Shoulder Rotator Cuff Tears Research Articles

Impact of surrogate outcomes in randomized controlled trials for shoulder rotator cuff tears.

Surrogate outcomes are clinical endpoints that are used as substitutes for direct measures of how a patient feels, functions, or survives. The present study aims to analyze the impact of surrogate outcomes on the results of randomized controlled trials on shoulder rotator cuff tears disorders. Randomized controlled trials (RCTs) related to rotator cuff tear conditions published up until 2021 were retrieved from the PubMed and ACCESSSS databases. The primary outcome of the article was considered a surrogate outcome when the authors used radiological, physiologic, or functional variables. The result of the article was considered positive when results supported the intervention based on the trial's primary outcome. We recorded the sample size, the mean follow-up, and the type of funding. Statistical significance was set at p < 0.05. A total of 112 papers were included in the analysis. The mean sample size was 87.6 patients; mean follow-up period was 25.97months. Thirty-six out of 112 RCTs used a surrogate outcome as a primary endpoint. More than half of papers using surrogate outcomes reported a positive finding (20 out of 36), while 10 out of 71 RCTs using patient-centered outcomes favored the intervention (14.08%, p < 0.001) [RR = 3.94 (95% CI 2.07-7.51)]. The mean sample size was smaller in trials using surrogate endpoints (75.11 vs 92.35 patients, respectively, p = 0.049), while the follow-up was shorter (14.12m vs. 31.9m, p < 0.001). Approximately 25% of the papers that reported surrogate endpoints (22.58%) were industry-funded projects. The substitution of surrogate endpoints for patient-important outcomes in shoulder rotator cuff trials quadruplicates the chances of obtaining a favorable result that favors the analyzed intervention.

What's New in Sports Medicine.

What's New in Sports Medicine.

Detection of Shoulder Rotator Cuff Tears from X-Ray Image by Using Convolutional Neural Network

Shoulder rotator cuff tears are common disabilities of the shoulder joint caused by daily activities, sports injuries, and aging. Magnetic resonance imaging is widely used to diagnose rotator cuff tears, but radiography is a more rapid and popular imaging technique. In this study, we proposed a detection method using convolutional neural networks (CNN) on X-ray images of the shoulder for simpler diagnosis of rotator cuff tears. 139 subjects, classified into two classes according to the severity of the tear, were compared in terms of detection accuracy between five regions of interest on the shoulder and two combinations of CNN models, with a maximum accuracy of 79.3% accuracy.

The Effect of PRP Augmentation of Arthroscopic Repairs of Shoulder Rotator Cuff Tears on Postoperative Clinical Scores and Retear Rates: A Systematic Review and Meta-Analysis.

The aim of this review and meta-analysis is to assess recent clinical trials concerning the combination of operative treatment of rotator cuff tears and the administration of PRP and its effect on clinical scores and postoperative retear rates. The trials were used to compare the combination of PRP treatment and arthroscopic rotator cuff repair to arthroscopy alone. Twenty-five clinical trials were reviewed. A risk-of-bias assessment was made for all randomized clinical trials included, using the Cochrane collaboration's tool as well as a quality assessment for all non-randomized studies utilizing the Newcastle-Ottawa scale. The PRP-treated patients showed statistically significant improvement postoperatively compared to control groups concerning the Constant-Murley (mean difference 2.46, 95% CI 1.4-3.52, p &lt; 0.00001), SST (mean difference 0.32, 95% CI 0.02-0.63, p = 0.04), and UCLA (mean difference 0.82, 95% CI 0.23-1.43, p = 0.07) scores. A statistically significant decrease of retear rates in the PRP-treated patients, with a risk ratio of 0.78 (95% CI 0.65-0.94, p = 0.01), was found. We believe that the results presented have positive aspects, especially concerning the retear risk, but are yet inconclusive concerning clinical results such as shoulder pain and function.

