Undergoing Rotator Cuff Repair Research Articles

Platelet-rich Plasma in the Management of Shoulder Disorders: Basic Science and Implications Beyond the Rotator Cuff.

Platelet-rich plasma (PRP) is an autologous mixture produced by centrifugal separation of whole blood. Understanding the clinical efficacy of PRP remains a challenge in the field of sports medicine, including the treatment of various shoulder conditions. Animal studies have examined the biologic actions of PRP on the rotator cuff tendon and shoulder capsule. Human studies have reported the outcomes of PRP in the management of subacromial impingement syndrome, rotator cuff tears, frozen shoulder, and glenohumeral osteoarthritis. These studies highlight the role of PRP in the nonsurgical management of these conditions and its utilization in the perioperative setting to augment tissue healing and optimize the surgical outcomes. The role of PRP as an adjunct therapy in patients undergoing rotator cuff repair has been in the spotlight during the last decade; however, a limited number of studies have examined the role of PRP in the management of non-rotator cuff shoulder conditions. This article aims to provide an overview of the biologic actions of PRP on shoulder tissues and to summarize the outcomes of PRP injection in patients with rotator cuff and non-rotator cuff disease of the shoulder. We sought to organize the existing literature and to provide recommendations on the use of PRP in various shoulder conditions, based on the existing evidence.

Evaluation of the Clinical Outcomes of the Arthroscopic Treatment of Rotator Cuff Tears Using the Modified Suture Bridge Technique.

Objective To evaluate the postoperative clinical outcomes of the arthroscopic repair of rotator cuff injuries using a suture configuration we have developed based on a modification of the Suture Bridge (Arthrex, Naples, FL, United States). Methods A retrospective study with 28 male (41.2%) and 40 female (58.8%) subjects with a mean age of 60 years. All patients underwent rotator cuff repair with the modified Suture Bridge technique and follow-up for a minimum period of 18 months. The clinical assessment was performed using the University of California, Los Angeles (UCLA) Shoulder Score. Results The mean postoperative range of motion was of 134° (range: 110° to 140°) for elevation, 58° (range: 40° to 70°) for lateral rotation, and T10 (range: L4 to T7) for medial rotation. The mean increase was of 15° for elevation, 14° for lateral rotation, and 2 vertebral levels for medial rotation. The outcomes were excellent in 61 (83.6%) cases, good in 8 (10.9%), and regular in 4 cases (5.5%). Conclusion The modified Suture Bridge technique for the arthroscopic repair of rotator cuff injuries led to excellent or good postoperative clinical outcomes in most cases (69; 94.5%).

Kinesiophobia could affect shoulder function after repair of rotator cuff tears

PurposeKinesiophobia (fear of movement) is a major limiting factor in the return to pre-injury sport level after surgery of rotator cuff tears. The study aims to gain insights into how kinesiophobia affects shoulder pain and function after the repair of full-thickness rotator cuff tears.MethodsA prospective study was conducted to evaluate patients who underwent rotator cuff repair between January 2019 and December 2019 in our institution. The patients were divided into a trial group with a high kinesiophobia (Tampa Scale for Kinesiophobia [TSK], TSK > 37) and a control group with a low kinesiophobia (TSK ≤ 37). The indicators of interest included the Constant-Murley scores, numerical rating scale (NRS), visual analogue scale (VAS), Oxford Shoulder Score (OSS), and the American shoulder and elbow score (ASES), shoulder function and strength, and range of motion (ROM) at 3 days, 6 weeks, and 12 months after repair of full-thickness rotator cuff tears.ResultsIn total, 49 patients who underwent repair of full-thickness rotator cuff tears were enrolled, which was divided into a trial group involving 26 patients (mean TSK 52.54) and a control group involving 23 patients (mean TSK 33.43). There were no statistically significant differences in basic information such as age, gender, and length of stay in the two groups. The preoperative and early postoperative functional scores and the Tampa Scale for Kinesiophobia were statistically significant differences between the two groups. However, long-term postoperative follow-up showed no statistically significant difference in ASES, and Constant-Murley scores, OSS, and VAS scores between the two groups as the kinesiophobia changed from positive to negative.ConclusionDegree of kinesiophobia reduced during post-operative rehabilitation of rotator cuff repair patients, but high kinesiophobia is still present in a large portion of the patients after rotator cuff repair. Patients after rotator cuff repair will benefit from early recognition and prevention of kinesiophobia.

Patients Who Undergo Rotator Cuff Repair Can Safely Return to Driving at 2 Weeks Postoperatively.

