Setting Of Rotator Cuff Tears Research Articles

Anterior cable reconstruction using subpectoral biceps tenodesis with biceps transfer in rotator cuff tears: a surgical technique

Massive rotator cuff tears (MRCTs) constitute approximately 20% of all rotator cuff tears. Poor tissue quality or significant retraction can lead to failure of the repair. The anterior rotator cuff cable is essential in transmitting force to the proximal humerus and serves as the main load-bearing structure within the supraspinatus. Utilizing the long head of the biceps tendon (LHBT) for anterior cable reconstruction in the setting of rotator cuff tears, known as biceps augmentation, has the potential for improved biomechanical and healing properties. Importantly, the proximal LHBT remains attached to the superior glenoid labrum, serving as a viable collagen scaffold, a structural scaffold for the cable, and potentially as a conduit for living tenocytes to migrate into the hypovascular region of the rotator cuff, promoting repair healing. Similar methods utilize the transfer of the intact LHBT into the rotator cuff without a biceps tenodesis. While this accomplishes the aforementioned goals, it may create a source of biceps pain in these patients, and it changes the length-tension relationship of the LHBT distal to the transfer site. In this technical note, we detail an anterior cable reconstruction employing an autologous LHBT to reinforce a repaired MRCT with concurrent subpectoral tenodesis of the LHBT to achieve goals of 1) rotator cuff augmentation and grafting and, importantly, 2) securing the LHBT in a subpectoral position to mitigate pain and maintain supination strength while maintaining the anatomic length-tension relationship of the biceps. We feel this approach is superior in ensuring sufficient tendon is retained for an effective transfer and allows for a subpectoral tenodesis to prevent biceps symptoms.

Defining pseudoparalysis and pseudoparesis: a consensus study

The purpose of this study was to establish consensus statements via a modified Delphi process on the definition of shoulder pseudoparalysis and pseudoparesis. A consensus process on the definition of a diagnosis of pseudoparalysis utilizing a modified Delphi technique was conducted, and 26 shoulder/sports surgeons from 11 countries, selected based on their level of expertise in the field, participated in these consensus statements. Consensus was defined as achieving 80%-89% agreement, whereas strong consensus was defined as 90%-99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. Three statements regarding the diagnosis of pseudoparalysis reached strong (>89%) consensus: passive range of motion should be unaffected, the passive range of abduction should not be considered, and diagnosis should be excluded if lidocaine injection produces a substantial improvement in range of motion. Additionally, consensus (>79%) was reached that the active range of external rotation should not be considered for diagnosis, pain as a cause of restricted motion must be excluded, and that distinctions between restricted active flexion and external rotation should be made by range of motion rather than tear characteristics. No consensus could be reached on statements regarding the size, number of tendons or chronicity of cuff tears. Nor was there agreement on the active range of flexion permitted or on the difference between pseudoparalysis and pseudoparesis. A modified Delphi process was utilized to establish consensus on the definition of shoulder pseudoparalysis and pseudoparesis. Unfortunately, almost half of the statements did not reach consensus, and agreement could not be reached across all domains for a unifying definition for the diagnosis of pseudoparalysis in the setting of rotator cuff tears. Furthermore, it was not agreed how or whether pseudoparalysis should be differentiated from pseudoparesis. Based on the lack of a consensus for these terms, studies should report explicitly how these terms are defined when they are used.

Arthroscopic Rotator Cuff Repair, Manipulation Under Anesthesia, and Capsular Release for Concurrent Rotator Cuff Tear and Adhesive Capsulitis Maintain Improvements in Outcomes and Range of Motion at Minimum 5-Year Follow-Up

