Does Surgical Intervention Alter the Natural History of Degenerative Rotator Cuff Tears? Comparative Analysis from a Prospective Longitudinal Study.

INTRODUCTION: The natural history of rotator cuff tears often involves progressive pain development, tear enlargement, and advancing muscle fatty degeneration. Both surgery and conservative management have proven to be effective treatments. Our study purpose was to compare the short to mid-term effects of rotator cuff repair on shoulder function, progression of tear size, and muscle degeneration compared to controls with asymptomatic tears that developed pain and were managed nonoperatively. METHODS: This comparative study consists of two separate longitudinal study arms. The control group consisted of asymptomatic degenerative cuff tears followed until pain development and then managed nonoperatively with continued surveillance. The surgical group consisted of subjects with degenerative tears that failed nonoperative treatment and underwent surgical intervention with a minimum of 2 years follow-up. Outcomes included VAS pain, ASES, AROM, strength, and ultrasonography. RESULTS: There were 83 controls and 65 surgical shoulders. The surgical group was younger at enrollment (58.9±5.3 yr vs. 61.2±7.8 yr, p=0.04). The median follow-up for control subjects after pain development was 5.1 years (IQR 3.6) and the median postoperative follow-up for the surgical group was 3.0 years (IQR 0.2). Baseline tear widths (median 14 mm, IQR 9 vs. 13 mm, IQR 8; p=0.45) and tear lengths (median 14 mm, IQR 13 vs. median 11 mm, IQR 8; p=0.06) were similar between the surgical group and controls. There were no differences in the baseline prevalence of fatty degeneration of the supraspinatus or infraspinatus muscles between groups (p=0.43 and p=0.58, respectively). At final follow-up, the surgical group demonstrated significantly lower VAS pain (0 [IQR 2] vs. 3.5 [IQR 4], p=0.0002), higher composite ASES (95 [IQR 13] vs. 65.8 [IQR 32], p=0.0002) and ADL scores (29 [IQR 4] vs. 22 [IQR 8], p=0.0002), greater abduction strength (69.6 N [SD 29] vs. 35.9 N [SD 29], p=0.0002), greater active forward elevation (155˚ [SD 8] vs. 142˚ [SD 28], p=0.002), greater active external rotation in abduction (mean 98.5˚, SD 12 vs. mean 78.2˚, SD 20; p=0.0002) compared to controls. Additionally, the prevalence of fatty muscle degeneration was lower in the surgical group for the supraspinatus and infraspinatus (25% vs. 41%, p=0.05; 17% vs. 34%, p=0.03; respectively). CONCLUSION: This prospective longitudinal study comparing a surgical cohort undergoing rotator cuff repair with a control group treated nonoperatively supports the notion that surgical intervention has the potential to alter the early natural history of degenerative rotator cuff disease. Patients in the surgical group demonstrated clinically relevant differences in pain and functional outcomes. Surgical intervention was protective against progressive muscle degeneration compared to nonoperative treatment.

Effects of Quality of Integrity on Clinical and Structural Outcomes of Rotator Cuff Repair: A Retrospective Cohort Study of 504 Cases.

BACKGROUND: The clinical implications of structural integrity have been a subject of long debate. The oversimplified binary categorization of structural integrity into either healing or retear, along with faulty preoperative baselines for comparison, may contribute to the controversy. PURPOSE: To determine how the quality of structural integrity in a repaired cuff tendon affects both clinical and structural outcomes by dividing the patients into groups based on integrity and using the immediate postoperative baseline (time zero). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 504 patients with a full-thickness rotator cuff tear who underwent arthroscopic rotator cuff repair and were followed up for at least a year with magnetic resonance imaging (MRI) were included. The quality of structural integrity was graded using the Sugaya classification. To evaluate clinical outcomes, pain, range of motion, strength, functional scores, and overall satisfaction and function were used for within- and between-group analyses at the last follow-up. For the assessment of structural outcomes, the Goutallier classification for fatty infiltration (FI) and the tangent sign, occupation ratio, and normalized cross-sectional area for muscle atrophy (MA) were used. The baselines for these structural measurements were both the preoperative and the time-zero MRI scans. RESULTS: The mean clinical follow-up period was 31.8 ± 27.5 months, and the MRI follow-up period was 10.9 ± 5.3 months. There were 178 (35.3%), 228 (45.2%), 58 (11.5%), 14 (2.8%), and 26 (5.2%) shoulders with Sugaya grades 1, 2, 3, 4, and 5, respectively. Regardless of structural integrity, all clinical outcomes at a mean follow-up of 31.8 months after repair significantly improved compared with those before repair. Only in shoulders with Sugaya grade 1 did the FI of the supraspinatus muscle improve significantly from baseline. FI of the infraspinatus muscle did not change significantly in those with grades 1 and 2 but worsened in those with grades 3 and 5. MA measured using the occupation ratio improved significantly in shoulders with Sugaya grades 1 and 2 but declined in those with grade 5. CONCLUSION: This study established a correlation between improved structural integrity of the repaired cuff tendon and enhanced structural outcomes in rotator cuff muscles. Furthermore, the findings revealed that both FI and MA could be reversed in patients exhibiting high-quality structural integrity. However, these structural improvements were not mirrored in the clinical outcomes.

