Revision Arthroscopic Rotator Cuff Repair Research Articles

Bioaugmentation demonstrates similar outcomes and failure rates for arthroscopic revision rotator cuff repair compared to revision without bioaugmentation

IntroductionArthroscopic revision rotator cuff repairs exhibit lower healing rates and inferior outcomes compared to primary repairs. There is limited evidence regarding the use of bioaugmentation in the setting of revision rotator cuff repairs. Autologous conditioned plasma (ACP) is a promising adjunct that has been shown to improve healing rates and patient report outcomes in the primary setting. In addition, bioinductive patches such as collagen bovine patches have become a popular adjunct for stimulating healing in the primary setting. The aim of this study is to assess the outcomes after use of ACP and collagen bovine patch augmentation for revision arthroscopic rotator cuff repair. We hypothesized improved patient report outcomes and higher healing rates would be observed with bioaugmentation for revision repair compared to without. MethodsThis was an IRB approved, retrospective case-control study from two fellowship-trained surgeons that included all consecutive patients undergoing arthroscopic revision rotator cuff repair from 2010 to 2021. Reconstruction such as superior capsular reconstruction, partial revision repair, and less than one year follow-up were excluded. The bioaugmentation cohort received ACP and/or collagen bovine patch at the time of revision repair. Patient reported outcomes were collected from all patients including: American Shoulder and Elbow Surgeons Standardized Assessment Form (ASES), visual analog scale for pain (VAS), Brophy score, Patient-Reported Outcomes Measurement Information System (PROMIS) mental and physical scores. Failure of revision rotator cuff repair was defined as an ASES postoperative total score less than 60 or a symptomatic re-tear confirmed on MRI. Students T-test was used for all comparisons of continuous variables. Chi-squared used for comparison of all categorical variables. Statistical significance was set at <0.05. ResultsThirty-eight patients met inclusion criteria with average follow-up of 3.5±1.7 years. There was no significant difference in follow-up between patients with and without bioaugmentation. Of the 38 patients, 14 patients met failure criteria. There was no significant difference in the rate of failure between the bioaugmentation cohort (6/19, 31.6%) versus patients who did not receive bioaugmentation (8/19, 42.1%), p=0.74) In addition, no significant differences were identified for ASES (64.6±20.1 versus 57.5±17.2, p=0.32), Brophy (6.4±5.2 versus 6.0±4.1, p=0.84), PROMIS Mental (13.4±3.9 versus 11.7±3.2) or PROMIS Physical (12.8±3.1 versus 11.9±3.2) scores between the bioaugmentation versus no bioaugmentation groups. ConclusionsBioaugmentation with a bioinductive collagen patch or autologous conditioned plasma demonstrated similar failure and patient reported outcomes compared to without bioaugmentation in the setting of revision rotator cuff repair.

Outcomes After Revision Arthroscopic Rotator Cuff Repair: A Systematic Review

Background: Arthroscopic rotator cuff repair (ARCR) is one of the most commonly performed orthopaedic procedures; however, it is unclear how to manage patients with symptomatic retears. Purpose: To perform a systematic review to evaluate the outcomes of revision ARCR in the literature. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic literature search based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed utilizing the Embase, MEDLINE, and Cochrane Library databases. Eligible for inclusion were clinical studies reporting on revision rotator cuff repair. Clinical outcomes were recorded. Results: The 17 included studies were composed of 888 shoulders in 885 patients. The mean age of the 885 patients was 58.6 ± 9.1 years, with a mean follow-up of 28.1 ± 22.1 months. The mean visual analog scale score was 2.1 ± 1.8, the mean American Shoulder and Elbow Surgeons score was 75.0 ± 18.3, and the mean Constant score was 67.4 ± 16.6. The overall rate of retears after revision was 25.3%, with an 8.0% reoperation rate including 2.7% undergoing reverse shoulder arthroplasty and 2.0% undergoing subsequent rotator cuff repair. Finally, the complication rate was 8.6%. Conclusion: Revision ARCR improved patient-reported outcomes, with 92% of patients free from reoperations at a mean follow-up of 2 years. Overall, 78.4% of patients were satisfied at final follow-up; however, the rate of retears was found to be higher than after primary ARCR.

Preoperative vitamin D supplementation is a cost-effective intervention in arthroscopic rotator cuff repair.

