Rotator Cuff Tendon Repair Research Articles

Patients With Diabetes Mellitus Have a Higher Risk of Tendon Retear After Arthroscopic Rotator Cuff Repair: A Meta-analysis.

Background:Retear of a repaired rotator cuff tendon is a major issue for shoulder surgeons. It is possible that diabetes mellitus (DM) is associated with a greater risk of tendon retear after arthroscopic rotator cuff repair.Purpose:To determine whether patients with DM have a higher tendon retear risk after arthroscopic rotator cuff repair.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the Web of Science, PubMed, and Embase databases. Inclusion criteria were articles written in the English language that included patients undergoing arthroscopic rotator cuff repair surgeries, reported the numbers of patients with and those without DM, and reported the number of rotator cuff retears. Data relevant to this study were extracted and statistically analyzed. Random-effects models were used to generate pooled odds ratio estimates and CIs.Results:A total of 160 studies were identified from the initial search, and 5 of them met the inclusion criteria. A total of 1065 patients (207 patients with DM and 858 patients without DM) were included. The pooled results showed that the patients in the DM group had a significantly higher tendon retear risk than did those in the non-DM group (relative risk, 2.25; 95% CI, 1.14-4.45; P = .02).Conclusion:Patients with DM have a 2.25 times higher risk of tendon retear after arthroscopic rotator cuff repair compared with patients without DM.

Preliminary outcomes of arthroscopic biceps rerouting for the treatment of large to massive rotator cuff tears

We aimed to evaluate the short-term outcomes of arthroscopic biceps rerouting (ABR) for the treatment of large to massive rotator cuff tears (LMRCTs). A prospective evaluation of patients treated with ABRfor the repair of LMRCTs was performed, with a minimum follow-up period of 18 months. Range of motionand functional outcomes (visual analog scale pain score, American Shoulder and Elbow Surgeons score, and Korean Shoulder Scale score) were assessed preoperatively and at final follow-up. Radiographs were used to evaluate the acromiohumeral interval (AHI). Magnetic resonance imaging was performed at 2 and 12 months postoperatively to examine the integrity of the repaired rotator cuff tendons. Eighty patients who met the study criteria underwent ABR from March 2017 to January 2019 in our hospital. Of these patients, 61 could be evaluated ≥18 months after surgery. The average age of the enrolled patients was 64.5 years. The visual analog scale pain score decreased from 3.7 preoperatively to 1.6 at final follow-up (P = .019), the American Shoulder and Elbow Surgeons score improved from 60.0 to 85.2 (P < .001), and the Korean Shoulder Scale score improved from 64.3 to 85.3 (P = .001). Assessment of range of motion showed significant improvement in forward flexion (from 138° to 146°, P < .001), external rotation at 90° of abduction (from 80° to 85°, P = .037), and internal rotation (from spinal level 9 to spinal level 10, P = .015) from preoperatively to last follow-up. The AHI was 7.1 mm at baseline and improved significantly to 9.7 mm at 3 months postoperatively (P < .001). The mean AHI at last follow-up was only 9 mm, but this was still significantly better than the mean preoperative AHI (P < .001). Of the patients, 16 (26%) exhibited a retear of the repaired rotator cuff on magnetic resonance imaging at 12 months postoperatively. Male sex was the only significant risk factor for retear (P = .037). ABR improved the functional and radiologicoutcomes of patients with LMRCTs. The ABR technique can be a useful treatment option for LMRCTs.

Rotator cuff repair with biological graft augmentation causes adverse tissue outcomes

