Advantages of Arthroscopic Rotator Cuff Repair With a Transosseous Suture Technique: A Prospective Randomized Controlled Trial.

BACKGROUND: Rotator cuff tear is a common finding in patients with painful, poorly functioning shoulders. The surgical management of this disorder has improved greatly and can now be fully arthroscopic. PURPOSE: To evaluate clinical and radiological results of arthroscopic rotator cuff repair using 2 different techniques: single-row anchor fixation versus transosseous hardware-free suture repair. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Sixty-nine patients with rotator cuff tears were enrolled: 35 patients were operated with metal anchors and 34 with standardized transosseous repair. The patients were clinically evaluated before surgery, during the 28 days after surgery, and at least 1 year after the operation by the use of validated rating scores (Constant score, QuickDASH, and numerical rating scale [NRS]). Final follow-up was obtained at more than 3 years by a QuickDASH evaluation to detect any difference from the previous follow-up. During the follow-up, rotator cuff integrity was determined through magnetic resonance imaging and was classified according to the 5 Sugaya categories. RESULTS: Patients operated with the transosseous technique had significantly less pain, especially from the 15th postoperative day: In the third week, the mean NRS value for the anchor group was 3.00 while that for transosseous group was 2.46 ( P = .02); in the fourth week, the values were 2.44 and 1.76, respectively ( P < .01). No differences in functional outcome were noted between the 2 groups at the final evaluation. In the evaluation of rotator cuff repair integrity, based on Sugaya magnetic resonance imaging classification, no significant difference was found between the 2 techniques in terms of retear rate ( P = .81). CONCLUSION: No significant differences were found between the 2 arthroscopic repair techniques in terms of functional and radiological results. However, postoperative pain decreased more quickly after the transosseous procedure, which therefore emerges as a possible improvement in the surgical repair of the rotator cuff. Registration: NCT01815177 ( ClinicalTrials.gov identifier).

Revision reverse shoulder arthroplasty in failed shoulder arthroplasties for rotator cuff deficiency.

PURPOSE: the aim of this systematic literature review is to report clinical outcomes of reverse shoulder arthroplasty (RSA) used as a revision surgery following failure of the primary implant due to rotator cuff insufficiency. METHODS: a systematic review was performed using the following key words: revision, shoulder, rotator cuff deficiency, outcome assessment, treatment outcome, complications. Studies eligible for inclusion in the review were clinical trials investigating patients in whom a primary shoulder arthroplasty implant with an incompetent rotator cuff was replaced with a reverse shoulder prosthesis. RESULTS: nine articles were identified and further reviewed. The results refer to a total of 226 shoulders that were treated with RSA as revision surgery. The patients in the studies had a mean age ranging from 64 to 72 years and the longest follow-up was 3.8 years. Improvements in function and reduction of pain were shown by many studies, but the mean Constant score ranged from 44.2 to 56. High complication rates (of up to 62%) were recorded, and a mean reoperation rate of 27.5%. CONCLUSIONS: RSA as revision surgery for patients with rotator cuff deficiency is a valid option, and often the only solution available, but it should be limited to elderly patients with poor function and severe pain. LEVEL OF EVIDENCE: level IV, systematic review of level I-IV studies.

History of rotator cuff surgery.

PURPOSE: Rotator cuff surgery is a rapidly evolving branch in orthopaedics, which has raised from a minor niche to a fully recognized subspecialty. This article summarizes its history, examining the development of its key principles and the technical advancements. METHODS: Literature was thoroughly searched, and few senior surgeons were interviewed in order to identify the significant steps in the evolution of rotator cuff surgery. RESULTS: A wide variety of surgical options is available to reduce pain and restore function after rotator cuff tears. Rotator cuff repair surgical techniques evolved from open to arthroscopic and are still in development, with new fixation techniques and biological solutions to enhance tendon healing being proposed, tested in laboratory and in clinical trials. Although good or excellent results are often obtained, there is little evidence that the results of rotator cuff repair are improving with the decades. An overall high re-tear rate remains, but patients with failed rotator cuff repairs can experience outcomes comparable with those after successful repairs. CONCLUSIONS: Rotator cuff repair techniques evolve at a fast pace, with new solutions often being used without solid clinical evidence of superiority. It is necessary to conduct high-level clinical studies, in which data relating to anatomical integrity, patient self-assessed comfort and function, together with precise description of patient's condition and surgical technique, are collected. LEVEL OF EVIDENCE: IV.

Long-term outcome after arthroscopic rotator cuff treatment.