This study investigates the potential role of preoperative 25(OH)D supplementation as a cost-effective strategy to decrease revision rotator cuff repair (RCR) rates and lower the total health care burden from patients undergoing primary arthroscopic RCR. Previous literature has emphasized the importance of vitamin D on bone health maintenance, soft tissue healing, and outcomes in RCR. Inadequate preoperative vitamin D levels may increase revision RCR rates following primary arthroscopic RCR. Although 25(OH)D deficiency is common in RCR patients, serum screening is not routinely performed. A cost-estimation model was developed to determine the cost-effectiveness of both preoperative selective and nonselective 25(OH)D supplementation in RCR patients in order to reduce revision RCR rates. Prevalence and surgical cost data were obtained from published literature through systematic reviews. Cost of serum 25(OH)D assay and supplementation were obtained from public-use data. Mean and lower and upper bounds of 1-year cost savings were calculated for both the selective and nonselective supplementation scenarios. Preoperative 25(OH)D screening and subsequent selective 25(OH)D supplementation was calculated to result in a mean cost savings of $6,099,341 (range: -$2,993,000 to $15,191,683) per 250,000 primary arthroscopic RCR cases. Nonselective 25(OH)D supplementation of all arthroscopic RCR patients was calculated to result in a mean cost savings of $11,584,742 (range: $2,492,401-$20,677,085) per 250,000 primary arthroscopic RCR cases. Univariate adjustment projects that selective supplementation is a cost-effective strategy in clinical contexts where the cost of revision RCR exceeds $14,824.69 and prevalence of 25(OH)D deficiency exceeds 6.67%. Additionally, nonselective supplementation is a cost-effective strategy in clinical scenarios where revision RCR cost is ≥$4216.06 and prevalence of 25(OH)D deficiency is ≥1.93%. This cost-predictive model promotes the role of preoperative 25(OH)D supplementation as a cost-effective mechanism to reduce revision RCR rates and lower the overall health care burden from arthroscopic RCR. Nonselective supplementation appears to be more cost-effective than selective supplementation, likely due to the lower cost of 25(OH)D supplementation compared to serum assays.

A High Rate of Bacteriologic Culture-Positive Findings Is Seen After Revision Rotator Cuff Surgery

To determine the incidence of subclinical infections in patients undergoing revision arthroscopic rotator cuff repair and identify any risk factors for developing these infections. Patients who underwent revision surgery by the senior author between January 2012 and December 2022 after a previous rotator cuff surgery were identified. All patients undergoing an open or arthroscopic revision of their previous rotator cuff surgery were included. Patients who had noted previous shoulder infections or had incomplete chart documentation were excluded. For each patient, demographic information, surgical information, and culture results were recorded. A total of 115 patients were identified. Thirty-nine were excluded due to incomplete chart documentation (35) or a history of infection (4); therefore, 22 patients (28.9%) had positive cultures (31 cultures in total). Seventeen patients had only Cutibacterium acnes identified. C acnes cultures turned positive on average 13.52 days after culture collection. There was no difference in infection incidence rates between isolated rotator cuff repair and rotator cuff repair plus additional surgeries (P= .88) or between initial arthroscopic versus open procedures (P= .83). None of the 12 identified risk factors, including age, sex, race, smoking history, previous corticosteroid injections, malnutrition, renal failure, liver failure, diabetes mellitus, immunocompromised status, intravenous drug use, and number of revisions, were correlated with the presence of a subclinical infection. Finally, 6 patients had control cultures taken. One culture (16.6%) was positive for C acnes, while this patient did not have a positive shoulder culture. Subclinical shoulder infections can be present in more than one-quarter of patients undergoing revision after rotator cuff repair. Level IV, diagnostic case series.

Combined Biologic Augmentation Strategies with Collagen Patch Graft, Microfractures, and Platelet Concentrate Injections Improve Functional and Structural Outcomes of Arthroscopic Revision Rotator Cuff Repair.

Arthroscopic revision rotator cuff repair (ARRCR) is challenging. Biologic strategies seem to be promising. The aim was to evaluate the effectiveness of the combination of microfractures of the greater tuberosity, augmentation with collagen patch graft, and platelet concentrate injections in ARRCR. A retrospective comparative study was conducted on patients that underwent ARRCR with a minimum follow-up of two years. Patients in the augmentation group underwent ARRCR combined with microfractures, collagen patch graft, and postoperative subacromial injections of platelet concentrate. A standard rotator cuff repair was performed in the control group. Constant-Murley score (CMS). disease-specific, health-related quality of life using the Disabilities of the Arm, Shoulder, and Hand (DASH) score; assessment of tendon integrity with magnetic resonance at least six months after surgery. Significance was set at p < 0.05. Forty patients were included. Mean follow-up was 36.2 ± 8.7 months. The mean CMS was greater in the augmentation group (p = 0.022). No differences could be found for DASH score. Healing failure rate was higher in the control group (p = 0.002). Biologic augmentation of ARRCR using a combination of microfractures, collagen patch graft, and subacromial injections of platelet concentrate is an effective strategy in improving tendon healing rate. retrospective cohort study, level III.

Revision Rotator Cuff Repair With Versus Without an Arthroscopically Inserted Onlay Bioinductive Implant in Workers’ Compensation Patients