To characterize the outcomes and range of motion at a minimum 5-year follow-up in patients undergoing arthroscopic rotator cuff repair (ARCR) with simultaneous manipulation under anesthesia (MUA) and capsular release (CR) for concurrent RC and adhesive capsulitis and to compare active range of motion of the operative and nonoperative shoulder. Patients undergoing ARCR with MUA and CR by a single surgeon were retrospectively reviewed andprospectively evaluated at a minimum of 5 years postoperatively. Standardized surveys, examinations, and patient-reported outcomes were recorded pre- and postoperatively. Outcome measures included range of motion, American Shoulder and Elbow Surgeon Score (ASES), visual analog score (VAS) for pain, Simple Shoulder Test (SST), subjective shoulder value (SSV), functional level, and satisfaction. Fourteen consecutive patients were evaluated at 7.5±1.6 years' follow-up. At final follow-up, the affected shoulder had substantial improvements in ASES (P < .001), VAS (P < .001), SST (P= .001), and SSV (P < .001), with similar ASES, VAS, SST, and SSV compared with the contralateral side. Range of motion was also similar to the contralateral side at final follow-up for forward elevation and internal rotation, but external rotation was noted to be 10.77 ± 17.06° (95% confidence interval 0.46-21.08, P= .042) more limited. Two patients (14%) underwent revision MUA and CR for stiffness at 6 months and 12 months' postoperatively. This study highlights significantly improved and maintained patient-reported outcomes and range of motion at minimum 5-year follow-up in patients undergoing concomitant ARCR, MUA, and CR. These results provide further evidence that preoperative stiffness in the setting of rotator cuff tear can be managed concurrently; however, patients may remain at an increased risk for recurrent stiffness and external rotation loss. Level IV, therapeutic case series.

Outcomes of Arthroscopic Nerve Release in Patients Treated for Large or Massive Rotator Cuff Tears and Associated Suprascapular Neuropathy: A Prospective, Randomized, Double-Blinded Clinical Trial

Background: Suprascapular neuropathy has been observed in the setting of rotator cuff tears (RCTs), but its association with these tears and their treatment are unclear. Hypothesis: Arthroscopic suprascapular nerve release during rotator cuff repair will not alter the outcomes of neuropathy. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 42 patients with large/massive reparable RCTs and suprascapular neuropathy were recruited and followed up at 6 and 12 months. Electrophysiological results as well as Disabilities of the Arm, Shoulder and Hand (DASH), American Shoulder and Elbow Surgeons (ASES), and Constant scores were evaluated at selected time periods. Patients were randomly assigned to 2 groups. Patients in the control group underwent arthroscopic repair of the rotator cuff without combined arthroscopic release of the superior transverse scapular ligament; in the second group, the superior transverse ligament was released. The primary outcome was to examine full suprascapular nerve recovery through electrophysiological changes between groups. The secondary/tertiary outcomes were analysis of clinical outcomes and assessment of the relation between RCT size and the degree of suprascapular nerve recovery. Patients, clinical staff members, and the neurologist were blinded to the type of surgical procedure. Results: Of 42 patients, 37 completed the follow-up at 12 months (median age, 64 years [range, 50-75 years]). Overall, 17 of 19 (89.5%) patients in the control group and 15 of 18 (83.3%) patients in the nerve release group had full nerve recovery, with no significant difference between the 2 groups. Clinically, all patients in both groups showed a significant improvement (P < .001), but no significant difference was observed between the 2 groups in terms of 12-month postoperative scores (control group: DASH: median, 5 [range, 0-21]; ASES: median, 88 [range, 83-98]; Constant: median, 86 [range, 70-98]) (nerve release group: DASH: median, 6 [range, 0-25]; ASES: median, 90 [range, 83-98]; Constant: median, 88 [range, 75-98]). Also, no significant difference was found between the 2 groups regarding other secondary and tertiary outcomes. Conclusion: Combined arthroscopic release of the superior transverse scapular ligament and rotator cuff repair in patients with large/massive RCTs and suprascapular neuropathy did not produce statistically significant improved outcomes compared with repair of the rotator cuff alone. Registration: NCT02318381 (ClinicalTrials.gov identifier).

Perivascular Stem Cells Diminish Muscle Atrophy Following Massive Rotator Cuff Tears in a Small Animal Model.

