Repair Of Rotator Cuff Tears Research Articles

Serial Changes of Fatty Degeneration and Clinical Outcomes after Repair of Medium-Sized Rotator Cuff Tears.

This study was designed to longitudinally analyze quantitative intramuscular and perimuscular fat and evaluate clinical outcomes according to healing degree after rotator cuff repair. From June 2013 through October 2018, patients who had undergone repair due to medium-sized rotator cuff tears and serial chest computed tomography (CT) preoperatively and at early (6-12 months) and late (at least 3 years) postoperative follow-ups were included. Supraspinatus (SST) intramuscular fat fraction ratio (IFFR) and perimuscular fat fraction ratio (PFFR) were calculated using chest CT. The rotator cuff integrity was categorized as healed, smaller retear (SRT), and larger retear (LRT) by comparing the preoperative tear size and retear size in shoulder CT arthrography at postoperative follow-ups. Clinical outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) score, the University of California at Los Angeles (UCLA) shoulder rating scale, and the Constant score preoperatively and at early and late postoperative follow-ups. In the LRT group, compared with the preoperative values, there were increases in the SST IFFR and PFFR at the early (p = 0.002 and p = 0.006, respectively) and late (p < 0.001 and p < 0.001, respectively) postoperative time points. Late postoperative clinical scores (UCLA and Constant scores) were not improved compared to preoperative scores (p = 0.156 and p = 0.094, respectively). In the SRT group, there was no difference in the mean SST IFFR and PFFR between preoperative and early postoperative time points (p = 0.766 and p = 0.180, respectively), but the late postoperative values were higher than preoperative values (p = 0.009 and p = 0.049, respectively). Late postoperative clinical scores (ASES, UCLA, and Constant scores) in the SRT group improved compared to preoperative time (p < 0.001, p < 0.001, and p = 0.016, respectively). In the healed group, compared with the preoperative values, there was no difference in the mean SST IFFR and PFFR at postoperative time points; however, the late postoperative clinical scores (ASES, UCLA, and Constant scores) were improved (all p < 0.001). In the SRT group, IFFR and PFFR progressed in the late postoperative period and clinical scores improved over time. However, in the LRT group, IFFR and PFFR progressed in the early and late postoperative periods and clinical scores did not improve at the late postoperative follow-up.

Effect of Patient Characteristics on the Minimal Clinically Important Difference and Patient Acceptable Symptom State Thresholds After Arthroscopic Bankart Repair

Background: There is scarce literature on clinically significant values after arthroscopic Bankart repair (ABR). Purpose: To determine the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) thresholds at 1 year for the Rowe and Athletic Shoulder Outcome Scoring System (ASOSS) scores after ABR and to determine the effect of patient characteristics on these metrics after ABR. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review of patients undergoing ABR from a single institution between January 2017 and January 2020 was performed. Patients with at least 1 episode of instability and a minimum follow-up of 12 months were included. The exclusion criteria were as follows: bony defects of >20% on the anteroinferior portion of the glenoid based on a preoperative computed tomography scan; engaging Hill-Sachs lesions at 90° of abduction and 90° of external rotation based on an arthroscopic examination; previous surgery on the same shoulder; multidirectional instability or concomitant repair of full-thickness rotator cuff tears; superior labral anterior to posterior lesions; posterior labral tears; or humeral avulsion of the glenohumeral ligament lesions. Patient-reported outcome measures were collected both preoperatively and 1-year postoperatively. Delta was defined as the change between preoperative and 1-year postoperative scores. Distribution-based (one-half the standard deviation of the difference between pre- and postoperative outcome scores) and anchored-based approaches (response to a satisfaction question at 1 year) were used to estimate the MCID and the PASS, respectively. The optimal cutoff point, where sensitivity and specificity were maximized, and the percentage of patients achieving those thresholds were also calculated. Results: Overall, 190 patients were included. The distribution-based MCID for the Rowe and ASOSS scores were calculated to be 8.2 and 8.7, respectively. The rate of patients who achieved MCID thresholds was 96% for the Rowe and 96% for ASOSS scores. The PASS threshold for the Rowe and ASOSS scores were ≥80 and ≥90, respectively. The rate of patients who achieved PASS scores after ABR were 86% and 83%, respectively. The MCID and PASS values showed great variability based on sex (men: 8.5 and ≥85 for Rowe / 8.9 and ≥90 for ASOSS, respectively, vs women: 6.7 and ≥73 for Rowe / 8.1 and ≥75 for ASOSS), age (≥21: 8.4 and ≥80 / 9.2 and ≥90 vs <21: 7.8 and ≥75 / 7.7 and ≥85), sports participation (sports: 8.8 and ≥85 / 9.5 and ≥90 vs no sports: 8.1 and ≥75 / 8.6 and ≥80), and type of athlete (competitive: 8.4 and ≥85 / 8.9 and ≥87 vs recreational: 7.5 and ≥73 / 8.1 and ≥68). Conclusion: This study identified the MCID and PASS thresholds for the Rowe and ASOSS scores at 1 year after ABR. However, these values showed great variability when accounting for different patient characteristics such as sex, age, sports participation, and type of athlete, highlighting the importance of considering individual patient-specific characteristics for optimal treatment decision-making and ensuring treatment success tailored to each patient’s unique needs and expectations.