Evidence-based guidelines are lacking for return to driving following rotator cuff repair (RCR). As a result, surgeons are often overly conservative in their recommendations, placing potential undue burden on patients and their families. Therefore, the primary objective of this study was to formulate evidence-based return-to-driving guidelines. Thirty-two subjects planning to undergo primary RCR were enrolled. Driving fitness was assessed in a naturalistic setting with an instrumented vehicle on public streets with a safety monitor onboard. Driving kinematic measures and behavioral data were obtained from vehicle data and camera capture. Several driving tasks and maneuvers were evaluated, including parking, left and right turns, straightaways, yielding, highway merges, and U-turns. The total course length was 15 miles (24 km) and the course took 45 to 55 minutes to complete. The subjects' baseline drive was performed prior to RCR and postoperative drives occurred at 2, 4, 6, and 12 weeks after RCR. All drives consisted of identical routes, tasks, and maneuvers. Driving metrics were analyzed for differences between baseline and postoperative drives, including differences in gravitational force equivalents (g). Twenty-seven subjects (mean age, 58.6 years [range, 43 to 68 years]) completed all 5 drives. Of the 13 analyzed kinematic metrics measured from 14 of 17 driving events, all exhibited noninferiority across all postoperative drives (2 to 12 weeks) after RCR compared with baseline. Beginning at postoperative week 2, subjects generally braked less aggressively, steered more smoothly, and drove more stably. Kinematic metrics during the performance of specific maneuver types also showed noninferiority when compared with baseline. Of note, subjects drove more smoothly on highway merges starting at postoperative week 2 (minimum longitudinal acceleration, -0.35 g [95% confidence interval (CI), -0.050 to -0.019 g]; standard deviation of longitudinal acceleration, 0.008 g [95% CI, 0.003 to 0.013 g]), but exhibited more aggressive driving and acceleration on highway merges at postoperative week 12 (maximum absolute yaw, -0.8°/sec [95% CI, -1.2°/sec to -0.4°/sec]). Patients showed no clinically important negative impact on driving fitness as early as 2 weeks after RCR. Adaptive behaviors were present both preoperatively and postoperatively. Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Evaluation of SS-31 as a Potential Strategy for Tendinopathy Treatment: An In Vitro Model

Background: Studies in our laboratory have demonstrated mitochondrial dysfunction in human and animal models of supraspinatus tendinopathy. SS-31 (elamipretide) has been reported to improve mitochondrial function and to be effective in clinical trials for several diseases. The potential of SS-31 in treating tendinopathy has not been explored. Hypothesis: SS-31 would improve mitochondrial function in human tenocytes sampled from patients with tendinopathy. Study Design: Controlled laboratory study. Methods: Healthy tenocytes were obtained from normal hamstring tendon biopsy specimens in 9 patients undergoing anterior cruciate ligament reconstruction, and tenocytes were collected from degenerative supraspinatus tendon biopsy specimens in 9 patients undergoing rotator cuff repair. Tenocytes were cultured, used at passage 1, and assigned to 4 groups: healthy tenocytes, healthy tenocytes with 1μM SS-31 treatment for 72 hours, degenerative tenocytes, and degenerative tenocytes with 1μM SS-31 treatment for 72 hours. The outcomes included measurements of mitochondrial potential, mitochondrial morphology by transmission electron microscopy imaging, reactive oxygen species and superoxidative dismutase activity, gene expression, and cell viability. Results: An increase in the cell fraction with depolarized mitochondria was found in degenerative tenocytes (P = .014), followed by a decrease after SS-31 treatment (P = .018). Transmission electron microscopy images demonstrated morphological changes with a decreased number and size of mitochondria per cell in the degenerative tenocytes (P = .018) and with improvement after SS-31 treatment. There was no significant difference in the level of reactive oxygen species between healthy and degenerative tenocytes in culture, but superoxidative dismutase activity was significantly decreased in the degenerative group (P = .006), which then increased after SS-31 treatment (P = .012). These findings suggested that mitochondrial dysfunction may be reversed by SS-31 treatment. The gene expression of matrix metalloproteinase-1 (matrix remodeling, P = .029) and fatty acid–binding protein 4 (fatty infiltration, P = .046) was significantly upregulated in the degenerative tenocytes and reduced by SS-31 treatment (P = .048; P = .007). Gene expression for hypoxia-inducible factor1 α and the proapoptotic regulator Bcl-2–associated X protein was increased in the degenerative tenocytes. There was a significant decrease in cell viability in degenerative tenocytes as compared with the healthy tenocytes, with small improvement after treatment with SS-31. Conclusion: There are changes in mitochondrial structure and function in tenocytes derived from degenerative tendons, and SS-31, as a mitochondrial protectant, could improve mitochondrial function and promote the healing of tendinopathy. Clinical Relevance: Mitochondrial dysfunction appears to play a role in the development of tendinopathy, and SS-31, as a mitochondrial protective agent, may be a therapeutic agent in the treatment of tendinopathy.