Background and purpose — Biological patches can be used to augment rotator cuff tendon repair in an attempt to improve healing and reduce rates of re-rupture. However, little is known about the in vivo tissue response to these patches. We assessed native rotator cuff tissue response after surgical repair and augmentation with 2 commercially available extracellular matrix (ECM) patches. Patients and methods — Patients underwent a rotator cuff repair augmented with either GraftJacket (Wright Medical), Permacol (Zimmer Biomet), or no patch (Control), applied using an onlay technique. A sample of supraspinatus tendon was collected intraoperatively and 4 weeks post-surgery, using ultrasound-guided biopsy. Histology and immunohistochemistry were performed on all samples. Results — The Permacol group (n = 3) and GraftJacket group (n = 4) demonstrated some changes in native tendon ECM compared with the control group (n = 3). Significant disruption of the extracellular matrix of the repaired native supraspinatus, underlying both patches, was observed. The patches did not generally increase cellularity, foreign body giant cell count, or vascularity compared to the control group. 1 patient in the Permacol group had an adverse tissue immune response characterized by extensive infiltration of IRF5+, CD68+, and CD206+ cells, suggesting involvement of macrophages with a pro-inflammatory phenotype. No significant differences in protein expression of CD4, CD45, CD68, CD206, BMP7, IRF5, TGFß, and PDPN were observed among the groups. Interpretation — Histological and immunohistochemical analysis of native tendon tissue after patch augmentation in rotator cuff repair raises some concerns about a lack of benefit and potential for harm from these materials.

3D printing of multilayered scaffolds for rotator cuff tendon regeneration

Repairing massive rotator cuff tendon defects remains a challenge due to the high retear rate after surgical intervention. 3D printing has emerged as a promising technique that enables the fabrication of engineered tissues with heterogeneous structures and mechanical properties, as well as controllable microenvironments for tendon regeneration. In this study, we developed a new strategy for rotator cuff tendon repair by combining a 3D printed scaffold of polylactic-co-glycolic acid (PLGA) with cell-laden collagen-fibrin hydrogels. We designed and fabricated two types of scaffolds: one featuring a separate layer-by-layer structure and another with a tri-layered structure as a whole. Uniaxial tensile tests showed that both types of scaffolds had improved mechanical properties compared to single-layered PLGA scaffolds. The printed scaffold with collagen-fibrin hydrogels effectively supported the growth, proliferation, and tenogenic differentiation of human adipose-derived mesenchymal stem cells. Subcutaneous implantation of the multilayered scaffolds demonstrated their excellent in vivo biocompatibility. This study demonstrates the feasibility of 3D printing multilayered scaffolds for application in rotator cuff tendon regeneration.

High Rate of Return to CrossFit Training After Arthroscopic Management of Rotator Cuff Tear.

Background:CrossFit is a conditioning program involving high-intensity exercises performed in rapid, successive repetitions with limited or no recovery time. The shoulder girdle is highly involved in most basic CrossFit training programs.Hypothesis:CrossFit athletes affected by rotator cuff tear may be successfully treated with arthroscopic surgery with a high rate of early return to CrossFit activities.Study Design:Case series; Level of evidence, 4.Methods:Included in this study were athletes participating regularly in CrossFit training who had undergone arthroscopic rotator cuff repair. At a minimum follow-up of 24 months, we compared pre- and postoperative clinical outcome scores, including the Constant Score (CS), the American Shoulder and Elbow Surgeons (ASES) score, and a visual analog scale (VAS) for pain, as well as imaging results. Participants completed a return-to-CrossFit questionnaire at the final follow-up, and changes in laboratory blood test results from preoperative to final follow-up were evaluated for association with outcomes and questionnaire responses.Results:A total of 22 CrossFit athletes (23 shoulders) completed the 24-month follow-up evaluation. Each athlete had undergone single-row rotator cuff tendon repair with additional procedures such as biceps tenodesis. All (100%) athletes returned to intensive CrossFit training at a mean 8.7 ± 3.4 months after surgery (range, 6-15 months). CS and ASES scores improved between preoperative and final follow-up from 73 to 92 (P = .037) and from 71 to 95 (P = .035), respectively; VAS pain score improved from 7.2 preoperatively to 0.8 at final follow-up (P < .001). Imaging evaluation of the repaired rotator cuff tendon showed complete healing in 18 cases (78%) and incomplete healing in 5 (22%). Of the 5 patients with incomplete healing, 2 had lower clinical scores at follow-up. In their questionnaire responses, 13 (59%) participants indicated return to a higher level of fitness, 7 (32%) returned to the same level, and 2 (9%) returned to a lower level. We found a significant association between patients who indicated return to a higher level of CrossFit fitness and higher levels of creatine phosphokinase and testosterone from preoperative to final follow-up (P = .029 and .023).Conclusion:Arthroscopic repair of rotator cuff tendons led to 100% return to CrossFit participation at approximately 9 months of follow-up. All athletes had returned to sport by the final follow-up. Nevertheless, 2 patients reported a lower level of performance and showed scapular dyskinesis.