3D-printed biomimetic scaffolds loaded with ADSCs and BMP-2 for enhanced rotator cuff repair.

Rotator cuff tear repair poses significant challenges due to the complex gradient interface structure. In the face of disease-related disruptions in the tendon-bone interface (TBI), the strategy of constructing a biomimetic scaffold is a promising avenue. A novel 3D-printed rotator cuff scaffold loaded adipose stem cells (ADSCs), bone morphogenetic protein-2 (BMP-2), and collagen type I (COL I). The efficiency of the slow-release BMP-2 design depended on the dopamine-hyaluronic acid (HAD) and BMP-2 reaction. The cumulative release of BMP-2 was 44.97 ± 5.45% at 4 weeks. The 3D-printed bilayer scaffold, incorporating COL I and BMP-2, effectively promoted the differentiation of ADSCs into osteogenic, tenogenic, and chondrogenic lineages in vitro. The combination of 3D-printed bioactive scaffolds and ADSCs demonstrated a superior repair effect on rotator cuff injuries in vivo. Therefore, these findings indicates that the 3D-printed biomimetic scaffold loaded with ADSCs and BMP-2 holds potential as a promising graft for TBI healing.

A Knotless Single-Row Suture Bridge Technique to Repair a Partial Articular Suproaspinatus Tendon Avulsion-Type Rotator Cuff Tear: Surgical Technique

With improving surgical and technological solutions for repairing rotator cuff tears, there has been increased interest in treatment of partial rotator cuff tears. The most prevalent type of partial tear is the PASTA (partial articular supraspinatus tendon avulsion) lesion. There is an ongoing debate on the best surgical technique to repair a PASTA lesion, which has led to the development of many different arthroscopic techniques. This Technical Note provides a cost-effective and reproducible technique of a transtendinous single-row bridge repair of PASTA lesions, using two 1.8 FiberTak Knotless Soft Anchors.

Arthroscopic Rotator Cuff Repair in the Elderly: Long-Term Outcomes

Abstract Introduction: Rotator cuff tear (RCT) is one of the most common ailments around the shoulder. Its incidence increases significantly with age. However, owing to the variable healing potential and retear rates, the ideal management of RCT in the elderly is still up for debate. The purpose of this study is to observe and analyze the long-term functional outcomes in patients older than 60 years of age, who have undergone arthroscopic RCT repair. Methods: Fifty-seven cases who had undergone arthroscopic RCT repair with a minimum postoperative follow-up for 3 years were identified, in this single surgeon monocentric retrospective study. They were assessed using shoulder pain and disability index (SPADI) scoring. Results: Out of the 57 patients with ages more than 60 years, 10 were beyond 70 years of age. The mean age of the group was 65.2 years (standard deviation [SD] =4.86) ranging from 60 to 84 years. The mechanism of injury was atraumatic in 27 cases. The mean follow-up period was 57.9 months (SD = 15.7). The cases were categorized based on the number of rotator cuff tendons involved in the tear. The mean SPADI% for pain in all the cases was 0.98% (SD = 2.1). Forty-two out of the total 57 cases had a SPADI of 0%. They were completely asymptomatic, with their operated shoulder as good as the other. No statistically significant correlation was found between the SPADI scores and the number of tendons repaired (r = 0.06). Conclusion: An optimal tension-free arthroscopic repair of the RCT can yield good results even in the elderly. The age of the patient, the duration of the tear before surgery, and the size of the tear should not be considered as a stand-alone factor to deny surgical management if the fatty infiltration is within a limit. Irrespective of the retear rates the overall functional outcomes are still good.

Neck fluid extravasation in shoulder arthroscopic surgery-a life-threatening complication: a report of two cases

Fluid extravasation in shoulder arthroscopy may lead to life-threatening consequences, such as airway compromise. These cases are rare and few were reported in the literature. Clinical cases of 2 female patients submitted to shoulder arthroscopy for a rotator cuff tear repair, complicated with fluid extravasation that led to trachea compression and need for intensive care unit (ICU) admission with postponed extubation. Neither patients showed any sequelae in the follow-up period. Report of these rare complications, with detailed and reproducible information, is vital for their comprehension and future elaboration of surveillance and treatment guidelines.