Paper 65: Arthroscopic rotator cuff repair with and without acromioplasty in the treatment of full-thickness rotator cuff tears: long term follow-up of a multicenter, randomized controlled trial

Objectives:In our previous trial of 86 patients randomized to undergo rotator cuff repair with or without acromioplasty, no differences in functional and quality-of-life indices at 24-months post-operative were observed. At that time point, four patients (9%) in the group without acromioplasty required reoperation due to persistent symptoms (1 with a type-II acromion and 3 with type-III acromion) while no patients that underwent acromioplasty had follow-up surgery. This is consistent with other short-term studies; however, no long-term follow-up of a randomized clinical trial has been conducted. The aim of this study was to re-evaluate the patients from the original trial determine the long-term efficacy of performing a subacromial decompression in cases of full thickness rotator cuff tears.Methods:This is a secondary study based on a previous multi-centre, double-blind, balanced randomization (1:1), parallel-group study with patients allocated to arthroscopic rotator cuff repair with (ACR) or without acromioplasty (No ACR). Recruitment for the original study was conducted between June 2003 and February 2009 with 24-month follow-up taking place between 2005 and 2011. This secondary study was conducted between April 2015 and March 2021 with all patients randomized in the main study comprising the study sample. Additional exclusion criteria were those who were unable or unwilling to provide informed consent. Patients from the original study were invited by a blinded assessor to return for a follow-up visit involving the same methodology as their previous visits. The visit included completion of a patient-reported outcome, the Western Ontario Rotator Cuff score (WORC) and clinical assessment. If a participant was unable to return for a clinical evaluation, they were asked to complete the WORC by mail.Results:Eighty-six patients were randomized in the original trial. Fifty-seven of those completed the long-term follow-up, 31 of 45 from the No ACR group and 25 of 41 from the ACR group. Sixty-one percent in the No ACR group and 64% in the ACR group were male. The mean (SD) duration of follow-up was 11.2 (2.4) years for No ACR and 11.5 (2.6) years for ACR, respectively. Mean (SD) age of patients at the time of initial surgery for the No ACR group was 58.5 (8.4) and for the ACR group was 56.2 (7.8), while mean age at the most recent follow-up was 69.0 (9.3) for No ACR and 67.7 (7.7) for ACR. Mean (SD) WORC scores at pre-operative, 24-months and long-term follow-up are presented by group in Table 1. There was no significant difference in WORC between the No ACR and ACR groups at the time of long-term follow-up (p=0.30). WORC score maintained a significant improvement from pre-operative scores in both groups (p < 0.001). In the initial study at 24-months post-operative, four patients were identified in the No ACR group who underwent revision surgery. Of those, 2 returned for long-term follow-up and 2 did not. In long term follow-up, another 6 patients were identified that underwent additional surgery on their study shoulder since the 24-month follow-up, including 3 rotator cuff revisions, 1 total shoulder arthroplasty, and 2 unknown shoulder surgeries (patient-reported). Therefore, 10 (22%) of the 45 patients in the No ACR group underwent further shoulder surgery. One participant, 2% of the initial 41 patients allocated to ACR, underwent a revision shoulder surgery.Conclusions:The main finding of this study was that at long-term (mean 11 years post-operative) follow-up of patients randomized to undergo rotator cuff repair with or without acromioplasty, there was no difference in patient-reported outcome, specifically WORC scores. Both groups maintained improved outcomes from their pre-operative status. However, revision rate was significantly higher in those that did not undergo acromioplasty at the time of their initial surgery.Figure 1.Patient flow through study.Figure 2.WORC scores over time by group.