Comparison between single and double suture passing techniques in the suture bridge rotator cuff repair with a 2-mm tape: A simulation study using a three-dimensional finite element method

BackgroundSuture bridge repair has been widely used as one of the standard procedures in the arthroscopic rotator cuff repair. We compared the intratendinous stress distribution between single and double suture passing techniques in the suture bridge repair using a 2-mm tape and clarified the roles of tensioning in this procedure. MethodsA board-like model of the supraspinatus tendon and humeral head was used in order to standardize conditions and exclude the influence of anatomical variations between individuals. Reattachment of the supraspinatus tendon to the bone was simulated using both single and double suture passing techniques for the suture bridge repair using a 2-mm tape. A tensile load was applied to the medial end of the tendon, and the stress distribution pattern was observed. Elastic analysis enabled comparison of the von Mises equivalent and maximum principal stresses between the single and double suture passing techniques. The tape configuration was subsequently translated 1 mm toward the insertion points of lateral anchors to simulate the tensioning maneuver. ResultsAlthough the distribution pattern of both the equivalent and the maximum principal stresses was similar for both models, areas with a high stress concentration were smaller in the single suture passing model than those in the double suture passing model. The equivalent stress concentrated within the tendon beneath the tapes as well as in the area between the crossing tapes and the lateral end of the tendon, whereas the maximum principal stress concentrated medial to the sites of suture penetration. ConclusionsSingle suture passing technique can reduce the extent of intratendinous stress concentration compared with double suture passing technique, which might be beneficial to reduce the incidence of type 2 retear after suture bridge repair of rotator cuff tendon using a 2-mm tape.

Contribution of postoperative ultrasound to early detection of anchor pullout after rotator cuff tendon repair: Report of 3 cases

IntroductionRotator cuff repair by suture bridge is now widely used. Few studies reported secondary pullout of radiotransparent anchors. The aim of the present prospective study was to demonstrate the contribution of in-office ultrasonography to detect pullout, and to describe the examination procedure. Material and methodA total of 102 patients underwent arthroscopic rotator cuff repair by suture bridge, with impacted second-row anchors. Ultrasonography was performed by the surgeon in postoperative consultations. ResultsAt 6 weeks’ follow-up, 3 patients showed mean 2nd-row implant pullout of 8.3mm.All underwent arthroscopic revision to extract the implant, which was mobile within its tunnel in all cases. Clinical progression was good, with mean Constant score 72 and no aggravation of the lesion on ultrasound at 3 months’ follow-up. DiscussionThe present series would seem to be the first to report: early radiotransparent in-vivo pullout 6 weeks after suture bridge cuff repair; ultrasound detection of pullout in consultation by the orthopedic surgeon; a description of the ultrasound technique for screening this rare and specific problem. ConclusionUltrasound now enables radiotransparent anchor positioning to be monitored following rotator cuff repair as of the first postoperative days, without compromising tendon healing. Level of evidenceII.

A Comparison of Open-Construct PEEK Suture Anchor and Non-Vented Biocomposite Suture Anchor in Arthroscopic Rotator Cuff Repair: A Prospective Randomized Clinical Trial