An engineered tenogenic patch for the treatment of rotator cuff tear

Rotator cuff tear of shoulder is a common tendon injury. Current therapeutic strategies are unsatisfactory because of poor biomechanical properties of the repaired rotator cuff tendons. To solve this problem, a newly biofabricated tenogenic patch by uniaxial cold-drawing technology was applied for the treatment of acute rotator cuff tear and its therapeutic effects were evaluated in vitro and in vivo. The cytocompatibility results indicated that the engineered patch was capable of promoting the spreading, migration and proliferation of tendon fibroblasts in vitro. Stress–strain curves of the sutured patch indicated improved elasticity followed by the yield phenomena, nonlinear plasticity and obviously delaminated rupture. The tenogenic patch also showed significantly enhanced collagen I deposition and better tendon-to-bone healing in the rat rotator cuff tear models in vivo. Furthermore, implantation with the tenogenic patch also promoted the fibrocartilage formation in Safranin-O/Fast green-staining. The analysis of biomechanical properties showed that the tenogenic patch is capable of improving the ultimate load of the repaired tendon. Therefore, the tenogenic patch may constitute an efficient strategy to enhance tendon-to-bone healing for clinical repair applications of rotator cuff tear.

A clinical case of a combined endoscopic treatment: brachial plexus decompression in the thoracic aperture and subacromial spacer implantation

Background: Thoracic outlet syndrome compression of the brachial plexus in the area between the clavicle and the first rib is a commonly spread and important pathology. It occurs, as usual, after a trauma or due to an anatomical malformation of this area. Thoracic outlet syndrome can be combined with a shoulder joint pathology. In the case of a conservative treatment's failure, the standard surgical procedure is decompression of the brachial plexus in the thoracic aperture. This procedure is usually done via an open approach. The development of the endoscopic surgical technique of decompression allows reducing the risk of complications and recurrences, improving the cosmetic result and relieving the rehabilitation period. Clinical case description: A 73-year-old female patient with a clinical picture of posttraumatic brachial plexopathy and a massive shoulder rotator cuff tear. The patient underwent a conservative treatment for 6 months after the trauma without a significant improvement. To confirm the diagnosis, ENMG and an ultrasound investigation of the brachial plexus, as well as MRI of the shoulder joint were performed. Simultaneous shoulder joint arthroscopy with subacromial spacer implantation and brachial plexus decompression in the thoracic aperture were performed to the patient. According to the VAS-scale (Visual Analogue Scale), the severity of pain syndrome before the surgery was 10 cm, while 6 months after the surgery, it decreased to 1 cm. According to the DASH scale (Disabilities of the Arm, Shoulder, and Hand), the dysfunction of the of shoulder joint before the surgery was 76 points, while 6 months after the surgery, it decreased to 12 points. The range of motion in the shoulder joint before the surgery was as follows: flexion 105, abduction 95, external rotation 15, which increased to 160, 165, and 45, respectively, 6 months after the surgery. Conclusion: The results allow us to characterize the method of simultaneous shoulder joint arthroscopy and endoscopic decompression of the brachial plexus in the thoracic aperture as a low-traumatic and effective technique. The technique provides complete brachial plexus decompression in the thoracic aperture which promotes restoration of the function of the upper extremity and shoulder joint, and elimination of pain syndrome from the upper extremity area.

Shoulder kinematics and muscle activity following latissimus dorsi transfer for massive irreparable posterosuperior rotator cuff tears in shoulders with pseudoparalysis.

The aim of this study was to evaluate the thoracohumeral (TH) and glenohumeral (GH) motion with muscle activity after latissimus dorsi transfer (LDT) in a shoulder with a massive irreparable posterosuperior rotator cuff tear (MIRT) and pseudoparalysis compared with the asymptomatic contralateral shoulder (ACS). We recruited and evaluated 13 patients after LDT in a shoulder with preoperative clinical pseudoparalysis and an MIRT on magnetic resonance imaging, with a minimum follow-up period of 1 year, and with a Hamada stage of 3 or less. Three-dimensional electromagnetic tracking was used to assess shoulder active range of motion in both the LDT shoulder and the ACS. The maximal active elevation of the shoulder (MAES) was assessed and consisted of forward flexion, scapular abduction, and abduction in the coronal plane. Maximal active internal rotation and external rotation were assessed separately. Surface electromyography (EMG) was performed to track activation of the latissimus dorsi (LD) and deltoid muscles during shoulder motion. EMG was scaled to its maximal isometric voluntary contraction recorded in specified strength tests. In MAES, TH motion of the LDT shoulder was not significantly different from that of the ACS (F1,12=1.174, P=.300) but the GH contribution was significantly lower in the LDT shoulder for all motions (F1,12=11.230, P=.006). External rotation was significantly greater in the ACS (26°±10° in LDT shoulder vs. 42°±11° in ACS, P<.001). The LD percentage EMG maximum showed no significant difference between the LDT shoulder and ACS during MAES (F1,11=0.005, P=.946). During maximal active external rotation of the shoulder, the LDT shoulder showed a higher percentage EMG maximum than the ACS (3.0%±2.9% for LDT shoulder vs. 1.2%±2.0% for ACS, P=.006). TH motion improved after LDT in an MIRT with pseudoparalysis and was not different from the ACS except for external rotation. However, GH motion was significantly lower after LDT than in the ACS in active-elevation range of motion. The LD was active after LDT but not more than in the ACS except for active external rotation, which we did not consider relevant as the activity did not rise above 3% EMG maximum. The favorable clinical results of LDT do not seem to be related to a change in LD activation and might be explained by its effect in preventing proximal migration of the humeral head in active elevation.