Pneumothorax after Shoulder Arthroscopy: A Case Report.

Shoulder arthroscopy is an increasingly common procedure. Pneumothorax post-shoulder arthroscopy is a rare complication. Our aim is to highlight a case report of pneumothorax post-shoulder arthroscopy and to conduct a literature review to evaluate the possible risk factors. We report the case of a 75-year-old male non-smoker, who underwent right shoulder arthroscopy without regional anaesthesia in the left lateral position and subsequently suffered a pneumothorax post-operatively. A PubMed Medline and Cochrane database search was carried out, and 32 articles were identified and thoroughly reviewed. Overall, among the articles that propose a mechanism, 75% (9/12) consider the pathogenesis to be multifactorial. The exact mechanism is currently unknown. Awareness of this complication and timely recognition are important to prevent life-threatening sequelae. Surgeons should maintain a low threshold for obtaining diagnostic plain radiographs in the event of clinical suspicion.

The Relationship Between All-Suture and Solid Medial-Row Anchors and Patient-Reported Outcomes for Double-Row Suture Bridge Rotator Cuff Repair.

Background: The use of all-suture anchors for rotator cuff repair is increasing. Potential benefits include decreased bone loss and decreased damage to the chondral surface. Minimal evidence exists comparing outcomes among medial-row anchor fixation methods in double-row suture bridge rotator cuff repair. Purpose: To compare the clinical outcomes between all-suture and solid medial-row anchors in double-row suture bridge rotator cuff repair. Study Design: Case series; Level of evidence, 4. Methods: A total of 352 patients (mean age at surgery, 60.3 years) underwent double-row suture bridge rotator cuff repair at our institution. Patients were separated into 2 groups based on whether they underwent all-suture (n = 280) or solid (n = 72) anchor fixation for the medial row. Outcomes data were collected via an ongoing longitudinal data repository or through telephone calls (minimum follow-up time, 2.0 years; mean follow-up time, 3.0 years). Outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) standardized shoulder assessment form and the visual analog scale (VAS). The same rehabilitation protocol was administered to all patients. The proportions of patients meeting previously published Patient Acceptable Symptom State (PASS) thresholds were calculated for the outcome measures, and outcome scores and the proportions of patients meeting PASS thresholds between groups were compared using linear and logistic regression, respectively. Results: The groups did not differ in terms of age at surgery, sex distribution, rotator cuff tear size, or number of medial-row anchors used. The solid anchor group had a longer follow-up time compared with the all-suture anchor group (3.6 ± 0.7 vs 2.8 ± 0.8 years, respectively; P < .01). After controlling for follow-up time, the solid and all-suture anchor groups did not differ in ASES scores (89.6 ± 17.8 vs 88.8 ± 16.7, respectively; P = .44) or VAS scores (1.1 ± 2.1 vs 1.2 ± 2.1, respectively; P = .37). Similarly, after controlling for follow-up time, the solid and all-suture anchor groups did not differ in the proportions of patients meeting PASS cutoffs for the ASES (84.7% vs 80.7%, respectively; P = .44) or the VAS (80.6% vs 75.0%, respectively; P = .83). Conclusion: Double-row suture bridge rotator cuff repair using all-suture anchors for medial-row fixation demonstrated similar excellent clinical outcomes to rotator cuff repair using solid medial-row anchors.

Doctor shopping trend of patients before undergoing rotator cuff repair in Korea: a multicenter study.

Background: To investigate the doctor shopping trend of patients with rotator cuff tear (RCT) before undergoing surgery and the relevance of the results to the public. Methods: A survey was conducted of 326 patients from 10 hospitals (male, 176; female, 150) who underwent arthroscopic rotator cuff repair (ARCR) for symptomatic RCT between September 2019 and February 2020. A questionnaire was used to obtain data regarding the type of medical care service, medical institutions visited before surgery, number of treatments received, and cost of treatment. Results: A total of 326 patients (87%) received treatment at least once at another medical institution before visiting the hospital where the surgery was performed. Patients visited an average of 9.4 health providers or physicians for shoulder pain before visiting the hospital where surgery was performed. Among the 326 patients, 148 (45%) visited more than two medical institutions and spent an average of 641,983 Korean won (KRW; $466, 50,000-5,000,000 KRW) before surgery. Medical expenses before surgery were proportional to the number of medical institutions visited (P=0.002), symptom duration (P=0.002), and initial visual analog scale (VAS) pain score (P=0.007) but were not associated with gender, age, VAS pain score immediately before surgery, or RCT size. Conclusions: Medical expense before ARCR was associated with the severity of preoperative pain and duration of symptoms. After onset of shoulder symptoms, patients should visit as soon as possible a hospital that has surgeons who specialize in shoulder repair to prevent unnecessary medical expense and proper treatment.

The impact of mental health on shoulder arthroplasty and rotator cuff repair: a meta-analysis.