To compare radiologic bone ingrowth and the clinical outcomes of an open-construct (PEEK) (polyether ether ketone) suture anchor with those of a non-vented biocomposite suture anchor in patients with arthroscopic rotator cuff repair. Sixty-nine patients were randomly allocated into 2 groups based on type of suture anchors used for rotator cuff repair; group 1: open-construct PEEK anchor (36 patients), group 2: non-vented biocomposite anchor (33 patients). The status of bone ingrowth into the anchor and the presence of cyst formation were evaluated at 6 months postoperatively by computed tomography scan using the Modified Barber's ossification scale. The American Shoulder and Elbow Surgeons score, Constant score, and visual analog scale score for pain and range of motion were evaluated. Magnetic resonance imaging or ultrasonography was performed at 12 months postoperatively to examine the integrity of the repaired rotator cuff tendon. Significant improvements in shoulder function and pain relief were observed regardless of the anchor used (both Group 1 and 2; P < .001). No differences were found in functional scores and range of motion between the 2 groups. Group 1 showed better bone ingrowth grades than group 2 (poor 2.8 vs 24.2%, fair 27.8 vs 39.4%, good 38.9 vs 33.3%, and excellent 30.6 vs 3.0%; P < .001). The rate of cyst formation around the anchor on the 6 months' postoperative computed tomography (group 1: 14% and group 2: 12%) and re-tear rate at 12 months (5% each) showed no difference between the 2 groups. Shoulder function was improved after complete rotator cuff repair and similar clinical outcomes were achieved regardless of suture anchor material and shape. However, the open-construct PEEK anchor provided better bone ingrowth into the anchor than the non-vented biocomposite anchor at 6 months after arthroscopic rotator cuff repair. Level I; Prospective Randomized Trial.

All-Suture Anchor Settling After Arthroscopic Repair of Small and Medium Rotator Cuff Tears

Background: All-suture anchors are increasingly being used in rotator cuff repair. However, there are debates on the micromotion of all-suture anchors. Purpose: To perform rotator cuff repair on patients with rotator cuff tears and different shoulder bone mineral densities (BMDs) and investigate (1) where the anchor is located under the cortex, (2) if there is any anchor migration settling during follow-up, and (3) if structural outcome differs according to shoulder BMD. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively investigated 88 patients who underwent arthroscopic single-row repair for small- to medium-sized rotator cuff tears (age [mean ± SD], 58.8 ± 7.1 years) from 712 cases of rotator cuff tendon repair between November 2015 and February 2018. Inclusion criteria were as follows: use of an all-suture anchor; preoperative shoulder BMD; and magnetic resonance imaging (MRI) conducted preoperatively, 2 days after surgery, and 10 months after surgery. Patients were excluded from the study if they underwent open rotator cuff repair (n = 118), got surgery with a double-row technique (n = 178), underwent surgery with anchors other than the all-suture type (n = 273), received anchor insertion in sites other than the greater tuberosity owing to concomitant procedures such as biceps tenodesis and subscapularis repair (n = 29), did not take preoperative shoulder BMD (n = 15), had more than a large-size tear (n = 6), and were lost to follow-up (n = 5). After compression of the all-suture anchor during surgery, the strands were pulled multiple times to ensure that the anchor was fixed onto the bone with appropriate tension. BMD was measured before surgery. Depth to anchor (DA), anchor settling, and repaired rotator cuff integrity were measured with MRI. Patients were categorized into 3 groups: group A (BMD, <0.4 g/cm2; n = 31), group B (BMD, 0.4-0.6 g/cm2; n = 32), and group C (BMD, >0.6 g/cm2; n = 25). A total of 65 patients had follow-up MRI. On the basis of rotator cuff tendon integrity, patients were categorized into either a sufficient thickness group (group S, Sugaya classification grade II or lower; n = 44) or an insufficient thickness group (group I, Sugaya classification grade III or higher; n = 21). Results: On time-zero MRI, the DA differed significantly among groups (group A, 3.62 ± 2.02 mm; group B, 5.18 ± 2.13 mm; group C, 6.30 ± 3.34 mm) (P = .001). The DA was deeper in patients with a higher BMD at time zero (r = 0.374; P = .001), but the DA did not differ at follow-up MRI (mean, 10.3 months after surgery). On follow-up MRI, anchor settling tended to increase with deeper time-zero DA (r = 0.769; P < .001). Anchor settling was significantly different among groups (group A, 1.33 ± 1.08 mm; group B, 2.78 ± 1.99 mm; group C, 3.81 ± 2.19 mm) (P = .001). The proportion of patients with sufficient thickness in each group did not show a statistical difference (group A, 70.8%; group B, 72.7%; group C, 57.9%) (P = .550). Conclusion: In conclusion, this study confirmed that the postoperative site of anchor insertion in arthroscopic single-row rotator cuff repair with all-suture anchors was located farther from the cortex in patients with higher shoulder BMD and closer to the subcortical bone in patients with lower BMD. On follow-up MRI, no further settling occurred past a certain distance from the cortex, and there was no significant difference in anchor depth or integrity of the rotator cuff tendon based on shoulder BMD. Therefore, minimal settling in the all-suture anchor did not show clinical significance.

