Rotator Cuff Surgery Research Articles

Elevated HbA1c is not associated with reoperation following arthroscopic rotator cuff repair in patients with diabetes mellitus

Hyperglycemia is a known risk factor for tendon degeneration due to oxidative stresses from production of advanced glycosylation end products. In patients with Diabetes Mellitus (DM), analysis of glycated hemoglobin (HgA1c) provides a 3-month window into a patient's glucose control. No guidelines exist for ideal preoperative HgA1c and glucose control prior to arthroscopic rotator cuff repair. This study evaluated if a critical HgA1c level is associated with reoperation following arthroscopic rotator cuff repair. We retrospectively evaluated patients with DM who underwent primary arthroscopic rotator cuff repair from January 2014 to December 2018 at a single institution. Patients required a preoperative Hg1Ac within 3 months of surgery. Medical records were queried to evaluate for reoperation and identify the subsequent procedures performed. Univariate statistical analysis was performed to assess factors associated with reoperation (p< 0.05 considered significant). Threshold, area under the curve (AUC), analysis was performed to assess if a critical HgA1c value was associated with reoperation. 402 patients met inclusion criteria. Patients had an average age of 65.5 years (range 40-89) at time of surgery; 244 (60.6%) patients were male; and average BMI was 32.96 +/- 5.81. Mean HgA1c was 7.36 (Range 5.2 to 12). Thirty-three patients (8.2%) underwent subsequent reoperation. Six patients (1.5%) underwent capsular release and lysis of adhesions, 20 (5.0%) patients underwent a revision rotator cuff surgery, combination revision rotator cuff repair and lysis of adhesions, graft augmented revision repair, or superior capsular reconstruction, and 7 (1.7%) patients underwent revision to reverse shoulder arthroplasty (1.7%). There were no cases of reoperation for infection. On AUC analysis, no critical HgA1c value was identified to predispose to reoperation. Interestingly, elevated preoperative ASA (2.8 vs 2.28, p = 0.001) was associated with a higher reoperation rate. In patients with DM, preoperative HgA1c is not a predictive factor for surgical failure requiring reoperation. Stable glycemic control is important to a patient's overall health and may play a role in minimizing postoperative medical complications, but an elevated preoperative HgA1c should not be a strict surgical contraindication for arthroscopic rotator cuff repair. In patients with DM, an elevated ASA score is associated with an increased rate of subsequent reoperation; diabetic patients should be counselled accordingly.

Midterm outcomes of autologous bridging of rotator cuff tears with an autologous tendon patch (TEAR patch)

Large and massive rotator cuff tears and tears after failed surgical repair are a challenging clinical problem with different treatment options. The purpose of the study was to evaluate the mid-term outcomes following rotator cuff repair (RCR) with autologous hamstring tendon graft bridging (TEAR patch) with the hypothesis, that outcomes would be reasonable and complication rates low. This is a retrospective case series study of patients who underwent open RCR using a TEAR patch from June, 2015 to March, 2019. evidence of cuff tear arthropathy, advanced fatty infiltration, moderate to severe arthropathy and workers compensation board or litigation involved. Clinical outcome measures: Constant score (CS), Disabilities of Arm, Shoulder and Hand score (DASH), Simple Shoulder Test (SST), Subjective Shoulder Value (SSV), range of motion (ROM) and manual muscle test (MMT) for forward elevation, abduction, external and internal rotation, patient satisfaction, willingness to do the operation again. Radiographic outcome measures: MRI, ultrasound and radiographs: Graft integrity and acromiohumeral distance (AHD). 44 patients were followed (89%) for ≥ 2 years (45 shoulders, mean age 60.3 years (48-76), mean follow-up 4.3 years (2-6)). All clinical outcome measures (CS, DASH, SST, SSV, ROM, and MMT) demonstrated significant improvement except active external and internal rotation. At 2 years follow-up, the mean patient satisfaction was high (12.2 out of 15 points) and 33 of 38 patients (73.3%) would do the operation again. A perfect graft integration was observed in n=30 (66.7%) a small gap in n=7 (15.6%), a retear in n=3 (7%) and a complete failure of the tendon patch in n=5 (11%) patients. Graft integrity was strongly correlated with the postoperative AHD (r=0.599 , p=0.001 ) and the gain in AHD (r=0.599 , p=0.001) but not with ROM or PROM's or patient satisfaction. Four patients required revision surgeries (three due to deep infection and one for poor function and pain). Mid-term clinical and radiographic outcomes following RCR with graft bridging using a TEAR patch were reasonable. The procedure resulted in improved shoulder function and a high level of patient satisfaction. The revision rate is acceptable in view of the specific patient group and treatment alternatives. The described technique of the TEAR patch can be a valuable alternative to existing methods and a novel autograft source for rotator cuff surgeries that need bridging of a tendon defect.