Background: The aim of this study was to evaluate the impact of mental health attributes, such as the presence of psychiatric comorbidities or psychological comorbidities (low resilience), on outcomes after rotator cuff repair (RCR) and total shoulder arthroplasty (TSA). Methods: PubMed, Cochrane, and Google Scholar (results pages 1-20) were searched up to November 2023. Mental health problems of interest included the presence of psychiatric comorbidities (depression, anxiety) or indicators of poor psychological functioning, such as low resilience or the presence of distress. Patients were assigned to poor or good mental health groups in this study based on their grouping in the original study. Results: Fourteen studies were included in the meta-analysis. Patients with good mental health had greater improvements in postoperative American Shoulder and Elbow Surgeons and Simple Shoulder Test scores in the TSA cohort (P=0.003 and P=0.01), RCR cohort (P<0.001), and the combined TSA and RCR cohort (P<0.001). No difference was found in visual analog scale score, satisfaction, external rotation, or flexion between the two mental health groups. Patients with poor mental health undergoing RCR experienced higher rates of adverse events and transfusions (P<0.001). Patients with poor mental health also had greater rates of revision and emergency department visits in the TSA cohort (P<0.001), RCR cohort (P=0.05 and P=0.03), and combined cohort (P<0.001). Patients with poor mental health undergoing TSA had a higher rate of re-admission (P<0.001). Conclusions: Patients with poor preoperative mental health showed inferior patient-reported outcome scores and increased rates of adverse events, revisions, and re-admissions.

Rebound pain after arthroscopic cuff repair with interscalene brachial plexus block anesthesia is reduced by surgeon administered multimodal shoulder injections: A prospective randomized controlled trial.

PURPOSE: To compare the effects of additional multimodal shoulder injections on postoperative rebound pain in patients undergoing arthroscopic rotator cuff repair (ASRCR) under interscalene brachial plexus block (ISBPB) anesthesia. METHODS: A single-blind randomized controlled trial was conducted with 67 patients between April 2023 and December 2023. Patients undergoing ASRCR got an ISBPB anesthesia, not general anesthesia, were included with a minimum follow-up period of 48 h. The injection group received 40 mL of 0.75% ropivacaine, 20 mg morphine, 1:200,000 epinephrine, and saline solution, totaling 100 mL. Following surgery, the injection was administered to the subacromial space (50 ml) with blind suprascapular nerve block (25 ml) and blind axillary nerve block (25 ml). Controls received 100 mL of saline solution. Intravenous patient-controlled analgesia (IV-PCA) was used as adjuvant analgesia for all patients. The primary outcome was evaluated using the visual analog scale (VAS) pain score at 12 h after surgery, with secondary outcomes of the incidence of rebound pain and VAS pain scores at 0, 2, 4, 8, 24, 36, and 48 h postoperatively. Fentanyl in IV-PCA and rescue analgesic amounts, complications, and satisfaction were recorded. RESULTS: Sixty-seven patients (32 in the injection group, 35 in the control group) with a mean age of 61.1±9.0 years were included. The primary outcome assessment, VAS pain score at 12 h, significantly favored the injection group (2.7±0.93 vs. 4.1±1.70, p<0.001). The incidence of rebound pain was 18.8% and 65.7% in the injection and control groups, respectively (18.8% vs 65.7%, p<0.001). The injection group reported better VAS pain scores at 24, 36, and 48 h, and lower fentanyl use over the 48 h postoperative period (p=0.014). The use of rescue analgesics was similar between groups and no complications were associated with multimodal shoulder injections. Satisfaction levels were similar in both groups. CONCLUSION: The present study found that multimodal shoulder injections during ASRCR under ISBPB anesthesia significantly lowered VAS pain scores at 12 hours postoperatively and reduced the incidence of rebound pain compared to the control group. Pain levels were consistently lower from 12 to 48 hours postoperatively. Additionally, the injection group had reduced opioid consumption within the first 48 hours postoperatively, with no complications observed. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Corticosteroid Infiltration to Treat Shoulder Stiffness After Rotator Cuff Repair.

Purpose: To investigate whether the preoperative shoulder range of motion (ROM), would increase the risk of postoperative shoulder stiffness, or whether it would be associated with other preoperative patient characteristics. Methods: The authors retrospectively analysed the 372 shoulders that underwent rotator cuff repair by 4 surgeons, between January 2010 and January 2011. All patients were followed up at 3 and 6 months by 2 independent observers to collect the ROM, including active forward elevation (AFE), passive forward elevation (PFE), and external rotation (ER), as well as subjective shoulder value (SSV). Results: Of the initial cohort of 372 patients, 10 were lost to follow-up (2.7%), leaving a final cohort of 362 patients available for outcome assessment at a minimum follow-up of 6 months. Of the 362 patients, 281 did not require corticosteroid infiltration, 68 received corticosteroid infiltrations for shoulder stiffness with no apparent cause, and 13 received corticosteroid infiltrations for other reasons. None of the variables were associated with infiltration for shoulder stiffness. Older patients had greater SSV scores (ß = 0.3; 95% CI [0.1, 0.6]; P = .015), while both manual and repetitive workers had lower SSV scores (ß = -10.7; 95% CI [-15.8, -5.6]; P < .001, and ß = -10.2; 95% CI [-15.1, -5.3]; P < .001). Conclusion: Postoperative SSV was significantly associated with age, as well as manual or repetitive work. Furthermore, postoperative PFE, AFE, and ER were significantly associated with preoperative PFE. Finally, at 3 and 6 months postoperative, patients who required infiltration for shoulder stiffness had significantly lower PFE, AFE, and ER compared to patients who did not require infiltration. Level of Evidence: IV, Case series.