Background: The addition of onlay biological grafts to augment difficult rotator cuff repairs has shown encouraging results in a case series. Purpose/Hypothesis: The purpose of this study was to determine whether the addition of an onlay bioinductive implant would improve repair integrity, shear wave elastographic appearance of the repaired tendon and patch, and patient-rated and/or surgeon-measured shoulder function when used in workers' compensation patients undergoing revision arthroscopic rotator cuff repair. We hypothesized that the addition of the bioinductive implant would enhance repair integrity and clinical outcomes compared with standard repair. Study Design: Cohort study; Level of evidence, 3. Methods: A post hoc matched-cohort study was conducted on prospectively recruited workers’ compensation patients who received a bioinductive implant for revision rotator cuff repair (n = 19). The control group was selected from consecutive workers’ compensation revision rotator cuff repair patients before the introduction of bioinductive implants. Then, they were matched for age and tear size (n = 32). Kaplan-Meier curves were generated to compare the primary outcome of repair integrity between groups. The secondary outcomes were to evaluate the elastographic appearance of the tendon and patch in the bioinductive implant group and to compare patient-rated and surgeon-measured shoulder function between groups preoperatively and at 1 week, 6 weeks, 3 months, and 6 months postoperatively. Results: No major complications associated with the bioinductive implants were identified. Six months after the revision rotator cuff repair, the retear rate in the bioinductive implant group was 16% (3/19), compared with 19% (6/32) in the age- and tear size-matched control group ( P = .458). At the final follow-up, the retear rate in the bioinductive implant group was 47% (9/19) at a mean of 14 months compared with 38% (12/32) at a mean of 29 months in the control group ( P = .489). The shear wave elastographic stiffness of repaired tendons augmented with the bioinductive implant remained unchanged at 6 m/s from 1 week to 6 months postoperatively, which is lower than the stiffness of 10 m/s in healthy tendons. There were no significant differences in patient-rated or surgeon-measured outcomes between groups 6 months postoperatively. Conclusion: There were no differences in repair integrity or clinical outcomes between workers’ compensation patients who underwent revision arthroscopic rotator cuff repair with an onlay bioinductive implant compared to those who underwent standard revision rotator cuff repair.

Clinical Outcomes of Arthroscopic Revision Rotator Cuff Repair.

Multiple studies have shown excellent clinical results in primary rotator cuff repairs; however, not much evidence is available in the literature on the outcomes of arthroscopic revision rotator cuff repairs. The purpose of this study was to report a cohort of patients who underwent revision arthroscopic rotator cuff repair and identify factors that may influence its outcomes. We examined a cohort of 62 patients which underwent revision arthroscopic rotator cuff repair in a single UK institution with a minimum of 24months follow-up. Active shoulder movements including forward flexion, abduction and external rotation were evaluated, as well as Oxford Shoulder Score (OSS). Further subgroup analysis was performed looking of the effects of age, size of tear, obesity and diabetes mellitus had on clinical outcomes. 59 patients were available for final review. 39 male and 23 were female. The mean age was 64years. Overall, significant improvements were seen in terms of OSS (p < 0.05), active forward flexion (p < 0.05), active abduction (p < 0.05) and active external rotation (p < 0.05). Our study showed that a significant proportion of patients undergoing arthroscopic revision rotator cuff repair achieve good outcomes. Repairing small- and medium-size tears was successful, diabetics had no post-operative improvements, obese patients achieved significant improvement in range of movement and age was not a predictor of surgical success. Overall, arthroscopic revision surgery is a successful option; however, appropriate patient selection and counselling is paramount.

Effect of arthroscopic subacromial decompression during arthroscopic repair of small to medium-sized rotator cuff tears

Although arthroscopic subacromial decompression (ASD) is a commonly used procedure during arthroscopic rotator cuff repair (ARCR), the effect of ASD on the clinical outcomes for ARCR is controversial. The purpose of this study was to compare the clinical outcomes of ARCR with or without ASD. Patients (n=315 with 320 shoulders) who underwent ARCR for small to medium-sized rotator cuff tears were followed for at least 24 months. ARCR was performed with ASD (180 shoulders, group A) or without ASD (140 shoulders, group N). There were no significant differences in patient demographics, including mean age and mean follow-up time. Rotator cuff repair was performed using the suture-bridge technique in all shoulders, and all patients were treated using the same rehabilitation protocol after surgery. University of California at Los Angeles score, Constant score, re-tear rates, revision surgery rates, and operating time were compared between groups. Re-tear was defined as Sugaya classification Types 4 and 5 using postoperative magnetic resonance imaging at more than 12 months. There was no statistically significant difference in clinical outcomes before and after ARCR between groups. However, the University of California at Los Angeles scores and Constant scores significantly improved in both groups after surgery (P<.001). Furthermore, there was no major difference in the re-tear rates between groups A (7/180 shoulders, 3.9%) and N (11/140 shoulders, 7.9%) (P=.146). Revision surgeries were performed on 3/180 shoulders (1.7%) in group A (due to postoperative deep infection in one shoulder and revision ARCR for re-tear in two shoulders). No revisions surgeries were needed in group N patients (P=.259). The mean surgical time for group A was 62.0±27.0 minutes (29-138 min.) and 52.4±26.1 minutes (17-124 min.) for group N (P=.007). These results suggest that ASD has a limited effect on clinical outcomes of ARCR for small to medium-sized rotator cuff tears.

Arthroscopic revision cuff repair: do tendons have a second chance to heal?