Health literacy in rotator cuff repair: a quantitative assessment of the understandability of online patient education material

The American Medical Association and National Institutes of Health recommend online health information be written at a 6th grade or lower reading level for clear understanding. While syntax reading grade level has previously been utilized, those analyses do not determine whether readers are processing key information (understandability) or identifying available actions to take (actionability). The Patient Education Materials Assessment Tool (PEMAT-P) is a method to measure the understandability and actionability of online patient education materials. The purpose of this study was to evaluate online resources regarding rotator cuff repair utilizing measures of readability, understandability, and actionability. The search term "rotator cuff surgery" was used in two independent online searches to obtain the top 50 search results. The readability of included resources was quantified using valid objective algorithms: Flesch-Kincaid Grade-Level, Simple Measure of Gobbledygook grade, Coleman-Liau Index, and Gunning Fog Index. The PEMAT-P form was used to assess actionability and understandability. A total of 49 unique websites were identified to meet our inclusion criteria and were included in our analysis. The mean Flesch-Kincaid Grade Level graded materials at a 10.6 (approximately a 10th grade reading level), with only two websites offering materials at a 6th grade reading level or below. The remaining readability studies graded the mean reading level at high school or greater, with the Gunning Fog Index scoring at a collegiate reading level. Mean understandability and actionability scores were 64.6% and 29.5%, respectively, falling below the 70% PEMAT score threshold for both scales. Fourteen (28.6%) websites were above the threshold for understandability, while no website (0%) scored above the 70% threshold for actionability. When comparing source categories, commercial health publishers provided websites that scored higher in understandability (P<.05), while private practice materials scored higher in actionability (P<.05). Resources published by academic institutions or organizations scored lower in both understandability and actionability than private practice and commercial health publishers (P<.05). No readability, understandability, or actionability score was significantly associated with search result rank. Overall, online patient education materials related to rotator cuff surgery scored poorly with respect to readability, understandability, and actionability. Only two (4.1%) of the patient education websites scored at the American Medical Association and National Institutes of Health recommended reading level. Fourteen (28.6%) scored above the 70% PEMAT score for understandability; however, no website met the threshold for actionability.

Poster 105: Rotator cuff healing using demineralised bone fibers in ovine infraspinatus tendon models

Objectives: Rotator cuff tears are a common cause of shoulder pain and functional deficits. Although surgical repair is often able to restore function and resolve pain, high rates of postoperative structural failures have been reported. To improve the outcomes and reduce re-tear rates biologic tissue scaffolds have been used to augment and reinforce the primary tendon repair by providing mechanical support of the initial repair and ideally improving the rate and/or quality of biological healing at the tendon-bone interface. Demineralised bone fibers (DBF) are bone collagen and can be formed into a patch providing a scaffold and inductive bone morphogenetic proteins known to facilitate healing. This study evaluated the in vivo response of human DBF Patches (hDBF-P) as an onlay over the infraspinatus tendon (IST) and at the tendon-bone interface in an ovine model. Methods: The hDBF-P was characterised using stereozoom (Figure 1A) and environment electron microscopy (Figure 1B). The osteoinductivity (OI) was evaluated in the standard nude rat intramuscular implantation (IM) model at 28 days using mCT and paraffin histology. A bilateral model of an onlay or an enthesis repair was performed in 12 adult wethers following ethical approval. Four groups were evaluated at 6 and 12 weeks (n=3 per time point): Onlay control and hDBF treated; Enthesis repair control and hDBF treated. The onlay model simulated a tendon injury by 4 longitudinal slits along the IST and lateral drill holes in the proximal humerus in the onlay control group [1]. In the onlay treated group the hDBF-P was hydrated in saline and secured to the IST with interrupted 2-0 non-resorbable sutures (Figure 2A). On contralateral side, the central third of the IST was sharply dissected, the footprint burred, and 2 medial row anchors inserted. The sutures were passed through the IST in the enthesis repair control group. In the enthesis repair treatment group, the sutures were passed through the hDBF-P which was placed at the tendon bone interface followed by sutures through the IST. Two lateral push lock anchors were used for a suture bridge (Figure 2B) in the control and treated groups. Endpoints included clinical recovery, macroscopic dissection, 3T MRI, radiographs, mCT and paraffin histology processing, H&amp;E staining, and light microscopic evaluations to assess local cell and tissue responses and healing. Results: OI was confirmed on IM implantation in nude rats. The sheep recovered uneventfully with no adverse events macroscopically or radiographically. MRI in the onlay control group revealed little response and no increase in tendon thickness which was confirmed histologically. In contrast the onlay hDBF-P treated demonstrated increased tendon thickness and hDBF resorption with time. Histology showed some initial inflammatory cells that decrease with time in the onlay group. MRI in the hDBF-P treated enthesis group supported increased activity at the bone interface at 6 and 12 weeks compared to controls. Histology at the interface with hDBF-P showed evidence of new bone formation at 6 weeks that matured with time support enthesis reformation. Conclusions: hDBF-P is a collagen graft composed of demineralized bone fibers that have osteoconductive and osteoinductive potential. When formed into a patch, this implant provides a scaffold that can participate with the local biology. hDBF-P used as on-lay in a tendon injury model increased tendon thickness. hDBF-P when used at the interface between the tendon and bone facilitated enthesis reformation through its conductive and inductive potential as well as scaffold architecture. DBF patches represent an exciting allograft implant with the potential to address the clinical problems in rotator cuff surgery. Literature cited Van Kampen, C., et al. (2013). Tissue-engineered augmentation of a rotator cuff tendon using a reconstituted collagen scaffold: a histological evaluation in sheep. Muscles, ligaments and tendons journal, 3(3), p.229.