PURPOSE: Arthroscopic techniques have become the gold standard in the operative management of several pathologic conditions of the shoulder. The purpose of this systematic review was to present the long-term outcomes following arthroscopic treatment of rotator cuff pathology. METHODS: A comprehensive literature review was performed to identify studies reporting clinical or structural results of arthroscopic rotator cuff repairs (ARCRs) at least 5 years after surgery. RESULTS: Ten articles were selected, which described 483 procedures. Study type, surgical approaches, complications, evidences of structural integrity of the repaired lesions, preoperative and postoperative functional scores are identified, analyzed and discussed. Satisfactory results are presented by all authors, and significant postoperative improvement is reported by all the studies with available preoperative data; 16 of 483 cases were re-operated. CONCLUSION: Although high-level evidences are lacking, ARCR appears to be an effective and safe option to treat the symptoms of rotator cuff tears and to provide successful clinical results durable with time. Current evidences are insufficient to clearly define the relationship between structural integrity of repaired cuffs and long-term clinical outcome. The available data do not allow to draw conclusions regarding the long-term superiority of double-row versus single-row repairs. LEVEL OF EVIDENCE: Review of level II, III and IV studies, Level IV.

Regenerative medicine in rotator cuff injuries.

Rotator cuff injuries are a common source of shoulder pathology and result in an important decrease in quality of patient life. Given the frequency of these injuries, as well as the relatively poor result of surgical intervention, it is not surprising that new and innovative strategies like tissue engineering have become more appealing. Tissue-engineering strategies involve the use of cells and/or bioactive factors to promote tendon regeneration via natural processes. The ability of numerous growth factors to affect tendon healing has been extensively analyzed in vitro and in animal models, showing promising results. Platelet-rich plasma (PRP) is a whole blood fraction which contains several growth factors. Controlled clinical studies using different autologous PRP formulations have provided controversial results. However, favourable structural healing rates have been observed for surgical repair of small and medium rotator cuff tears. Cell-based approaches have also been suggested to enhance tendon healing. Bone marrow is a well known source of mesenchymal stem cells (MSCs). Recently, ex vivo human studies have isolated and cultured distinct populations of MSCs from rotator cuff tendons, long head of the biceps tendon, subacromial bursa, and glenohumeral synovia. Stem cells therapies represent a novel frontier in the management of rotator cuff disease that required further basic and clinical research.

70° frontal visualization of lateral compartment of the elbow allows extensor carpi radialis brevis tendon release with preservation of the radial lateral collateral ligament.

PURPOSE: To determine whether the radial component of the lateral collateral ligament (R-LCL) and extensor carpi radialis brevis (ECRB) are consistently visible, using a 70° arthroscope, as parallel structures in the extra-articular space of the elbow, and to evaluate the clinical outcomes of these techniques in a series of patients. METHODS: An arthroscopic ECRB tendon release was performed between 2008 and 2010. Eighteen patients were retrospectively evaluated at a minimum of 24 months' follow-up. The surgeon performed the ECRB release while protecting the R-LCL and viewing the structures extra-articularly with a 70° arthroscope through the anteromedial portal. Patients underwent surgery if they presented with localized tenderness and pain not responding to conservative treatment for 12 months and had magnetic resonance imaging scans indicating tendinopathy or degeneration. Arthritis, posterolateral rotatory instability, trauma, and previous surgeries were exclusion criteria. Intraoperative videos were reviewed and a clinical examination was performed by an independent reviewer at 24 months postoperatively. Patients were also evaluated with the Mayo Elbow Performance Score; Andrews-Carson score; and shortened Disabilities of the Arm, Shoulder and Hand questionnaire. Direct varus stress was applied in extension and flexion (40°), and the posterolateral pivot-shift and chair tests were performed. RESULTS: Visualization with the 70° arthroscope through the anteromedial portal was successful in all of the cases (100%). Visualization of the residual ECRB tendon stump, as well as the posterior common extensor tendon, was also achieved 94% of the time. The final mean Mayo Elbow Performance Score and Andrews-Carson score were 82.5 (range, 60 to 100) and 185.3 (range, 125 to 200), respectively. The mean postoperative score on the shortened Disabilities of the Arm, Shoulder and Hand questionnaire was 20.14 (range, 5 to 57.5). Clinical tests showed stability in all the cases. CONCLUSIONS: The 70° arthroscope allows visualization of the ECRB insertion and R-LCL frontally and in parallel. A surgical plane could be created between the structures. The clinical outcome was good or excellent in 78% of the cases. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Long-term degradation of poly-lactic co-glycolide/ß-tricalcium phosphate biocomposite anchors in arthroscopic bankart repair: a prospective study.