Few studies have investigated postoperative tendon integrity after reoperation for failed rotator cuff repair. The purpose of this study was to evaluate the anatomic and clinical outcomes of arthroscopic revision rotator cuff repair (AR-RCR) and identify the risk factors related to re-retear. Sixty-nine consecutive patients (mean age, 55 years) with primary failed open (38%) or arthroscopic (62%) cuff repairs underwent AR-RCR and were reviewed regarding clinical examination findings and imaging studies. Patients with massive cuff tears and upward humeral migration (acromiohumeral distance < 6 mm) or glenohumeral osteoarthritis were excluded. Revision repair was performed by a single, experienced shoulder surgeon. Complete footprint coverage was achieved in all cases using a single-row (70%), double-row (19%), or side-to-side (11%) technique. The primary outcome measure was tendon healing assessed with magnetic resonance imaging (57 cases) or computed tomography arthrogram (12 cases) performed at minimum 1-year follow-up. Secondary outcome measures included functional outcome scores, subjective results, and complications. The mean follow-up period was 43 months (range, 12-136 months). The cuff tendons did not heal to the tuberosity in 36% of the shoulders (25 of 69) following revision cuff surgery. Absence of tendon healing was associated with poorer shoulder function (average Constant score, 69±20 vs. 54±18; P=.003) and a decreased Subjective Shoulder Value (72% vs. 54%, P=.002). Factors that were negatively associated with tendon healing were age ≥ 55 years (odds ratio [OR], 4.5 [95% confidence interval, 1.6-12.5]; P=.02), tendon retractionof stage 2 or higher (OR, 4.4 [95% confidence interval, 1.4-14.3]; P=.01), and fatty infiltration index > 2 (OR, 10.2; P<.0001). No differences in retear rates were found between single-row and double-row cases. In 36 shoulders, tissue samples were harvested and submitted for bacteriologic culture analysis; 13 (36%) showed positive findings for infection (Cutibacterium acnesin 12 of 13) and associated antibiotic treatment was given. Overall, 25% of patients had unsatisfactory clinical results and 22% were disappointed or dissatisfied. At last follow-up, 4 patients (5.7%) underwent reoperations, with a second AR-RCR in 1 and conversion to reverse shoulder arthroplasty in 3. Despite careful patient selection and intraoperative complete footprint coverage, in this study the tendons did not heal to bone in 36% of cases after revision cuff surgery. The absence of tendon healing is associated with poorer clinical and subjective results. Patients aged ≥ 55 years and patients with larger tears (stage 2 or higher) and/or muscle fatty infiltration (fatty infiltration index > 2) have significantly lower rates of healing. Surgeons should be aware that structurally failed cuff repair may also be associated with low-grade infection.

Rotator Cuff Repair With Acromioplasty Is Associated With an Increased Rate of Revision and Subsequent Procedures

To evaluate the mid-term rate of revision arthroscopic rotator cuff repair as well as ipsilateral shoulder reoperations after index rotator cuff repair performed with or without acromioplasty in the United States. The Medicare Standard Analytic File, which encompasses the entire Medicare billing and payment data, was queried between 2005 and 2014. Patients undergoing arthroscopic rotator cuff repair were identified and stratified based on whether ipsilateral acromioplasty was concurrently performed using Current Procedural Terminology codes. Groups were matched by age, sex, year of index procedure, and Elixhauser index at a 2:1 ratio. Primary end point was defined as undergoing a repeat ipsilateral shoulder surgery related to the rotator cuff at 5 years of follow-up. Kaplan-Meier survival curves were constructed, and the 2 groups were compared using the log-rank test. After matching, 54,209 shoulders in the rotator cuff repair with acromioplasty group and 26,448 shoulders in the rotator cuff repair without acromioplasty group were identified. Shoulders undergoing concurrent acromioplasty at index rotator cuff repair had a significantly increased rate of repeat ipsilateral cuff repair at 5 years postoperatively (8.5% vs 6.8%, P < .001). Similarly, there was an increased rate of reoperation of all types to the ipsilateral shoulder in cases where concurrent acromioplasty was performed (9.6% vs 9.1%, P < .001). Using a large, national database, concurrent acromioplasty at the time of rotator cuff tear was found to be associated with both an increase rate of overall subsequent procedures and revision rotator cuff repair. III, retrospective comparative study.

Poster 140: Shoulder Strengthening and Stabilization Systems – A Viable Option for Early Passive Range of Motion after Arthroscopic Rotator Cuff Repair