Influence of Diabetes-Induced Glycation and Oxidative Stress on the Human Rotator Cuff.

Most shoulder rotator cuff tears (RCTs) are caused by non-traumatic age-related rotator cuff degeneration, of which hyperglycemia is a risk factor due to its glycation reaction and oxidative stress. We aimed to identify the influence of diabetes-induced glycation and oxidative stress in patients with non-traumatic shoulder RCTs. Twenty patients, aged over 50 years, with non-traumatic shoulder RCTs participated in this study. Patients with a history of diabetes mellitus or preoperative HbA1c ≥ 6.5% were assigned to the diabetic group (n = 10), and the rest to the non-diabetic group (n = 10). Cell proliferation; expression of genes related to oxidative stress, glycation reaction, inflammation, and collagen; intracellular reactive oxygen species (ROS) levels; and apoptosis rates were analyzed. The diabetic group had significantly lower cell proliferation than the non-diabetic group. In the diabetic group, the mRNA expression levels of NOX1, NOX4, IL6, RAGE, type III collagen, MMP2, TIMP1, and TIMP2 were significantly higher; type I collagen expression was significantly lower; and the rate of ROS-positive cells and apoptotic cells, as well as the expression of advanced glycation end-products (AGEs) and the receptor for AGEs (RAGE), was significantly higher. In conclusion, hyperglycemia caused by diabetes mellitus increased AGE and RAGE expression, and led to increased NOX expression, ROS production, and apoptosis in the human rotator cuff. This provides scope to find a preventive treatment for non-traumatic RCTs by inhibiting glycation and oxidative stress.

Usefulness of Multiphase Scaffolds for Improving Tendon to Bone Healing for Rotator Cuff Tears in Shoulder

Usefulness of Multiphase Scaffolds for Improving Tendon to Bone Healing for Rotator Cuff Tears in Shoulder

Efficacy and Role of Double Spinned Platelet Rich Plasma Therapy in Elderly with Rotator Cuff Tear of Shoulder

Aim: To assess the efficacy of local injection of autologous P.R.P. into the shoulder joint on pain and function of patients with rotator cuff tears. Objectives: To evaluate and analyze the results of local injection of platelet rich plasma in elderly with rotator cuff tear; To follow up the patients who had undergone the procedure and note the functional outcome and complications pertaining to the procedure.

Treatment of Massive Irreparable Rotator Cuff Tear with Arthroscopic Subacromial Bursectomy, Biceps tenotomy, and Tuberoplasty.

The alternative surgery for massive and irreparable shoulder rotator cuff tears in older patients is the debridement of subacromial bursa, biceps tenotomy, and tuberoplasty (reverse acromioplasty). This study aimed to report the effectiveness of such a treatment performed arthroscopically in a small group of patients for a short period of time. This prospective study was conducted on 12 patients with massive irreparable rotator cuff tear during 2014-2017. Participants with the mean age of 65 were subjected to arthroscopic debridement of subacromial bursa, necrotic rotator cuff tendon remnants, and tuberoplasty without coracoacromial ligament excision. The sign and symptoms of patients before and after the surgery were evaluated based on Modified-University of California at Los Angeles (UCLA) Shoulder Score. With the mean follow-up of 18 months (12-24 months), the mean of the modified UCLA score improved from 9.2 to 27.5. The obtained results of the study revealed that the pain and range of motion improved to near normal in the participants. The functional outcome was good although there were a decrease of acromiohumeral distance from 5 to 4 mm and a slight increase in degenerative changes. This simple arthroscopic procedure is recommended for massive irreparable rotator cuff tear, especially in elderly patients. IV.