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 100: Evaluation of SS-31 as a Potential Therapeutic in the Treatment of Tendinopathy

Poster 100: Evaluation of SS-31 as a Potential Therapeutic in the Treatment of Tendinopathy

The impact of external beam radiation therapy on shoulder surgical outcomes: a case series study

External beam radiation therapy (XRT) is a commonly used treatment adjunct in patients with breast cancer and is known to cause soft tissue dysfunction. However, data on XRT as a preoperative risk factor for shoulder surgery is limited. The purpose of this study was to assess whether prior history of breast cancer treated with XRT has an impact on surgical complications or outcomes. We hypothesize that patients treated with XRT will have a higher rate of surgical complications and lower outcomes. A 20-year retrospective chart review across a large, academic health care system was performed. Inclusion criterion comprised any patient with history of breast cancer of the upper-outer or axillary region treated with XRT. Patients also must have undergone a surgical procedure to the ipsilateral shoulder with at least 1-year postoperative follow-up. Patients were stratified by demographics, hand dominance, and surgery type. Postoperative outcomes including range of motion (ROM) and visual analog scale (VAS) scores for pain were also collected. Eighteen patients were identified (100% female) with an average age of 66.3 years (standard deviation 10.5 years). Ten shoulders underwent rotator cuff repair (RCR), 4 total shoulder arthroplasty (TSA), 3 reverse shoulder arthroplasty (RSA), and 1 arthroscopic superior labrum anterior to posterior (SLAP) repair. Four patients treated with RCR (40%) experienced postoperative complications related to their procedure. These included scapular winging, adhesive capsulitis, stiffness, and one retear. Two patients treated with shoulder arthroplasty (28.6%) experienced postoperative complications that included lymphedema and periprosthetic fracture following a mechanical fall in one RSA patient and periprosthetic infection in a TSA patient. ROM across all groups improved, most significantly in forward flexion and internal rotation among RCR patients (P<.001). Furthermore, a statistically significant improvement in VAS scores was achieved in each group (6.2±2.14 preoperation, 1.06±1.75 postoperation; P<.001). When compared to national averages, complication rates in our cohort were higher (40% vs. 10%-17% in RCR patients and 28.6% vs. 4%-14% in arthroplasty patients). On further scrutiny, many of these complications were independent of a history of XRT and many resolved with appropriate therapy. Most importantly, functional outcomes as measured by ROM and pain scores showed appropriate improvement consistent with normal populations without history of XRT. Thus, our results suggest that performing shoulder surgery after ipsilateral XRT for breast cancer is likely safe and may offer improved pain and ROM compared to forgoing surgery without necessarily increasing the risk for postoperative complication.

Utility of Preoperative Shear-Wave Elastography of the Supraspinatus Muscle for Predicting Successful Rotator Cuff Repair: A Prospective Observational Study With MRI Correlation.

BACKGROUND. After rotator cuff tear, properties of the torn muscle predict failed surgical repair. OBJECTIVE. The purpose of our study was to explore the utility of preoperative shear-wave elastography (SWE) measurements of the supraspinatus muscle to predict successful rotator cuff repair, including comparison with MRI-based measures. METHODS. This prospective study included 74 patients (37 men, 37 women; mean age, 63.9 ± 10.0 [SD] years) who underwent rotator cuff repair between May 2019 and January 2021. Patients underwent preoperative clinical shoulder MRI and investigational shoulder ultrasound including SWE using shear modulus. The mean elasticity values of the supraspinatus and trapezius muscles were measured, and the elasticity ratio (i.e., ratio of mean elasticity of supraspinatus muscle to mean elasticity of trapezius muscle) was calculated. The muscular fatty infiltration score (1-3 scale) was recorded on gray-scale ultrasound. On MRI, muscular fatty infiltration was assessed by Goutallier grade (0-4 scale), and muscular atrophy was assessed by the occupation ratio (ratio of cross-sectional areas of supraspinatus muscle and supraspinatus fossa) and by the muscle atrophy grade (0-3 scale). After rotator cuff repair, the surgeon classified procedures as achieving sufficient (n = 60) or insufficient (n = 14) repair. RESULTS. Patients with insufficient repair, versus those with sufficient repair, more commonly exhibited a large (3-5 cm) tear (100.0% vs 50.0%). Patients with insufficient, versus sufficient, repair exhibited higher mean Goutallier grade (3.8 ± 0.4 vs 1.9 ± 1.1), mean muscle atrophy grade (2.0 ± 0.8 vs 0.5 ± 0.7), mean supraspinatus elasticity (44.15 ± 8.06 vs 30.84 ± 7.89 kPa), mean elasticity ratio (3.66 ± 0.66 vs 1.83 ± 0.58), and mean gray-scale fatty infiltration grade (2.86 ± 0.36 vs 1.63 ± 0.66) and showed lower mean occupation ratio (0.3 ± 0.1 vs 0.6 ± 0.1) (all, p < .001). AUC for predicting insufficient repair was 0.945 for Goutallier grade, 0.961 for occupation ratio, 0.900 for muscle atrophy grade, 0.874 for mean elasticity, 0.971 for elasticity ratio, and 0.912 for gray-scale fatty infiltration grade. Elasticity ratio (cutoff ≥ 2.51) achieved sensitivity of 100.0% and specificity of 90.0% for insufficient repair. At multivariable analysis including tear size, the three MRI measures, elasticity ratio, and gray-scale fatty infiltration grade, the only independent predictors of insufficient repair were muscle atrophy grade of 2-3 (odds ratio [OR] = 9.3) and elasticity ratio (OR = 15.7). CONCLUSION. SWE-derived elasticity is higher in patients with insufficient rotator cuff repair; the elasticity ratio predicts insufficient repair independent of tear size and muscle characteristics. CLINICAL IMPACT. Preoperative SWE may serve as a prognostic marker in patients with rotator cuff tear.

