Tear Size Research Articles

Expression and distribution pattern of aggrecanases and miR-140s in the thickened synovia of shoulder joints in rotator cuff tears: A retrospective observational study.

The rotator cuff (RC) is frequently torn at the enthesis composed of fibrocartilage. We aimed to histopathologically evaluate lining layers and assess the distribution of a disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS)4, ADAMTS5, and microRNA (miR)-140s in the synovia of patients with RC tears. We recruited 51 patients who underwent arthroscopic surgical treatment for full-thickness rotator cuff tears, including 26 patients with < 3 cm tear size (group N) and 25 patients with ≥ 3 cm tear size (group W). Biopsied synovia were analyzed using histological and immunohistological techniques for the presence ADAMTS4 and ADAMTS5. The layers of the synovial lining were morphologically classified into 3 grades according to the synovitis score and staining levels of ADAMTSs. The glenohumeral synovia from 8 patients with recurrent shoulder dislocation (group C) were used as controls. Furthermore, in situ hybridization was performed to evaluate the presence of miR-140s in patients with massive tears and recurrent shoulder dislocation. The staining levels were evaluated and analyzed based on comparison between patient groups and correlation between ADAMTS5 and miR-140s. Histological analysis revealed significant differences between groups W and C. ADAMTS5 and ADAMTS4 were strongly expressed in the synovial lining of patients in group W, and this expression was significantly higher than that in groups C and N. In addition, expression of ADAMTS5 was inversely correlated with that of miR-140-3p. This study showed that synovia from group W had a significantly higher rate of severely thickened areas with strong expression of both aggrecanases. Furthermore, the area with weak expression of miR-140-3p showed strong ADAMTS5 expression.

Do Age, Demographics, and Tear Characteristics Affect Outcomes After Rotator Cuff Repair? Results of Over 2000 Rotator Cuff Repairs at 5-Year Follow-up.

Background:The New Zealand Rotator Cuff Registry represents the largest prospective cohort of rotator cuff repairs. Despite this, there are limited medium- to long-term data of rotator cuff repair outcomes.Purpose:To (1) analyze the pain and functional outcomes of a large cohort of primary rotator cuff repairs and (2) evaluate the effect of patient factors and tear characteristics on medium-term outcomes.Study Design:Cohort study; Level of evidence, 2.Methods:This was a multicenter, multisurgeon prospective cohort study of rotator cuff repairs from March 2009 until December 2010. Surgical data were collected by the operating surgeon. Primary outcome measures were the Flexilevel Scale of Shoulder Function (FLEX-SF) and a pain score, collected at baseline, 6, 12, and 24 months, and 5 years. Univariate and multivariate analyses were carried out.Results:Overall, 2533 primary rotator cuff repairs were analyzed with 81% follow-up at 5 years. The mean age of the cohort was 56 years. In the 2052 patients with final follow-up data, improvement on the FLEX-SF continued until 24 months postoperatively and remained high at 5 years. Mean improvement in FLEX-SF from baseline to 5 years was 15 points. Patients aged >70 years had lower FLEX-SF scores but no significant difference in improvement compared with patients ≤70 years. The mean anteroposterior tear size was 2.2 cm, and on multivariate analysis, tears >4 cm had worse 5-year FLEX-SF scores. If the affected tendon was easily reducible, there was no difference in FLEX-SF score for retracted or larger tears compared with smaller tears. The reoperation rate was 6.2%.Conclusion:Results indicated that rotator cuff repairs provide a sustained clinical improvement out past 5 years. Most functional improvement and pain relief occurred within the first 6 months, but improvement continued out to 24 months. Most population groups did well after rotator cuff repairs, including those >70 years. Tear size >4 cm and tendon reducibility correlated with outcome. Even patients with large tear sizes had clinically significant improvement in FLEX-SF scores after repair.

Video Analysis of Pectoralis Major Injuries in Professional Australian Football Players.

Background:There is little evidence regarding the mechanisms of pectoralis major (PM) injury and player outcomes in Australian Football League (AFL) players.Purposes/Hypothesis:The study aims were to investigate (1) the mechanisms of PM muscle injury in elite AFL players via video analysis and (2) the player profile, method of management, and clinical outcomes of the PM injuries sustained. We hypothesized that the majority of PM tears would occur in outer-range PM positions (hyperextension of the glenohumeral joint).Study Design:Case series; Level of evidence, 4.Methods:We analyzed video of the precipitating event for traumatic PM injuries during AFL competition or training over a 20-year period (2002-2021). The footage was analyzed by 4 experienced assessors, and the following were evaluated: mechanism of injury, injury variables (arm position, initial contact point, visual awareness, and use of taping), player characteristics (age at the time of injury, hand dominance, and history of injury), injury profile (location and size of tear), method of management (operative vs nonoperative), patient outcomes (time to return to full senior training/match play), and complication rates.Results:The mean ± standard deviation age of the players was 26.5 ± 3.1 years (range, 21-32 years). Overall, 22 PM injuries were identified in the AFL injury database for a rate of 1.1 per year; 16 of these injuries had accompanying video footage. We identified 3 mechanisms for PM injury: horizontal hyperextension (62.5%), hyperflexion-abduction (25.0%), and horizontal adduction (sustained tackling; 12.5%). The most common site of the tear was the insertion point of the sternocostal head (91.0%). Twenty players (91.0%) required surgical repair, with 75% undergoing surgery within 1 week (range, 0-26 weeks). The mean return to competition for the surgical repair group was 11.1 weeks (range, 8-15 weeks). The rerupture rate was 5.0% (1 repair; <4 weeks postoperatively in 2004).Conclusion:PM tears in elite male AFL players were due to 1 of 3 distinct mechanisms: horizontal hyperextension, hyperflexion-abduction, and horizontal adduction (sustained tackling). Players returned to play on average 11 weeks after injury. Knowledge regarding mechanisms of injury, player profile, and return-to-sport timelines is important for appropriate medical management and provides potential areas to target for prevention of PM injuries.