Revision Surgery for Shoulder Infection after Arthroscopic Rotator Cuff Repair: Functional Outcomes and Eradication Rate-A Systematic Review.

The outcomes after arthroscopic rotator cuff repair (RCR) have been reported to be successful. The incidence of deep infections (defined as an infection involving any part of the anatomy other than the skin and subcutaneous tissue) after surgery ranges between 0.03% and 3.4%. This systematic review aims to investigate the outcomes of revision surgery for infection following arthroscopic RCR. Clinical outcomes and eradication rates among patients treated with different surgical and antibiotic therapies are analyzed. A total of five studies were eligible for systematic review. A total of 146 patients were treated and evaluated, of whom 71 (48%) and 75 (52%) underwent arthroscopic and open surgery to manage the infection, respectively. The most common causative bacterium was Cutibacterium acnes (50.4%). Two studies reported the pre-and postoperative ASES score and Constant-Murley score (CMS), and a statistically significant improvement was found after surgery (p < 0.001 for both). Eradication was observed in a total of 138 patients (94.5%); no difference was found between arthroscopic and open revision surgery (92.8% and 96%, respectively, p = 0.90). The frequency-weighted mean duration of the intravenous antibiotic therapy was 6.6 ± 5.4 days, while the overall mean duration of antibiotic therapy, considering intravenous and oral administration, was 43.5 ± 40 days. Patients with infection following arthroscopic RCR undergoing revision surgery experienced a high rate of eradication. A significant improvement in shoulder functionality and less residual pain can be expected.

Pre-Operative Transverse Tendon Thickness In Small and Mid Sized Rotator Cuff Tears Does Not Affect Clinical Outcomes After Arthroscopic Repair.

INTRODUCTION: Previous studies on rotator cuff tears have examined both clinical and radiographic parameters which may influence post-operative clinical outcomes. While rotator cuff tears are frequently classified by size or depth, there is currently no literature available examining the thickness of the remnant tendon, and its impact on post-operative outcomes. We hypothesize that decreased pre-operative transverse tendon thickness will result in poorer post-operative clinical outcomes. METHODS: We prospectively recruited patients who underwent arthroscopic repair of small to medium full-thickness rotator cuff tears. These patients were followed up for a minimum of 2 years post-operatively. Basic biodata, as well as Visual Analog Scale (VAS) for pain, Constant-Murley Score (CMS), UCLA Shoulder Score (USS), and Oxford Shoulder Score (OSS) at 3 different time points (pre-operatively, 1 year post-operatively, and 2 year post-operatively) were collected. Transverse tendon thickness was measured by independent blinded radiologists on pre-operative ultrasonographic images. Wilcoxon signed-rank test was used to compare outcome scores and multivariable robust linear model was fitted to assess the effect of transverse tendon thickness on post-operative scores. RESULTS: A total of 63 patients were enrolled in this study, predominantly female (65%) and had a median age of 72 years. Pre-operatively, the median transverse cuff thickness was 5.0 mm and median tear size was 1.4 cm. The median VAS at preoperative was 7, which reduced to 0 at 2 year post-operative, indicating statistically significant improvement in pain levels (p<0.001). Statistically significant improvement in shoulder function measured by CMS, UCLA score and OSS were also seen over time (p<0.001). Robust regression analysis revealed that transverse cuff thickness had no statistically significant effect on VAS (p=0.99), CMS (p=0.84), UCLA score (p=0.22), and OSS scores (p=0.73) at 2 year postoperatively. DISCUSSION: Pre-operative transverse tendon thickness of small- to mid-sized supraspinatus tears do not influence clinical outcomes after arthroscopic repair. Differences in transverse tendon thickness may have an association with tendon healing but does not translate to an association with post-operative outcomes in terms of pain, function, and patient reported outcome measures. Level of evidenceIV.

Arthroscopic rotator cuff repair in active patients younger than 45 Years: a prospective analysis with a mean 5-year follow-up.