PURPOSE: To evaluate, using magnetic resonance (MR), the biological efficacy of anchors made of 30% ß-tricalcium phosphate and 70% poly-lactic co-glycolide (PLGA) used for the repair of Bankart lesions after shoulder instability. METHODS: Twenty consecutive patients who were candidates for surgical treatment for unidirectional, post-traumatic shoulder instability were treated arthroscopically with anchors made of 70% PLGA plus 30% ß-tricalcium phosphate preloaded with OrthoCord suture (DePuy Mitek, Raynham, MA). Fifteen of them were evaluated by MR at least 16 months after the intervention. A second evaluation was performed at least 12 months after the first evaluation in the patients in whom implanted anchors were still visible at the first evaluation (n = 5) with a low-intensity signal in all sequences. Two radiologists, with different amounts of experience (15 and 3 years), separately evaluated the MR patterns of the trabecular glenoid bone, the walls of the bone tunnel, and the signal from the anchors. The following parameters were considered in the MR evaluation: integrity of the tunnel edge (grade 0 to 2), intensity of the signal from the anchor site (grade 1 to 3), and presence of cystic lesions. The normal signal from the glenoid trabecular bone has been used as the reference parameter. The anchors were considered independent variables, and thus each one was analyzed individually, even in the same patient. At the final clinical follow-up, a Rowe questionnaire was filled out for each patient. RESULTS: Overall, 44 anchors were evaluated (33 anchors at the first follow-up and 11 anchors at the second follow-up). The mean follow-up period was 28.6 months. With the exception of 2 patients (10%), none of the patients had any episodes of dislocation, having satisfactory postoperative results. No cystic lesions were detected by MR imaging. The interobserver concordance between the 2 radiologists calculated with the Cohen κ was substantial (κ = 0.780 and κ = 0.791 for integrity of tunnel edge and for intensity of signal from anchor site, respectively). Both the integrity of the tunnel border and the intensity of the signal at the site of the anchors that had been implanted more than 24 months before the evaluation were significantly different from those of anchors implanted less than 24 months before the evaluation (tunnel border grade of 0 in 41%, 1 in 50%, and 2 in 9% v 0 in 4.5%, 1 in 50%, and 2 in 45.5% [P = .003]; anchor signal grade of 1 in 41%, 2 in 45.5%, and 3 in 13.5% v 1 in 13.5%, 2 in 41%, and 3 in 45.5% [P = .03]). Analysis of the linear contrasts (analysis of variance) showed a linear increase in the mean values for time to increased tunnel border grade (grade 0, 22 ± 4 months; grade 1, 27 ± 8 months; and grade 2, 29 ± 5 months [P = .02]) and grade of intensity of the signal in the anchor site (grade 1, 24 ± 6 months; grade 2, 26 ± 7 months; and grade 3, 29 ± 7 months [P = .05]). CONCLUSIONS: Anchors made of 30% ß-tricalcium phosphate and 70% PLGA showed excellent biological efficacy, without causing significant cystic lesions, producing gradual changes in the MR signal that seems to become equivalent to that of the glenoid trabecular bone at a mean of 29 months after implantation. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Platelet rich plasma in arthroscopic rotator cuff repair: a prospective RCT study, 2-year follow-up.

HYPOTHESIS: Local application of autologous platelet rich plasma (PRP) improves tendon healing in patients undergoing arthroscopic rotator cuff repair. STUDY DESIGN: Prospective, randomized, controlled, double blind study; considering an alpha level of 5%, a power of 80%, 22 patients for group are needed. MATERIALS AND METHODS: Fifty-three patients who underwent shoulder arthroscopy for the repair of a complete rotator cuff tear were randomly divided into 2 groups, using a block randomization procedure. A treatment group (N = 26) consisted of those who received an intraoperative application of PRP in combination with an autologous thrombin component. A control group (N = 27) consisted of those who did not receive that treatment. Patients were evaluated with validated outcome scores. A magnetic resonance image (MRI) was performed in all cases at more than 1 year post-op. All patients had the same accelerated rehabilitation protocol. RESULTS: The 2 groups were homogeneous. The pain score in the treatment group was lower than the control group at 3, 7, 14, and 30 days after surgery (P < .05). On the Simple Shoulder Test (SST), University of California (UCLA), and Constant scores, strength in external rotation, as measured by a dynamometer, were significantly higher in the treatment group than the control group at 3 months after surgery (strength in external rotation [SER]: 3 ± 1.6 vs 2.1 ± 1.3 kg; SST: 8.9 ± 2.2 vs 7.1 ± 2.7; UCLA: 26.9 ± 3 vs 24.2 ± 4.9; Constant: 65 ± 9 vs 57.8 ± 11; P < .05). There was no difference between the 2 groups after 6, 12, and 24 months. The follow-up MRI showed no significant difference in the healing rate of the rotator cuff tear. In the subgroup of grade 1 and 2 tears, with less retraction, SER in the PRP group was significant higher at 3, 6, 12, and 24 months postoperative (P < .05). CONCLUSION: The results of our study showed autologous PRP reduced pain in the first postoperative months. The long-term results of subgroups of grade 1 and 2 tears suggest that PRP positively affected cuff rotator healing.

