, there was not a significant difference between the two groups in the number of recurrent tears, conversion to total knee arthroplasty or complications identified. Our results show meniscal root repair can be performed in patients with severe patellofemoral chondromalacia with similar results as patients undergoing root repair without severe patellofemoral chondromalacia. Patellofemoral chondromalacia should not be considered a contraindication to meniscal root repair.

Subacromial Balloon Spacer Does Not Reduce the Retear Rate for Massive Rotator Cuff Tears: A Comparative Study

To determine whether a subacromial spacer decreases the recurrent rotator cuff tear rate in arthroscopically managed massive rotator cuff tears (MRCTs) with 1 year of follow-up. We selected all patients who met the following criteria: (1) an MRCT excluding Collin type A, (2) Goutallier stage equal or less than 2, and (3) complete arthroscopic repair of the MRCT. Patients were allocated into 2 groups: A (without subacromial spacer) or B (with subacromial spacer) for a prospective evaluation 1 year after surgery. The primary outcome was the retear rate, determined with magnetic resonance imaging (MRI) according to the classification of Sugaya. Secondary outcome measures were the functional outcomes using visual analog score, Shoulder Subjective Value, and Constant-Murley Score. Preoperative rotator cuff characteristics such as number of tendons involved and the tear retraction also were evaluated. Patient-related data such as sex, age, laterality, history of smoking, and diabetes mellitus were analyzed. In total, 31 patients were included in group A and 33 in group B. Preoperatively, only 2 differences were found between both groups: a significant (but not clinical) greater Constant score in group A (P= .034) and a slightly greater retraction of the supraspinatus in group B (P= .0025). The overall retear rate between the 2 groups was similar regarding the number of patients (P= .746) and the total number of tendons involved in the recurrent tear (P= .112). At 1-year follow-up, no differences were found in VAS (P= .397), SSV (P= .309), and Constant score (P= .105). In reparable massive rotator cuff tears (excluding Collin type A), the augmentation of repair with a subacromial spacer did not significantly reduce the number of patients with recurrent rotator cuff tears identified by MRI. It was also ineffective in reducing the number of re-ruptured tendons in these patients. No patient-reported or clinically significant findings were noted in Constant, SSV, and VAS scores at 1-year postoperative follow-up. Patients with MRI findings of a healed rotator cuff (Sugaya 1-3) had better clinical outcomes compared with those without. Level III, retrospective comparative study.

Presurgical Perspectives and Post-treatment Evaluation of Achilles Tendon Injuries.

The Achilles is a commonly injured tendon, prone to degeneration and tear. Achilles tendon treatment ranges from conservative management to injections, tenotomy, open versus percutaneous tendon repair, graft reconstruction, and flexor hallucis longus transfer. Interpreting postoperative imaging of the Achilles tendon is a difficult task for many providers. This article clarifies these issues by presenting the imaging findings following standard treatments and depicts expected appearance versus recurrent tear and other complications.

Repair of a meniscus tear within 3weeks after trauma significantly reduces the likelihood of a recurrent tear compared with later repairs.

To evaluate the potential benefit of meniscus tear repair within 3weeks after rupture compared with more than 3weeks after rupture. Ninety-one patients (95 menisci) underwent repair within 3weeks after meniscus rupture [Group 1] and 15 patients (17 menisci) [Group 2] underwent repair more than 3weeks after rupture. The posterior part of the ruptured meniscus was repaired with Contour Arrows®, using a Crossbow as the insertion instrument, whereas the middle third was repaired by inserting PDS 2.0 stitches using a Meniscus Mender® outside-in device. The patients were followed-up for a mean(SD) 8.9years (range: 1-12years). Of the 91 patients (95 menisci) in Group 1, 88 (96.7%) healed without complications. One meniscus in one patient did not heal after 11months, requiring resection. Two other menisci in two other patients showed partially healed tears. This part was removed while preserving most of the meniscus (failure rate: 3/91 patients: 3.3%). The other 88 patients recovered without complaints and participated in sports without restraint. Four menisci in four patients experienced a second sports-related incident, resulting in a renewed tear between 12months and 3years. These tears were repaired successfully again. Of the 15 patients in Group 2, 12 (80.0%) healed without complications. The ruptured part of the remaining menisci in the other three patients, (20%) was removed, with all patients remaining symptom-free until the end of follow-up. Rates of treatment failure differed significantly in these two groups (3.3% vs 20.0%, p = 0.04). The overall failure rate was significantly lower in patients who underwent meniscus repair within 3weeks than in those who underwent repair at 3weeks (or more) after the trauma. Thus, early repair of meniscus tears is beneficial, and can prevent failure of meniscus repair surgery. III.