Background: To report clinical and activity-specific outcomes after arthroscopic rotator cuff repair (ARCR) for full-thickness supraspinatus tears in active individuals aged less than or equal to 45 years. The pre hoc hypothesis was that patients in this age group would demonstrate significant improvements in clinical outcomes following ARCR along with a significant improvement of athletic abilities. Methods: Patients were included in this study if they were (1) active individuals aged between 18 and 45 years at the time of surgery, (2) had a full-thickness rotator cuff tear of the supraspinatus tendon with or without anterior or posterior extension, and (3) underwent ARCR. Preoperative and postoperative patient-reported outcomes scores including the American Shoulder and Elbow Surgeons (ASES) score; Disabilities of Arm, Shoulder and Hand; Single Assessment Numeric Evaluation; and Short Form-12 Physical Component Summary were prospectively collected and postoperative patient satisfaction (scale of 1-10) was recorded at a minimum of 2 years postoperatively. Attainment of the minimal clinically important difference and patient acceptable symptom state for the ASES was calculated. Athletic activity-specific outcomes and return to activity were investigated prospectively via a custom-made comprehensive questionnaire. Results: Between November 2005 and June 2020, of 1149 RCRs performed by the senior author, 54 patients (mean age 40.9 years, 13 female; follow-up 69.7 ± 35.2 months in a range of 24.6-179.6 months) were included into the outcomes analysis. Of those, 4 patients (7.4%) had progressed to revision RCR. At a follow-up of 5.8 years, outcome scores had significantly improved compared to preoperative baselines (ASES 55.6 ± 13.8 to 90.1 + 15.8; P < .001; Disabilities of Arm, Shoulder and Hand 38.9 ± 18.4 to 11.9 ± 17.1; P < .001, Single Assessment Numeric Evaluation 60.7 ± 22.7 to 79.3 ± 27.6; P = .001, Short Form-12 Physical Component Summary 41.6 ± 8.3 to 51.9 ± 9.0; P ≤ .001). Ninety three point six percent of the patients reached the minimal clinically important difference and 72.6% reached the patient acceptable symptom state. Median satisfaction was 9.5/10. Eighty six percent of the patients returned to sports, while 67% of the patients returned to a similar level compared to preoperatively. All sport-specific metrics such as shoulder strength and endurance (P < .001), intensity (P < .001), and impairments from pain affecting speed (P = .002), endurance (P = .002), and competition (P < .001) significantly improved postoperatively. Conclusion: ARCR of full-thickness rotator cuff tear in active individuals aged 45 years or less results in a clinically relevant improvement of outcomes, function, and quality of life at a minimum of 2 years and mean 5.8-year follow-up with a low rate of revision. While 86% of patients were able to return to activity and sport-specific outcome metrics significantly and substantially improved compared to preoperatively, a return to preinjury levels was not reliably achieved in all patients, with particular limitations observed in overhead active individuals. The data support the hypothesis that patients in this age group demonstrate significant improvements in clinical outcomes following ARCR along with significant improvements in athletic abilities.

Arthroscopic margin convergence of large-sized rotator cuff tears does not lead to better clinical outcome compared with conventional repair.

Background: The margin convergence (MC) technique is used to repair longitudinal-type tears as direct repair of the apex of the longitudinal-type tear from medial to lateral is challenging. Few studies have compared the postoperative clinical outcomes and retear rates of arthroscopic rotator cuff repair (ARCR) using the MC technique with those of conventional ARCR without using the MC technique. Therefore, this study aimed to investigate the efficacy of MC on the clinical outcome and retear rates of patients with large-sized rotator cuff tears. It was hypothesized that ARCR using the MC technique would yield clinical outcome and retear rates similar to those of ARCR without using the MC technique. Methods: The medical records of consecutive patients who underwent ARCR for large-sized rotator cuff tears were retrospectively evaluated. Forty-four and 35 shoulders were repaired using MC (MC group) and not using MC (non-MC group), respectively. The range of motion (ROM) and the Japanese Orthopaedic Association (JOA) score were assessed preoperatively and after a minimum follow-up period of 12 months postoperatively. Magnetic resonance imaging was performed at least 3 months postoperatively to determine whether the tendons had healed. Results: The average postoperative follow-up duration was 26.6 months and 24.3 months in the MC and non-MC groups, respectively. The mean ROM and JOA score improved significantly in both groups postoperatively; however, the postoperative range of external rotation and the total JOA score was significantly lower in the MC group. The overall retear rate did not differ significantly between the MC (13/44, 29.5%) and non-MC (7/35, 20.0%) groups, respectively (P = .332). No significant differences were observed between the cases with retears in the 2 groups in terms of the postoperative ROM and the total JOA score. In contrast, the postoperative range of external rotation and the total JOA score of the patients with healed tendons in the MC group were significantly poorer than those of the patients with healed tendons in the non-MC group. Conclusion: ARCR using MC of large-sized longitudinal-type tears does not lead to better postoperative range of external rotation and clinical outcome compared with those of conventional repair.

Passive shoulder abduction range of motion at 3 months postoperatively is the most important prognostic factor for achieving full recovery of range of motion at 6 months after arthroscopic rotator cuff repair.

Background: After arthroscopic rotator cuff repair (ARCR), it is crucial for clinicians to predict the functional recovery in the early postoperative period for considering rehabilitation strategies. The aim of this study was to identify the prognostic factors in the early postoperative period for achieving full recovery of range of motion (ROM) at 6 months after ARCR. Methods: This study included 184 patients who underwent ARCR. Patients were divided into the full recovery and nonrecovery groups using the Constant ROM score at 6 months postoperatively. The area under the curve for predicting the full recovery group was calculated for all independent variables such as demographic data, ROM, shoulder functional scores at preoperative and 3 months postoperative using receiver operating characteristic curve analysis. Multivariable logistic regression analysis was then performed using candidate variables with an area under the curve of 0.7 or greater to determine prognostic factors for full recovery at 6 months postoperatively. The same analysis as above was also performed by dividing the patients into groups according to their preoperative ROM. Results: Multivariable logistic regression analysis revealed that preoperative active flexion, 3 months postoperative passive abduction, and internal rotation at 90° abduction ROM were significant prognostic factors of achieving full ROM recovery at 6 months postoperatively. Only passive abduction ROM at 3 months postoperatively was significantly extracted in the preoperative ROM limitation group. Conclusion: This study demonstrated that passive abduction ROM at 3 months postoperatively was a significant prognostic factor of achieving full recovery of ROM at 6 months after ARCR.