Are psychosocial variables, sleep characteristics or central pain processing prognostic factors for outcome following rotator cuff repair? A protocol for a prospective longitudinal cohort study

IntroductionPrognosis following surgical rotator cuff repair (RCR) is often established through the assessment of non-modifiable biomedical factors such as tear size. This understates the complex nature of recovery following RCR....

Risk factors of reintervention after endovascular treatment of type B acute and subacute aortic dissections

The treatment of type B aortic dissections is not driven by well defined guidelines. At the time of diagnosis these dissections can be complicated by rupture or organ or limb malperfusion, which require an emergency surgical treatment, or not complicated. In these cases, optimal medical care only was recommended in first intention. The ADSORB and INSTEAD-XL studies recently led us to change our therapeutic attitude by showing the superiority of TEVAR associated with the optimal medical care compared to medical care only in terms of aortic remodeling, healing of the false lumen, and mortality related to the pathology aortic. Studies highlighted several risk factors for a poor prognosis at the time of the diagnosis, including the maximum aortic diameter, the laminated aspect of the true lumen, the principal main entry tear size, or the patency of the false lumen, which contributed to define the population needing TEVAR in association with the best medical care. These risk factors were measured at the time of the diagnosis, i.e. before the medical or surgical treatment. The literature also reported 25% - 50% reintervention rates for the patients who survived the acute phase. The aim of our study was to determine the risk factors of survival without secondary aortic intervention of the patients presenting with a type B aortic dissection, complicated or not, and treated in the 90 days of the diagnosis by TEVAR with coverage of the principal main entry tear.

Rotator cuff tear reaching the superior half portion of the humeral head causes shoulder abduction malfunction.

To examine the biomechanical properties governing posterosuperior rotator cuff (RC) tear progression and dynamic shoulder abduction function, in the absence of excess loading. Twelve freshly frozen cadaveric shoulders were evaluated via an established dynamic shoulder abduction stimulator. The shoulder abduction functions were primarily evaluated using subacromial contact pressure (SACP) during an abduction procedure, and subsequent middle deltoid force (MDF) under 5 conditions: (1) intact, (2) anterior 1/3 posterosuperior rotator cuff (PSRC) tear, (3) anterior 2/3 PSRC tear, (4) entire PSRC tear, and (5) global RC tear (tear involving the entire superior RC). No obvious differences were observed in the peak MDF required for abduction, and in the peak SACP among the four PSRC tear statuses (49.8 ± 9.2N, 0.39 ± 0.05mPa [1/3 PSRC tear]; 49.3 ± 6.8N, 0.40 ± 0.06mPa [2/3 PSRC tear]; 51.6 ± 7.0N, 0.44 ± 0.08mPa [entire PSRC tear]), as well as intact statuses (48.3 ± 9.8N, 0.40 ± 0.05mPa). However, significant elevations in the peak MDF and peak SACP levels were observed among the four PSRC tear statuses and global RC tear (68.1 ± 9.3N; 4.12 ± 1.50mPa, P < 0.01). In the absence of excess loading, the biomechanical function of the shoulder was not impaired by a simple PSRC tear. However, once the tear size reached the half superior portion of the humeral head, the humeral head migrated to the surface of the subacromion, and this action markedly decreased shoulder abduction function.

Outcomes after arthroscopic repair of rotator cuff tears in the setting of mild to moderate glenohumeral osteoarthritis.

BACKGROUNDRotator cuff pathology is a very common source of shoulder pain. Similarly, osteoarthritis of the glenohumeral joint can cause shoulder pain and produce similar symptoms. Surgical management can be indicated for both pathologies, however, outcomes data is limited when examining rotator cuff repair (RCR) in the setting of glenohumeral arthritis (GHOA). Thus, this study sought to determine outcomes for patients who undergo RCR in the setting of GHOA.AIMTo evaluate if a relationship exists between outcomes of RCR in the setting of GHOA.METHODSThis was a retrospective analysis of patients who underwent arthroscopic rotator cuff repair with concurrent glenohumeral osteoarthritis between 2010-2017. Patients were stratified based on rotator cuff tear size and glenohumeral osteoarthritis severity. Cohorts were paired 1:1 with patients without glenohumeral osteoarthritis. Patients included had a minimum two year follow-up. Rate of conversion to total shoulder arthroplasty, complication rates following initial surgery, and patient-reported outcome measures were collected.RESULTSA total of 142 patients were included. The number of patients that required total shoulder arthroplasty within two years after index surgery was low. 2/71 (2.8%) patients with GHOA, and 1/71 (1.4%) without GHOA. Following rotator cuff repair, both groups showed favorable patient-reported outcomes.CONCLUSIONPatients with glenohumeral osteoarthritis who underwent arthroscopic rotator cuff repair showed comparable outcomes to patients without glenohumeral osteoarthritis.