Local Intraoperative Marrow-Derived Augmentation for Primary Rotator Cuff Repair: An Updated Systematic Review and Meta-analysis of Studies From 2010 to 2022

Recurrent tears of the rotator cuff pose a substantial problem despite advances in repair technique. Biologic augmentation via marrow stimulation or vented anchors may strengthen the suture-tendon junction and improve healing rates of native tissue, thereby enhancing outcomes of primary surgical repair. To provide a focused systematic review and meta-analysis of local, intraoperative marrow-derived augmentation techniques in clinical primary rotator cuff repair. Systematic review; Level of evidence, 4. A systematic review of PubMed, Embase, and Cochrane was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 2131 studies from 2010 to 2022, focused on either marrow stimulation or vented anchors, were isolated and classified as either preclinical or clinical. Meta-analysis was performed for comparative marrow stimulation and vented anchor studies. Heterogeneity was tested through calculation of I 2. A total of 13 clinical studies were included in the review. All 9 comparative studies included in the meta-analysis demonstrated high methodologic quality or a low risk of bias. The pooled retear rate across all 9 clinical studies for patients undergoing marrow stimulation was 11%. For the 5 studies in the meta-analysis, the pooled retear rates were 15% for marrow stimulation and 30% for controls. Meta-analysis demonstrated a significant difference in the overall retear rate that favored marrow stimulation (odds ratio [OR], 0.41; 95% CI, 0.25-0.66; P = .0003; I 2 = 0%). Similarly, meta-analysis of the Constant score at final follow-up demonstrated a statistically significant difference between the 2 groups that favored a higher Constant score in the marrow stimulation group (mean difference, 2.84; 95% CI, 1.02-4.66; P = .002; I 2 = 29%). Vented anchors demonstrated improved ossification and bone density at the anchor site, but no difference in outcomes or retear. Pooled retear rates were 22.5% for vented anchors and 27.8% for controls. Current evidence demonstrates that marrow-stimulation techniques may have a positive impact on healing and retear rate, while vented anchors have a muted impact relative to nonvented anchors. Although available evidence is limited and more research is needed, findings to date suggest that marrow stimulation techniques may be an inexpensive, straightforward technique to consider in qualifying patients to prevent rotator cuff retears.

Effects of preexisting depression and anxiety on postoperative outcomes following arthroscopic rotator cuff repair.

Rotator cuff repairs (RCRs) are one of the most commonly performed shoulder surgeries in the United States. Psychological health has been shown to influence postoperative outcomes in orthopedic procedures. The purpose of this study is to evaluate the relationship between depression and anxiety (DA) and psychotropic medication and postoperative outcomes following RCR. A single institution retrospective observational cohort study of 816 patients undergoing arthroscopic RCR from January 2014 to October 2020 was conducted. Univariate statistics were used to assess differences in demographics, operative characteristics, and postoperative outcomes; multivariate analysis was used to evaluate risk factors for postoperative complications. Patients with DA were more likely to have a higher first (3.60 vs. 3.00, P=.004) and last (1.23 vs. 0.96, P=.042) postoperative pain scores, lower first (18.67 vs. 21.85, P=.008) and last (61.87 vs. 64.71, P=.014) Upper Extremity Functional Score (UEFS), more likely to experience an emergency department visit postoperatively (9.1 vs. 5.0%, P=.028), have a symptomatic recurrent tear (8.2 vs. 3.3%, P=.003), and persistent pain (4.3 vs. 1.2%, P=.011). After controlling for age, sex, body mass index, American Society of Anesthesiologists score, diabetes, smoking, coronary artery disease, asthma, hypertension, psychotropic medication and DA, having DA at the time of surgery was independently predictive of any complication (odds ratio, 2.033; P=.028) and persistent pain (odds ratio, 8.232; P≤.001). Patients with and without DA showed significant improvement in postoperative pain and UEFS from the first to the last measurement (P<.001). DA is not a deterrent for RCR but targeted interventions may be needed to decrease the occurrence of complications.