Racial disparities in outcomes of arthroscopic rotator cuff repair: A propensity score matched analysis using multiple national data sets

BackgroundDisparities in access, utilization and outcomes exist throughout the healthcare system for minority groups, including racial and ethnic minorities; these disparities have wide-reaching implications for individuals as well as the healthcare system as a whole. This study will examine the impact of race on short and medium term outcomes for patients undergoing rotator cuff repair (RCR) using matched cohorts. MethodsPatients undergoing arthroscopic rotator cuff repair from 2016 to 2018 were extracted from two national databases: the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and TriNetX Research Network. Using the ACS-NSQIP database, univariate analysis was performed to identify differences in comorbidities between white and minority patients. Patients were propensity score matched based on significant differences between groups and 30-day postoperative outcomes were assessed. These comorbidities were then used to propensity score match white and minority patients in the TriNetX database and two-year postoperative outcomes were evaluated. ResultsFollowing propensity score matching, 3716 patients remained in each group from the ACS-NSQIP database and 4185 patients remained in each group from the TriNetX database. The OR time for minority patients was longer than white patient in the ACS-NSQIP database (92.2 vs. 87.6 min, p < .001). There was no difference in medium-term outcomes for repeat RCR, infection or frozen shoulder between white and minority patients in the TriNetX database. ConclusionAfter propensity score matching the only significant short-term outcome between white and minority patients undergoing RCR was a difference in OR time; there were no differences in medium-term outcomes. This may indicate that the source of racial disparities is one of access to healthcare rather than an innate difference in the patients’ outcomes. Further study is needed to elucidate this issue.

Posterior Rotator Cuff Tears: Is Extracorporeal Shockwave Therapy a Risk Factor?

Negative effects of extracorporeal shock wave therapy (ESWT) on vulnerable tendon structures have been reported. Meanwhile, tears of the posterior rotator cuff tendon, which is thinner than the anterior, are not common, and the clinical features remain poorly understood. Therefore, we evaluated the relationship between ESWT and posterior rotator cuff tears (RCTs) by investigating the risk factors. Of 294 patients who underwent rotator cuff repair between October 2020 and March 2021, a posterior RCT more than 1.5 cm from the biceps tendon or an isolated infraspinatus tear was identified in 24 (8.1%, group P). Sixty-two patients (21%) with an anterior RCT within 1.5 cm of the biceps tendon were analyzed as a control group (group A). Preoperative clinical characteristics were assessed to determine the risk factors of posterior RCTs. Calcific deposits were more frequently observed in group P (n = 7, 29.2%) than group A (n = 6, 9.7%, p = 0.024). Further, those in group P were more likely to undergo ESWT (n = 18, 75.0%) than those in group A (n = 15, 24.2%, p < 0.001). Of these, 7 patients experiencing calcific tendinitis from group P (29.2%) and 4 from group A (6.5%, p = 0.005) underwent ESWT for calcification removal. Furthermore, 11 patients experiencing tendinopathy from group P (45.8%), and 11 from group A (17.7%, p = 0.007) underwent ESWT for pain relief. The mean level of fatty infiltration of the supraspinatus was significantly higher in group A than group P (1.8 vs. 1.0, p < 0.001). Since a high prevalence rate of posterior RCTs was related to ESWT, it should be carefully considered when treating calcific tendinitis or pain in patients experiencing tendinopathy.