Histological changes and neural elements in the subacromial bursa on patients with rotator cuff tear: Pilot study.

Objective:This study aimed to investigate the neural elements of the subacromial bursa (SAB) in rotator cuff tears.Materials and methods:Twenty patients with rotator cuff tears were recruited, and their visual analog scale (VAS) score, duration of symptoms, and range of motion (ROM), including flexion, external rotation, and internal rotation were evaluated. Tear size was measured using magnetic resonance imaging (MRI). The SAB specimens obtained during arthroscopic rotator cuff repair were studied using routine hematoxylin and eosin staining and immunohistochemistry (S-100 protein and PGP 9.5 protein). The SAB specimen for the control group was obtained from 2 fresh cadavers and 2 patients with acute humeral shaft fracture. The Mann-Whitney U test was applied to assess the difference between histological findings of the rotator cuff tear group and control group. The correlation between the histological findings and clinical features was evaluated using the Spearman correlation coefficient.Results:The mean duration of symptom was 10.2 ± 6.4 months. The preoperative average VAS score was 2.9 ± 1.2. The degrees of preoperative ROM in forward flexion and external and internal rotations were 143.8 ± 19.5, 49.5 ± 23.1, and –4.3 ± 4.2, respectively. The tear was 2.0 ± 0.9 cm. For histological findings, the number of neural elements per low power field in the rotator cuff tear group was significantly less than the control group in both immunohistochemical stainings (S-100: 0.5 ± 0.7 vs 2.8 ± 0.5, p < .01; PGP 9.5: 0.4 ± 0.7 vs 3.5 ± 0.6, p < .01). During the correlation analysis, the number of neural elements in the PGP 9.5 staining was negatively correlated with the ROM in forward flexion and external rotation.Conclusion:This study revealed that chronic rotator cuff tears may induce degeneration of neural elements in SAB.

Preoperative Magnetic Resonance Imaging Abnormalities Predictive of Lumbar Herniation Recurrence After Surgical Repair

There are currently no standard criteria for evaluating the risk of recurrent disk herniation after surgical repair. This study investigated the predictive values of 5 presurgical imaging parameters: paraspinal muscle quality, annular tear size, Modic changes, modified Phirrmann disk degeneration grade, and presence of sacralization or fusion. Between 2015 and 2018, 188 patients (89 female, 99 male, median age 50) receiving first corrective surgery for lumbar disk herniation were enrolled. Microdiskectomy was performed in 161 of these patients, and endoscopic translaminar diskectomy approach was performed in 27 patients. Clinical status was evaluated before surgery and 4, 12, and 24 months post surgery using a visual analog scale, Oswestry Disability Index, and Short Form36. Recurrent disk herniation was observed in 21 of 188 patients. Seventeen of the recurrent disk herniations were seen in those who underwent microdiskectomy and 4 in those who underwent endoscopic translaminar diskectomy. There were significant differences in visual analog scale, Oswestry Disability Index, and Short Form 36 scores at 4, 12, and 24 months between patients with recurrence and the 167 no-recurrence patients. The median annular tear length was significantly greater in patients with recurrence than without recurrence. In addition, there were significant differences in recurrence rate according to Modic change type distribution, sacralization or fusion presence, Pfirmann disk; degeneration grade distribution, dichotomized annular tear size, dichotomized Modic change; and type and simplified 3-tier muscle degeneration classification distribution. Patients with poor clinical scores and recurrence exhibited additional radiologic abnormalities before surgery, such as poor paraspinal muscle quality, longer annular tears, higher Modic change type, higher modified Phirrmann disk degeneration grade, and sacralization or fusion. This risk evaluation protocol may prove valuable for patient selection, surgical planning, and choice of postoperative recovery regimen.

Tear Size and Stiffness Are Important Predictors of Retear: An Assessment of Factors Associated with Repair Integrity at 6 Months in 1,526 Rotator Cuff Repairs.