Repair of Massive Rotator Cuff Tear With Medialization and Balloon Spacer Insertion

Retracted massive rotator cuff tears can be challenging to repair. Reduction of the retracted tendon to the native footprint may result in a repair with excessive tension. Repair under excessive tension predisposes to increased tendon retear rates. Footprint medialization involves securing the tendon medial to the anatomic footprint, resulting in decreased tension during repair. Several surgical adjuncts can also be employed to reinforce such tears so as to reduce the risk of retear. The aim of this Technical Note is to describe a surgical technique of rotator cuff repair with medialization of the footprint combined with a balloon spacer insertion.

Comparison of post-operative outcomes in arthroscopic repair of traumatic and atraumatic rotator cuff tears

Background Traumatic or atraumatic etiologies are associated with different pathophysiology, and thus, may lead to different post-operative outcomes after arthroscopic rotator cuff repair (RCR). Methods Institutional records were used to identify patients who underwent arthroscopic RCR in 2019-2020. Retrospective review of medical records was performed to determine mechanism of injury, pre- and post-operative range of motion and strength measures. Results Among 100 RCR patients, 53 sustained a traumatic RC injury. Patients with traumatic rotator cuff tears (TR) presented to the clinic after onset of pain sooner than patients with atraumatic tears (aTR) (TR: 166±193 vs aTR: 595±679 days; P&lt;0.001). Pre-operative measurements were worse among traumatic patients than atraumatic patients: forward elevation (TR: 130º±48º vs aTR: 152º±25º; P=0.036), external rotation (TR: 49º±17º vs aTR: 55º±16º; P=0.076), internal rotation (TR: L4 vs aTR: L3; P=0.033), forward elevation strength (TR: 4/5 vs aTR: 5/5; P=0.035), external rotation strength (TR: 5/5 vs aTR: 5/5; P=0.065), and internal rotation strength (TR: 5/5 vs aTR: 5/5; P=0.150). However, there was no significant difference in post-operative measurements between cohorts: forward elevation (TR: 158º±19º vs aTR: 153º±28º; P=0.433), external rotation (TR: 53º±16º vs aTR: 50º±15º, P=0.332), internal rotation (TR: L2 vs aTR: L2; P=0.703), forward elevation strength (TR: 5/5 vs aTR: 5/5; P=0.926), external rotation strength (TR: 5/5 vs aTR: 5/5; P=0.920), and internal rotation strength (TR: 5/5 vs aTR: 5/5; P=0.519). Conclusion Traumatic RCR patients had significantly worse functional measurements during pre-operative exam than atraumatic RCR patients, but there was no significant difference in post-operative outcomes.

Arthroscopic treatment of massive rotator cuff tears involving subscapularis

Introduction. Massive rotator cuff tears represent a major challenge in shoulder surgery. Contemporary arthroscopic techniques allow for repair in majority of cases. In the setting of a massive rotator cuff tear, engagement of subscapularis plays a significant role in function deterioration and is a risk factor for pseudoparalysis.&#x0D; Materials and methods. We present our experience and clinical results with arthroscopic repair of massive rotator cuff tears engaging subscapularis in 32 patients, followed for 12,5 months.&#x0D; Results. Complete repair was performed in 25 (78.1%) and partial repair in 7 (21,9%) of the cases with significant improvement in active forward flexion and good to excellent functional result in 68,8%, according to Constant score. Acute pseudoparalysis was successfully reversed in 8 out of 9 cases (88,8%). Transient neurologic complication was observed in 1 case (3%).&#x0D; Conclusion. Subscapularis plays an important role in massive rotator cuff tears and should always be repaired. Arthroscopic repair of massive rotator cuff tears engaging subscapularis is safe and efficient with good clinical results during one year follow up. While complete repair of all torn tendons with secure reattachment to the tuberosities is the preferred surgical treatment, repair of subscapularis and lower portion of infraspinatus is crucial for normal rotator cuff function. Careful patient selection and individually tailored surgery is important for successful treatment.