Impact of surgeon volume, experience, and training on outcomes after arthroscopic rotator cuff repair: a nationwide analysis of 1489 surgeons.

Background: Given the complexity of arthroscopic rotator cuff repair (ARCR) and increasing prevalence, there is a need for comprehensive, large-scale studies that investigate potential correlations between surgeon-specific factors and postoperative outcomes after ARCR. This study examines how surgeon-specific factors including case volume, career length, fellowship training, practice setting, and regional practice impact two-year reoperation rates, conversion to total shoulder arthroplasty (anatomic or reverse), and 90-day post-ARCR hospitalization. Methods: The PearlDiver Mariner database was used to collect surgeon-specific variables and query patients who underwent ARCR from 2015 to 2018. Patient outcomes were tracked for two years, including reoperations, hospitalizations, and International Classification of Diseases, Tenth Revision codes for revision rotator cuff repair (RCR) laterality. Hospitalizations were defined as any emergency department (ED) visit or hospital readmission within 90 days after primary ARCR. Surgeon-specific factors including surgeon case volume, career length, fellowship training, practice setting, and regional practice were analyzed in relation to postoperative outcomes using both univariate and multivariate logistic regression. Results: 94,150 patients underwent ARCR by 1489 surgeons. On multivariate analysis, high-volume surgeons demonstrated a higher risk for two-year total reoperation (odds ratio [OR] = 1.06, 95% confidence interval [CI]: 1.01-1.12, P = .03) and revision RCR (OR = 1.06, 95% CI: 1.01-1.12, P = .02) compared to low-volume surgeons. Early-career surgeons showed higher rates of 90-day ED visits (mid-career surgeons: OR = 0.78, 95% CI: 0.73-0.83, P < .001; late-career surgeons: OR = 0.73, 95% CI: 0.68-0.78, P < .001) and hospital readmission (mid-career surgeons: OR = 0.74, 95% CI: 0.63-0.87, P < .001; late-career surgeons: OR = 0.73, 95% CI: 0.61-0.88, P = .006) compared to mid- and late-career surgeons. Sports medicine and/or shoulder and elbow fellowship-trained surgeons demonstrated lower two-year reoperation risk (OR = 0.95, CI: 0.91-0.99, P = .04) and fewer 90-day ED visits (OR = 0.93, 95% CI = 0.88-0.98, P = .002). Academic surgeons experienced higher readmission rates compared to community surgeons (OR = 1.16, 95% CI = 1.01-1.34, P = .03). Surgeons practicing in the Northeast demonstrated lower two-year reoperation (OR = 0.88, 95% CI: 0.83-0.93, P < .001) and revision (OR = 0.88, 95% CI: 0.83-0.94, P < .001) RCR risk compared to surgeons in the Southern United States. Conclusion: High-volume surgeons exhibit higher two-year reoperation rates after ARCR compared to low-volume surgeons. Early-career surgeons demonstrate increased hospitalizations. Sports medicine or shoulder and elbow surgery fellowships correlate with reduced two-year reoperation rates and 90-day ED visits.

Biceps tenotomy vs. tenodesis in patients undergoing transtendinous repair of partial thickness rotator cuff tears.

Background: Patients with partial thickness rotator cuff tears (PTRCTs) often present with concurrent pathology of the long head of the biceps tendon (LHBT). To address both conditions simultaneously, long head of the biceps (LHB) tenotomy or tenodesis can be performed at the time of arthroscopic rotator cuff repair (RCR). This study aims to compare postoperative shoulder active range of motion (AROM) and complications following transtendinous RCR with concurrent LHB tenodesis or tenotomy. Methods: A total of 90 patients with PTRCTs met inclusion criteria for this study. Patients who underwent tear-completion-and-repair, revision surgery, or open repair of the LHB tendon were excluded. Patients were stratified into tenotomy, arthroscopic suprapectoral tenodesis, or no biceps operation cohorts and were propensity matched 1:1:1 on age, sex, body mass index, and smoking status. Primary outcome measures included AROM in forward flexion, abduction, external rotation, and internal rotation at 6 weeks, 3 months, and 6 months postoperatively. The development of severe stiffness and rates of rotator cuff retear at final follow-up were recorded as secondary outcomes. Results: When comparing the tenotomy and tenodesis cohorts, tenotomy patients were found to have increased AROM at 3 months in forward flexion (153.2° vs. 130.1°, P = .004), abduction (138.6° vs. 114.2°, P = .019), and external rotation (60.4° vs. 43.8°, P = .014), with differences in forward flexion remaining significant at 6 months (162.4° vs. 149.4°, P = .009). There were no significant differences in interval rates of recovery in any plane between cohorts. Additionally, there were no significant differences in rates of symptomatic retears between groups (P = .458). Rates of severe postoperative stiffness approached but did not achieve statistical significance between tenotomy (4.2%) and tenodesis (29.2%) cohorts (P = .066). Smoking status was a significant predictor of severe stiffness (odds ratio, 13.69; P = .010). Conclusion: Despite significant differences in absolute AROM between cohorts, the decision to perform tenotomy or tenodesis was not found to differentially affect rates of AROM recovery for patients undergoing arthroscopic transtendinous RCR for PTRCT. Notably, however, transient stiffness complications were more commonly observed in smokers, and data trends suggested an increased risk of stiffness for patients undergoing LHB tenodesis. Overall, postoperative stiffness is likely multifactorial and attributable to both patient- and procedure-specific factors, and LHB tenotomy may be more appropriate for patients with risk factors for developing stiffness postoperatively.