Background:This study aimed to identify whether early postoperative shoulder stiffness is associated with improved healing following rotator cuff repair, and if so, how this factor might interact with other factors known to affect rotator cuff repair integrity.Methods:We conducted a retrospective analysis of prospectively collected data from 1,526 primary arthroscopic rotator cuff repairs. Six-week range of motion was assessed to determine shoulder stiffness, and repair integrity was evaluated at 6 months by ultrasound. Multiple logistic regression analysis was used to identify variables that affected retear, and receiver operating characteristic (ROC) curve analysis was used to evaluate predictive thresholds for retear.Results:Tear-size area was the most accurate predictor of retear (area under the curve [AUC] = 0.77; 95% confidence interval [CI] = 0.72 to 0.81), followed by 6-week passive external rotation (AUC = 0.67; 95% CI = 0.63 to 0.72), 6-week passive forward flexion (AUC = 0.67; 95% CI = 0.62 to 0.72), age (AUC = 0.65; 95% CI = 0.60 to 0.70), tear type (partial-thickness versus full-thickness) (AUC = 0.65; 95% CI = 0.61 to 0.69), and hospital type (public versus private) (AUC = 0.43; 95% CI = 0.37 to 0.49). Patients with smaller tears, reduced 6-week passive external rotation, reduced 6-week passive forward flexion, younger age, partial-thickness tears, and operations performed in a private day surgery or hospital setting were more likely to have an intact rotator cuff repair at 6 months. The AUC of this curve was 0.84 (95% CI = 0.80 to 0.87), which indicates that this combination of factors can accurately predict 84% of retears. Reduced range of motion at 6 weeks was associated with improved repair integrity for patients with tears of >1 to 6 cm2; however, this effect was less pronounced in tears of ≤1 cm2 or >6 cm2.Conclusions:Early postoperative stiffness following arthroscopic single-row, inverted-mattress rotator cuff repair at 6 weeks was associated with an intact repair at 6 months. The protective effects of postoperative stiffness and tear size were additive. The chance of retear in patients with a tear of ≤1 cm2 and external rotation of ≤27° at 6 weeks was 1%, while those with tears of >6 cm2 and external rotation of >27° had a 40% chance.Level of Evidence:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for failure to achieve minimal clinically important difference and significant clinical benefit in PROMIS computer adaptive test domains in patients undergoing rotator cuff repair.

The Patient-Reported Outcomes Measurement Information System (PROMIS) has emerged as a valid and efficient means of collecting outcomes in patients with rotator cuff tears. The purpose of this study was to establish threshold score changes to determine minimal clinically important difference (MCID) and substantial clinical benefit (SCB) in PROMIS computer adaptive test (CAT) scores following rotator cuff repair (RCR). Additionally, we sought to identify potential risk factors for failing to achieve MCID and SCB. Patients undergoing arthroscopic RCR were identified over a 24-month period. Only patients who completed both preoperative and postoperative PROMIS CAT assessments were included in this cohort. PROMIS CAT forms for upper extremity physical function (PROMIS-UE), pain interference (PROMIS-PI), and depression (PROMIS-D) were used with a minimum of 1.5-year follow-up. Statistical analysis was performed to determine threshold score changes to determine anchor-based MCID and SCB, as well as risk factors for failure to achieve significant clinical improvement following surgery. Of 198 eligible patients, 168 (84.8%) were included in analysis. ΔPROMIS-UE values of 5.8 and 9.7 (area under the curve [AUC]=0.906 and 0.949, respectively) and ΔPROMIS-PI values of -11.4 and -12.9 (AUC=0.875 and 0.938, respectively) were identified as threshold predictors of MCID and SCB achievement. On average, 81%, 65%, and 55% of patients achieved MCID for PROMIS-UE, PROMIS-PI, and PROMIS-D whereas 71%, 61%, and 38% of patients in the cohort, respectively, achieved SCB. MCID achievement in PROMIS-UE significantly differed according to risk factors, including smoking status (likelihood ratio [LR]: 9.8, P=.037), tear size (LR: 10.4, P<.001), distal clavicle excision (LR: 6.1, P=.005), and prior shoulder surgery (LR: 19.2, P<.001). Factors influencing SCB achievement for PROMIS-UE were smoking status (LR: 9.3, P=.022), tear size (LR: 8.0, P=.039), and prior shoulder surgery (11.9, P<.001). Significantly different rates of MCID and SCB achievement in PROMIS-PI for smoking status (LR: 7.0, P=.030, and LR: 5.2, P=.045) and prior shoulder surgery (LR: 9.1, P=.002, and LR: 7.4, P=.006) were also identified. The majority of patients showed clinically significant improvements that exceeded the established MCID for PROMIS-UE and PROMIS-PI following RCR. Patients with larger tear sizes, a history of prior shoulder surgery, tobacco users, and those who received concomitant distal clavicle excision were at risk for failing to achieve MCID in PROMIS-UE. Additionally, smokers and patients who underwent prior shoulder surgery demonstrated significantly lower improvements in pain scores following surgery.

Poster 153: Dynamic Radiographic Evaluation of Scapulohumeral Rhythm in Patients with Massive vs Small Rotator Cuff Tears