Home based unsupervised rehabilitation protocol following rotator cuff repair has good outcomes: A prospective study

Background: Rehabilitation after rotator cuff repair achieves good results but it involves time and costs. A simple home based program will reduce costs, time to travel and chance of exposure in a pandemic scenario. The objective of the study was to assess outcomes of home based rehabilitation protocol following rotator cuff repair. Methods: This was a prospective study of 42 patients who underwent rotator cuff repair followed by an unsupervised home based rehabilitation protocol. The tears were identified using clinical examination and Magnetic Resonance Imaging. The cuff repair was done with mini open incision technique. The patients were taught an exercise protocol, which they did by themselves at home. There was no daily supervision by the treating surgeon or a physiotherapist. The study measured pain scores, return to work, range of motion and failures at one year. Results: Mean duration of followup was 14 months. Visual Analogue Score for pain improved from preoperative mean 7.5 to followup mean 1.3. Disability of the Arm, Hand and Shoulder score, measured in 26 patients improved from preoperative mean 33.2 to followup mean 4.5. Range of motion improved in 39 patients. Cuff strength was normal in 39 patients. 37 patients returned to full work by three months. There were three failures with one patient developing significant stiffness and two patients showing a retear. The retear was seen in patients with large retracted tears and the repair was done under tension. Conclusion: Home based exercise protocol for postoperative rehabilitation in rotator cuff repairs can achieve good results in carefully selected patients. The study does not recommend this for large tears with difficult repairs. Since the patients are doing the postoperative rehabilitation at home, this reduces the costs, time lost in travel and exposure to external factors.

Patient-Reported Outcomes Measurements Information System (PROMIS) upper extremity and pain interference do not significantly predict rotator cuff tear dimensions.

BackgroundProper diagnosis of rotator cuff tears is typically established with magnetic resonance imaging (MRI); however, studies show that MRI-derived measurements of tear severity may not align with patient-reported pain and shoulder function. The purpose of this study is to investigate the capacity for the Patient-reported Outcomes Measurements Information System (PROMIS) computer adaptive tests to predict rotator cuff tear severity by correlating preoperative tear morphology observed on MRI with PROMIS upper extremity (UE) and pain interference (PI) scores. This is the first study to investigate the relationship between tear characteristics and preoperative patient-reported symptoms using PROMIS. Considering the essential roles MRI and patient-reported outcomes play in the management of rotator cuff tears, the findings of this study have important implications for both treatment planning and outcome reporting.MethodsTwo PROMIS–computer adaptive test forms (PROMIS-UE and PROMIS-PI) were provided to all patients undergoing rotator cuff repair by one of three fellowship-trained surgeons at a single institution. Demographic information including age, sex, race, employment status, body mass index, smoking status, zip code, and preoperative PROMIS-UE and -PI scores was prospectively recorded. A retrospective chart review of small to large full- or partial-thickness rotator cuff tears between May 1, 2017 and February 27, 2019 was used to collect each patient’s MRI-derived tear dimensions and determine tendon involvement.ResultsOur cohort consisted of 180 patients (56.7% male, 43.3% female) with an average age of 58.9 years (standard deviation, 9.0). There was no significant difference in PROMIS-UE or -PI scores based on which rotator cuff tendons were involved in the tear (P > .05). Neither PROMIS-UE nor PROMIS-PI significantly correlated with tear length or retraction length of the supraspinatus tendon (P > .05). The sum of tear lengths in the anterior-posterior and medial-lateral directions was weakly correlated with PROMIS-UE (P = .042; r = -0.152, r2 = 0.031) and PROMIS-PI (P = .027; r = 0.165, r2 = 0.012).ConclusionRotator cuff tear severity does not significantly relate to preoperative PROMIS-UE and -PI scores. This finding underscores the importance of obtaining a balanced preoperative assessment of rotator cuff tears that acknowledges the inconsistent relationship between rotator cuff tear characteristics observed on MRI and patient-reported pain and physical function.

Increased Glenohumeral Joint Loads Due to a Supraspinatus Tear Can Be Reversed With Rotator Cuff Repair: A Biomechanical Investigation

To evaluate the effect of an isolated full-thickness supraspinatus (SSP) tear on glenohumeral kinematics and contact mechanics, as well as to quantify improvement following rotator cuff repair (RCR). Ten fresh-frozen cadaveric shoulders (mean age: 63.1 ± 4.6 years) were tested using a dynamic shoulder simulator. A pressure-mapping sensor was placed between the humeral head and the glenoid. Each specimen underwent the following three conditions: 1) native, 2) isolated full-thickness SSP tear, and 3) RCR. Maximum abduction angle (MAA) and superior humeral head migration (SHM) were measured using 3D motion tracking software. Cumulative deltoid force (CDF) and glenohumeral contact mechanics, including contact area (GCA) and contact pressure (GCP), were assessed at the resting position, as well as at 15°, 30°, 45°, and 60° of glenohumeral abduction. Compared to native, the SSP tear resulted in a significant decrease in MAA (Δ-8.3°; P < .001) along with a SHM of 6.4 ± 3.8 mm, while significantly increasing CDF (Δ20.5 N; P=.008), GCP (Δ63.1 kPa; P < .001), and peak GCP (Δ278.6 kPa; P < .001), as well as decreasing GCA (Δ-45.8 mm2; P<.001) at each degree of abduction. RCR reduced SHM to 1.2 ± 2.5 mm, while restoring native MAA, CDF (Δ1.8 N), GCA (Δ4.5 mm2), GCP (Δ-4.5 kPa) and peak GCP (Δ19.9 kPa) at each degree of abduction (P > .999, respectively). In a dynamic biomechanical cadaveric model, increased glenohumeral joint loads due to a full-thickness SSP tear can be reversed with RCR. More specifically, RCR restored native glenohumeral contact area and contact pressure, while preventing superior humeral head migration and decreasing compensatory deltoid forces. These time 0 observations indicate that undergoing rotator cuff repair may prevent the development of degenerative changes by significantly reducing glenohumeral joint loads and ensuring sufficiently stable joint kinematics.