Arthroscopic rotator cuff repair in patients over 65 years of age: successful functional outcomes and a high tendon integrity rate can be obtained after surgery

BackgroundAlthough interest in studies evaluating the outcomes of rotator cuff repair is steadily increasing, the results and tendon integrity after arthroscopic rotator cuff repair in elderly patients have only been minimally investigated. The aim of this study was to evaluate clinical outcomes and repair integrity in patients over 65 years of age who underwent arthroscopic repair of full-thickness rotator cuff tears. MethodsA retrospective study was conducted with the following inclusion criteria (1) elective shoulder arthroscopy for rotator cuff repair for full-thickness postero-superior tears; (2) age over 65 years at surgery; and (3) participation in 24 months follow-up. Preoperatively, the range of motion (ROM) and the Constant-Murley Score (CMS) and at follow-up, the ROM, the SF-12, the American Shoulder and Elbow Surgeons (ASES), and the CMS were evaluated; an ultrasonographic assessment of tendon integrity was performed according to the adapted Sugaya classification. ResultsThe final sample consisted of 110 patients with an average age of 69.2±3.5 years. The mean duration of nonoperative management before surgery was 2.6 ± 0.8 months. The mean period of preoperative physical therapy was 0.6 ± 0.9 months. ROM and CMS showed statistically significant improvement (all p<0.001) after a mean follow-up time of 54.5±22.3 months. The ultrasonographic assessment showed tendon integrity (types I and II) in 75% of cases; 21% were type III repair, and rotator cuff retear (types IV and V) was recorded in 4% of cases. All scores directly correlated with the integrity of the tendon. In the multivariate analysis, higher postoperative CMS was associated with male sex (p<0.001, β=-6.085) and lower age (p=0.004, β=-0.533). Higher postoperative ASES were associated with lower age (p=0.020, β=-0.414). Higher postoperative SF-12 PCS and MCS were associated with lower age (p=0.013, β=-0.550 and p<0.001, β=-0.520, respectively) and shorter preoperative physical therapy period (p=0.013, β =-2.075 and p=0.006, β =-1.093, respectively). ConclusionsA significant ROM and CMS recovery and a rotator cuff integrity rate of 75% can be expected in patients over 65 years of age who undergo arthroscopic repair for full-thickness rotator cuff tears. Better functional, physical and mental health outcomes correlate with rotator cuff integrity and are predicted by male sex and a shorter period of preoperative physical therapy.

Recombinant Human Parathyroid Hormone Biocomposite Promotes Bone-to-Tendon Interface Healing by Enhancing Tenogenesis, Chondrogenesis, and Osteogenesis in a Rabbit Model of Chronic Rotator Cuff Tears

To investigate the effect of recombinant human parathyroid hormone (rhPTH) biocomposite on bone-to-tendon interface (BTI) healing for surgical repair of a chronic rotator cuff tear (RCT) model of rabbit, focusing on genetic, histologic, biomechanical and micro-computed tomography (CT) evaluations. Sixty-four rabbits were equally assigned to the 4 groups: saline injection (group A), nanofiber sheetalone (group B), rhPTH-soaked nanofiber sheet (nanofiber sheet was soaked with rhPTH, group C), and rhPTH biocomposite (rhPTH permeated the nanofiber sheet by coaxial electrospinning, group D). The release kinetics of rhPTH (groups C and D) was examined for 6 weeks invitro. Nanofiber scaffolds were implanted on the surface of the repair site 6 weeks after the induction of chronic RCT. Genetic and histologic analyses were conducted 4 weeks after surgery. Furthermore, genetic, histologic, biomechanical, micro-CT, and serologic analyses were performed 12 weeks after surgery. Invivo, group D showed the highest collagen type I alpha 1 (COL1A1), collagen type III alpha 1 (COL3A1), and bone morphogenetic protein 2 (BMP-2) messenger RNA (mRNA) expression levels (all P < .001) 4 weeks after surgery; however, there were no differences between groups at 12 weeks postsurgery. After 12 weeks postsurgery, group D showed better collagen fiber continuity and orientation, denser collagen fibers, more mature bone-to-tendon junction, and greater fibrocartilage layer formation compared with the other groups (all P < .05). Furthermore, group D showed the highest load-to-failure rate (28.9 ± 2.0 N/kg for group A, 30.1 ± 3.3 N/kg for group B, 39.7 ± 2.7 N/kg for group C, and 48.2 ± 4.5 N/kg for group D, P < .001) and micro-CT outcomes, including bone and tissue mineral density, and bone volume/total volume rate (all P < .001) at 12 weeks postsurgery. In comparison to rhPTH-soaked nanofiber sheet and the other control groups, rhPTH biocomposite effectively accelerated BTI healing by enhancing the mRNA expression levels of COL1A1, COL3A1, and BMP-2 at an early stage and achieving tenogenesis, chondrogenesis, and osteogenesis at 12 weeks after surgical repair of a chronic RCT model of rabbit. The present study might be a transitional study to demonstrate the efficacy of rhPTH biocomposites on BTI healing for surgical repair of chronic RCTs as an adaptable polymer biomaterial in humans.