Objectives:The management of rotator cuff tears varies based on patient age, function, tear size, and chronicity. Treatment of massive tears results in less favorable or predictable outcome, presenting a challenge in determining the optimal intervention. Classification of a tear as “massive” is often based on MRI and confirmed intraoperatively. However, the use of a functional measure of shoulder motion, such as the scapulohumeral rhythm (SHR), offers an alternate, clinically relevant method to help guide diagnosis and surgical management. Defined as the ratio of glenohumeral (GH) to scapulothoracic (ST) motion, SHR is known to be altered in patients with rotator cuff tears. While previously challenging to measure SHR in a clinical setting, a novel technique known as Dynamic Digital Radiography (DDR) provides a safe and cost-effective method to directly compare changes in motion between patients with rotator cuff tears and correlate these changes to tear severity. The purpose of this study was to evaluate patients with massive and small rotator cuff tears using DDR, assessing for differences in SHR and range of motion between the two groups.Methods:Shoulders were prospectively analyzed using DDR via obtaining a series of pulsed radiographs at up to 15 Hz of the joint in motion. Scapulothoracic motion and glenohumeral motion were quantified based on the DDR images (figure 1). Measurements were taken in humeral abduction at 0-30°, 30-60°, 60-90°, and full abduction using the Grashey view. SHR at different points was calculated by dividing the humeral arc of motion by the scapular arc of motion in each of those motion ranges. Pairwise t-tests were performed on the obtained data to compare differences between groups at an α level of 0.05.Results:42 patients with a primary diagnosis of rotator cuff tear matched for age and BMI were analyzed (table 1). Based on clinical presentation and MRI, 29 patients were classified as massive rotator cuff tear (MRCT) and 13 patients were classified as small rotator cuff tear (SRCT). The final angle calculations are displayed in table 2. SRCT patients had a significantly higher average overall SHR of 3.04 ± 1.16 compared to the MRCT SHR of 1.91 ± 0.51 (p=0.003). When analyzed across 30-degree intervals of humeral abduction, MRCT patients had a significantly lower SHR compared to SRCT patients at 30-60° (1.83 ± 0.97 vs 3.39 ± 1.62, p=0.005). MRCT also had a lower SHR between 0-30° (2.63 ± 2.08 vs 4.74 ± 3.83, p=0.08) and 60-90° (2.13± 0.80 vs 2.91 ± 1.41 , p=0.13) of humeral abduction compared to SRCT patients, but these differences were not statistically significant. SHR changes across these intervals of humeral abduction are plotted in figure 2. Scapular range of motion during humeral abduction was lower in SRCT compared to MRCT (29.71 ± 12.91 vs 41.57 ± 10.41, p=0.08). No statistically significant difference was found in humeral range of motion between MRCT (76.02 ± 22.66) and SRCT (80.93 ± 20.71).Conclusions:A dynamic measurement of motion demonstrates that scapulohumeral rhythm is significantly different between patients with small vs. massive rotator cuff tears. Based on DDR analysis, patients had a marked difference in the initiation of motion and through the first 60 degrees of humeral abduction, resulting in a nearly 2x lower SHR in MRCT compared to SRCT. Moreover, evaluation of glenohumeral and scapulothoracic motion during humeral abduction demonstrated that patients with larger tears had an increased reliance on scapular contributions to overall humeral elevation. Dynamic measurement of SHR represents a novel method for evaluating rotator cuff tears, with marked differences noted in the earlier phases of shoulder motion. Further study and validation of the dynamic assessment of SHR has the potential to augment the diagnostic algorithm for rotator cuff tears, and ultimately inform prognostic and functional expectations for both the patient and the physician.Table 1.Patient DemographicsTable 2.Relative contributions by glenohumeral (GH) and scapulotlioracic (ST) joint to shoulder girdle motionFigure 1.Reference lines used for calculation of the humeral and scapular abduction arcs. Measurements were taken in reference to a vertical line. Calculations were made in the neutral position, at initiation of abduction, 30°, 60°, 90° and full abduction.Figure 2.SHR measured at 30-degree intervals of humeral abduction. The * Indicates a statistically significant difference at α = 0.05 in SHR measured between massive rotator cuff tear and small rotator cuff tear patients. P-values from left to right are 0.08 (0-30 °), 0.005 (30-60 °), 0.13 (60-90 °), and 0.003 (total)

Treatment strategy for patients with thoracic and lumbar spine fractures with dura mater tear

Background. The dura mater tear are quite common in patients with thoracic and lumbar fractures. Prevention and management of cerebrospinal fluid leakage and sealing of the dura mater suture is an important stage in the treatment of such patients.Objective: to find an optimal surgical tactics for patients with fractures of the thoracic and lumbar spine and dura mater tear.Materials and methods. This study included 167 patients operated on for fractures of the thoracic and lumbar spine with concomitant traumatic spinal canal stenosis. We analyzed their clinical data and results of instrumental examination. All patients underwent laminectomy at the level of their fractures and transpedicular fixation. The main group included 55 patients with dura mater tear, whereas the control group comprised 112 patients without dura mater tear.Results. Dura mater tear was found in 32.9 % of patients with fractures of the thoracic and lumbar spine. Of them, 21.8 % had compression of the spinal cord or nerve roots at the sites of dura mater tear. This fact should be taken into account when performing decompression and the reduction maneuver to prevent additional injuries to the neural structures. Thirty-three (60.0 %) patients underwent direct suturing aimed to restore the dura mater integrity. Their mean size of the dura mater tear was 13.2 ± 7.4 mm2. Thirteen patients (23.6 %) with larger dural tear (27.5 ± 6.3 mm2) underwent their repair using either a fragment of dura mater from a deceased donor (n = 2), Reperen implants (n = 5), or Durepair patches (n = 6). In 9 patients (16.4 %), the integrity of dura mater was restored without suturing (the «sandwich»-sealing method) (mean size of the dura mater defect 5.0 ± 2.6 mm2). Twenty-one patients had additional sealing of dura mater suture using bioglue.Postoperative wound cerebrospinal fluid leakage was registered in 5 out of 55 patients from the main group. Cerebrospinal fluid leakage was most common in patients who had undergone dura mater repair with implants (23.1 %), while those who had undergone direct dura mater suturing were less likely to develop it (6.1 %). No cerebrospinal fluid leakage was observed in patients with small defects (≤3 mm2) or in those whose dural tears were located at the nerve root cuffs. Patients with postoperative cerebrospinal fluid leakage had no additional sealing of dura mater suture using bioglue.Postoperative wound infection was registered in 4 (7.3 %) patients from the main group and 6 (5.4 %) patients from the control group.Conclusion. Sealing of dura mater sutures with glue compositions is an effective method to prevent postoperative cerebrospinal fluid leakage. Sealing of dura mater sutures with a collagen sponge does not prevent wound cerebrospinal fluid leakage.