Rotator Cuff Injury and Repair.

Rotator cuff pathology is a commonly encountered clinical and radiologic entity that can manifest as tendinopathy or tearing. Magnetic resonance imaging (MRI) and ultrasonography offer similar sensitivity and specificity for the evaluation of the native rotator cuff, and the chosen modality may vary, depending on local practice and accessibility. MR arthrography is frequently used in the postoperative setting as a problem-solving tool. Key findings to include in the preoperative MRI report include the size and location of the tear, thickness of the tendon involved (partial versus full thickness), and overall tendon quality. The report should also address features associated with poor surgical outcomes, such as fatty atrophy, a decreased acromiohumeral interval, and evidence of rotator cuff arthropathy. Musculoskeletal radiologists should be familiar with the various surgical techniques and expected postoperative imaging appearance of rotator cuff repairs. Imaging also plays a role in identifying recurrent tearing, graft failure, hardware loosening, infection, and other complications.

Use of a Nanofiber Resorbable Scaffold During Rotator Cuff Repair: Surgical Technique and Results After Repair of Small- to Medium-Sized Tears.

Background:The rate of retear after primary rotator cuff failure remains unacceptably high (up to 36% for small- to medium-sized tears). Augmentation of cuff repair with scaffold devices has been reported to improve healing after cuff repair.Purpose/Hypothesis:To describe the surgical technique of using an interpositional nanofiber scaffold during rotator cuff repair and report on a retrospective series of patients regarding functional outcomes and postoperative healing on magnetic resonance imaging (MRI). We hypothesized that augmentation of cuff repair with an interpositional scaffold would result in a high rate of tendon healing and excellent functional outcomes.Study Design:Case series; Level of evidence, 4.Methods:A total of 33 patients underwent arthroscopic rotator cuff repair augmented with a nanofiber, bioresorbable polymer patch secured as an inlay between the tendon and underlying bone. Patients were evaluated preoperatively and postoperatively with the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) shoulder score, and active range of motion (ROM) measurements. Postoperative MRI was used to evaluate repair status.Results:At a minimum follow-up of 6 months, the patients showed significant improvement on SST and ASES scores (P < .0001 for both). ROM in forward flexion, abduction, internal rotation, and external rotation significantly improved at 6 months postoperatively (P < .05 for all). MRI at an average of 11 months postoperatively showed healing in 91% of patients; one patient had a recurrent tear with transtendon failure, and another patient had retear at the insertional site. The patch was not visible on postoperative imaging, suggesting complete resorption in all patients. No adverse events were associated with the patch.Conclusion:Our results demonstrate the preliminary safety and efficacy of a novel, bioresorbable synthetic scaffold for rotator cuff repair. The use of the scaffold resulted in a 91% tendon healing rate and significant improvements in functional and patient-reported outcome measures. The results are promising for improving the current unacceptably high rate of rotator cuff repair failure.