Poster 173: Comparison of Sensitivity of Diagnosis of Subscapularis Tear on 1.5 Tesla versus 3.0 Tesla Magnetic Resonance Imaging

Objectives: Diagnosis of subscapularis tears via Magnetic Resonance Imaging (MRI) has been reported to have variable accuracy, with prior studies indicating sensitivity of MRI ranging from 30.0-83.0%. In the current literature, studies utilizing 3.0T MRI scans have generally shown higher sensitivity compared to studies utilizing 1.5T MRI scans; however, there has not been direct comparison of differences in accuracy of 1.5 vs. 3.0T for diagnosis of subscapularis tear. The aim of this study is to investigate this difference. We hypothesize that 3.0T MRI scans will show higher sensitivity for the detection of subscapularis tears compared to 1.5T MRI scans. Methods: A single institution data set was queried to identify patients undergoing rotator cuff repair between January 2015 and January 2020. Patients were separated based on 1.5T and 3.0T MRI strength and these cohorts were analyzed based on intraoperative findings of subscapularis tears and interpretation of these MRI reports. Likewise, demographic information of the cohorts was analyzed including BMI, age, and sex. Univariate analysis, multivariate analysis, and Pearson’s χ2 test, Mann- Whitney U test were used when appropriate. Results: In a total 756 of patients, 151 were identified as having rotator cuff surgery with preoperative MRI that met our inclusion criteria. A total of 50 (33.1%) of patients were identified as having intraoperative findings of subscapularis tears that were not appreciable on MRI. A statistically significant difference was found when comparing the sensitivity of 3.0T MRI for identifying subscapularis tears when compared to 1.5T MRI. 3.0T MRI had a sensitivity of 72.9% compared to 56.4% respectively[TTW1] [GIM2] ( P &lt; 0.05). Both groups had a PPV of 100% given no false positive results. 3.0T MRI had a NPV of 92.5% while 1.5T had a NPV of 92.2%. Conclusions: When a subscapularis tear is clinically suspected, surgeons should be critical over the choice of 1.5T vs 3.0T MRI imaging and understand their sensitivity to guide recommendations for intervention, preoperative planning, and overall patient satisfaction. [Table: see text][Table: see text]

Poster 202: Subacromial Decompression is Associated with a Number Needed to Treat of 4 for Reduced Revision Rotator Cuff Repair: A Large Matched Cohort Insurance Database Analysis

Objectives: Subacromial decompression (SAD) during arthroscopic rotator cuff repair (ARCR) has traditionally been performed to relieve impingement of the rotator cuff tendons as they pass through the subacromial space. The purpose of this study is to quantify the reduced risk of revision rotator cuff surgery conferred by performing SAD with ARCR. Methods: The PearlDiver administrative claims database was queried for patients who underwent ARCR between 2015-2020 with a minimum follow up of 2 years. The study population was stratified by whether concurrent SAD was performed at the time of the index ARCR. Groups were matched on age, gender, Charlson Comorbidity Index (CCI), complete versus partial tear, and comorbidities previously correlated with RCR healing. The primary outcome was requiring a revision rotator cuff repair. Results: The final analysis included 30,407 patients per group, with a mean age of 60 years (SD=7) and 45.3% women. Baseline demographics were similar between groups after matching. 551 (1.8%) patients without SAD vs. 437 patients with SAD (1.4%) underwent a revision rotator cuff repair, corresponding to a number needed to treat (NNT) of 3.8 (unadj-OR=0.79. 95% CI 0.70-0.90, P&lt;0.001). In a multivariable model, factors associated with revision rotator cuff repair included subacromial decompression (adj- OR=0.79, 95%CI 0.70-0.90, P&lt;0.001), male gender (adj-OR 0.97, 95% CI 0.97-0.98, P=0.017), older age (adj-OR=0.97, 95% CI 0.97-0.98, P&lt;0.001), complete tear (adj-OR=3.62, 95% CI 2.87-4.57, P&lt;0.001), tobacco use (adj-OR 1.33, 95% CI 1.12-1.52, P&lt;0.001), and CCI (adj-OR 1.05, 95% CI 1.01-1.09, P=0.027). Conclusions: In a large cohort of over 60,000 patients with partial or complete rotator cuff tears, performing concurrent SAD conferred a 26% relative risk reduction (NNT»4 patients) for revision rotator cuff repair when compared to ARCR alone. These findings suggest that SAD may reduce the risk of revision rotator cuff surgery. [Table: see text][Table: see text]

States of contra-lateral rotator cuff – Based on bilateral shoulder ultrasound results of 401 patients