Objectives:Post-operative rehabilitation following arthroscopic rotator cuff repair (ARCR) is crucial for optimal outcomes. Early post-operative passive range of motion (PROM) is encouraged by some surgeons to minimize the development of adhesions and subsequent decreased range of motion. Existing literature comparing early and delayed PROM for small and medium size tears has demonstrated equivalent functional outcomes, with early PROM resulting in improved long-term active range of motion (AROM). The specific modality used for early PROM varies and may include manual home exercises, machine-assisted home exercises, or formal physical therapy (PT). In this study, we investigated Shoulder Strengthening and Stabilization Systems (SSS) (Advanced Integrated Motion; Elizur), a home-based machine monitored through telemedicine which allows for passive, active-assisted, and active motion in the early post-operative rehabilitation process. The benefit of SSS predominantly derives from the convenience of performing early PROM at home instead of attending in-person formal physical therapy. The objective of this study was to compare patient reported outcomes (PROs) and perioperative AROM after ARCR between patients who utilized SSS and those who underwent formal PT. We hypothesized that those who use SSS would have equivalent ROM and PROs compared to those who did not use SSS.Methods:A retrospective study comprised of patients undergoing RCR between 2018-2020 was conducted. Cohorts were defined by confirmation of SSS utilization via data provided by Elizur. SSS was started within several days following surgery in lieu of formal PT which started at 6 weeks. This was matched with a control group undergoing ARCR over the same time range, who initiated a formal PT protocol without the SSS machine when it was not available at our institution. The post-operative rehabilitation protocol consisted of PROM/pendulums beginning at 10 days, AROM at 6 weeks, and strengthening at 12 weeks. Data were collected from electronic medical records (EMR), entered into an institutional redcap database (UL1-TR-001857), and institutional review board approval was acquired. Patients undergoing concomitant labral repairs, capsular reconstruction procedures, revision ARCR, or with less than 3 months follow up were excluded. Primary outcome measure was subjective shoulder value (SSV) score. Secondary outcomes included American Shoulder and Elbow Surgeons Shoulder Score (ASES), visual analog scale (VAS), and AROM (forward flexion and external rotation). Baseline characteristics were analyzed with two sample t-tests and chi-square or Fisher’s exact test for continuous and categorical variables, respectively. A linear mixed model with fixed effects for cohort, time, and the cohort-time interaction was used to analyze PROs and AROM at various timepoints. Statistical significance was set at p < 0.05.Results:A total of 417 patients (243 SSS; 174 no SSS) with an average follow up of 5.5 months met inclusion criteria. SSS was used for an average of 36.2 days. Baseline characteristics including gender, BMI, nature of injury, time from injury to surgery, and preoperative PROs (SSV, ASES, and VAS) did not differ significantly between cohorts. The cohort without SSS was older at the time of surgery (61.3 years vs. 59.3 years, p=0.03). Linear mixed model analysis revealed no significant differences in AROM at any timepoint (table 1). There was no significant difference between cohorts with respect to SSV, ASES, and VAS at any timepoint (Table 2). Both cohorts had significant increases in each PRO over time, exceeding minimal clinically important difference (MCID) at 6 months post-operatively.Conclusions:The use of SSS demonstrated excellent ROM and patient reported outcomes equivalent to those who initiated formal PT in the early postoperative period. The convenience of a home-based therapy program monitored via telemedicine in lieu of formal PT during the first 6 post-operative weeks may be an attractive option for patients following ARCR. Future studies will elucidate whether there are potential cost saving implications.Table 1.Active Range of Motion Over TimeTable 2.Patient Reported Outcomes Over Time

Significant Improvement in Shoulder Function and Pain in Patients Following Biologic Augmentation of Revision Arthroscopic Rotator Cuff Repair Using an Autologous Fibrin Scaffold and Bone Marrow Aspirate Derived From the Proximal Humerus

PurposeTo clinically evaluate patients who underwent a biologic augmentation technique in revision arthroscopic rotator cuff repair using an autologous fibrin scaffold and concentrated stem cells isolated from bone marrow aspirate (BMA) obtained from the proximal humerus.MethodsThis is a retrospective review of prospectively collected data from patients who underwent biologic augmentation of revision arthroscopic rotator cuff repair using an autologous fibrin scaffold and BMA obtained from the proximal humerus between 2014 and 2015. Minimum follow-up was 12 months. Outcome measures were collected preoperatively and postoperatively including range of motion as well as American Shoulder and Elbow Surgeons Shoulder Form, Simple Shoulder Test, single assessment numeric evaluation, and visual analog score. In addition, BMA samples of each patient were assessed for the number of nucleated cells and colony-forming units. Regression analysis was performed to investigate whether the number of nucleated cells and colony-forming units had an influence on outcome and failure.ResultsTen patients who underwent biologic augmentation of revision arthroscopic rotator cuff repair using an autologous fibrin scaffold and concentrated BMA obtained from the proximal humerus between 2014 and 2015 were included. The mean follow-up time was 30.7 (range: 12-49) months. Four patients were revised at final follow-up. Postoperative clinical scores improved significantly: American Shoulder and Elbow Surgeons (28.1 ± 5.4 to 60.9 ± 9.0; P < .01), single assessment numeric evaluation (6.6 ± 2.3 to 65.1 ± 10.9; P < .01), visual analog scale (7.2 ± 0.9 to 3.1 ± 0.9; P < .01), and Simple Shoulder Test (1.6 ± 0.5 to 10.3 ± 5.7; P < .01). Postoperative range of motion increased significantly with regard to flexion (97.0 ± 13.6 to 151.0 ± 12.2; P < .01) and abduction (88.0 ± 14.0 to 134.0 ± 15.1; P = .038) but not with external rotation (38.0 ± 5.7 to 50.5 ± 6.5; P = .16). Less pain was correlated to an increased number of nucleated cells (P = .026); however, there was no correlation between failure rate and number of nucleated cells (P = .430).ConclusionsPatients who underwent biologic augmentation of revision arthroscopic rotator cuff repair using an autologous fibrin scaffold and concentrated BMA demonstrated a significant improvement in shoulder function along with reduction of pain. However, the overall revision rate for this procedure was 40%.Level of EvidenceLevel IV, therapeutic case series.