Magnetic resonance imaging analysis of screw in-type lateral anchor pull-out in large to massive rotator cuff repair in patients older than 60 years.

BackgroundThis study was performed to identify the incidence of screw in-type lateral anchor pull-out in patients older than 60 years who underwent rotator cuff repair for large to massive rotator cuff tear (RCT).MethodsWe reviewed 25 patients over 60 who were diagnosed with large to massive RCT and underwent arthroscopic rotator cuff repair in our hospital from March 2017 to February 2021. Preoperative tear size (anterior to posterior, medial to lateral) was measured via preoperative magnetic resonance imaging (MRI). All 25 patients underwent MRI scanning on postoperative day 1 and at 3 months after surgery. The change of anchor position was measured in axial views on MRI images postoperative day 1 and 3 months after surgery. And it was statistically compared according to bone mineral density (BMD), sex, and number of lateral anchors.ResultsTwo MRIs (postoperative day 1 and 3 months) in 25 patients were compared. Anchor pull-out occurred in six patients during 3 months (6.7%), and the mean pull-out length difference was 1.56 mm (range, 0.16–2.58). There was no significant difference in the number of pull-out anchors, degree of pull-out difference by comparing BMD (A, BMD≤-2.5; B, BMD>-2.5), sex, or number of anchors used in each surgery (C, two anchors; D, three anchors) (p>0.05).ConclusionsPull-out of screw in-type anchors was rarely observed and the mean pull-out length difference was negligibly small in our study. The screw in-type lateral anchor seems to be a decent option without concern of anchor pull-out even in elderly patients.

Subacromial Bursal Tissue and Surrounding Matrix of Patients Undergoing Rotator Cuff Repair Contains Progenitor Cells

To build upon previous literature to identify a complete analysis of cellular contents of subacromial bursal tissue as well as the matrix surrounding the rotator cuff. Samples of subacromial bursal tissue and surrounding matrix milieu from above the rotator cuff tendon and above the rotator cuff muscle bellies were obtained from 10 patients undergoing arthroscopic rotator cuff repair. Samples were analyzed using fluorescent-activated cell sorting and histologic analysis with staining protocols (Oil Red O, Alcian Blue, and Picro-Sirius Red), for identification of matrix components, including fat, proteoglycans, and collagen. Progenitor cells and fibroblast-type cells were present in significant amounts in subacromial bursal tissue in both tissues obtained from over the tendinous and muscle belly portions. Markers for neural tissue, myeloid cells, and megakaryocytes also were present to a lesser extent. There were prominent amounts of fat and proteoglycans present in the matrix, based on ImageJ analysis of stained histologic slides. The subacromial bursal tissue and surrounding matrix of patients undergoing rotator cuff repair contains progenitor cells in significant concentrations both over the tendon and muscle belly of the rotator cuff. This presence of progenitor cells, in particular, in the subacromial bursal tissue provides a potential basis for future applications of augmentation purposes in rotator cuff healing, and calls into question the practice of routine bursectomy. As the potential role of bursal tissue contents in growth and regeneration in the setting of rotator cuff healing is more well understood, maintaining this tissue may become more relevant. Concentration of these cellular components for use in autologous re-implantation is also an avenue of interest.

COVID-19-related rotator cuff repair delay.