The Impact of COVID-19 on the Timing of Rotator Cuff Repair and Method of Postoperative Follow-up.

Objective Rotator cuff repair (RCR) is one of the most common arthroscopic procedures. Our investigation aims to quantify the impact that the COVID-19 pandemic had on RCR, specifically on patients with acute, traumatic injuries. Methods Institutional records were queried to identify patients who underwent arthroscopic RCR between March 1 st to October 31 st of both 2019 and 2020. Patient demographic, preoperative, perioperative, and postoperative data were collected from electronic medical records. Inferential statistics were used to analyze data. Results Totals of 72 and of 60 patients were identified in 2019 and in 2020, respectively. Patients in 2019 experienced shorter lengths of time from MRI to surgery (62.7 ± 70.5 days versus 115.7 ± 151.0 days; p = 0.01). Magnetic resonance imaging (MRI) scans showed a smaller average degree of retraction in 2019 (2.1 ± 1.3 cm versus 2.6 ± 1.2 cm; p = 0.05) but no difference in anterior to posterior tear size between years (1.6 ± 1.0 cm versus 1.8 ± 1.0 cm; p = 0.17). Less patients in 2019 had a telehealth postoperative consultation with their operating surgeon compared with 2020 (0.0% versus 10.0%; p = 0.009). No significant changes in complications (0.0% versus 0.0%; p > 0.999), readmission (0.0% versus 0.0%; p > 0.999), or revision rates (5.6% versus 0.0%; p = 0.13) were observed. Conclusion From 2019 to 2020, there were no significant differences in patient demographics or major comorbidities. Our data suggests that even though the time from MRI to surgery was delayed in 2020 and telemedicine appointments were necessary, RCR was still performed in a timely manner and with no significant changes in early complications. Level of Evidence III.

Results of Arthroscopic Revision Rotator Cuff Repair for Failed Open or Arthroscopic Repair: A Prospective Multicenter Study on 100 Cases

Background: Retears after rotator cuff repair (RCR) have been associated with poor clinical results. Meaningful data regarding the role of arthroscopic revision RCR are sparse thus far. Purpose/Hypothesis: To investigate results after arthroscopic revision RCR. We hypothesized that (1) arthroscopic revision RCR would lead to improved outcomes, (2) the clinical results would be dependent on tendon integrity and (3) tear pattern, tendon involvement, and repair technique would influence clinical and structural results. Study Design: Case series; Level of evidence 4. Methods: During a 40-month period, 100 patients who underwent arthroscopic revision RCR were prospectively enrolled in this multicenter study. Outcomes were evaluated preoperatively, at 6 months (6M), and at 24 months (24M) using the Constant score (CS), the Oxford Shoulder Score (OSS), and the Subjective Shoulder Value (SSV). Tendon integrity at 2 years was analyzed using magnetic resonance imaging. A total of 13 patients (13%) were lost to follow-up, and 14 patients (14%) had a symptomatic retear before the 24M follow-up. Results: All clinical scores improved significantly during the study period (CS: preoperative, 44 ± 16; 6M, 58 ± 22; 24M, 69 ± 19 points; OSS: preoperative, 27 ± 8; 6M, 36 ± 11; 24M, 40 ± 9 points; SSV: preoperative, 43% ± 18%; 6M, 66% ± 24%; 24M, 75% ± 22%) (P < .01). At 2 years, a retear rate of 51.8% (43/83) and a surgical revision rate of 12.6% (11/87) were observed. Mean full-thickness tear size decreased from 5.00 ± 1.61 cm2 to 3.25 ± 1.92 cm2 (P = .041). Although the Sugaya score improved from 4.5 ± 0.9 to 3.7 ± 1.4 (P = .043), tendon integrity did not correlate with better outcome scores. Previous open RCR, involvement of the subscapularis, chondral lesions of Outerbridge grade ≥2, and medial cuff failure were correlated with poorer SSV scores at 2 years (P≤ .047). Patients with traumatic retears had better CS and OSS scores at 2 years (P≤ .039). Conclusion: Although arthroscopic revision RCR improved shoulder function, retears were frequent but usually smaller. Patients with retears, however, did not necessarily have poorer shoulder function. Patient satisfaction at 2 years was lower when primary open RCR was performed, when a subscapularis tear or osteoarthritis was present, and when the rotator cuff retear was located at the musculotendinous junction. Patients with traumatic retears showed better functional improvement after revision.

Associations between range of motion, strength, tear size, patient-reported outcomes, and glenohumeral kinematics in individuals with symptomatic isolated supraspinatus tears.