The combination of a tibial slope correction osteotomy with ACL revision at a mean follow-up of 10 years provides good clinical results without revision surgery

Objectives:The objective is to discover the long-term outcome of ACL reconstruction associated with tibial slope correction osteotomy for a second ACL tear. This study is preceded by an initial publication with a 4-year follow-up. The hypothesis was stable functional scores and the absence of osteoarthritis progression.Methods:The initial consecutive retrospective series included 9 patients who had a revision surgery for ACL reconstruction associated with single-stage OTDF. They were reviewed by an independent observer for a second follow-up with a minimum retrospect of 7 years. The analysis was based on IKDC-SKF and Lysholm scores, and radiographic analysis.Results:Of the original 9 patients, 7 were seen again, 1 was only interviewed by telephone, and 1 was lost to follow-up. At the last follow-up of 9.9 ± 3.0 years, all 8 patients had stable or improved functional scores compared to the previous follow-up. The mean Lysholm score increased from 73.8 ± 5.8 (65-82) to 84.5 ± 11.9 (59-95) and the mean IKDC-SKF score increased from 71.6 ± 6.2 (62-79) to 82.9 ± 12.1 (61-98). Of the six patients who already had proof of osteoarthritis at the previous follow-up, the grade of osteoarthritis increased for two (with a history of meniscectomy, from grade 2 to grade 3 and from grade 1 to grade 3) but remained stable for three patients and could not be assessed for one.Conclusion:At 7-15 years (mean: 9.9 years), patients’ functional scores were stable or improving compared to the previous 2-8 year follow-up period, with no new tear or revision surgery. This validates tibial slope correction after recurrent ACL tears with an increase in the tibial slope

Allograft Reconstruction for Unsalvageable and Recurrent Tears of Both Peroneal Tendons

Category:Ankle; Hindfoot; SportsIntroduction/Purpose:Surgical reconstruction for the complete loss of both peroneal tendons is challenging, with no established standard. This is true both for concomitant tears that extend superior to the superior peroneal retinaculum, and for nonfunctioning, unsalvageable peroneal tendons after prior repair or reconstruction, which have recurrent tears, tendon degeneration, scarring, and stretching. These cases have in common that there is no option for retention of the native tendons. Allograft reconstruction can bridge long defects, reestablishing the insertion of the proximal musculo-tendinous unit to the lateral foot. However, there are limited published data on allograft reconstruction, and series are small and heterogenous. This study reports the results of allograft reconstruction at a mean of 4.1 years follow-up (range 1.5-7.3 years).Methods:A retrospective study reviewed patients who had allograft reconstruction for unsalvageable or recurrent tears of both the peroneus brevis and peroneus longus tendons. In all cases, the unsalvageable segments of both peroneal tendons were excised. A hamstring allograft tendon with width of >6mm was pre-stretched, then anchored to the proximal 5thmetatarsal, and also sutured to itself and the adjacent brevis stump, if viable. The peroneal retinaculae were reconstructed over the allograft tendon. The peroneal muscle-proximal tendon units were extensively stretched inferiorly using suture loops in the tendons. They were maximally tensioned and anastomosed to the maximally tensioned allograft while holding the hindfoot in maximum eversion. Of the 14 eligible patients, 13 had minimum one-year follow-up and constituted the study population. Mean age was 50.7 years (range 26.3-68.6 years). Ten patients had at least one prior peroneal tendon surgery; four patients had at least two.Results:At mean follow-up of 4.1-years, seven patients were 'very satisfied,' one 'satisfied,' one 'neutral,' and two 'dissatisfied.' Ten stated they would have the procedure again, one would not. Two could not be reached to answer these questions. Visual analogue scale pain score decreased from 4.6 to 3.4 (p=0.150), ankle osteoarthritis scale (AOS) pain subscale decreased from 36.2 to 13.8 (p=0.013), AOS disability subscale decreased from 42.8 to 21.9 (p=0.032), and AOS total score decreased from 39.5 to 17.8 (p=0.014). No statistical change in SF-36 physical function score (p=0.547) or PROMIS physical function score (p=0.580) was detected. At last examination, 12 of 13 patients had active eversion and a palpable, tensioned graft. The patient without active eversion underwent triple arthrodesis; no other patient had additional peroneal or hindfoot surgery.Conclusion:Allograft interposition is effective to reconstruct unsalvageable concomitant tears of both peroneal tendons as well as the most difficult revision cases of nonfunctioning, unsalvageable peroneal tendons after prior repair or reconstruction, which have recurrent tears, tendon degeneration, scarring, and stretching. There is a high rate of restoration of peroneal function, a reasonable rate of patient satisfaction, and statistically significant improvements in ankle-specific patient-reported outcomes.

