Reverse shoulder arthroplasty for irreparable massive rotator cuff tears: a systematic review with meta-analysis and meta-regression.

BACKGROUND: Massive rotator cuff tears (MRCTs) are very large tears that are often associated with an uncertain prognosis. Indeed, some MRCTs even without osteoarthritis are considered irreparable, and nonanatomic solutions are needed to improve the patient's symptoms. Reverse shoulder arthroplasty (RSA) is an option that can provide a more predictable pain relief and recovery of function. Nonetheless, outcomes after RSA for irreparable MRCTs have not been well defined. The aim of this study was to quantitatively aggregate the findings associated with the use of RSA in this subset of patients and analyze the effect on patient functional status and pain. METHODS: A comprehensive search was performed until October 2015 using MEDLINE, Scopus, Cochrane Database of Systematic Reviews, and Central Register of Controlled Trials databases. Studies that assessed the outcomes of RSA in patients with irreparable MRCT without osteoarthritis (with at least 2 years of follow-up) were included. If the results of MRCT without osteoarthritis were not possible to subgroup, the study was excluded. Methodologic quality was assessed using the Coleman Methodology Score. RESULTS: Included were 6 studies (266 shoulders) with a follow-up ranging from 24 to 61.4 months. The mean Coleman Methodology Score was 58.2 ± 11.8 points. There was an overall improvement from preoperative to postoperative assessments of the clinical score (Cohen d = 1.35, P < .001), forward flexion (d = 0.50, P = .009), external rotation (d = 0.40, P < .001), function (d = 1.04, P < .001), and pain (d = -0.89, P < .001). CONCLUSION: Patients with irreparable MRCT without presence of osteoarthritis have a high likelihood of achieving a painless shoulder and functional improvements after RSA.

Mosaicplasty Using Grafts From the Upper Tibiofibular Joint.

Autologous mosaicplasty has been widely used for the treatment of focal, full-thickness, articular cartilage lesions of the knee and ankle joints. Commonly, the autografts are harvested from non-weight-bearing areas of the knee joint, leading to associated donor-site morbidity and representing a considerable disadvantage. This Technical Note presents a mosaicplasty procedure for harvesting autologous osteochondral plugs from the upper tibiofibular joint to repair articular cartilage defects. With this technique, it is possible to achieve low or no risk of donor-site morbidity, being therefore a safe and favorable option to treat large cartilage defects. Because of its minimal size-related restrictions, it enables harvesting larger plugs (filling an area up to 5 cm2) without any additional iatrogenic complications. Hence, mosaicplasty using the upper tibiofibular joint autografts can overcome many of the reported complications associated with osteochondral autograft harvesting. Thus, the upper tibiofibular joint articular surface should be considered as a safe and reliable autograft source for harvesting osteochondral plugs.

Mesenchymal Stem Cell Secretome: A Potential Tool for the Prevention of Muscle Degenerative Changes Associated With Chronic Rotator Cuff Tears.

BACKGROUND: Massive rotator cuff tears (MRCTs) are usually chronic lesions with pronounced degenerative changes, where advanced fatty degeneration and atrophy can make the tear irreparable. Human mesenchymal stem cells (hMSCs) secrete a range of growth factors and vesicular systems, known as secretome, that mediates regenerative processes in tissues undergoing degeneration. PURPOSE: To study the effect of hMSC secretome on muscular degenerative changes and shoulder function on a rat MRCT model. STUDY DESIGN: Controlled laboratory study. METHODS: A bilateral 2-tendon (supraspinatus and infraspinatus) section was performed to create an MRCT in a rat model. Forty-four Wistar-Han rats were randomly assigned to 6 groups: control group (sham surgery), lesion control group (MRCT), and 4 treated-lesion groups according to the site and periodicity of hMSC secretome injection: single local injection, multiple local injections, single systemic injection, and multiple systemic injections. Forelimb function was analyzed with the staircase test. Atrophy and fatty degeneration of the muscle were evaluated at 8 and 16 weeks after injury. A proteomic analysis was conducted to identify the molecules present in the hMSC secretome that can be associated with muscular degeneration prevention. RESULTS: When untreated for 8 weeks, the MRCT rats exhibited a significantly higher fat content (0.73% ± 0.19%) compared with rats treated with a single local injection (0.21% ± 0.04%; P < .01) or multiple systemic injections (0.25% ± 0.10%; P < .05) of hMSC secretome. At 16 weeks after injury, a protective effect of the secretome in the multiple systemic injections (0.62% ± 0.14%; P < .001), single local injection (0.76% ± 0.17%; P < .001), and multiple local injections (1.35% ± 0.21%; P < .05) was observed when compared with the untreated MRCT group (2.51% ± 0.42%). Regarding muscle atrophy, 8 weeks after injury, only the single local injection group (0.0993% ± 0.0036%) presented a significantly higher muscle mass than that of the untreated MRCT group (0.0794% ± 0.0047%; P < .05). Finally, the proteomic analysis revealed the presence of important proteins with muscle regeneration, namely, pigment epithelium-derived factor and follistatin. CONCLUSION: The study data suggest that hMSC secretome effectively decreases the fatty degeneration and atrophy of the rotator cuff muscles. CLINICAL RELEVANCE: We describe a new approach for decreasing the characteristic muscle degeneration associated with chronic rotator cuff tears. This strategy is particularly important for patients whose tendon healing after later surgical repair could be compromised by the progressing degenerative changes. In addition, both precise intramuscular local injection and multiple systemic secretome injections have been shown to be promising delivery forms for preventing muscle degeneration.