Clinical failure associated with nonoperative treatment of rotator cuff tears may be due to inadequate characterization of the individual's functional impairments. Clinically, restricted passive range of motion (ROM) (restrictions imply capsular tightness), limitations in muscle strength, and larger rotator cuff tears are hypothesized to be related to altered glenohumeral kinematics. Understanding these relationships, as well as the relationship between glenohumeral kinematics and patient-reported outcomes (PROs) prior to exercise therapy, may help characterize functional impairments in individuals with rotator cuff tears. The objectives of the study were to describe the baseline presentation of individuals with an isolated supraspinatus tear, including passive ROM, rotator cuff muscle strength, tear size, PROs, and glenohumeral kinematics, and to determine associations among these variables. One hundred one individuals with symptomatic isolated supraspinatus tears were recruited for the study and underwent assessments of passive glenohumeral ROM, isometric muscle strength, and ultrasonography to assess anterior-posterior tear size. Glenohumeral kinematics during scapular-plane abduction were measured using biplane radiography. Furthermore, PROs including the American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Rotator Cuff Index (WORC) score were collected. Individuals presented with decreased ROM, external rotation weakness compared with the uninvolved side, and pain and disability as measured by the ASES and WORC scores. These findings were not associated with glenohumeral kinematics, with the exception of a weak positive association between glenohumeral contact path lengths and WORC scores (ρ=0.25, P=.03). Tear size was 11.7±5.7 mm, and maximum anterior translation, superior translation, and contact path length were 3.0%±3.8% of glenoid width, 3.5%±3.8% of glenoid height, and 38.2%±20.7% of glenoid size, respectively. Individuals with a symptomatic isolated supraspinatus tear presented with decreased ROM, external rotation weakness, and pain and disability as measured by the ASES and WORC scores. However, no abnormal kinematics associated with these limitations were observed. Thus, given that the tear is isolated to the supraspinatus tendon and no capsular restrictions are present, normal function of the glenohumeral joint may be possible during scapular-plane abduction.

Mental health status, not resilience, influences functional recovery after arthroscopic rotator cuff repairs

Recent literature has shown the importance of patient psychosocial status in overcoming stressful events, such as surgery. Resilience, the ability to "bounce back" from adversity, has been recently correlated to outcomes following arthroscopic rotator cuff repair (RCR). Overall mental well-being has also been shown to be important because patients with clinical depression and anxiety may have worse outcomes. Substantial clinical benefit (SCB) is the threshold of outcome improvement that a patient perceives as considerable. The purpose of this study was to assess the influence of preoperative resilience, mental health status, and rotator cuff tear size on patient outcome recovery measured by the American Shoulder and Elbow Surgeons (ASES) score. Patients undergoing arthroscopic RCR performed from 2016 through 2019 at a single tertiary institution by fellowship-trained sports surgeons with a high-volume shoulder practice were included. The Brief Resilience Scale (BRS) score and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Score (MCS) were collected preoperatively. ASES scores were obtained preoperatively, as well as 6 and 12 months postoperatively. Patients were divided into 2 groups based on the SCB threshold of 87 for the ASES score based on validated, established literature. Rotator cuff tear size was classified as small (≤3 cm) or large (>3 cm). VR-12 MCS, BRS, and ASES scores were compared at baseline, 6 months, and 1 year using separate mixed-model analyses of variance between the tear size and SCB groups. For ASES score comparison, the VR-12 MCS was used as a covariate to account for differences in baseline mental status. RCR was performed in 119 patients, with an average age of 61 years (standard deviation, 10 years). There were 71 male and 48 female patients. At 6 months, 43% of patients met the SCB threshold. The VR-12 MCS was significantly different between RCR patients who met the SCB threshold for the ASES score and those who did not at 6 and 12 months for large rotator cuff tears (P=.001) but not small tears (P=.07). The BRS score was not different between the tear size and SCB groups at any time point (P=.12). Our results show that patients who met the SCB threshold at 6 months postoperatively after arthroscopic RCR demonstrated higher preoperative VR-12 MCS values; however, higher preoperative BRS scores were not seen in those meeting the SCB threshold. In fact, when baseline VR-12 MCS values were accounted for in patients with large rotator cuff tears, the differences in ASES scores normalized. This finding suggests that baseline mental health status, as measured by the VR-12 MCS, significantly influenced patients' functional recovery following RCR. Future research should focus on preoperative psychosocial well-being to optimize postoperative outcomes.

Progression of Symptomatic Partial-Thickness Rotator Cuff Tears: Association With Initial Tear Involvement and Work Level.