Shoulder pain management strategies and early functional outcome after arthroscopic rotator cuff tear repair. A randomized controlled study

BackgroundThe management of acute postoperative pain after rotator cuff surgery can be challenging. To our knowledge, there are no data available in the literature correlating satisfactory pain control with improvement in terms of function. The purposes of the present study were to evaluate: 1) pain pattern after arthroscopic rotator cuff repair in patients operated with two different techniques (transosseous vs transosseous equivalent); 2) safety/efficacy of three different pharmacological pain control strategies; 3) possible relationship between a correct shoulder pain management protocol in the early post-operative period and patients’ functional improvement. Methods114 patients underwent rotator cuff tear repair, either with a Transosseus or a Transosseus equivalent technique. 62 (54%) were male and 52 (46%) were female. The average age was 59 ± 9 years. They were randomly assigned into three different pain management protocols: Paracetamol as needed (max 3 tablets/day) for 1 week (Protocol A), Paracetamol + Codein 1 tablet three times per day for 7 days (Protocol B), or Paracetamol + Ibuprofen 1 tablet two times per day for 7 days (Protocol C). Immediate passive mobilization of the operated shoulder was allowed. VAS and Passive Flexion values were recorded at 7 (T1), 15 (T2) and 30 (T3) days post-surgery. DASH values were recorded at 90 days post-surgery. All patients were asked to register any kind of signs/symptoms that may appear during drug assumption according to each pain management protocols. ResultsAll the pain management protocols administered were well tolerated by all the study population, and no adverse signs/symptoms were highlighted during drug assumption.Pain pattern: in both surgical techniques, patients within Protocol A were associated with worst results in terms of mean VAS at each time point examined when compared to Protocol B and C (p < 0,05). In patients within Protocol A, no statistically significant differences were found at each point time examined comparing the two surgical techniques, with the exception of T2, where the TO was associated with an higher VAS value than TOE (p < 0.05). No differences were highlighted in Protocol B and C when comparing the values between two surgical techniques.ROM: in both surgical techniques, patients within Protocol A were associated with worst results in terms of mean PROM at each time point examined when compared to Protocol B and C (p < 0,05). In the TO group, patients within Protocol B had better PROM values at T1 (p < 0,05) and T2 (p < 0,05) compared to Protocol C, but no differences were highlighted at T3. In the TOE group, no statistically significant differences were found between patients within Protocol B and C at each time point examined.DASH: In the TO group, no statistically significant differences were found regarding the DASH values comparing Protocol B vs Protocol C, but they were highlighted comparing the values between Protocol A and Protocol B (p < 0,05), and between Protocol A and Protocol C (p < 0,05). Similar results were recorded in the TOE group. ConclusionPost-operative pain is influenced by the surgical technique used being transosseous more painful in the first 15 days after surgery. Oral anti-inflammatory drugs are a feasible strategy to appropriately control post-operative pain. An association between Paracetamol and either Codein or Ibuprofen can lead to better outcomes in terms of VAS reduction and early recovery of passive ROM.

Influence of body mass index on severity of rotator cuff tears

Research on the relationship between obesity and rotator cuff tears (RCTs) has been limited to the impact of obesity on the results of arthroscopic repair of RCTs; thus, a need for rigorous research controlling for other factors affecting RCTs is warranted, especially to better understand the impact of body mass index (BMI) on RCT severity. A retrospective study of admission records contained in electronic medical records pertaining to patients who were admitted for RCT repair on one shoulder between January 2018 and July 2022 was conducted. In total, 386 patients were included. In accordance with guidance regarding obesity from Taiwan's Ministry of Health and Welfare, patients were divided into three groups: underweight or normal weight (BMI <24.0 kg/m2), overweight (BMI 24.0-26.9 kg/m2), or obese (BMI ≥27.0 kg/m2). Magnetic resonance imaging (MRI) was used to assess RCT severity in terms of four parameters: Patte stage (PS), fatty infiltration (FI), anteroposterior tear size (AP), and retraction size. Multinomial logistic regression analysis was performed on Patte stage and FI grade data, and multiple linear regression analysis was performed on AP tear size and retraction size in order to analyze impact. Our results revealed that the average age of the 386 patients was 63.41 years (SD = 9.29) and the mean BMI was 25.88 (SD = 3.72) kg/m2. We found significant differences in PS (p =.003), FI (p <.001), retraction size (p =.001), and AP tear size (p =.001) among patients who were underweight or normal weight, overweight, and obese. After controlling for other risk factors, including age, gender, RCT-prone occupation, duration of shoulder pain prior to surgery, history of shoulder injury, and tobacco use, we found that obese patients had higher severity levels in PS (B = 1.21, OR = 3.36, p = .029), FI (B = 1.38, OR = 3.96, p < .001), retraction size (β = .18, p = .001), and AP tear size (β = .18, p = .001) compared to underweight or normal weight patients. Our study demonstrates that a correlation exists between BMI-measured obesity and RCT severity. We therefore suggest that adults control their weight given that maintaining a healthy weight is highly associated with better shoulder health.