BackgroundFor patients with rotator cuff tear (RCT), the contra-lateral shoulders have higher risk of RCT than general population. It has been proved by several previous studies. The focus of this study is to obtain the data of contra-lateral rotator cuff tear in Chinese population, and to find the rules of contra-lateral rotator cuff tear through statistical analysis. MethodsFrom March 2016 to January 2020, patients who underwent shoulder arthroscopic surgery were included in the study, we conduct bilateral shoulder ultrasound before surgery, patients information collection include gender, age, occupation and whether received contra-lateral rotator cuff surgery within 1–3 years. The above information was statistically analyzed. ResultsAccording to the inclusion and exclusion criteria, 401 patients were included. The incidence of contra-lateral rotator cuff tear was 24.3%, 5.58% of them underwent contra-lateral rotator cuff repair surgery within 3 years. The degree of contra-lateral rotator cuff tear was positively correlated with the degree of the primary side; Patients with full-thickness rotator cuff tear were more likely to have contra-lateral rotator cuff tear than patients with partial rotator cuff tear. For patients with supraspinatus tendon tear, the contra-lateral rotator cuff tear risk increases, For patients with subscapularis muscle tear, the contra-lateral rotator cuff tear risk doesn't increases. Contra-lateral rotator cuff tear is related to age, the risk of contra-lateral rotator cuff tear is higher in elderly patients. ConclusionsThe contra-lateral RCT data obtained in our study was 24.3%, significantly lower than that of previous studies. The reasons may include ethnic variation, lifestyle, and proportion of heavy physical labor. The condition of contra-lateral rotator cuff is closely related to affected side rotator cuff tear.

Longer Operative Time and the Use of Anticoagulants Are Associated With Increased Blood Loss in Elderly Patients Undergoing Arthroscopic Rotator Cuff Repair

To study the effects of rotator cuff tear size, operation time, and the use of anticoagulant on blood loss in elderly patients undergoing arthroscopic rotator cuff surgery. Patients aged older than 65 years who underwent arthroscopic rotator cuff repair with subacromial decompression at our hospital from January 2015 to December 2021 were identified. We measured hemoglobin levels preoperatively, postoperatively, and 7 days after surgery. First, subjects were divided according to the operation time (group I, <90 minutes; group II, <120 minutes; group III <150 minutes; and group IV, >150 minutes). Second, we classified the subjects by the size of the rotator cuff tear (group A, <3 cm; group B, <5 cm; and group C, >5 cm). Lastly, we categorized the subjects into 2 groups according to the use of anticoagulant medication. A total of 566 patients were included. The mean hemoglobin (Hgb) levels were 13.8 ± 1.4 g/dL preoperatively, 13.2 ± 1.4 g/dL postoperatively, and 12.8 ± 1.3 g/dL 7 days after surgery, and the differences among them were statistically significant (P < .001). The Hgb level changes 7 days after surgery showed a significant decrease in the group with a longer operation time, and the Hgb loss increased from group 1 to group 4 (P < .001). They did not show any difference in the Hgb levels among the groups according to the size of a cuff tear preoperatively, postoperatively, and 7 days after surgery. The subjects with anticoagulant use showed more decrease in Hgb levels between immediately after the surgery and 7 days after the surgery (P= .031). Still, both groups did not show a statistical difference in the Hgb level 7days after surgery (P= .115). In this study, blood loss after arthroscopic rotator cuff repair in elderly patients was greater than expected. Bleeding increased in elderly patients who had longer surgical times or were taking anticoagulant medications after surgery. Tear size was not associated with a decrease in Hgb levels. Level III, retrospective comparative study.

The Glenoid Fossa's Morphometric Investigation and Its Clinical Implications.

Background The inconsistent morphology of the scapula is based on variable dimensions of its glenoid cavity, in addition to its broadened and truncated lateral angle. Its variable shapes are attributed to the spinoglenoid cavity (superior and posterior aspect of thescapula), which appears oval, inverted comma-shaped, and piriform (pear-shaped).Traumatic conditions often lead to glenoid dislocation/fracture. The precise administration of total shoulder arthroplasty with glenoid component adjustment warrants a comprehensive knowledge of scapular morphology. This study aims to assess the glenoid cavity/scapula shapes (anthropometric assessment) among individualslocated in Odisha, India. Methods This cross-sectional analysis was undertaken on 74 left-sided and 70 right-sided, dry, and undeteriorated scapulae of human adult specimens obtained from the anatomy department irrespective of their gender and age. Results The glenoid cavity was most commonly inverted comma-shaped (34.02%) and pear-shaped (48.61%) while 17.36% of scapulae had oval-shaped glenoid cavities. The mean scapular breadth and length dimensions were 98.12±7.87mm and 135.76±12.85mm, respectively. Statistically insignificant bilateral variations were observed between the glenoid cavity index (mean value: 68.44±7.98%), glenoid diameter-2 (anteroposterior; mean value: 16.17±2.24mm), glenoid diameter-1 (anteroposterior; mean value: 22.67±1.53mm), and glenoid diameter (superoinferior; mean value: 36.03±2.15mm). Conclusion The size and shape of the glenoid cavity are directly associated with the dislocation of the shoulder joint and may disturb the results of total shoulder arthroplasty and rotator cuff surgeries. The current study analyzed the morphological types and diameters of the glenoid cavity in the scapulae to improve efficiency and lessen the failure proportions in shoulder arthroplasty. The study shows that morphological measurement of scapulae plays a vital role in the effective maintenance of posture and shoulder functions.