Improvement in Sleep Disturbance Following Arthroscopic Rotator Cuff Repair.

BACKGROUND: Approximately 90% of patients express concerns with sleep shortly after developing shoulder-related symptoms. Previous small cohort studies have demonstrated the impact of rotator cuff repair on sleep, but none have characterized the observed benefits. The purpose of this study is to evaluate sleep improvement after rotator cuff repair including the speed of sleep recovery, the time at which improvement plateaus, and the longer-term maintenance of improved sleep. METHODS: A retrospective review of our institution's shoulder and elbow repository identified patients who underwent primary arthroscopic rotator cuff repair from 2012 - 2021 and reported sleep disturbance preoperatively. Patients were evaluated using sleep-related questions from the Simple Shoulder Test and American Shoulder and Elbow Surgeons score. Sleep outcomes were compared from a preoperative visit to 3-month, 6-month, 12-month, and most recent follow-ups to evaluate efficacy of treatment, speed of recovery and improvement plateaus. RESULTS: Among 677 RCR patients, 95.7% (648/677) reported sleep disturbance preoperatively. A total of 474 met inclusion criteria with median follow-up of 4.1 years (IQR, 2.1-6.1). At most recent follow-up, 81.8% were able to sleep comfortably and 65.7% were able to sleep on the affected side. A plateau in the ability to sleep comfortably was seen at 6 months while no plateau was observed in the ability to sleep on the affected side. More rapid improvement in the ability to sleep comfortably occurred during the first 3 months and from 3 - 6 months for the ability to sleep on the affected side. CONCLUSION: The majority of patients with sleep disturbance who undergo RCR, report significant, rapid, and lasting improvement in the ability to sleep comfortably and the ability to sleep on the affected side.

Improved restoration of biomechanical factors using a narrow-box shape reconstruction compared to a wide one in superior capsular reconstruction for irreparable supraspinatus tendon tears. A biomechanical study using a static shoulder simulator.

PURPOSE: To biomechanically compare superior glenohumeral translation, subacromial contact pressures and area in a box-shape reconstruction using the long head of biceps tendon (LHBT) in an irreparable supraspinatus tendon tear model. METHODS: Seven cadaveric shoulders (mean age 61 years; range 32-84 years; SD 22.3) were tested with a custom testing rig used to evaluate superior translation, subacromial contact pressures and areas at 0°, 30° and 60° of glenohumeral abduction. Conditions tested included the native state, a complete tear of the supraspinatus tendon, a wide box-shaped, double-bundle LHBT superior capsular reconstruction (wide BS-SCR), and a narrow box-shaped, double-bundle LHBT superior capsular reconstruction (narrow BS-SCR). RESULTS: Compared to the wide box-shape SCR, the narrow box-shape SCR had statistically significant lower median contact pressure at 30° and 60°. The subacromial contact area showed a statistically significant difference at 0° (p=0.001) and 30° (p=0.004) for the narrow compared to wide box-shape SCR. At an abduction angle of 0°, the narrow SCR could restore superior translation statistically significant better compared to the wide construct. For all angles, the wide and narrow box-shaped SCR increased the median subacromial distance statistically significantly. The contact areas in 30° and 60° of abduction were higher for all scenarios, both peaking in the intact state in 30° with approximately 600 mm2. CONCLUSIONS: In comparison to a wide box-shape, a narrow box-shape SCR using the LHBT has biomechanical advantages in regard of subacromial contact pressures, the subacromial contact areas as well as the acromiohumeral distance. The width of the reconstruction therefore has direct influence in the success of the technique.

What Is the Trajectory of Recovery in the Early Postoperative Period after the Big 3 Shoulder Surgeries? Comparative Analysis Using 3 Previous Prospective Studies.