Arthroscopic Revision Rotator Cuff Repair: The Role of Previously Neglected Subscapularis Tears

Background: Concomitant full-thickness tear of the subscapularis tendon is often neglected during primary posterosuperior rotator cuff repair, and its significance has not been investigated by any previous clinical study. Purpose: To investigate (1) the clinical and radiological outcomes of revision arthroscopic rotator cuff repair and (2) the number of neglected concomitant subscapularis full-thickness tears in the revision of posterosuperior rotator cuff retears and their structural integrity after repair. Study Design: Case series, Level of evidence, 4. Methods: This study retrospectively examined 58 patients who underwent arthroscopic rotator cuff revision for a retear of a previously repaired posterosuperior rotator cuff. Preoperative and postoperative functional scores and active range of motion (ROM) were assessed. The initial and most recent follow-up magnetic resonance imaging scans before revision and arthroscopic findings at the time of primary repair were reviewed to determine whether the concomitant subscapularis tear was newly developed or preexisting. Final confirmation of the tendon’s full-thickness tear was made during the revision procedure. Results: At final follow-up, mean functional shoulder scores and ROM improved significantly compared with the preoperative values (P < .001). Among the 58 revision cases, 25 (43.1%) had a neglected full-thickness tear of the subscapularis tendon. The fatty infiltration grade of the neglected subscapularis tear progressed from a mean of 1.1 before primary repair to a mean of 1.6 before revision, and the change indicated statistically significant deterioration (P < .001). Despite clinical improvement after revision surgery, the retear rate was considerable in the re-repaired cuff tendons (37.9%) as well as for the repaired concomitant subscapularis tears (24%). Conclusion: Among revision rotator cuff repairs, 43.1% had neglected subscapularis tears, and fatty infiltration of these initially neglected subscapularis tendons showed further progression at the time of revision. The retear rate after the repair of neglected subscapularis tears was higher than expected. Thus, detecting and treating subscapularis tear via meticulous preoperative evaluation and thorough inspection during primary arthroscopy are essential.

Preoperative rotator cuff tendon integrity, tear size, and muscle atrophy and fatty infiltration are associated with structural outcomes of arthroscopic revision rotator cuff repair.

A few studies have focused on factors predisposing to retear after arthroscopic revision rotator cuff repair (ARRCR). This study aimed to retrospectively evaluate (1) the structural and clinical outcomes of ARRCR and (2) pre- and intraoperative factors affecting the integrity of the rotator cuff (RC) tendon by focusing on preoperative RC tendon integrity, tear size, muscle hypotrophy and fatty infiltration. Patients who underwent ARRCR between 2006 and 2016 were reviewed. Preoperative variables included demographic data, RC tendon integrity, tear size, and muscle hypotrophy and fatty infiltration on preoperative magnetic resonance imaging (MRI). Intraoperative variables included repair technique and completeness of repair. The visual analog scale for pain (PVAS), functional VAS (FVAS), American Shoulder and Elbow Surgeons scores, and shoulder range of motion (ROM) were assessed. Postoperative tendon integrity was evaluated using over 6-month follow-up MRI. Patients were classified into groups A (healed) and B (retear), and their variables were compared. Overall 65 patients with a mean follow-up of 49.5 ± 30.2 (range, 24.0-148.9) months were analyzed. Fifty-six of 65 (86.2%) patients underwent MRI at 9.1 ± 9.7 (range, 4.4-40.2) months after ARRCR, and 20 of 56 (35.7%) patients (group B) exhibited retear. Group A (36/56, 64.3%) showed higher functional scores and ROMs than group B at the final follow-up, with significant differences in the FVAS scores (Group A versus B: FVAS, 7.6 ± 1.8 versus 6.4 ± 1.9, p = 0.036). Intraoperative variables, including preoperative tendon integrity (p = 0.021), tear size (p = 0.007), supraspinatus and infraspinatus muscle hypotrophy and fatty infiltration (p < 0.001 and p = 0.046), and completeness of repair (p = 0.030), differed significantly between the groups. Multivariate analysis revealed that preoperative supraspinatus muscle hypotrophy and fatty infiltration were independent predisposing factors for retear after ARRCR [odds ratio = 7.5, 95% confidence interval (CI) 1.1-55.8, p = 0.048]. The retear was found in 20/56 patients (35.7%) after ARRCR for less than massive rotator cuff tears in this limited study population. Preoperative tendon integrity, tear size, supraspinatus and infraspinatus muscle hypotrophy and fatty infiltration, and completeness of repair was revealed to be associated with tendon integrity following ARRCR. Among them, preoperative supraspinatus muscle atrophy and fatty infiltration were the independent factors for retear after ARRCR, although generalization is limited. IV.

Defining Clinically Significant Outcomes for Revision Arthroscopic Rotator Cuff Repair (230)