The Effect of Critical Shoulder Angle on Clinical Scores and Retear Risk After Rotator Cuff Tendon Repair at Short-term Follow Up

The authors aimed to investigate whether standard acromioplasty can reduce critical shoulder angle (CSA) effectively and to investigate the effects of postoperative CSA on the clinical outcomes and retear rates. Patients are divided in to three groups: group 1 (24 patients): CSA under 35° before surgery, group 2 (25 patients): CSA over 35° before surgery and under 35° after surgery and group 3 (17 patients): CSA over 35° before and after surgery. Standard acromioplasty was performed if CSA is over 35 and no acromioplasty was performed if the CSA is already under 35. Preoperative and postoperative CSAs, UCLA, Constant-Murley clinical score and visual analog scale (VAS) pain score were measured. The size of the rotator cuff tear was classified by the Patte classification in preoperative MRI and the quality of the repair was evaluated as retear if discontinuity detected in the postoperative first year MRI. There were 31 female and 35 male patients with a mean age of 59.3 ± 4.5 years (range, 48–68) at the time of surgery. The mean CSA is reduced from 37.8° ± 1.4 to 34.9° ± 1.2 (p < 0.001) significantly for patients who underwent acromioplasty. In 25 (59.5%) of the 42 patients, the CSA was reduced to under 35°, whereas in the other 17 (40.5%) patients, it remained over 35°. The mean Constant and UCLA score was 46.4 ± 6.6; 18.5 ± 1.6 preoperatively and 82.4 ± 6.2; 31.1 ± 1.9 postoperatively respectively (p < 0,001). The mean VAS decreased from 4.94 ± 1.09 to 0.79 ± 0.71 (p < 0.001). No Clinical difference was seen between patients in which CSA could be reduced under 35° or not in terms of Constant-Murley score, UCLA and VAS score. Retear was observed in 2 (8.3%) patients in group 1, in 4 (16%) patients in group 2 and in 3 patients (17.6%) in group 3. There was not any significant difference between the patients who had retear or not in terms of neither the CSA values nor the change of CSA after the surgery. Standard acromioplasty, which consists of an anterolateral acromial resection, can reduce CSA by approximately 3°. This is not always sufficient to decrease the CSAs to the favorable range of 30°–35°. In addition, its effect on clinical outcomes does not seem to be noteworthy.

Fatty degeneration and wnt10b expression in the supraspinatus muscle after surgical repair of torn rotator cuff tendon.

In the torn rotator cuff muscles, decreased expression of wnt10b prior to elevation of peroxisome proliferator-activated receptor γ (PPARγ) and CCAAT/enhancer-binding protein α (C/EBPα) has previously been reported. The purpose of this study is to elucidate the expression profiles of these adipogenesis-related genes after rotator cuff detachment and reattachment in a rabbit model. We investigated gene expression profiles of PPARγ, C/EBPα, and wnt10b in different parts of rabbit supraspinatus (SSP) muscle after tendon detachment (n = 6 for each time point). In addition, we assessed expression of the same genes after SSP reattachment with different intervals from initial detachment (n = 6). Fatty degeneration of the SSP muscle was examined by Oil red-O staining. Gene expression profiles were examined by quantitative real-time polymerase chain reaction. After SSP detachment, Oil red-O-positive oil deposits increased after 3 weeks. In the SSP reattachment model, numerous Oil red-O-positive cells were present at 5-week reattachment, following 2- and 3-week detachment. PPARγ and C/EBPα messenger ribonucleic acid expression exhibited a significant increase at 2 and 3 weeks after SSP detachment and remained increased at 5-week reattachment after 2- and 3-week detachment. A decreased expression of wnt10b was observed from 1 week after SSP detachment. Expression of wnt10b was recovered not in the central area of the SSP muscle but in the periphery after reattachment. Adipogenic change was not observed when SSP tendon was reattached after 1-week detachment. These results may suggest that once the adipogenic transcription factors, PPARγ and C/EBPα, were elevated, repair surgery after rotator cuff tear could not prevent the emergence of fat in the SSP muscle.