Background:Partial-thickness rotator cuff tears (PTRCTs) often progress to full-thickness rotator cuff tears (FTRCTs). Thus, it is important to analyze the risk factors for tear progression to determine the proper timing of repair.Purpose:To identify the risk factors associated with progression of PTRCT.Study Design:Case-control study; Level of evidence, 3.Methods:Included were 89 patients diagnosed with PTRCT on magnetic resonance imaging (MRI) scans who underwent nonoperative treatment at the authors’ institution between August 2012 and August 2019. Patient characteristics, shoulder stiffness (compared with the contralateral shoulder); work level (classified as high [heavy manual labor], medium [manual labor with less activity], and low [sedentary activity]); and radiological factors including initial tear size, acromion type (flat, curved, hooked, or heel-shaped), and initial tear involvement (as a percentage of the rotator cuff tendon footprint length) were analyzed to assess their association with tear progression, defined as >20% increase in tear involvement.Results:The mean MRI follow-up period was 22.3 ± 17.2 months (median, 16.1 months; range, 6.4-89.5 months), and tear progression was observed in 12 patients (13.5%). In these 12 patients, tear involvement increased by 60% of the rotator cuff footprint, while mediolateral (ML) and anteroposterior (AP) tear sizes progressed by 1.1 and 1.8 mm, respectively. Univariate regression analysis showed that shoulder stiffness (P = .031), work level (P = .001), initial tear involvement (P < .001), ML and AP tear sizes (P < .001 and P = .005, respectively), and acromion type (P = .003) were significantly associated with tear progression. Multivariate regression analysis showed that initial tear involvement (odds ratio [OR], 1.053; 95% CI, 1.006-1.102; P = .026) and high work level (OR, 15.831; 95% CI, 1.150-217.856; P = .039) were independent risk factors for tear progression. The cutoff value for initial tear involvement was 47.5% (sensitivity, 81.8%; specificity, 85.7%).Conclusion:Tear progression was observed in 14% of patients with PTRCT in this study. To predict tear progression, evaluating the tear involvement during initial MRI is essential. The risk of tear progression increased with initial tear involvement >47.5% and a heavy work level.

Increased stiffness and reoperation rate in partial rotator cuff repairs treated with a bovine patch: a propensity-matched trial

Treating high-grade (grade 2 and 3) partial-thickness rotator cuff tears after failed conservative care remains challenging. Arthroscopic repair techniques are often considered with or without subacromial decompression and biological injections. More recently, a bioinductive bovine collagen patch (Regeneten; Smith & Nephew, Memphis, TN, USA) has been proposed to create a healing response and thicken the injured tendon. Although promising early results have been shown, previous studies lacked control subjects or comparison to other surgical treatments. The purpose of this study was to compare the reoperation rates of arthroscopic débridement and repair without a bioinductive collagen patch vs. arthroscopic débridement and repair with a bioinductive collagen patch in patients with high-grade partial-thickness rotator cuff tears in whom a minimum of 6 months of nonoperative treatment failed. Thirty-two patients with high-grade partial-thickness supraspinatus tears were treated with surgical repair with a bioinductive patch. A control group of 32 patients with high-grade partial-thickness supraspinatus tears treated with débridement or tear completion and repair without a bioinductive patch was selected and matched for age, sex, and tear size. Patients were followed up at regular intervals of 6 weeks, 12 weeks, and 6 months postoperatively, and range of motion was assessed at respective clinic visits. Stiffness and reoperations were compared between groups. Postoperative stiffness was observed in the first 12 weeks in 8 of 32 patients in the patch group compared with 1 of 32 patients in the control group. Six patients in the patch group underwent reoperations compared with no patients in the control group (P<.001). All 6 reoperations in the patch group were performed to address stiffness. There were no differences in race, smoking status, or diabetes between groups (P>.05). Patients in the patch group had a significantly higher rate of postoperative stiffness. In the majority of patients in whom shoulder stiffness developed, reoperation was required.

Sex-Based Differences in Athletes Undergoing Primary Hip Arthroscopy With Labral Reconstruction: A Propensity-Matched Analysis With Minimum 2-Year Follow-up

Background:There is a paucity of literature comparing sex-based outcome differences in athletes after primary hip arthroscopy with labral reconstruction for femoroacetabular impingement syndrome (FAIS) and irreparable labral tears.Purpose:To report sex-based differences in clinical characteristics, patient-reported outcome (PRO) scores, and return-to-sports (RTS) rates in athlete who underwent primary hip arthroscopy with labral reconstruction.Study Design:Cohort study; Level of evidence, 3.Methods:Data were reviewed for recreational, organized amateur, high school, collegiate, and professional athletes who underwent primary hip arthroscopy with labral reconstruction for FAIS and irreparable labral tears between July 2014 and May 2019. Inclusion criteria included preoperative and minimum 2-year postoperative PRO scores (modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score–Sports Specific Subscale, International Hip Outcome Tool [iHOT-12], and visual analog scale [VAS] for pain). Exclusion criteria were Tönnis grade >1, hip dysplasia (lateral center-edge angle, <18°), or prior ipsilateral hip surgery/conditions. Patients were divided into groups by sex and were propensity-matched in a 1:1 ratio by age, body mass index, graft type, labral tear size, and sports level.Results:A total of 101 hips were eligible, and 94 hips (93.1%) had a minimum 2-year follow-up. Twenty-nine female athlete hips were propensity-matched to 29 male athlete hips. Female athletes underwent higher rates of capsular repair (79.3% vs 24.1% for men; P < .001) and lower rates of acetabular microfracture (0.0% vs 20.7% for men; P = .024). Both female and male athletes experienced significant improvement on all PRO scores (P < .001 for all), high RTS rates (women, 84% vs men, 80.8%), and high rates of achieving the minimal clinically important difference for the iHOT-12 and VAS pain (women, 88.5% vs men, 71.4% for both) and achieving the patient acceptable symptom state for the iHOT-12 (women, 88.5% vs men, 71.4%), with no significant difference between the sexes.Conclusion:Despite different clinical characteristics and surgical procedures, both female and male athletes undergoing primary hip arthroscopy with labral reconstruction had significant improvements in all PROs at the minimum 2-year follow-up, high RTS rates, and similar rates of achieving the minimal clinically important difference and patient acceptable symptom state.