Rotator cuff tears are a common cause of shoulder pain and often necessitate operative repair. Muscle atrophy, fibrosis, and fatty infiltration can develop after rotator cuff tears, which may compromise surgical outcomes. This study investigated the regenerative potential of 2 human adipose-derived progenitor cell lineages in a murine model of massive rotator cuff tears. Ninety immunodeficient mice were used (15 groups of 6 mice). Mice were assigned to 1 of 3 surgical procedures: sham, supraspinatus and infraspinatus tendon transection (TT), or TT and denervation via suprascapular nerve transection (TT + DN). Perivascular stem cells (PSCs) were harvested from human lipoaspirate and sorted using fluorescence-activated cell sorting into pericytes (CD146 CD34 CD45 CD31) and adventitial cells (CD146 CD34 CD45 CD31). Mice received no injection, injection with saline solution, or injection with pericytes or adventitial cells either at the time of the index procedure ("prophylactic") or at 2 weeks following the index surgery ("therapeutic"). Muscles were harvested 6 weeks following the index procedure. Wet muscle weight, muscle fiber cross-sectional area, fibrosis, and fatty infiltration were analyzed. PSC treatment after TT (prophylactic or therapeutic injections) and after TT + DN (therapeutic injections) resulted in less muscle weight loss and greater muscle fiber cross-sectional area than was demonstrated for controls (p < 0.05). The TT + DN groups treated with pericytes at either time point or with adventitial cells at 2 weeks postoperatively had less fibrosis than the TT + DN controls. There was less fatty infiltration in the TT groups treated with pericytes at either time point or with adventitial cells at the time of surgery compared with controls. Our findings demonstrated significantly less muscle atrophy in the groups treated with PSCs compared with controls. This suggests that the use of PSCs may have a role in the prevention of muscle atrophy without leading to increased fibrosis or fatty infiltration. Improved muscle quality in the setting of rotator cuff tears may increase the success rates of surgical repair and lead to superior clinical outcomes.

Suprascapular neuropathy in the setting of rotator cuff tears: study protocol for a double-blinded randomized controlled trial.

BackgroundIt has been indicated that rotator cuff tears, especially large or massive ones, can cause suprascapular neuropathy. When such a diagnosis has been established, it is still unknown whether an arthroscopic release of the superior transverse scapular ligament during cuff repair can change the course of this neuropathy.Methods/designThis is a single-center, double-blinded randomized controlled trial for which 42 patients with large or massive repairable rotator cuff tears and suprascapular neuropathy will be recruited and followed up at 6 and 12 months. Nerve function will be measured by nerve conduction and electromyography studies preoperatively and at the selected follow-up periods. Patients will be randomly divided into equally numbered groups, the first one being the control group. Patients of this group will undergo arthroscopic repair of the rotator cuff without combined arthroscopic release of the superior transverse scapular ligament; in the second group the ligament will be released. The primary objective is to test the null hypothesis that arthroscopic repair of large/massive rotator cuff tears in patients with combined suprascapular neuropathy provides equivalent outcomes to one-stage arthroscopic cuff repair where the superior suprascapular ligament is additionally released. The secondary objective is to search for a relation between rotator cuff tear size and degree of suprascapular nerve recovery. The tertiary objective is to demonstrate any relation between rotator cuff muscle fatty infiltration grade and degree of suprascapular nerve function. Patients, clinicians during follow-up clinics and the neurologist will be blinded to the type of surgery performed.DiscussionTo the best of our knowledge, we are unaware of any prospective, randomized double-blinded studies with similar objectives. So far, the evidence suggests a positive correlation between massive rotator cuff tears and suprascapular neuropathy. However, there is mixed evidence suggesting that neuropathy can be effectively treated with rotator cuff repair with or without release of the superior transverse scapular ligament.Trial registrationClinicalTrials.gov registration number NCT02318381; date of initial release: 5 December 2014.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-016-1672-y) contains supplementary material, which is available to authorized users.