Influence of a nerve injury proximal to the suprascapular nerve on healing of repaired rotator cuff tear

BackgroundMassive rotator cuff tears have a high rate of re-injury because of severe fatty infiltration. Our data showed that injuries proximal to the suprascapular nerve may be one cause of massive rotator cuff tears. The purpose of this study was to evaluate, using a rat model, how brachial plexus injury associated with a massive rotator cuff tear influences healing of the rotator cuff repair. MethodsSeventy Sprague–Dawley rats were divided into three groups: rotator cuff tear with BP injury (DT group) (n = 28), rotator cuff tear without brachial plexus injury (T group) (n = 28), and a sham-operated group (n = 14). In the DT group, the rotator cuff tear was made and repaired 4 weeks after brachial plexus ligation. The gross assessment (evaluated the wet weight), biomechanical testing (evaluated the yield stress and the Young's modulus) and histological analyses (using the Bonar scale) were performed at baseline in the sham group, and at 4 and 12 weeks postoperatively in the DT and T groups (n = 7/group/time). ResultsMean wet weight and yield stress were significantly lower in the DT group than in the T group. Additionally, the mean Young's modulus was significantly higher in the DT group than in the T group. Histologically, greater tendon degeneration was observed around the musculotendinous junction in the DT group than in the T group. ConclusionThe gross, biomechanical and histological data show that the repaired rotator cuff tendon with brachial plexus injury in rats does not heal as well as a repaired tendon without an accompanying brachial plexus injury. This suggests that more proximal neuropathy is one risk factor for re-tear of a repaired rotator cuff tendon.

Use of stem cells and growth factors in rotator cuff tendon repair.

The management of rotator cuff tears continues to prove challenging for orthopaedic surgeons. Such tears affect most age groups and can lead to significant morbidity in patients. The aetiology of these tears is likely to be multifactorial; however, an understanding of the mechanisms involved is still under review. Despite advancements in surgical operative techniques and the materials used, post-operative recurrence rates after surgical repair remain high. A growing area of research surrounds biological adjuncts used to improve the healing potential of the repaired tissues. This review of recent publications focuses on the strengths and limitations of using stem cells and growth factors in rotator cuff repair.

Extruded collagen fibres and biphasic collagen sponge for rotator cuff tendon repair application: an ovine in vitro study

Extruded collagen fibres and biphasic collagen sponge for rotator cuff tendon repair application: an ovine in vitro study

Superior Capsule Reconstruction for Reinforcement of Arthroscopic Rotator Cuff Repair Improves Cuff Integrity