Plasma and drainage fluid levels of soluble receptor activator of nuclear factor-kB (sRANK), soluble receptor activator of nuclear factor-kB ligand (sRANKL) and osteoprotegerin (OPG) during proximal humerus fracture healing.

Fracture healing is an ordered process that restores the structural integrity of the bone. Soluble receptor activator of nuclear factor-kB (sRANK), its ligand (sRANKL) and osteoprotegerin (OPG) are involved in bone remodelling, thus they may play a role in fracture repair. OPG, soluble RANK and RANKL levels were measured in plasma and in drainage fluid, collected from pre-surgery phase to healing in ten patients of both genders (age range 26-65 years) with proximal humerus fracture needing osteosynthesis. All patients showed fracture healing. No significant modifications in the concentrations of sRANKL and OPG were observed, while sRANK showed a significant increase in drainage fluid 24 hours post-surgery compared with intra-surgery time. OPG levels were higher in plasma and drainage fluid than sRANK and sRANKL at each time point. Since there are no published data about sRANK involvement in fracture healing, our study represents the first preliminary indication about a local increase of this marker concentration immediately after surgery.

The CARE technique: arthroscopic CoracoAcromial ligament RE-attachment.

During standard acromioplasty, the inferior fibers of the coracoacromial ligament are inevitably detached. Partial or complete sectioning of the coracoacromial ligament results in secondary weakening of the deltoid muscle and an incremental risk of anterior-superior glenohumeral migration. This technique allows the re-attachment of the inferior fibers to the intact portion of the ligament and re-establishes mechanical continuity of the coracohumeral arc.

Prophylactic use of antibiotic-loaded bone cement in primary total knee replacement.

Despite significant advances in intraoperative antimicrobial procedures, deep infection remains the most devastating complication following total joint arthroplasty. Clinical studies' results and safety profile of antibiotic-loaded bone cement are discussed in this review. Antibiotic bone cement prophylaxis is a safe and effective strategy in reducing the risk of deep infection following primary total joint arthroplasty.

Infectious and thromboembolic complications of arthroscopic shoulder surgery.

HYPOTHESIS: This study investigates the rate of infectious and thromboembolic complications in shoulder arthroscopy and their association with pharmacologic prophylaxis. MATERIALS AND METHODS: On behalf of the Italian Society for Knee Surgery, Arthroscopy, Sport Traumatology, Cartilage and Orthopaedic Technologies (SIGASCOT), we asked the members to complete an on-line Web survey about their experiences and strategies of prophylaxis in shoulder arthroscopy. RESULTS: In the period 2005-2006, 9385 surgeries were performed. We report 15 infections and 6 DVTs. The overall rate of infections was 0.0016 (1.6/1000) and the rate of DVTs was 0.0006 (0.6/1000) CONCLUSION: The association between infection and antibiotic prophylaxis was significant (P=0.01); however, the risk of DVTs was not decreased with heparin prophylaxis. LEVEL OF EVIDENCE: Level 3.

Quantification of active ROM after arthroscopic Bankart repair with rotator interval closure.

Several series report patients homogeneously treated using arthroscopic Bankart repair exclusively, or in some cases arthroscopic Bankart repair with rotator interval closure. Current international literature has few reports on arthroscopic Bankart repair with rotator interval closure procedures undertaken on a homogeneous series of patients. The purpose of this study was to evaluate the residual active range of motion (ROM) and clinical outcome in this patient population. Fourteen patients affected by recurrent anterior instability were consecutively treated. Rowe, Walch-Duplay, and UCLA scores, as well as differences in active ROM of both shoulders (treated and contralateral), were recorded. A significant reduction in active external rotation was noted along the side of the arm (P<.001) and at 90 degrees of abduction (P=.007). The average reduction was 12.14 degrees and 7.21 degrees, respectively, which represents 17.8% and 8% of the arc of motion of the opposite side in external rotation. No significant differences were found for flexion, abduction, and internal rotation. According to Walch-Duplay and Rowe scores, 71.4% and 85.7% of patients had excellent or good results. Arthroscopic Bankart repair with rotator interval closure results in a reduction of external rotation and provides satisfactory stability results.