Presurgical tear characteristics and estimated shear modulus as predictors of repair integrity and shoulder function one year after rotator cuff repair.

BackgroundRotator cuff repair provides pain relief for many patients; however, retears are relatively common and affect approximately 20%-70% of patients after repair. Although magnetic resonance imaging (MRI) offers the ability to assess tissue characteristics such as tear size, retraction, and fatty infiltration, it provides little insight into the quality of the musculotendinous tissues the surgeon will encounter during surgery. However, shear wave elastography (SWE) could provide an indirect assessment of quality (ie, stiffness) by measuring the speed of shear waves propagating through tissue. The objective of this study was to determine the extent to which estimated shear modulus predicts repair integrity and functional outcomes 1 year after rotator cuff repair.MethodsThirty-three individuals scheduled to undergo arthroscopic rotator cuff repair were enrolled in this study. Before surgery, shear modulus of the supraspinatus tendon and muscle was estimated using ultrasound SWE. MRIs were obtained before and 1 year after surgery to assess tear characteristics and repair integrity, respectively. Shoulder strength, range of motion, and patient-reported pain and function were assessed before and after surgery. Functional outcomes were compared between groups and across time using a two-factor mixed model analysis of variance. Stepwise regression with model comparison was used to investigate the extent to which MRI and shear modulus predicted repair integrity and function at 1 year after surgery.ResultsAt 1 year after surgery, 56.5% of patients had an intact repair. No significant differences were found in any demographic variable, presurgical tear characteristic, or shear modulus between patients with an intact repair and those with a recurrent tear. Compared with presurgical measures, patients in both groups demonstrated significant improvements at 1 year after surgery in pain (P < .01), self-reported function (P < .01), range of motion (P < .01), and shoulder strength (P < .01). In addition, neither presurgical MRI variables (P > .16) nor shear modulus (P > .52) was significantly different between groups at 1 year after surgery. Finally, presurgical shear modulus generally did not improve the prediction of functional outcomes above and beyond that provided by MRI variables alone (P > .22).ConclusionAlthough SWE remains a promising modality for many clinical applications, this study found that SWE-estimated shear modulus did not predict repair integrity or functional outcomes at 1 year after surgery, nor did it add to the prediction of outcomes above and beyond that provided by traditional presurgical MRI measures of tear characteristics. Therefore, it appears that further research is needed to fully understand the clinical utility of SWE for musculoskeletal tissue and its potential use for predicting outcomes after surgical rotator cuff repair.

Arthroscopic Treatment Results of Triangular Fibrocartilage Complex Tears in Adolescents: A Systematic Review.

Introduction: Injury to the triangular fibrocartilage complex (TFCC) may cause chronic wrist pain and instability if left untreated. The current literature of adult cases suggests that arthroscopic treatment offers favorable outcomes and is associated with a low complication rate. This systematic review evaluated the outcomes of arthroscopic TFCC surgery in adolescents. Materials and Methods: A PRISMA-guided literature search of PubMed, Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Cochrane Clinical Answers was conducted in May 2020. All studies reporting on (1) arthroscopic TFCC repair or debridement in (2) patients under the age of 19 years with (3) a minimum case number of four patients were extracted by two independent observers. The level of evidence of each study was assessed according to the Oxford Centre for Evidence-Based Medicine, and study quality was graded according to the Modified Coleman Methodology Score and the MINORS criteria. Clinical outcome scores, functional parameters, and any complications were reviewed. Results: The selected search terms initially resulted in a total of 986 possible articles. The authors eventually identified eight papers (all LoE IV) for inclusion in this systematic review. A total of 254 patients with verified TFCC tears and a mean age of 16 years (range, 7–19) received arthroscopic repair (162 patients, 67.1% of total) or debridement (77 patients, 29.7% of total). Arthroscopic treatment resulted in low pain levels, high patient satisfaction, and a fast return to sport. Complications overall were sparse and consisted mainly of persistent wrist pain (n = 31) and temporary paresthesia (n = 6) of the dorsal sensory branch of the ulnar nerve. Recurrent tears were sparse, with only four reported cases due to sports participation. Conclusion: Wrist arthroscopy is a reliable surgical option for treating TFCC tears in adolescents. The results obtained are comparable to those published in the literature. However, the variety of repair techniques and the low level of evidence across all included articles demand further prospective studies.