The effect of platelet-rich fibrin, platelet-rich plasma, and concentrated growth factor in the repair of full thickness rotator cuff tears

Rotator cuff lesions rank among the prevalent causes of shoulder pain. Combining surgical interventions with growth factors, scaffolds, and stem cell therapies can effectively decrease the likelihood of rotator cuff repair recurrence. Platelet-rich plasma (PRP), platelet-rich fibrin (PRF), and concentrated growth factor (CGF), isolated from blood and rich in growth factors, have a critical role in cell migration, cell proliferation, and angiogenesis during the tissue regeneration process. Investigations have further substantiated the beneficial impact of PRP and PRF on the biomechanical and histologic attributes of the tendon-bone interface. We aimed to investigate the effectiveness of CGF compared with PRF and PRP in the repair of rotator cuff lesions as a new treatment strategy. Incision was performed on both shoulder regions of 21 adult rabbits. After 8 weeks, both shoulders of the rabbits were repaired by suturing. PRF and CGF were administered to 2 separate groups along with the repair. Tissues were collected for biomechanical measurements and histologic evaluations. Histologically, CGF, PRF, and PRP showed similar results to the healthy control group. The level of improvement was significant in the PRF and PRP groups. In the PRF group, the distribution of Ki67 (+), CD31 (+), and CD34 (+) cells was determined intensely in the tendon-bone junction regions. Apoptotic cells increased significantly in the repair group compared with the healthy group, whereas fewer apoptotic cells were found in the PRF-, PRP-, and CGF-applied groups. In the biomechanical results, no statistical difference was recorded among the groups. The use of PRF, PRP, and CGF in rotator cuff repair shows promise in shortening the treatment period and preventing the recurrence of rotator cuff lesions.

Greater Socioeconomic Disadvantage as Measured by the Area Deprivation Index Is Associated With Failure of Healing Following Arthroscopic Repair of Massive Rotator Cuff Tears but Not With Clinical Outcomes

To analyze the relationship between Area Deprivation Index (ADI) and preoperative status and short-term postoperative clinical outcomes among patients who underwent arthroscopic rotator cuff repair (ARCR) of massive rotator cuff tears (MRCTs). A retrospective review was conducted on prospectively maintained data on patients who underwent ARCR of MRCTs defined as tear size ≥5 cm or complete tear of at least 2 tendons, with a minimum 2-year follow-up and a valid home address between January 2015 and December 2018. Each patient's home address was mapped to the ADI to determine neighborhood disadvantage. This composite index is composed of 17 census-based indicators, including income, education, employment, and housing quality to quantify the level of socioeconomic deprivation. Ratings were recorded and categorized based on the sample's percentile. Patients were then divided into 2 groups: upper quartile (ie, most disadvantaged [≥75th percentile]) and lower 3 quartiles (ie, least disadvantaged [<75th percentile]). Bivariate analysis was performed to associate ADI with patient-reported outcomes (PROs) and range of motion pre- and postoperatively, as well as complications, healing rate, satisfaction, and return to work. Patients reaching or exceeding the minimal clinically important difference for visual analog scale (VAS), American Shoulder and Elbow Surgeons, Veterans Rand 12-Item questionnaire, and subjective shoulder value were recorded for both cohorts. Ninety-nine patients were eligible for study analysis. Preoperative PROs and range of motion were similar, except for a greater VAS for pain (6.3 vs 4.3; P < .01) and lower American Shoulder and Elbow Surgeons score (32.2 vs 45.1; P= .01) in the most disadvantaged group. Both groups showed similar postoperative PROs scores, but greater VAS improvement was seen in the upper quartile group (Δ 4.2 vs Δ 3.0; P= .04). In contrast, only the least-disadvantaged group significantly improved in internal rotation (P= .01) and forward flexion (18°; P < .01) from baseline. Although satisfaction, complications, and return to work were comparable (P > .05), failure of healing occurred more frequently in the most disadvantaged group (21% vs 6%; P= .03). Patients with MRCTs residing in the most disadvantaged neighborhoods as measured by the ADI have more pain and functional limitations before undergoing ARCR but demonstrate similar postoperative functional improvements to patients from other socioeconomic backgrounds. Failure of healing of MRCTs may be more common in disadvantaged groups. Furthermore, both groups reported similar rates of clinically important functional improvement. Level III, retrospective cohort comparison.

Economic Evaluation of a Bioinductive Implant for the Repair of Rotator Cuff Tears Compared with Standard Surgery in Italy.