BackgroundAlthough nonoperative treatment is effective for degenerative rotator cuff tears (RCTs), it remains unclear whether the delay created by a trial of nonoperative treatment negatively influences the outcome of a subsequent surgical repair. In March 2020, the COVID-19 pandemic resulted in an involuntary delay in the surgical treatment of rotator cuff disease, creating a natural experiment. The purpose of this study was to evaluate the outcomes and healing of patients who underwent delayed surgical treatment of chronic degenerative RCTs as compared with the nondelayed surgical treatment of RCTs.MethodsThis was a prospective study of two groups: patients planned to undergo arthroscopic rotator cuff repair between March 16, 2020 and May 1, 2020—the end of the ban on elective surgery—and patients who underwent rotator cuff repair starting six weeks after the ban on elective surgery had been lifted. Preoperatively and at six months postoperatively, we collected the Simple Shoulder Test, the American Shoulder and Elbow Surgeons (ASES) score, and the visual analog scale for pain. We also obtained magnetic resonance imaging (MRI) at six months postoperatively. A power analysis was conducted, and assuming a mean ± standard deviation ASES score of 93.1 ± 13.9 points and a minimum clinically important difference in the ASES score of 27.1 points, 7 patients per group (14 patients in total) would be necessary to have 90% chance of finding a difference.ResultsWe included 15 patients within each group and obtained 100% follow-up at six months. In the delay group, the mean ± standard deviation delay was 63 ± 24 days. There were no significant preoperative differences between groups in demographics or tear characteristics. Intraoperatively, there were no differences between groups in repair characteristics. Using a repeated-measures analysis of variance, there were significant preoperative vs. postoperative differences in ASES scores (P < .001), visual analog scale scores (P < .001), and Simple Shoulder Test scores (P < .001), but no differences between groups (P = .910, .519, and 0.852, respectively). On MRI, within the delay group, 58% had healed, whereas within the control group, 85% had healed (P = .202).ConclusionCOVID-19 caused a two-month delay in the operative treatment of RCTs. This delay did not significantly alter patient-reported outcomes. This delay resulted in a 27% difference in MRI healing rates, which was not statistically significant in this small study. Larger studies should be conducted as our results suggest that a delay in treatment may negatively impact healing rates.

Risk factors for the development of degenerative changes among patients undergoing rotator cuff repair: A systematic review.

Osteoarthritis (OA) of the glenohumeral joint results in significant pain and functional limitations. It is unclear which risk factors increase the risk of developing glenohumeral OA amongst Rotator Cuff Repair (RCR) patients. The purpose of this systematic review was to examine the risk factors which may contribute to the development of osteoarthritic changes post-operatively. MEDLINE, Embase, and PubMed databases were searched to identify studies reporting on demographics of patients who develop OA following RCR. Seventeen articles were identified investigating a total of 1292 patients. The overall quality of evidence was low. Pooled assessment of OA incidence following RCR at minimum 5 years follow-up found 26% of patients developed OA. Patients requiring revision surgery following retears developed OA at a rate of 29%. Surgical technique and patient demographics may also contribute to degenerative changes. This review found correlations between the aforementioned risk factors and glenohumeral joint degeneration at long-term follow-up after RCR. These findings suggest that future long-term studies should aim to identify prognostic factors that may place a patient at increased risk of developing OA. Such data can be used to counsel patients with respect to long-term outcomes following surgical intervention.

Use of Nerve Block in Addition to General Anesthesia Reduces Pain and Time in Post-Anesthesia Care Unit After Rotator Cuff Repair

Purpose To determine if use of nerve blocks during rotator cuff repairs will result in an overall improvement of post-operative pain and reduction of time spent in the post-anesthesia care unit (PACU) without any increases in avoidable emergency department (ED) or urgent care (UC) visits within 7 and 30 days. Methods A large integrated health system was queried for all rotator cuff repairs conducted between January 1, 2016 and December 31, 2017 and separated into two groups: general anesthesia only or general anesthesia with an additional nerve block. Maximal pain scores in the PACU, time spent in the PACU and avoidable visits to the ED/UC within 7 and 30 days were recorded and compared. Results A total of 3,128 patients undergoing rotator cuff repair were included (39.5% received general anesthesia with a nerve block). The use of an additional nerve block was associated with a 1.3 (p &lt; 0.001) point reduction in maximum reported pain scores and a 15.7 (11.9%, p &lt; 0.001) minute reduction in PACU time per patient. Furthermore, there was no statistically significant difference in avoidable ED/UC visits within 7 (p = 0.432) and 30 (p = 0.454) days between groups. Conclusion The use of a nerve block in addition to general anesthesia was associated with a significant reduction in maximum pain scores and time spent in the PACU with no increases in avoidable ED/UC visits within 7 or 30 days. Therefore, use of a nerve block in addition to general anesthesia could lead to longitudinally decreased costs in the rotator cuff repair surgical pathway. Level of Evidence III