Association of Recurrent Tear After Arthroscopic Rotator Cuff Repair and Superoxide-Induced Oxidative Stress

Background: Recurrent tears after arthroscopic rotator cuff repair (ARCR) remain a significant clinical problem. Oxidative stress contributes to the degeneration of the rotator cuff, and a degenerative rotator cuff can lead to recurrent tear after ARCR. However, the correlation between oxidative stress and retear after ARCR is unclear. Purpose: To investigate the correlation between superoxide-induced oxidative stress and recurrent tear after ARCR. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 68 patients who underwent ARCR using a suture-bridge technique participated in this study. Specimens were collected from the edge of the torn tendon during surgery. The modified Bonar score was used to evaluate degeneration of the rotator cuff on histological specimens, and fluorescence intensity on dihydroethidium (DHE) staining was used to detect oxidative stress. Superoxide dismutase (SOD) enzyme activity was also measured. The following were used for clinical evaluation: age, tear size on magnetic resonance imaging (MRI) before surgery, Goutallier classification on MRI before surgery, and Japanese Orthopaedic Association score before and 6 months after surgery. After the repaired rotator cuffs were evaluated on MRI 6 months after surgery, the patients were divided into groups: those with a healed rotator cuff (healed group; n = 46) and those with a recurrent tear (retear group; n = 22). The significant differences between the groups were determined with regard to clinical evaluation, modified Bonar score, DHE intensity, and SOD activity. In addition, multivariate logistic regression analysis was performed to investigate risk factors for recurrent tear. Results: Age, tear size, Goutallier classification, modified Bonar score, DHE intensity, and SOD activity were significantly greater in the retear group than in the healed group, although the Japanese Orthopaedic Association score was not significantly different. Multiple logistic regression analysis demonstrated that age, tear size, and SOD activity were significantly correlated with recurrent tear. Conclusion: In addition to tear size and age, superoxide-induced oxidative stress may be an exacerbating factor for retear after ARCR.

In vitro evaluation of the response of human tendon-derived stromal cells to a novel electrospun suture for tendon repair.

Recurrent tears after surgical tendon repair remain common. Repair failures can be partly attributed to the use of sutures not designed for the tendon cellular niche nor for the promotion of repair processes. Synthetic electrospun materials can mechanically support the tendon whilst providing topographical cues that regulate cell behaviour. Here, a novel electrospun suture made from twisted polydioxanone (PDO) polymer filaments is compared to PDS II, a clinically-used PDO suture currently utilised in tendon repair. We evaluated the ability of these sutures to support the attachment and proliferation of human tendon-derived stromal cells using PrestoBlue and Scanning Electron Microscopy. Suture surface chemistry was analysed using X-ray Photoelectron Spectroscopy. Bulk RNA-Seq interrogated the transcriptional response of primary tendon-derived stromal cells to sutures after 14 days. Electrospun suture showed increased initial cell attachment and a stronger transcriptional response compared to PDS II, with relative enrichment of pathways including mTorc1 signalling and depletion of epithelial mesenchymal transition. Neither suture induced transcriptional upregulation of inflammatory pathways compared to baseline. Twisted electrospun sutures therefore show promise in improving outcomes in surgical tendon repair by allowing increased cell attachment whilst maintaining an appropriate tissue response.