Objectives:While clinically significant outcomes including Minimal Clinically Important Difference (MCID), Substantial Clinical Benefit (SCB), and Patient Acceptable Symptom State (PASS) have been defined in primary rotator cuff repair (RCR), these values have not been established in revision RCR. Revision cases may be associated with lower absolute improvement compared to primary cases, and outcomes should therefore be assessed against revision-specific clinically significant differences. The purpose of this study was to define clinically significant outcomes in American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Constant scores, and to investigate factors associated with achievement of significant improvement following revision arthroscopic RCR. We hypothesized that MCID, SCB, and PASS values would be lower than those reported for primary RCR patients.Methods:A retrospective review of revision RCRs from July 2014 through June 2019 was performed. Patients who did not complete any patient reported outcomes (PROs) and those who underwent superior capsular reconstructions were excluded; graft augmentations were included. MCID was calculated with the distribution-based method, whereas SCB and PASS were calculated using anchor-based methodology from postoperative PRO scores. The SCB was determined by comparing the PRO scores of the substantial improvement and control patient cohorts, and PASS was determined by comparing the PRO scores of patients responding as satisfied and unsatisfied with their postoperative outcome. Receiver operating characteristic (ROC) curves and area under the curve (AUC) analysis were used to calculate optimal threshold scores corresponding to achievement of the SCB and PASS. Optimal thresholds were determined through maximization of sensitivity and specificity via Youden’s index. This process was repeated for each questionnaire (ASES, SANE, and Constant). Wilcoxon signed-rank paired tests were used to assess improvement in PRO scores from baseline. Threshold analysis to determine if any preoperative PRO scores were sufficiently predictive of achieving the MCID, SCB, or PASS were performed.Results:A total of 97 patients were identified and 54 patients (51 anchor responses) answered 1-year PROs. All PROs demonstrated significant increases from baseline to 1-year postoperatively (all P < 0.001). There was a gain of 22.4, 19.9, and 5.7 points for ASES, SANE, and Constant from baseline, respectively. MCID was 13.7, 14.1, and 4.2 for ASES, SANE, and Constant, respectively (Table 1). Values for SCB using the physical function and pain anchors, and PASS using the satisfaction anchor are demonstrated in Table 1. For physical function improvement, 26 patients (51.0%) had some degree of improvement, 15 patients (29.4%) had no change or negligible change in their status, and 10 patients (19.6%) were worse based on the anchor question. For the pain anchor, 24 patients (47.1%) had some degree of pain improvement, 16 patients (31.4%) had no change or negligible change in their status, and 11 patients (21.6%) were worse. Preoperative PRO score thresholds that were predictive of achieving MCID, SCB, and PASS are presented in Table 2. There were no significant effects of sex on attaining any clinically significant outcome, but a greater age was associated with a higher likelihood of achieving SCB (r = 0.299, p = 0.043) on Constant. BMI was negatively correlated with achieving SCB on SANE (r = -0.383, p = 0.009), while WC status was negatively correlated with achievement of SCB (13.3% WC vs 58.9% non-WC, p = 0.005) and PASS (13.3% WC vs 58.9% non-WC, p = 0.029) on SANE.Conclusions:In this study, we defined MCID, SCB, and PASS values at 1-year for ASES, SANE, and Constant in patients undergoing revision RCR. Our MCID values were higher for ASES but lower for SANE and Constant compared to prior studies on clinically significant outcomes in primary RCR. Our findings suggest different clinical thresholds should be used in the revision RCR population.

Rotator cuff retear after repair surgery: comparison between experienced and inexperienced surgeons.

BackgroundWe hypothesized in this study that the characteristics of retear cases vary according to surgeon volume and that surgical outcomes differ between primary and revision arthroscopic rotator cuff repair (revisional ARCR).MethodsSurgeons performing more than 12 rotator cuff repairs (RCRs) per year were defined as high-volume surgeons, and those performing fewer than 12 RCRs were considered low-volume surgeons. Of the 47 patients who underwent revisional ARCR at our clinic enrolled in this study, 21 cases were treated by high-volume surgeons and 26 cases by low-volume surgeons. In all cases, the interval between primary surgery and revisional ARCR, degree of “acromial scuffing,” number of anchors, RCR technique, retear pattern, fatty infiltration, retear size, operating time, and clinical outcome were recorded.ResultsDuring primary surgery, significantly more lateral anchors (p=0.004) were used, and the rate of use of the double-row repair technique was significantly higher (p<0.001) in the high- versus low-volume surgeon group. Moreover, the “cut-through pattern” was observed significantly more frequently among the cases treated by high- versus low-volume surgeons (p=0.008). The clinical outcomes after revisional ARCR were not different between the two groups.ConclusionsDouble-row repair during primary surgery and the cut-through pattern during revisional ARCR were more frequent in the high- versus low-volume surgeon groups. However, no differences in retear site or size, fatty infiltration grade, or outcomes were observed between the groups.

Decreased Colony-Forming Ability of Subacromial Bursa-Derived Cells During Revision Arthroscopic Rotator Cuff Repair

PurposeTo compare the cellular viability and differentiation potential of subacromial bursa–derived cells (SBDCs) located over the rotator cuff muscle and tendon of patients undergoing primary versus revision arthroscopic rotator cuff repair (ARCR).MethodsSubacromial bursa was harvested from 18 primary (57.1 ± 4.6 years) and 12 revision ARCRs (57.3 ± 6.7 years). Bursa was collected from 2 sites (over rotator cuff tendon and muscle), digested with collagenase, and grown in culture. The number of nucleated cells, colony-forming units (CFUs), differentiation potential, and mesenchymal stem cell surface markers were compared in primary and revision cases.ResultsThere was no difference in the number of nucleated cells between primary and revision ARCR harvested from the subacromial bursa overlying the tendon (3019.3 ± 1420.6 cells/mg and 3541.7 ± 2244.2 cells/mg, respectively; P = .912) or muscle (2753.5 ± 1547.1 cells/mg and 2989.0 ± 2231.4 cells/mg, respectively; P = .777). There was no difference in the number of CFUs between primary and revision ARCR over the rotator cuff tendon (81.5 ± 49.5 CFUs and 53.0 ± 36.9 CFUs, respectively; P = .138), but there were significantly fewer CFUs over the muscle in revision cases (28.1 ± 22.7 CFUs) compared with primary cases (55.7 ± 34.5 CFUs) (P = .031). SBDCs from revision ARCR expressed characteristic mesenchymal stem cell surface epitopes and had multidifferentiation potentials for chondrogenesis, osteogenesis, and adipogenesis.ConclusionsSBDCs harvested over the rotator cuff muscle demonstrated significantly decreased colony-forming abilities in revision arthroscopic rotator cuff repairs compared with primary repairs. However, the subacromial bursa retains its pluripotent differentiation potential for chondrogenic, osteogenic, and adipogenic lineages in the revision setting.Clinical RelevanceThe subacromial bursa may play a role in the healing response of the repaired rotator cuff. This capacity is not necessarily diminished in the revision setting and may be harnessed as an orthobiologic.