Rotator cuff tear (RCT) is a painful, progressive condition resulting from damage to the rotator cuff tendons and is the leading cause of shoulder-related disability. Surgical repair of rotator cuff is an established standard of care (SOC); however, failure of the procedure can occur. In this context, the use of collagen-based bioinductive implant REGENETEN showed long-term improvements in clinical scores. The aim of the study was to assess the cost-effectiveness of REGENETEN combined with SOC (SOC + REGENETEN) compared to SOC alone from both National Healthcare Service (NHS) and societal perspectives in Italy. A decision analytic model was developed to estimate the number of tears healed and costs for the two considered treatment strategies over 1year. Clinical data were retrieved from the literature, and the clinical pathways for the management of patients with RCTs were retrieved from four key opinion leaders in Italy. Over a 1-year time horizon, healed lesions were 90.70% and 72.90% for surgical repair of RCTs with and without REGENETEN, respectively. Considering the NHS perspective, mean costs per patient were €7828 and €4650 for the two strategies, respectively, leading to an incremental cost-effectiveness ratio (ICER) of €17,857 per healed tear. From the societal perspective, the mean costs per patient were €12,659 for SOC and €11,784 for REGENETEN, thus showing savings of €4918 per healed tear when the bioinductive implant is used. The sensitivity analyses confirmed the robustness of the model results. In the context of paucity of cost-effectiveness studies, our findings provide additional evidence for clinicians and payers regarding the value of a new treatment option that supports a tailored approach for the management of patients with RCTs.

Mini open anterolateral rotator cuff tear repair with the help of suture anchor

Background: It is generally accepted that mini open rotator cuff tear repair with the help of suture anchor gives satisfactory results in the long term, although most studies have so far shown a fairly high rate of good structural and functional outcome. The purpose of this study is to asses functional outcome of mini-open anterolateral rotator cuff tear repair with the help of suture anchor. Method: The 30 consecutive rotator cuff tear patients were selected from outpatient department at medical college. All patients were diagnosed with full thickness rotator cuff tear and subsequently treated with mini-open anterolateral approach technique. Each patient was clinically assessed with DASH questionnaire and constant Murley score for their satisfaction. Results: After a minimum of 12 month follow up period, the average clinical outcome scores all improved significantly at the time of final follow up. Conclusions: Patient with mini-open anterolateral rotator cuff tear repair with the help of anchor suture showed improvement in their functional outcome and range of motion.

The pathology of oxidative stress-induced autophagy in a chronic rotator cuff enthesis tear.

Partial-thickness rotator cuff tears (PTRCTs) are often found in daily orthopedic practice, with most of the tears occurring in middle-aged patients. An anaerobic process and imbalanced oxygenation have been observed in PTRCTs, resulting in oxidative stress. Studies have shown the roles of oxidative stress in autophagy and the potential of unregulated mechanisms causing disturbance in soft tissue healing. This article aims to review literature works and summarize the potential pathology of oxidative stress and unregulated autophagy in the rotator cuff enthesis correlated with chronicity. We collected and reviewed the literature using appropriate keywords, in addition to the manually retrieved literature. Autophagy is a normal mechanism of tissue repair or conversion to energy needed for the repair of rotator cuff tears. However, excessive mechanisms will degenerate the tendon, resulting in an abnormal state. Chronic overloading of the enthesis in PTRCTs and the hypovascular nature of the proximal tendon insertion will lead to hypoxia. The hypoxia state results in oxidative stress. An autophagy mechanism is induced in hypoxia via hypoxia-inducible factors (HIFs) 1/Bcl-2 adenovirus E1B 19-kDa interacting protein (BNIP) 3, releasing beclin-1, which results in autophagy induction. Reactive oxygen species (ROS) accumulation would induce autophagy as the regulator of cell oxidation. Oxidative stress will also remove the mammalian target of rapamycin (mTOR) from the induction complex, causing phosphorylation and initiating autophagy. Hypoxia and endoplasmic reticulum (ER) stress would initiate unfolded protein response (UPR) through protein kinase RNA-like ER kinase (PERK) and activate transcription factor 4, which induces autophagy. Oxidative stress occurring in the hypovascularized chronic rotator cuff tear due to hypoxia and ROS accumulation would result in unregulated autophagy directly or autophagy mediated by HIF-1, mTOR, and UPR. These mechanisms would disrupt enthesis healing.

Postoperative psychological factors and quality of life but not shoulder brace adherence affect clinical outcomes after arthroscopic rotator cuff repair.