Background: Retear of repaired rotator cuff tendons worsens patient outcome and decreases patient satisfaction. Superior capsule reconstruction (SCR) was developed to center the humeral head and thus restore the force couple for patients with rotator cuff tears. Purpose: To evaluate whether SCR for reinforcement before arthroscopic rotator cuff repair (ARCR) improves cuff integrity. Study Design: Cohort study; Level of evidence, 3. Methods: Thirty-four consecutive patients (mean age, 69.1 years) with severely degenerated but reparable rotator cuff tears underwent SCR with fascia lata autografts for reinforcement before ARCR. All tears were medium (1-3 cm) or large (3-5 cm), and the number of torn tendons was 2 (supraspinatus and infraspinatus) in 29 shoulders and 3 (supraspinatus, infraspinatus, subscapularis) in 5 shoulders. To assess the benefit of SCR for reinforcement, all data were compared with those after ARCR alone among 91 consecutive patients with medium or large rotator cuff tears (mean age, 63.6 years). The American Shoulder and Elbow Surgeons (ASES) and Japanese Orthopaedic Association (JOA) scores, active shoulder range of motion, and cuff integrity (Sugaya magnetic resonance imaging classification) were compared (t test and chi-square test) between ARCR with and without SCR, as well as before surgery and at final follow-up. Results: All 34 patients who underwent SCR before ARCR had neither postoperative retear nor type III cuff integrity, whereas those treated with ARCR alone had a 4% incidence (4 of 91) of retear and 8% incidence of type III cuff integrity. ASES and JOA scores, active elevation, active external rotation, and active internal rotation increased in both treatment groups (P < .001). Postoperative ASES score and active range of motion did not differ between groups, although the Goutallier grade of the supraspinatus was higher for ARCR with SCR (mean, 2.8) than ARCR alone (mean, 2.1; P < .0001). Conclusion: SCR for reinforcement prevented retear at 1 year after ARCR and improved the quality of the repaired tendon on magnetic resonance imaging. Functional outcomes were similar between groups, even though degeneration of the torn tendons was greater among patients who underwent ARCR with SCR.

Early Sling Discontinuation Following Rotator Cuff Repair

Following rotator cuff repair, patients typically are immobilized in a sling for 6 weeks with or without early motion. We hypothesize that early sling discontinuation at 2 weeks combined with rehabilitation protocol would not adversely affect clinical outcomes or tendon healing in small nonretracted rotator cuff tears following double-row repair. We prospectively evaluated 20 patients at 6 months postoperatively who underwent double-row rotator cuff repair for small nonretracted tears. Patients were immobilized in a sling for 2 weeks then allowed to remove the sling for daily activities below shoulder height. Formal rehabilitation started at 6 weeks. Patients were evaluated by physical examination, patient-rated outcomes (Constant-Morley Shoulder Scores, American Shoulder and Elbow Society score, Veterans Rand 36 General Health Survey), and magnetic resonance imaging. Average length of follow-up was 6 months. American Shoulder and Elbow Society scores increased an average of 32.2 points (P<0.001), normalized Constant scores increased on average 31.5 points (P<0.001), and Veterans Rand 36 General Health Survey physical scores improved on average 11.8 points (P<0.001). Healing rate on magnetic resonance imaging was 95%. Early sling discontinuation following double-row rotator cuff repair did not result in adverse effects on the repaired rotator cuff tendons, and may be an acceptable option for small nonretracted rotator cuff tears in properly selected patients with a high likelihood of healing.

Anterior Cable Reconstruction Using the Proximal Biceps Tendon for Large Rotator Cuff Defects Limits Superior Migration and Subacromial Contact Without Inhibiting Range of Motion: A Biomechanical Analysis

To assess an anterior cable reconstruction (ACR) using autologous proximal biceps tendon for large to massive rotator cuff tears. Nine cadaveric shoulders (mean age, 58years) were tested with a custom testing system. Range of motion, superior translation of the humeral head, and subacromial contact pressure were measured at 0°, 30°, 60°, and 90° of external rotation (ER) with 0°, 20°, and 40° of glenohumeral abduction. Five conditions were tested: intact, stage II tear (supraspinatus), stage II tear+ ACR, stage III tear (supraspinatus+ anterior half of infraspinatus), and stage III tear+ ACR. ACR involved a biceps tendon tenotomy at the transverse humeral ligament, preserving its labral attachment. ACR included nonpenetrating suture-loop fixation using 2 side-to-side sutures and an anchor at the articular margin to restore anatomy and secure the tendon along the anterior edge of the cuff defect. ACR was performed in 20° glenohumeral abduction and 60° ER. ACR for both stage II and stage III showed significantly higher total range of motion compared with intact at all angles (P ≤ .001). ACR significantly decreased superior translation for stage II tears at 0°, 30°, and 60° ER for both 0° and 20° abduction (P ≤ .01) and for stage III tears at 0° and 30° ER for both 0° and 20° abduction (P ≤ .004). ACR for stage III tear significantly reduced peak subacromial contact pressure at 30° and 60° ER with 0° and 40° abduction and at 30° ER with 20° abduction (P ≤ .041). ACR using autologous biceps tendon biomechanically normalized superior migration and subacromial contact pressure, without limiting range of motion. ACR may improve rotator cuff tendon repair longevity by providing basic static ligamentous support to the dynamic tendon while helping to limit superior migration without restricting glenohumeral kinematics.