Results after Revision Arthroscopic Rotator Cuff Repair: A Prospective Multi-Center Analysis

Primary arthroscopic rotator cuff repair has shown to provide reliable clinical results with a low re-tear rate. Rotator cuff re-tears following surgical repair are associated with poor shoulder function and unsatisfactory clinical results. Data regarding the role of revision arthroscopic rotator cuff repair (RARCR) are sparse. Hence, this study aimed to investigate the clinical and radiological results following RARCR. It was hypothesized that (1) RARCR would lead to an improved clinical outcome and that (2) the clinical results would be dependent on tendon integrity at two years. During a 3-year period, 100 patients who underwent RARCR were prospectively enrolled in this multi-center study of ten European shoulder centers. Clinical results were evaluated pre-operatively, at six months and at two years by the Constant Score (CS), the Oxford Shoulder Score (OSS) and the Subjective Shoulder Value (SSV). Tendon integrity was analyzed by MRI at two years using the Sugaya classification. 13 patients (13%) were lost to follow-up. All clinical scores improved significantly during the study period (CS from 44±16 preoperatively to 58±22 at six months to 69±19 points at two years; OSS from 27±8 preoperatively to 36±11 at six months to 40±9 points at two years; SSV from 43±18% preoperatively to 66±24% at six months to 75±22% at two years; p < .01). At two years, a re-tear rate of 51.7% and a surgical revision rate of 12.6% were observed. While the Sugaya score improved from 4.5±0.9 preoperatively to 3.7±1.4 at two years, tendon integrity could not be correlated with better outcome scores. Prior open rotator cuff repair, involvement of the subscapularis tendon and medial cuff failure were correlated with poorer SSV scores at two years (p < .05). While RARCR leads to an improved clinical outcome, re-tears are frequently observed at a mid-term follow-up. Patients with re-tears, however, do not necessarily have poorer shoulder function than those with healed tendons. Patient satisfaction was lower when the primary surgery was performed by an open technique, when an associated lesion of the subscapularis was present and when the rotator cuff re-tear was located at the musculotendinous junction.

Successful Revision Arthroscopic Rotator Cuff Repair Is Possible in the Setting of Prior Deep Infection

PurposeTo report on clinical outcomes of revision arthroscopic rotator cuff (RC) repair in the setting of prior deep infection.MethodsA retrospective review was conducted of a single surgeon’s experience treating patients with deep infection after RC repair. Pain by visual analog scale (VAS), American Shoulder Elbow Society (ASES), Simple Shoulder Test (SST), and Single Assessment Numeric Evaluation (SANE) scores, as well as active range of motion, were collected preoperatively and at final follow-up.ResultsThree patients age 54.0 ± 7.5 years, mean ± standard error of the mean) with mean follow-up of 62 months (range 24 to 83) were treated for deep infection after RC repair. Improvements were observed in all subjective and objective outcomes; VAS pain (5.0 ± 0.6 vs 0.3 ± 0.3, P = .005), ASES score (37.2 ± 4.0 vs 93.9 ± 6.1, P = .003), and active forward elevation (68.3° ± 28.5° vs 173.3° ± 6.7°, P = .06.) Excellent outcomes in SST (mean 11.3 ± 0.7) and SANE (95.0 ± 5.0) scores were also observed. No recurrent infections were noted at final follow-up.ConclusionArthroscopic reconstruction of the RC is a feasible goal in the setting of prior deep infection. When a thorough arthroscopic debridement can be achieved, it is possible to address residual RC tears with either revision repair or allograft reconstruction with the possibility of excellent short-term clinical outcomes.Level of EvidenceLevel IV, retrospective case series

Rotator Cuff Tendon Adhesion to the Acromial Undersurface: Identification and Management Techniques

Identifying and mobilizing rotator cuff tissue during arthroscopic revision rotator cuff repair can be challenging. A particularly complex situation is encountered when rotator cuff tendons become adhered to surrounding bony structures. Tendon adherence to the undersurface of the acromion may occur after rotator cuff repair, especially when concurrent acromioplasty was carried out during the index procedure. This adhered and retracted rotator cuff tissue may be difficult to both recognize and mobilize, once identified, arthroscopically. The authors present a technique that can aid in both identifying and lateralizing this adhered rotator cuff tissue within the subacromial space.