Despite the high prevalence, there is no consensus for postsurgical management after rotator cuff repair. We aimed to assess the impact of psychological well-being on patients who underwent rotator cuff repair. We also investigated correlations and possible predictors between patient demographics and adherence to the use of the shoulder brace and outcomes in terms of shoulder functionality and quality of life. We conducted a retrospective study with prospective data collection enrolling 120 consecutive patients who underwent shoulder arthroscopy for rotator cuff tear repair. Each patient was clinically evaluated after a mean follow-up of 24.2 (±9.8) months using (1)the Disability of the Arm, Shoulder and Hand (DASH) scale, (2) the Hospital Anxiety and Depression Scale (HADS), (3) the Rotator Cuff Quality of Life (RC-QoL), (4) the visual analog scale, and (5) the Medical Adherence Measure. The final sample consisted of 100 patients (45 females, 45%) averaging 60.9 (±8.5) years. The average brace wearing time was 3.4 (±0.6) weeks, with an adherence superior to 80% in 84% of cases, and 96% of patients were living with family members. The mean postoperative DASH scores were 20.1 (±16.7), 23.4 (±25), and 18.9 (±21.5) for the general, work, and sport sections, respectively. The mean Medical Adherence Measure score reached 72.5 (±14.2) points, and the RC-QoL mean score was 30.4% (±20.5). The Hospital Anxiety and Depression Scale-Anxiety and Hospital Anxiety and Depression Scale-Depression scores' continuous mean values were 5.1 (±3.4) and 3.9 (±3.6), respectively. The DASH, Hospital Anxiety and Depression Scale-Anxiety, Hospital Anxiety and Depression Scale-Depression, and RC-QoL scores directly correlated with each other, and all these questionnaires directly correlated with the visual analog scale scores. Moreover, we found a direct correlation (r=0.204, P=.033) between the female sex and adherence to the brace and a direct correlation (r=0.242, P=.015) between adherence to the brace and the number of weeks it was worn according to the medical recommendation. A correlation between lower educational qualifications and poorer outcomes was found. No correlation emerged between adherence to the brace and functional results. According to the regression analysis, diabetes was found to be a predictor of worse postoperative DASH scores (β=0.245, P=0.28). A lower perceived quality of life was associated with worse functional results, anxiety and depression symptoms, and pain after rotator cuff repair surgery. The adherence to the use of the shoulder brace was associated with the female sex and a longer prognosis, but no correlation emerged between adherence to the brace and functional outcomes.

Comparison of the Functional Outcomes of Arthroscopic Debridement and Repair of Bursal-side Partial-thickness Rotator Cuff Tears

Background: To compare the clinical and functional scores of arthroscopic debridement and repair (conversion to full thickness) surgeries in patients with bursal-side partial-thickness rotator cuff tears (BPTRCT). Materials and Methods: A single-center retrospective study was conducted to compare the arthroscopic debride-ment and arthroscopic repair for BPTRCT performed between March 2017 and September 2021. Arthroscopic debridement patients were grouped as Group 1 and the repair group as Group 2. A total of 98 patients with an average age of 57.5 years (range 29-83 years), including 41 male and 57 female patients, met the inclusion criteria. VAS (Visual Analogue Scale) and UCLA (University of California Los Angeles) shoulder scores applied in the preopera-tive period and in the 12th month of the postoperative clinical follow-ups were evaluated. In addition to the pre-operative and postoperative comparison of both scores, their improvement of these scores was also compared. Results: The mean age of the repair group and the debridement group was 64.4 ±11.02 and 52.6 ±11.24, respective-ly. No significant difference between the two groups was observed in terms of demographic characteristics (p˃0.05). The mean operation time was 91.46 ±16.44 min in the repair group and 49.82 ±13.46 min in the debridement group. The VAS score dramatically improved, from preoperative 5.10±1.23 to postoperative 3.68±1.33 points in the deb-ridement group and from preoperative 5.17±1.35 to postoperative 3.58±1.16 points in the repair group. The two groups had no statistically significant difference in postoperative VAS scores (p=0.991). Preoperative and postopera-tive VAS score improvement was also compared between the groups, however, there was also no statistically signifi-cant difference in terms of VAS score changes (p=0.132). The UCLA scores also dramatically improved, from pre-operative 17.14±4.19 to postoperative 24.57±5.04 points in the debridement group and from preoperative 17.46±5.05 to postoperative 25.48±5.61 points in the repair group. No statistically significant difference was ob-served between the two groups in terms of postoperative UCLA scores (p=0.361). In the postoperative first-year follow-up, no re-tears were observed either in the debridement or in the repair group. Conclusions: Both arthroscopic debridement and arthroscopic repair surgeries provide clinically comparable suc-cessful results and high satisfaction for patients with bursal-side rotator cuff tears. No statistically significant differ-ence was observed between these two methods. Easier early postoperative rehabilitation seems to be the main advantage of the debridement method.