A Study on Outcomes of Mini Open Procedures on Rotator Cuff Injuries

Background: Many treatment options exist for the management of rotator cuff tears, varying from non-operative-benign neglect to complex arthroscopic partial repair using an interval slide technique. Although satisfactory results may be obtained with many of these options, it should be remembered that few prospective, randomized trials exist comparing these treatments. Thus, controversy remains as to the absolute indications for each, and individual patient factors may significantly affect the final treatment decision. Methods: Hospital-based observational study. Informed consent was taken from the patients. A total of 30 patients who got admitted to the Department of Orthopaedics, Government General Hospital, Kakinada from November 2018 to September 2020 were included in the study. Results: Twenty five cases showed excellent results four cases showed good results and one showed poor result using University of California LosAngeles shoulder scale. Twenty nine cases showed excellent results and one case showed good result with Constant Murley Score. Conclusion: In the era of arthroscopic rotator cuff surgery the mini open technique with open acromio plasty and rotator cuff repair adds to rural surgeon as an elective procedure and can produce clinically competing results that of other contemporary techniques.

Minimum 5-Year Clinical Outcomes of Arthroscopically Repaired Massive Rotator Cuff Tears: Effect of Age on Clinical Outcomes

Background: Massive rotator cuff tears (MRCTs) can be challenging to treat, and the efficacy of repair of MRCTs in older patients has been debated. Purpose: To report minimum 5-year outcomes after primary arthroscopic rotator cuff repair of MRCT and determine whether age affects outcomes. Study Design: Case series; Level of evidence 4. Methods: The study included consecutive patients with MRCTs who were treated with arthroscopic rotator cuff repair by a single surgeon between February 2006 and October 2016. MRCTs were defined as ≥2 affected tendons with tendon retraction to the glenoid rim and/or a minimum exposed greater tuberosity of ≥67. Patient-reported outcome (PRO) data collected preoperatively and at a minimum of 5 years included the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numeric Evaluation (SANE) score; the shortened version of the Disabilities of the Arm, Shoulder and Hand score (QuickDASH); the 12-Item Short Form Health Survey (SF-12) Physical Component Summary (PCS); and patient satisfaction. Surgical failure was defined as subsequent revision rotator cuff surgery or conversion to reverse total shoulder arthroplasty. Regression analysis was performed to determine whether age had an effect on clinical outcomes. Results: A total of 53 shoulders in 51 patients (mean age, 59.7 years; range, 39.6-73.8 years; 34 male, 19 female) met inclusion criteria with a mean follow-up of 8.1 years (range, 5.0-12.1 years). Three shoulders (5.7%) failed at 2.4, 6.0, and 7.1 years. Minimum 5-year follow-up was obtained in 45 of the remaining 50 shoulders (90%). Mean PROs improved as follows: ASES from 58.8 to 96.9 (P < .001), SANE from 60.5 to 88.5 (P < .001), QuickDASH from 34.2 to 6.8 (P < .001), and SF-12 PCS from 41.1 to 52.2 (P < .001). Patient satisfaction was a median of 10 (on a scale of 1-10). Age was not associated with any PRO measures postoperatively (P > .05). Conclusion: This study demonstrated significantly improved clinical scores, decreased pain, and increased return to activity for patients with MRCT at midterm follow-up (mean, 8.1 years; range, 5.0-12.1 years). In this patient cohort, no association was found between age and clinical outcomes.

Failed rotator cuff surgery that resulted in reverse total shoulder arthroplasty within 5 years or less: a descriptive analysis of 42 shoulders from a US integrated healthcare system

BackgroundAlthough reverse total shoulder arthroplasty (RTSA) has become an effective treatment for patients after failed rotator cuff surgery, minimizing these failed surgeries by identifying patients who are likely to fail would improve resource utilization and decrease patient morbidity. MethodsFrom an integrated healthcare system’s Shoulder Arthroplasty Registry, of 570 RTSA performed between 2010 and 2015, we identified 42 shoulders (in 39 patients) that underwent RTSA after any prior rotator cuff surgery (repair or non-repair) within the previous five years. The medical records and imaging studies available were reviewed before and after the index rotator cuff surgery and the RTSA. Patient clinical and radiographic characteristics were analyzed statistically to identify patterns. ResultsThose 42 shoulders that underwent RTSA after a prior rotator cuff surgery were younger (mean ± standard deviation: 70.2 ± 6.5 vs. 74.0 ± 7.4, P < .01) with a higher prevalence of female sex (81.0% vs. 66.1%, P < .01) than those that did not have prior cuff surgery within five years in the Shoulder Arthroplasty Registry. 64.2% of index rotator cuff surgeries were reconstructive, while 35.7% were symptomatic. The median time from index surgery to RTSA was 15.5 months (range: 4-55 months). At the time of the index rotator cuff surgery, 50.0% exhibited pseudoparalysis. Most rotator cuff tears at their index surgery (75.7%) were retracted to near or beyond the glenoid rim, and 70.2% showed advanced fatty infiltration (Goutallier grade 3 or 4). Two-tendon tears accounted for 45.9% of patients (24.3% supraspinatus/subscapularis, 21.6% supraspinatus/infraspinatus). Isolated supraspinatus tears accounted for 43.2% of patients (34.2% full thickness and 10.8% partial thickness). Three or more tendon tear involvement only accounted for 10.8% of patients (4 patients). ConclusionRotator cuff tear retraction, fatty infiltration, pseudoparalysis, age near 70 years, and female sex are prevalent in patients who fail rotator cuff surgery and require conversion to RTSA. Therefore, repeated attempts at rotator cuff repair may be unwarranted in the presence of these unfavorable characteristics, and these patients may be better suited for initial management with RTSA.