Shoulder Impairment Rating: Sixth Edition Clarifications (Authoritative Article*)

Abstract A request for an impairment rating using both the fourth and sixth editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) demonstrated two interesting facts: In the sixth edition, Table 15-34, Shoulder Range of Motion has two typographical errors. First, Grade Modifier 3 (column 6) and the Internal Rotation (IR) (row 12) lists ≤20° ER = 8% UEI; this should be ≥20° ER = 8% UEI; and Grade Modifier 4 (column 7) and IR (row 12) lists: 20° to 50° IR = 6% UEI, ≥60° IR or 10° IR to ER = 0% UEI; this should be ≥60° IR or 10° IR to ER = 10% UEI. Second, the impairment rating using the fourth and sixth editions resulted in the same total impairment. A case example presents a 54-year-old male who experienced a right shoulder strain that was determined to be a right shoulder rotator cuff tear of the supraspinatus and infraspinatus muscles. The patient was evaluated for impairment based on the range-of-motion method in the fourth edition of the AMA Guides, and 13% upper extremity impairment was determined. Using the sixth edition produced similar results, demonstrating how similar impairment ratings can be based on the fourth and sixth editions.

Reconstruction of small and medium rotator cuff tear with single row anchor under all-arthroscopy

Objective To investigate the clinical efficacy of single row anchor under all-arthroscopy in the treatment of small and medium rotator cuff tear. Methods From January 2014 to December 2016, 13 cases of shoulder pain and activity limitation were diagnosed as shoulder rotator cuff tear after excluding other shoulder diseases by preoperative symptoms, signs, imaging examination. The rotator cuff tear size was further confirmed during the operation. Under all-arthroscopy, the single row anchor was used to reconstruct the rotator cuff tear. After the operation, the California University shoulder score system (UCLA) was used for the follow-up. Results All the wounds achieved primary healing. No joint infection and nerve injury occurred. According to imaging examination, there was no slippage of the anchor and recurrence of rotator cuff tear. The follow-up time ranged from 6 to 36 months with an average of 23 months. The postoperative pain symptoms were relieved effectively, and the shoulder function recovered well. According to the UCLA score system, the results were rated as excellent in 10 cases, good in 2 cases and poor in 1 case. The rate of patient satisfaction was 100%. Conclusion Arthroscopic single row anchor for reconstruction of small and medium rotator cuff tear has the advantages of simple operation, small trauma, short operation time, light postoperative pain, quick function recovery, relatively low cost. It is an ideal treatment method for repair of such injuries. Key words: Shoulder joint; Arthroscopes; Rotator cuff injury; Single row anchor

Interposition Dermal Matrix Xenografts: A Successful Alternative to Traditional Treatment of Massive Rotator Cuff Tears

Background: Management of massive rotator cuff tears in shoulders without glenohumeral arthritis remains problematic for surgeons. Repairs of massive rotator cuff tears have failure rates of 20% to 94% at 1 to 2 years postoperatively as demonstrated with arthrography, ultrasound, and magnetic resonance imaging. Additionally, inconsistent outcomes have been reported with debridement alone of massive rotator cuff tears, and limitations have been seen with other current methods of operative intervention, including arthroplasty and tendon transfers. Hypothesis: The use of interposition porcine acellular dermal matrix xenograft in patients with massive rotator cuff tears will result in improved subjective outcomes, postoperative pain, function, range of motion, and strength. Study Design: Case series; Level of evidence, 4. Methods: Sixty patients (61 shoulders) were prospectively observed for a mean of 50.3 months (range, 24-63 months) after repair of massive rotator cuff tears with porcine acellular dermal matrix xenograft as an interposition graft. Subjective outcome data were obtained with visual analog scale for pain score (0-10, 0 = no pain) and Modified American Shoulder and Elbow Surgeons (MASES) score. Active range of motion in flexion, external rotation, and internal rotation were recorded. Strength in the supraspinatus and infraspinatus muscles was assessed manually on a 10-point scale and by handheld dynamometer. Ultrasound was used to assess the integrity of the repair during latest follow-up. Results: Mean visual analog scale pain score decreased from 4.0 preoperatively to 1.0 postoperatively (P < .001). Mean active forward flexion improved from 140.7° to 160.4° (P < .001), external rotation at 0° of abduction from 55.6° to 70.1° (P = .001), and internal rotation at 90° of abduction from 52.0° to 76.2° (P < .001). Supraspinatus manual strength increased from 7.7 to 8.8 (P < .001) and infraspinatus manual strength from 7.7 to 9.3 (P < .001). Mean dynamometric strength in forward flexion was 77.7 N in nonoperative shoulders (shoulder that did not undergo surgery) and 67.8 N (P < .001) in operative shoulders (shoulder that underwent rotator cuff repair with interposition porcine dermal matrix xenograft). Mean dynamometric strength in external rotation was 54.5 N in nonoperative shoulders and 50.1 N in operative shoulders (P = .04). Average postoperative MASES score was 87.8. Musculoskeletal ultrasound showed that 91.8% (56 of 61) of repairs were fully intact; 3.3% (2 of 61), partially intact; and 4.9% (3 of 61), not intact. Conclusion: Patients who underwent repair of massive rotator cuff tears with interposition porcine acellular dermal matrix graft have good subjective function as assessed by the MASES score. Patients have significant improvement in pain, range of motion, and manual muscle strength. Postoperative ultrasound demonstrated that the repair was completely intact in 91.8% of patients, a vast improvement compared with results previously reported for primary repairs of massive rotator cuff tears.