Perivascular Stem Cells Diminish Muscle Atrophy and Retain Viability in a Rotator Cuff Tear Model

Objectives:Rotator cuff tears (RCTs) are a common cause of shoulder pain and often necessitate surgical repair. Muscle changes including atrophy, fibrosis, and fatty degeneration can develop after RCTs, which may compromise surgical repair and clinical outcomes. Lipoaspirate-derived human perivascular stem cells (PSCs) have demonstrated myogenic and angiogenic potential in other small animal models of muscle injury. We hypothesized that the administration of PSCs following massive RCTs may help to diminish these muscle changes in a small animal model.Methods:A total of 90 immunodeficient mice were used (15 groups, N=6). Each was assigned to one of three surgical groups: i) sham, ii) supraspinatus and infraspinatus tendon transection (TT), or iii) TT and suprascapular nerve denervation (TT+DN). PSCs were harvested from human lipoaspirate and sorted using fluorescence-activated cell sorting into small blood vessel residing pericytes (CD146+ CD34- CD45- CD31-) and large blood perivascular adventitial cells (CD146- CD34+ CD45- CD31-). Mice received either a) no injection, b) saline injection, c) pericyte injection, or d) adventitial cell injection at the time of the index procedure or at two weeks following index surgery. The supraspinatus muscles were harvested six weeks after the index procedure. Muscle atrophy was assessed by measuring percent wet muscle weight change for each sample. Muscle fiber cross-sectional area (CSA), fibrosis, and fatty degeneration were analyzed using Image J™. Additionally, pericytes and adventitial cells were transduced with a luciferase-containing construct. Animals were given injections of luciferin and imaged using IVIS to track in vivo bioluminescence following injections to assess cell viability.Results:Treatment with PSC injection after TT resulted in less wet weight loss and greater muscle fiber CSA than control groups (P<0.05). The TT+DN groups treated with PSC injections two weeks post-op also had less muscle weight loss and greater muscle fiber CSA than their respective control groups. The TT+DN groups treated with PSC injections at the time of surgery demonstrated no differences in weight loss, but had greater muscle fiber CSA than their respective controls. There was no difference in fibrosis between the TT groups. However, TT+DN groups treated with pericyte injections at both time points and adventitial cell injections two weeks post-op had less fibrosis than TT+DN controls. There was less fatty degeneration in the TT groups treated with pericyte injections at both time points and adventitial cells at the time of surgery compared to matched controls. There were no differences in the amount of fatty degeneration between the TT+DN groups. Bioluminescence imaging demonstrated viability of the injected cells at three weeks following injections (Figure 1).Conclusion:Our findings demonstrate significantly less muscle atrophy in the groups treated with PSC injections compared to respective controls for both TT and TT+DN procedures. These results suggest that the use of PSCs may have a role in the prevention of muscle atrophy by aiding in the maintenance of muscle bulk without leading to increased fibrosis or fatty infiltration. Additionally, bioluminescence data suggests that these cells maintain viability and engraft within the native muscle to improve muscle bulk. Improved muscle quality in the setting of rotator cuff tears may increase the success rates of rotator cuff repair and lead to superior clinical outcomes.

Arthroscopic Management of the Stiff Shoulder.

Shoulder stiffness affects a diverse population of patients suffering a decrease in function and shoulder pain. Arthroscopic management of this debilitating spectrum of pathology is a safe and effective course of action in cases recalcitrant to nonoperative therapy. Arthroscopic management of the stiff shoulder has been reported to be effective in the treatment of stiffness due to adhesive capsulitis, birth palsy, stiffness in the setting of rotator cuff tears, and osteoarthritis in the posttraumatic patient, in the postoperative patient, and in the throwing athlete. Arthroscopic management is most effective in treating the stiff shoulder in the setting of adhesive capsulitis recalcitrant to nonoperative therapy or posttraumatic stiffness. Results are more guarded in the treatment of postoperative stiffness. Excessive force and trauma to the shoulder, including fracture of the humerus, can be avoided with a 360[degrees] capsular release for shoulder stiffness rather than manipulation under anesthesia.

Evaluation of shoulder pathology: three-dimensional enhanced T1 high-resolution isotropic volume excitation MR vs two-dimensional fast spin echo T2 fat saturation MR.