Superior Capsular Reconstruction Versus Latissimus Dorsi Tendon Transfer for Irreparable Rotator Cuff Tears: Minimum 5-year Outcomes.

Arthroscopic superior capsular reconstruction (SCR) has been introduced as a successful alternative to latissimus dorsi tendon transfer (LDTT) for irreparable posterosuperior rotator cuff tears. To compare minimum 5-year clinical outcomes of SCR and LDTT for the treatment of irreparable posterosuperior rotator cuff tears in patients with minimal evidence of arthritis and intact or reparable subscapularis tears. Cohort study; Level of evidence, 3. Patients who underwent SCR or LDTT and had undergone surgery ≥5 years earlier were included. The SCR technique used a dermal allograft customized to the defect. Surgical, demographic, and subjective data were collected prospectively and reviewed retrospectively. Patient-reported outcome (PRO) scores utilized were the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), the short version of the Disabilities of the Arm, Shoulder and Hand score (QuickDASH), 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS), and patient satisfaction. Further surgical procedures were documented, and treatment that progressed to reverse total shoulder arthroplasty (RTSA) or revision rotator cuff surgery was considered a failure. Kaplan-Meier survivorship analysis was performed. Thirty patients (n = 20 men; n = 10 women) with a mean follow-up of 6.3 years (range, 5-10.5 years) were included. A total of 13 patients underwent SCR and 17 patients underwent LDTT. The mean age of the SCR group was 56 years (range, 41.2-63.9 years), and the mean age of the LDTT group was 49 years (range, 34.7-57 years) (P = .006). One patient in the SCR group and 2 patients in the LDTT group progressed to RTSA. Two additional (11.8%) patients in the LDTT group had further surgery-1 had arthroscopic cuff repair and 1 had hardware removal with biopsies. The SCR group demonstrated significantly better ASES (94.1 ± 6.3 vs 72.3 ± 16.4; P = .001), SANE (85.6 ± 8 vs 48.7 ± 19.4; P = .001), QuickDASH (8.8 ± 8.7 vs 24.3 ± 16.5; P = .012), and SF-12 PCS (56.1 ± 2.3 vs 46.5 ± 6; P = .001) PROs at the final follow-up. There was no significant difference between groups in median satisfaction (SCR, 9; LDTT, 8 [P = .379]). At 5 years, survivorship rates were 91.7% and 81.3% for the SCR and LDTT groups, respectively (P = .421). At the final follow-up, SCR yielded superior PROs compared with LDTT for the treatment of massive, irreparable posterosuperior rotator cuff tears despite similar patient satisfaction and survivorship between procedures.

IMPACT OF CLINICAL COMMUNICATION SUMMARY REPORT ON INJURED WORKERS’ SATISFACTION FOLLOWING ROTATOR CUFF SURGERY

The purpose of the this survey study was twofold: 1) to examine different aspects of satisfaction with post-operative care in injured workers who have undergone rotator cuff surgery and 2) to examine the relationship between receiving a newly implemented summary report and the overall satisfaction with surgery and recovery.The clinical communication summary report was given to injured workers following their review assessment to share with the family doctor or other health care providers. The form indicated a need for further assessments or investigations and return to work recommendations. The study involved using a satisfaction survey that examined different aspects of follow-up visit and workers’ opinion about their understanding of the nature of surgery, their progress, clinical management, and usefulness of the newly implemented summery report.Eighty patients completed the questionnaire (mean age: 54 (8), 62(78%) males, of whom 26 (34%) had a rotator cuff decompression and 31 (40%) had a rotator cuff repair with 20 (26%) having both procedures and three missing data. There were no statistically significant relationships between the patient demographics (age, sex or type of surgery) and satisfaction. However, there was a significant correlation between how patients perceived the summary report in terms of helpfulness and the overall satisfaction with surgery (FTE&lt;0.0004, p=0.001) and the satisfaction with recovery (FTE&lt;0.0001, p=0.001). This may indicate that improvement in worker's understanding of their treatment recommendations and restrictions is associated with higher levels of overall satisfaction in this population.Our results indicate a positive linear relationship between expressing a high satisfaction and the helpfulness of the summary report. As part of improving care, adding a summary report may facilitate sharing information with the injured workers, their care providers and their workplace.

ENHANCEMENT OF ROTATOR CUFF HEALING WITH A COMBINED GROWTH FACTOR (IGF-1, TGF-Β1 AND PTH) HYDROGEL IN A RAT CHRONIC ROTATOR CUFF TEAR MODEL