Is poststroke complex regional pain syndrome the combination of shoulder pain and soft tissue injury of the wrist?: A prospective observational study: STROBE of ultrasonographic findings in complex regional pain syndrome.

Patients with poststroke complex regional pain syndrome (CRPS) show different symptoms compared to other types of CRPS, as they usually complain of shoulder and wrist pain with the elbow relatively spared. It is thus also known by the term “shoulder-hand syndrome.”The aim of this study is to present a possible pathophysiology of poststroke CRPS through ultrasonographic observation of the affected wrist before and after steroid injection at the extensor digitorum communis (EDC) tendon in patients suspected with poststroke CRPS.Prospective evaluation and observation, the STROBE guideline checklist was used.Twenty-three patients diagnosed as poststroke CRPS in accordance to clinical criteria were enrolled. They had a Three Phase Bone Scan (TPBS) done and the cross-sectional area (CSA) of EDC tendon was measured by using ultrasonography. They were then injected with steroid at the EDC tendon. The CSA of EDC tendon, visual analogue scale (VAS), and degree of swelling of the wrist were followed up 1 week after the injection.TPBS was interpreted as normal for 4 patients, suspected CRPS for 10 patients, and CRPS for 9 patients. Ultrasonographic findings of the affected wrist included swelling of the EDC tendon. After the injection of steroid to the wrist, CSA and swelling of the affected wrist compared to that before the treatment was significantly decreased (P < 0.001). The VAS score declined significantly after the injection (P < 0.001).Our results suggest that the pathophysiology of poststroke CRPS might be the combination of frozen shoulder or rotator cuff tear of shoulder and soft tissue injury of the wrist caused by the hemiplegic nature of patients with stroke.

Interposition Porcine Acellular Dermal Matrix Xenograft Successful Alternative in Treatment for Massive Rotator Cuff

Objectives:Despite advances in the surgical techniques of rotator cuff repair (RCR), the management of massive rotator cuff tears in shoulders without glenohumeral arthritis poses a difficult problem for surgeons. Failure of massive rotator cuff repairs range from 20-90% at one to two years postoperatively using arthrography, ultrasound, or magnetic resonance imaging. Additionally, there are inconsistent outcomes reported with debridement alone of massive rotator cuff tears as well as limitations seen with other current methods of operative intervention including arthroplasty and tendon transfers. The purpose of this prospective, comparative study was to determine if the repair of massive rotator cuff tears using an interposition porcine acellular dermal matrix xenograft improves subjective function, pain, range of motion, and strength at greater than two years follow-up. To our knowledge, this is the largest prospective series reporting outcomes of using porcine acellular dermal matrix xenograft as an interposition graft.Methods:Thirty-seven patients (37 shoulders) with an average age of 66 years (range 51-80 years) were prospectively followed for 33 months (range 23-48) following massive RCR using porcine acellular dermal matrix interposition xenograft. Subjective outcomes were measured using the Visual Analog Scale (VAS) pain score (0-10, 0 = no pain), Modified American Shoulder and Elbow Score (M-ASES), and Short-Form12 (SF-12) scores. Preoperative and postoperative objective outcome measures included active range of motion and supraspinatus and infraspinatus manual muscle strength. Postoperative outcome measures included quantitative muscle strength using a dynamometer and static and dynamic ultrasonography to assess the integrity of the repair.Results:Average VAS pain score decreased from 4.5 to 1.1 (P<0.001). Average postoperative M-ASES was 89.23. Average postoperative SF-12 was 52.6. Mean forward flexion, external and internal rotation significantly improved from 133.2° to 157.9° (P=0.003), 51.56° to 64.25° (P=0.001), and 49.8° to 74.0° (P<0.001), respectively. Manual strength (10 point scale) in supraspinatus and infraspinatus increased from 7.3 to 8.9 (P<0.001) and 7.4 to 9.4 (P<0.001), respectively. Using a dynamometer, supraspinatus quantitative strength was a mean of 68.6N and infraspinatus quantitative strength was a mean of 50.6N. Ultrasound evaluation of repairs showed 33 (89.1%) to be fully intact, three (8.1%) had partial tears, and one repair (2.7%) was not intact. The one patient whose repair was not intact by ultrasound was a revision repair. No infections, evidence of inflammatory reaction, tissue rejection, or major adverse outcomes were identified. Three patients underwent ipsilateral shoulder surgery for lysis of adhesions due to post-operative decreased ROM during the follow-up period.Conclusion:Following repair of massive rotator cuff tears with interposition porcine acellular dermal matrix xenografts, patients had significant improvement in pain, range of motion, strength and reported good subjective function based on M-ASES and SF-12 scores. The repair was completely intact in 89% of patients, a vast improvement compared with results reported for primary repairs of massive rotator cuff tears. Tissue grafts such as the porcine acellular graft used in our study hold great promise in the treatment of massive, retracted rotator cuff tears.