To evaluate the diagnostic accuracy of three-dimensional (3D) enhanced T1 high-resolution isotropic volume excitation (eTHRIVE) shoulder MR for the detection of rotator cuff tears, labral lesions and calcific tendonitis of the rotator cuff in comparison with two-dimensional (2D) fast spin echo T2 fat saturation (FS) MR. This retrospective study included 73 patients who underwent shoulder MRI using the eTHRIVE technique. Shoulder MR images were interpreted separately by two radiologists. They evaluated anatomic identification and image quality of the shoulder joint on routine MRI sequences (axial and oblique coronal T2 FS images) and compared them with the reformatted eTHRIVE images. The images were scored on a four-point scale (0, poor; 1, questionable; 2, adequate; 3, excellent) according to the degree of homogeneous and sufficient fat saturation to penetrate bone and soft tissue, visualization of the glenoid labrum and distinction of the supraspinatus tendon (SST). The diagnostic accuracy of eTHRIVE images compared with routine MRI sequences was evaluated in the setting of rotator cuff tears, glenoid labral injuries and calcific tendonitis of the SST. Fat saturation scores for eTHRIVE were significantly higher than those of the T2 FS for both radiologists. The sensitivity and accuracy of the T2 FS in diagnosing rotor cuff tears were >90%, whereas sensitivity and accuracy of the eTHRIVE method were significantly lower. The sensitivity, specificity and accuracy of both images in diagnosing labral injuries and calcific tendonitis were similar and showed no significant differences. The specificity of both images for the diagnosis of labral injuries and calcific tendonitis was higher than the sensitivities. The accuracy of 3D eTHRIVE imaging was comparable to that of 2D FSE T2 FS for the diagnosis of glenoid labral injury and calcific tendonitis of SST. The 3D eTHRIVE technique was superior to 2D FSE T2 FS in terms of fat saturation. Overall, 3D eTHRIVE was inferior to T2 FS in the evaluation of rotator cuff tears because of poor contrast between joint fluid and tendons. The accuracy of 3D eTHRIVE imaging is comparable to that of 2D FSE T2 FS for the diagnosis of glenoid labral injury and calcific tendonitis of SST.

Clinical and radiologic results of arthroscopic biceps tenodesis with suture anchor in the setting of rotator cuff tear

The purpose of this study was to report clinical and radiologic results of arthroscopic biceps tenodesis with 1 suture anchor in rotator cuff tear patients. During a 2-year period, 84 consecutive patients (45 men; 39 women) who underwent arthroscopic tenodesis were evaluated retrospectively. Mean age was 58 years. The primary indication for surgery was rotator cuff tear in 96.4%. Tenodesis was performed with 1 suture anchor placed in the bicipital groove with 2 knots, 1 lasso-type and 1 that pierced the tendon. At final follow-up at a mean of 33.2 months, visual analog scale pain (pain-VAS) score, shoulder scores (American Shoulder and Elbow Surgeons [ASES] and Constant score), Popeye deformity (PD), anterior arm pain, and elbow flexion power were evaluated. Postoperative magnetic resonance images were evaluated in 60 patients to determine the integrity of the tenodesis and the location of the suture anchor. The average pain-VAS decreased from 5.3 to 1.4 (P < .001). ASES and Constant scores significantly increased, from 42.9 and 56.2 to 85.2 and 82.5, respectively. PD occurred in 11 patients (12.9%), and 2 (2.3%) had self-consciousness; however, no patients complained about the deformity and the PD did not correlate with poorer clinical scores. Six patients (7.1%) complained of anterior cramping pain. Elbow flexion power was similar compared with the contralateral side. In postoperative magnetic resonance imagine analysis, 15 patients (25%) showed distal migration of tenodesed biceps tendon, although only 6 (7.1%) had clinical PD. Postoperative clinical outcomes were not influenced by the location of the suture anchor within the bicipital groove. Arthroscopic biceps tenodesis with 1 suture anchor resulted in good clinical outcomes at 2 years postoperatively. PD was seen in 12.9% of the patients.