Re-rupture rates after rotator cuff repair remain high because of inadequate biological healing at the tendon-bone interface. Single-growth factor therapies to augment healing at the enthesis have so far yielded inconsistent results. An emerging approach is to combine multiple growth factors over a spatiotemporal distribution that mimics normal healing. We propose a novel combination treatment of insulin-like growth factor 1 (IGF-1), transforming growth factor β1 (TGF-β1) and parathyroid hormone (PTH) incorporated into a controlled-release tyraminated poly-vinyl-alcohol hydrogel to improve healing after rotator cuff repair. We aimed to evaluate this growth factor treatment in a rat chronic rotator cuff tear model.A total of 30 male Sprague-Dawley rats underwent unilateral supraspinatus tenotomy. Delayed rotator cuff repairs were then performed after 3 weeks, to allow tendon degeneration that resembles the human clinical scenario. Animals were randomly assigned to: [1] a control group with repair alone; or [2] a treatment group in which the hydrogel was applied at the repair site. All animals were euthanized 12 weeks after rotator cuff surgery and the explanted shoulders were analyzed for biomechanical strength and histological quality of healing at the repair site.In the treatment group had significantly higher stress at failure (73% improvement, P=0.003) and Young's modulus (56% improvement, P=0.028) compared to the control group. Histological assessment revealed improved healing with significantly higher overall histological scores (10.1 of 15 vs 6.55 of 15, P=0.032), and lower inflammation and vascularity.This novel combination growth factor treatment improved the quality of healing and strength of the repaired enthesis in a chronic rotator cuff tear model. Further optimization and tailoring of the growth factors hydrogel is required prior to consideration for clinical use in the treatment of rotator cuff tears. This novel treatment approach holds promise for improving biological healing of this clinically challenging problem.

Impact of age on glenoid size: three-dimensional computed tomographic analysis of glenoid anatomy

ObjectivePredictors of glenoid size are not fully understood. Reported factors include ethnicity, sex, and height. However, many studies have been conducted with relatively younger age groups on the assumption that no significant change in the size of the glenoid fossa occurs after the termination of bone growth. The purpose of this study was to examine glenoid size in a population representing the age groups eligible for rotator cuff surgery and to identify the influence of age on the size of the glenoid. MethodsThis retrospective review included 380 shoulders in 380 patients (151 females and 229 males; mean age: 67.2 ± 10.1 years; range: 27–89 years) who underwent preoperative three-dimensional computed tomography (3D-CT) evaluation and elective shoulder surgery (open or arthroscopic). The exclusion criteria were: history of prior shoulder surgery or glenoid fractures; history of shoulder instability; patients aged younger than 25 years; and those with advanced glenohumeral osteoarthritis. Anatomic parameters of the glenoid (height and width) were measured using 3D-CT images. A generalized linear model with the gamma distribution (multivariate gamma regression) was used in the analysis with the glenoid size (height or width) as the dependent variable. Initial exploratory models included all independent variables, followed by the stepwise selection of variables based on the P value, variance inflation factor, and Akaike’s information criterion for developing the final models. ResultsThe final analytical model showed that age was a significant predictor in both glenoid height and width. The mean glenoid width was 31.2 mm in men and 26.1 mm in women, and the mean glenoid height was 41.1 mm in men and 38.8 mm in women. Other factors that were significant were sex, body height, and hand dominancy. The analysis models accounted for 65% of the glenoid height (pseudo r-squared = 0.65; likelihood ratio test, P = .011) and 73% of the glenoid width (pseudo r-squared = 0.73; likelihood ratio test, P < .0001). ConclusionThis study showed that predictors of glenoid size (height and width) included age. Other positive predictors were shown to be taller body height, male gender, and dominant hand. The influence of rotator cuff tear was not observed.

Increased operative time has a negative impact on clinical outcome in arthroscopic rotator cuff repair.

Few data are available about the impact of operative time on outcome of rotator cuff repair. The aim of this study was to evaluate the impact of operative time on clinical outcome and tendon healing after arthroscopic rotator cuff repair. Patients operated on for distal supraspinatus tear in our institution between 2012 and 2018 were included retrospectively. Operative time, from skin incision until skin closure, was extracted from medical files. For statistical analysis, operative time was treated as a quantitative variable. Endpoints were clinical outcome (Constant score, range of motion), tendon healing (on CT or MRI) and complications at 1year. The significance threshold was set at p = 0.05. A total of 219 Patients, with a mean age of 54.6years (range 40-70years), were included. Mean operative time 44.9min (range 14-140min). Significant correlations (p < 0.05) were found for Constant score and external rotation at 1year: increasing operative time by 1min led to a decrease in Constant score of 0.115 points, or 6.9 points for a 60-min increase (p = 0.0167) and a decrease in external rotation of 0.134°, or 8.04° for a 60-min increase (p = 0.0214). No significant correlations were found for anterior elevation at 1year (p = 0.2577), tendon healing at 1year (p = 0.295) or onset of complications during follow-up (p = 0.193). The minimal clinically important difference in Constant score in patients undergoing rotator cuff surgery is between 6 and 10 points. An increase of more than 60min in operative time significantly impacted clinical outcome of arthroscopic distal supraspinatus repair, but not tendon healing. Level III: Retrospective Cohort Design. Therapeutic Study.

Payor Type Is Associated with Increased Rates of Reoperation and Healthcare Utilization following Rotator Cuff Repair: A National Database Study.