A prospective multi-site registry study of a specific protocol of autologous bone marrow concentrate for the treatment of shoulder rotator cuff tears and osteoarthritis.

IntroductionShoulder pain is a common musculoskeletal complaint in the general population. Bone marrow concentrate (BMC) injections offer promising potential as a minimally invasive approach for treatment of shoulder pain in degenerative disease. In this study, we investigated the clinical outcomes of the BMC injections for treatment of shoulder pain and disability due to osteoarthritis (OA) and rotator cuff tears in a treatment registry population.MethodsA total of 115 shoulders in 102 patients were treated with autologous BMC injections for symptomatic OA at the glenohumeral joint and/or rotator cuff tears. Data were collected for factors potentially influencing outcome, including age, sex, body mass index, and the type of condition treated (ie, OA or rotator cuff tear). Clinical outcomes were assessed serially over time using the disabilities of the arm, shoulder and hand score (DASH), the numeric pain scale (NPS), and a subjective improvement rating scale. Baseline scores were compared to the most recent outcome scores at the time of the analysis and adjusted for demographic differences. We reported comparisons of pre- and post-treatment scores, the differences between osteoarthritis and rotator cuff groups, and the predictive effects on the clinical outcomes.ResultsAt the most current follow-up assessment after treatment, the average DASH score decreased (improved) from 36.1 to 17.1 (P<0.001) and the average numeric pain scale value decreased (improved) from 4.3 to 2.4 (P<0.001). These changes were associated with an average subjective improvement of 48.8%. No differences were observed between outcomes among the shoulders treated for OA versus rotator cuff tears, nor did age, sex, or body mass index influence pain or functional outcomes. There were no significant treatment-related adverse events reported.DiscussionWe observed preliminarily encouraging results following BMC injections for shoulder OA and rotator cuff tears. These results serve as basis for the design of an adequately powered randomized controlled trial.

Effect of Fatty Degeneration of the Infraspinatus on the Efficacy of Arthroscopic Patch Autograft Procedure for Large to Massive Rotator Cuff Tears