Arthroscopic Superior Capsular Reconstruction and Over-the-Top Rotator Cuff Repair Incorporation for Treatment of Massive Rotator Cuff Tears

Massive rotator cuff tears pose significant clinical and surgical challenges for orthopaedic surgeons and increased morbidity to the patient. Left untreated, this pathology can lead to inability to perform daily activities, weakness, pain, and eventual cuff tear arthropathy. Several treatment options exist for irreparable cuff tears, such as reverse shoulder arthroplasty and tendon transfers. However, there exists significant concern for high complication rates and unpredictable clinical outcomes following such treatments. Superior capsular reconstruction (SCR) represents a viable alternative in treating irreparable cuff tears, providing biomechanical stability and improving pain related to this pathology by reducing superior humeral instability and subacromial impingement. Over-the-top repair of the native rotator cuff tendons with incorporation of the SCR allograft may provide surgeons the opportunity to perform a robust repair in situations where arthroplasty or other more invasive procedures were once the only options. The authors present a surgical technique with associated pearls and pitfalls for their preferred procedure of SCR with incorporation of the native rotator cuff in transosseous equivalent double-row repair for the treatment of massive, irreparable rotator cuff tears.

PRP as an Adjunct to Rotator Cuff Tendon Repair.

Arthroscopic rotator cuff repair is a commonly performed repair. Technical developments provide surgeons the tools to create biomechanically robust repairs. How can the biological response mirror the strong and stable surgery? Platelet-rich plasma (PRP) is a supraphysiological platelet concentration which may positively augment rotator cuff healing. Not all PRPs are the same. High leukocyte levels and thrombin activation may be detrimental to tendon healing. Thrombin activation triggers an immediate release of growth factors and may actually inhibit some parts of the healing response. Clear differences exist between liquid PRP (products released within hours after activation) and solid fibrin PRP which slowly releases factors over days. The heterogenicity data and grouping liquid and solid PRP together make systematic reviews confusing. Solid PRP fibrin constructs are often associated with increased tendon healing. PRP fibrin matrix offers the greatest promise for improving clinical success after rotator cuff tendon repair.

Fibrous structures in augmentation for rotator cuff repair: an experimental comparison

Background and purpose. Rotator cuff tendon (RCT) injuries are difficult to manage as current strategies do not restore tissue functionality. Driven by this market demand, several devices have been developed during the last years, however, to develop a structure that properly mimics the mechanical performance of the native tissue remains a challenge. This way, in this work we study a set of design criteria for a synthetic graft development for RCT repair and reconstruction, in order to achieve a structure with an adequate mechanical performance to substitute the damaged tissue, and that can also act as a scaffold, allowing and guiding tissue ingrowth. Materials and Methods. Two three-dimensional (3D) and two planar (2D) warp-knitted structures were developed using polyethylene terephthalate (PET) yarn, and are characterized in terms of their morphology, absorption and wicking behavior, and mechanical properties. Results. The present warp-knitted structures mimic the non-linear mechanical behavior of the native tissue. A less porous planar structure was concluded to be the best to provide mechanical augmentation, as it demonstrated mechanical properties suitable for RCT repair. Pre-tensioning techniques were adequate to increase this type of textile’s mechanical properties. Furthermore, the physical properties of this structure can allow and guide tissue ingrowth, demonstrating its potential to act also as a scaffold. Conclusions. As this is a relatively new field of application of knitting technologies, this work provides important information on how a warp-knitted structure should be tailored and treated post-production, in order to be used for RCT repair.