Despite strong evidence supporting the efficacy of rotator cuff repair (RCR), previous literature has demonstrated that socioeconomic disparities exist among patients who undergo surgery. There is a paucity of literature examining whether payor type, including Medicare, Medicaid, and commercial insurance types, impacts early medical complications and rates of reoperation following RCR. Patients with Medicare, Medicaid, or commercial payor type insurance who underwent primary open or arthroscopic RCR between 2010 and 2019 were identified using a large national database. Ninety-day incidence of medical complications, emergency department (ED) visit, and hospital readmission, as well as one-year incidence of revision repair, revision to arthroplasty, and cost of care were evaluated. Propensity score matching was used to control for patient demographic factors and comorbidities as covariates. 113,257 Medicare, 23,074 Medicaid, and 414,447 commercially insured patients were included for analysis. Medicaid insurance was associated with an increased 90-day risk of various medical complications, ED visit (OR 2.87; p<0.001) and one-year revision RCR (OR 1.60; p<0.001) compared to Medicare insurance. Medicaid insurance was also associated with an increased risk of various medical complications, ED visit (OR 2.98; p<0.001), hospital readmission (OR 1.56; p=0.002), as well as one-year risk of revision RCR (OR 1.60; p<0.001) and conversion to arthroplasty (OR 1.4358; p<0.001) compared to commercially insured patients. Medicaid insurance was associated with a decreased risk of conversion to arthroplasty compared to Medicare patients (OR 0.6887; p<0.001). Medicaid insurance was associated with higher one year cost of care compared to patients with both Medicare (p<0.001) and commercial insurance (p<0.001). Medicaid insurance is associated with increased rates of medical complications, healthcare utilization, and reoperation following rotator cuff surgery, despite controlling for covariates. Medicaid insurance is also associated with a higher one-year cost of care. Understanding the complex relationship between sociodemographic factors, such as insurance status, medical comorbidities, and outcomes, is necessary to ensure optimal healthcare access for all patients and to allow for appropriate risk stratification.

Rotator Cuff Repair With a Novel Interpositional Allograft Augmentation

Background: Nearly half a million rotator cuff repairs are performed annually in the United States. Rotator cuff healing occurs at the interface between the tendon and greater tuberosity, known as the enthesis. Given that a significant number of rotator cuff tears do not heal following surgical repair, multiple adjunctive strategies have been devised to improve the structural integrity of the repaired construct. Recently, a biphasic, demineralized allograft bone implant has been developed to improve enthesis healing. Indications: Relative indications for use of tissue augmentation include greater tuberosity osteopenia, revision rotator cuff surgery, attenuated rotator cuff tissue quality, and massive rotator cuff tears. Relative contraindications include a history of infection and recent immunosuppression. Technique Description: Following preparation of the footprint with an arthroscopic burr, two triple-loaded PEEK suture anchors were placed along the medial aspect of the greater tuberosity. Sutures were then passed through the rotator cuff tendon in a horizontal mattress configuration, and each pair of suture limbs were tied along the medial row. To aid in arthroscopic passage, the biphasic graft is folded longitudinally and clamped with a curved hemostat. The graft is loaded into an arthroscopic cannula and both are delivered simultaneously through a lateral arthroscopic portal. Two 18-gauge spinal needles are placed percutaneously to fix the allograft in the desired position. Subsequently, double-row transosseous-equivalent rotator cuff repair with standard techniques is done, which provides sufficient stability to the graft. Discussion: In a series of 192 patients who underwent arthroscopic rotator cuff repair augmented with a similar bioinductive collagen implant, patients demonstrated significant improvement in patient-reported outcomes at 1 year postoperatively. Moreover, a meta analysis published in 2022 demonstrated a significantly reduced retear rate among patch-augmented rotator cuff repairs as compared to isolated rotator cuff repairs. Conclusion: Tissue augmentation can be performed efficiently and reproducibly to promote biologic healing of arthroscopic rotator cuff repairs. The specific biphasic cancellous allograft presented in this video may be a viable treatment adjunct in the setting of deficient greater tuberosity bone stock, revision cases, or impaired native enthesis healing; however, further research is needed to assess clinical outcomes associated with its use. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Rotator cuff repair: what questions are patients asking online and where are they getting their answers?

This study analyzed questions searched by rotator cuff patients and determined types and quality of websites providing information. Three strings related to rotator cuff repair were explored by Google Search. Result pages were collected under the "People also ask" function for frequent questions and associated webpages. Questions were categorized using Rothwell classification and topical subcategorization. Webpages were evaluated by Journal of the American Medical Association (JAMA) benchmark criteria for source quality. One hundred twenty "People also ask" questions were collected with associated webpages. Using the Rothwell classification of questions, queries were organized into fact (41.7%), value (31.7%), and policy (26.7%). The most common webpage categories were academic (28.3%) and medical practice (27.5%). The most common question subcategories were timeline of recovery (21.7%), indications/ management (21.7%), and pain (18.3%). Average JAMA score for all 120 webpages was 1.50. Journal articles had the highest average JAMA score (3.77), while commercial websites had the lowest JAMA score (0.91). The most commonly suggested question for rotator cuff repair/ surgery was, "Is rotator cuff surgery worth having?," while the most commonly suggested question for rotator cuff repair pain was, "What happens if a rotator cuff is not repaired?" The most commonly asked questions pertaining to rotator cuff repair evaluate management options and relate to timeline of recovery and pain management. Most information is provided by medical practice, academic, and medical information websites, which have highly variable reliability. By understanding questions their patients search online, surgeons can tailor preoperative education to patient concerns and improve postoperative outcomes.