Biceps Tenotomy Versus Tenodesis: Clinical Outcomes

We present a systematic review of the current literature regarding the use of the 2 most common surgical treatments for lesions of the long head of the biceps brachii, tenotomy or tenodesis. Currently, there is no consensus management in the literature because most studies lack high levels of evidence. PubMed was systematically reviewed for eligible articles relating to biceps tenotomy or tenodesis. Level I to IV evidence and English-language studies reporting on the clinical outcomes of these 2 procedures were included. The primary clinical outcome measurements for each study were determined and were normalized and reported as the percentage of "excellent/good" versus "poor" results based on criteria laid out in each study. Sixteen studies met the inclusion criteria. All articles reviewed were of Level IV evidence, except for one Level II prospective cohort study.(10) All studies, a total of 433 tenodesis procedures resulted in an excellent/good outcome in 74% of patients, with an 8% rate of cosmetic deformity. A total of 699 tenotomy procedures resulted in an excellent/good outcome in 77% of patients, with a 43% occurrence of cosmetic deformity. Postoperative bicipital pain was found in 43 of 226 cases (19%) of tenotomy and 18 of 74 cases (24%) of tenodesis. The 4 studies that compared the procedures directly did not show any significant clinical differences between the groups other than a cosmetic deformity being present more frequently after tenotomy. Tenotomy and tenodesis have comparably favorable results in the literature, with the only major difference being a higher incidence of cosmetic deformity with biceps tenotomy. However, there is currently no consensus regarding the use of tenotomy versus tenodesis for the treatment of lesions of the long head of the biceps brachii. The lack of prospective, randomized trials limits our ability to recommend 1 technique over the other. There is a great need for controlled trials to investigate the differences between these 2 procedures. Individual patient factors and needs should guide the surgeon on which procedure to use. Level IV, systematic review of Level IV studies.

Treatment of Biceps Tendon Lesions in the Setting of Rotator Cuff Tears: Prospective Cohort Study of Tenotomy Versus Tenodesis

Treatment of Biceps Tendon Lesions in the Setting of Rotator Cuff Tears: Prospective Cohort Study of Tenotomy Versus Tenodesis

Treatment of Biceps Tendon Lesions in the Setting of Rotator Cuff Tears

Background: During rotator cuff repair, biceps tendon lesions are frequently encountered. However, there is still controversy about optimal treatment for these lesions. Purpose: To compare the results of tenotomy and suture anchor tenodesis prospectively. Study Design: Cohort study; Level of evidence, 2. Methods: From January 2006 to June 2007, 90 patients (age, >55 years) with a rotator cuff tear and biceps tendon lesion (tear more than 30%, subluxation or dislocation, or degenerative superior labrum anterior to posterior lesion type II) were evaluated prospectively. The first 45 patients treated consecutively underwent biceps tenodesis, and the next 45 underwent biceps tenotomy. Postoperatively, patient evaluations were conducted with a focus on (1) “Popeye” deformity, (2) arm cramping pain, and (3) elbow flexion powers (measured with a hand dynamometer). Overall shoulder function was assessed with the American Shoulder and Elbow Surgeons (ASES) score and the Constant score. Results: At final follow-up, 43 in the tenodesis and 41 in the tenotomy groups were available for evaluation. There was no difference between groups in demographic data such as age, sex, dominant arm, and the time from symptom to surgery and in preoperative ASES score, Constant score, and rotator cuff tear size. A Popeye deformity occurred in 4 (9%) in the tenodesis group and in 11 (27%) in the tenotomy group (P = .0360). Mild cramping pain was observed in 2 in the tenodesis group and 4 in the tenotomy group (P = .4274). Mean elbow flexor power ratio (vs the contralateral side) showed no difference between the 2 groups, with mean values of 0.92 ± 0.15 (tenodesis) and 0.94 ± 0.19 (tenotomy) (P = .7475). The ASES and Constant scores were improved from 38.9 ± 14.2 and 52.1 ± 21.3 to 84.7 ± 13.6 and 82.9 ± 13.5 in the tenodesis group (P < .0001) and from 35.2 ± 10.5 and 48.1 ± 21.3 to 79.6 ± 15.8 and 78.3 ± 14.1 in the tenotomy group (P < .0001), respectively. Conclusion: Suture anchor tenodesis of the long head of the biceps tendon appears to lead to less Popeye deformity than tenotomy. No other clinical variables showed a difference between the 2 modalities.