(1) Background: The aims of this study were to compare serial changes in outcome measures in the early postoperative period after rotator cuff repair (RCR), anatomical total shoulder replacement (ATSR), and reverse total shoulder replacement (RTSR). (2) Methods: In total, 143 patients who underwent RCR (n = 47), ATSR (n = 46), and RTSR (n = 50) were included. The visual analogue scale (VAS) for pain, the activity of daily living (ADL) score, and the American Shoulder and Elbow Surgeons (ASES) score were completed. (3) Results: At 3 months, the recovery rate for the VAS pain score was 43.7% in the RCR, 89.1% in the ATSR, and 78.4% in RTSR. The recovery rate for the ADL score was 36.3%, 69.5%, and 76.4%. The recovery rate for ASES score was 40.9%, 79.5%, and 77.4%. For all outcome measures, a lower recovery rate was observed in the RCR group than in the ATSR and RTSR groups. At 6 months after surgery, the recovery rate for the VAS pain score was 69.9%, 100%, and 90.3%. The recovery rate for the ADL score was 66.8%, 92.8%, and 91.5%. The recovery rate for the ASES score was 68.7%, 96.5%, and 90.9%. (4) Conclusion: Compared with ATSR and RTSR, a slower recovery rate was observed for RCR, measured to be approximately 40% at 3 months and 70% at 6 months after surgery. Rapid improvement in pain and shoulder function was achieved after ATSR and RTSR, with a recovery rate of over 70% at 3 months and over 90% at 6 months after surgery.

Accuracy of Clinical Suspicion for Rotator Cuff Tears by Orthopedic Surgeons When MRI Was Ordered on Initial Visits: Should Physical Therapy Be Mandated by Insurance Before MRI?

INTRODUCTION: Insurance companies often mandate six weeks of physical therapy (PT) prior to approving MRIs for patients with atraumatic rotator cuff (RTC) tears. While this is designed to limit unnecessary imaging orders, it can increase healthcare costs and delay diagnosis and surgery. This study investigated the incidence of full- and partial-thickness tears when an MRI was ordered at the time of initial consultation for shoulder pain by an orthopedic provider. METHODS: A retrospective review of patients who had an MRI ordered upon initial orthopedic consultation for chronic shoulder pain was conducted. The primary outcome measured was the presence of RTC tears as determined by the MRI report. The cost of six weeks of PT versus the cost of immediate MRI in these patients was collected from our institution's financial database. ANOVA, independent T-test, and chi-square test were used to analyze the differences between groups. RESULTS: A total of 365 patients were included. There were no significant differences in demographics between patients with full, partial, or no tears, with the exception that patients with full-thickness tears were older. Specifically, 43.0% had a full-thickness tear, 24.7% had a partial-thickness tear, and 32.2% had no tear on MRI. A total of 56.1% of the full-thickness tears proceeded to surgery. The cost of an upper extremity MRI without contrast averages $2,268, while two sessions of PT per week for six weeks totals $2,328. DISCUSSION: Over 67% of MRI orders yielded a positive finding of an RTC tear and remained at 67.2% in the absence of a history of conservative treatment, validating a specialist's clinical suspicion for an RTC tear and indication for MRI. Pre-MRI PT to satisfy insurance requirements may therefore delay intervention and increase healthcare costs when an orthopedic provider believes an MRI is warranted for clinical decision-making.

Bioinductive Patch as an Augmentation for Rotator Cuff Repair, a Systematic Review and Meta-Analysis.

INTRODUCTION: Rotator cuff tears (RCTs) are a prevalent cause of shoulder pain and dysfunction. For those who fail initial conservative treatment, operative intervention can be pursued. A significant and common complication after rotator cuff repair (RCR) is retearing or non-healing. Numerous augmentations to traditional suture RCR have been studied. Of these, the Smith+Nephew Regeneten bioinductive collagen patch has had promising initial results; however, analytic data for its use is lacking, and there is no meta-analysis comparing the available data to historical RCR outcomes. METHODS: A PRISMA-guided literature search was conducted using Ovid MEDLINE, PubMED, Cochrane, and ClinicalTrials.gov. 13 studies met inclusion and exclusion criteria. Only clinical trials on full and partial-thickness tears were included. American Shoulder and Elbow Surgeon score (ASES), Constant-Murley score (CMS), the visual analog scale for pain (VAS), the minimal clinically important difference (MCID), tendon thickness, and complication rates were primary outcomes of interest. A meta-analysis was performed to determine the overall complication and retear rate from the included studies. RESULTS: ASES, CMS, and VAS improved significantly in all studies that reported them, and most patients achieved MCID. Patient-reported outcome measure (PROM) improvements were similar to historical improvements in standard RCR, and a similar proportion of patients achieved MCID after standard repair. Tendon thickness improved significantly and to a similar degree as standard RCR. Overall retear rate after full thickness RCR augmented with the bioinductive patch was 8.3%. For partial thickness RCR, total retear rate of 1.1% across all patients. The overall complication rate with the bioinductive patch was 15.5% across all full-thickness RCR studies and 16.2% in partial thickness RCR. We found overall retear rate to be lower after augmentation with the bioinductive patch compared to traditional repair; however, the overall complication rate was similar for full-thickness tears and higher for partial-thickness tears. Lastly, adverse reactions to the bioinductive patch were noted at 0.2%. CONCLUSIONS: The bioinductive collagen patch appears to be a safe augmentation for rotator cuff repair. Patients are likely to experience significant subjective improvement in PROMs and significant increases in tendon thickness. Retear rate has been a concern after RCR for decades, and the bioinductive patch may help mitigate this risk. There is a lack of case-control studies comparing the bioinductive patch to traditional suture RCR. Such data is needed to better determine the role of the bioinductive patch in the treatment of full and partial-thickness rotator cuff repairs.