Background: In a 2013 study involving 24 patients whose shoulders had large or massive rotator cuff tears (RCTs) and low-grade fatty degeneration of the infraspinatus (Goutallier stage 1 or 2), we reported significantly improved clinical results after an arthroscopic fascia lata autograft patch procedure, with a 79.2% rate of intact repairs. Based on that study, we began applying the fascia lata autograft patch procedure to shoulders with stage 3 or 4 degeneration of the supraspinatus and stage 3 or 4 degeneration of the infraspinatus. Purpose: To investigate the effects of the fascia lata autograft patch procedure on massive RCTs in shoulders with high-grade degeneration of the infraspinatus by comparing the clinical outcomes and structural features with those in shoulders with low-grade degeneration of the infraspinatus. Study Design: Cohort study; Level of evidence, 3. Methods: A case series of 45 consecutive patients with large to massive RCTs with high-grade fatty degeneration of the supraspinatus and either low-grade (group L; n = 26 [the same patients as in our previous study plus 2 additional patients]) or high-grade (group H; n = 19) fatty degeneration of the infraspinatus were treated with the fascia lata autograft patch procedure. Clinical (Constant and American Shoulder and Elbow Surgeons [ASES]) scores, structural outcomes on MRI, and muscle strength were assessed at a minimum 2-year follow-up and compared between the 2 groups. Results: Patients in group L had a higher frequency of intact repairs than did those in group H (73.1% vs 10.6%; P < .001), as assessed by MRI. Clinical scores, range of motion, and muscle strength ratios were improved after surgery in both groups. However, at the final follow-up, the mean Constant (78.4 in group L vs 63.9 in group H; P < .0001) and ASES (91.3 in group L vs 73.6 in group H; P < .001) scores were significantly higher in group L than in group H. Moreover, there were significant between-group differences in the mean muscle strength ratio of the affected to healthy sides for both abduction (0.68 in group L vs 0.54 in group H) and external rotation (0.67 in group L vs 0.50 in group H) for abduction at the final follow-up (P < .0001 for both). Conclusion: The arthroscopic fascia lata autograft patch procedure was not as beneficial for massive RCTs with high-grade fatty degeneration of the supraspinatus and infraspinatus as other treatment options that produce similar functional results.

Anaesthetic management of shoulder arthroscopic repair in Parkinson's disease with deep brain stimulator.

We describe the anaesthetic management of arthroscopic repair for complete rotator cuff tear of shoulder in a 59-year-old female with Parkinson's disease (PD) with deep brain stimulator (DBS) using a combination of general anaesthesia with interscalene approach to brachial plexus block. The DBS consists of implanted electrodes in the brain connected to the implantable pulse generator (IPG) normally placed in the anterior chest wall subcutaneously. It can be programmed externally from a hand-held device placed directly over the battery stimulator unit. In our patient, IPG with its leads was located in close vicinity of the operative site with potential for DBS malfunction. Implications of DBS in a patient with PD for shoulder arthroscopy for anaesthesiologist are discussed along with a brief review of DBS.

Vancomycin-induced thrombocytopenia in a 60-year-old man: a case report

IntroductionVancomycin, a glycopeptide antibiotic, is used to treat resistant gram-positive infections. There has been a 10- to 20-fold increase in its use over the past 25 years. Although ototoxicity and nephrotoxicity are well known side effects of vancomycin, it can also induce platelet reactive antibodies leading to life-threatening thrombocytopenia. Vancomycin is often clinically overlooked as a cause of thrombocytopenia, especially in a scenario of sepsis or when there is use of heparin. We report a proven case of vancomycin-induced thrombocytopenia and its reversal after discontinuation of vancomycin.Case presentationA 60-year-old man with a history of hypertension, congestive heart failure and dyslipidemia was admitted for a right shoulder rotator cuff tear. He underwent right-shoulder arthroscopy and rotator cuff repair. About three weeks later, he developed pain, swelling and purulent drainage from his right shoulder. Arthroscopic irrigation and drainage was then performed. Intraoperative fluid revealed the presence of Methicillin susceptible Staphylococcus aureus, vancomycin-sensitive Enterococcus spp. and Serratia marcescens. The patient had no known allergies. After reviewing his antimicrobial susceptibility, he was started on vancomycin 1500 mgs intravenously every 12 hours (to treat both Staphylococcus aureus and Enterococcus spp) and ciprofloxacin 750 mgs by oral induction every 12 hours. The patient's condition improved following antibiotic treatment. He was discharged and allowed to go home on IV vancomycin and oral ciprofloxacin. The patient's platelet count on the day of starting vancomycin therapy was 253 × 103/mm3. At weeks one, two and three, the counts were 231 × 103/mm3, 272 × 103/mm and 6 × 103/mm3, respectively. The patient was admitted for further work-up of the thrombocytopenia. He was later shown to have vancomycin-induced platelet-reactive antibodies, causing significant thrombocytopenia, and then reversal after his vancomycin medication was discontinued.ConclusionThrombocytopenia is a potentially life-threatening condition. Vancomycin is often clinically overlooked as a cause of thrombocytopenia, especially in a scenario of sepsis or when there is use of heparin. Simple laboratory testing with drug-dependent antibodies can be helpful in identifying vancomycin as a cause of thrombocytopenia.