Unicameral bone cyst of the humeral head: arthroscopic curettage and bone grafting.

Arthroscopic surgery has improved greatly over the past decade. Treatment of various juxta-articular disorders around the shoulder have benefited from endoscopic approaches. Cystic lesions of the shoulder on the scapular side have been treated in this way. This article describes a case of a 29-year-old patient with a unicameral bone cyst on the posterior aspect of the humeral head. Arthroscopic visualization using an accessory posteroinferior portal localized the cyst through the bare area of the humeral head. A cannulated burr was used to create an opening through the cortical wall between the cyst and the joint, and a careful curettage was performed. The cavity was filled with a demineralized bone matrix enriched with autologous blood packed into an arthroscopic cannula and delivered through the accessory portal. The patient reported pain relief immediately postoperatively and at follow-up. This case demonstrates the feasibility of arthroscopic treatment of a simple bone cyst of the humeral head. We believe that the knowledge of the juxta-articular anatomy allows the applications of scope-assisted procedures to be expanded, maximizing the results of a technique that allows a shorter recovery and less painful rehabilitation.

Release of growth factors after arthroscopic acromioplasty.

It has recently been postulated that a variety of growth factors may be released from cancellous bone after an acromioplasty. The aim of this study was to demonstrate the presence of growth factors in the subacromial space after acromioplasty. Between October 2006 and March 2007, 23 patients underwent arthroscopic acromioplasty. A sample of at least 3 ml of fluid from the shoulder was obtained 15 min after the end of the procedure. At the same time another sample of 3 ml of the patient's venous blood was obtained as a control. The concentrations of growth factors in the fluids collected were determined using enzyme-linked immunosorbent assay (ELISA). The growth factors assayed were platelet-derived growth factor-AB (PDGF-AB), basic fibroblast growth factor basic (bFGF) and transforming growth factor beta 1 (TGF-beta1). The concentrations of TGF-beta1 (p = 0.0001), PDGF-AB (p = 0.02), and bFGF (p < 0.0001) were significantly higher in the fluid from the subacromial space than in the blood sample. There are high concentrations of several growth factors in the subacromial space after acromioplasty.

Randomization procedures in orthopaedic trials.

Historically, the surgical literature has lacked in reports of randomized clinical trials. This deficit is now being addressed, but the best methods are not always followed. One opportunity for improvement is in the area of randomization. Randomization is of central importance in clinical trials because it reduces bias and represents a basis for ensuring the validity of data analysis using statistical testing. Randomization requires a table of random numbers. Simple randomization is adequate for large trials. Block randomization is a method of balancing equal numbers of patients in each treatment group. Stratification allows balanced distribution of one or more confounding prognostic variables among treatment groups to ensure that groups have similar prognoses (minimizing selection bias). Block randomization and stratification improve validity in trials with fewer patients. Commercially available computer software facilitates randomization.

Autologous platelet rich plasma for arthroscopic rotator cuff repair. A pilot study.

BACKGROUND AND PURPOSE: Arthroscopic repair of rotator cuff tears can produce excellent results. The application of platelet rich plasma during arthroscopic rotator cuff repair is safe, and produces results which do not deteriorate over time. METHODS: A total of 14 patients undergoing arthroscopic repair of a rotator cuff tear received an intra-operative application of autologous platelet rich plasma in combination with an autologous thrombin component after tear repair. Following the procedure, patients were given a standardized rehabilitation protocol, and followed for 24 months. Outcome measures included a pain score (VAS) as well as functional scoring (UCLA and Constant scores). RESULTS: Of the original 14 patients, 13 were seen at a final follow-up appointment 24 months after the index operation. Patients demonstrated a significant decrease in VAS scores and significant increases in the UCLA and Constant scores at 6, 12 and 24-month follow-ups compared to a pre-operative score. CONCLUSION: No adverse events related to this application were noted during the procedure. The application of platelet rich plasma during arthroscopic rotator cuff repair is safe and effective, and produces results which seem to be stable with time. A prospective randomized investigation will be necessary to ascertain the efficacy of platelet rich plasma application to improve or expedite the surgical outcome following arthroscopic rotator cuff repair.

Spinal cord sonography in newborns: anatomy and diseases.

Sonography of the spinal cord is a relatively recent acquisition that makes it possible to evaluate the content of the vertebral canal and study its pathologies. The aim of this study was to verify the reliability of ultrasound images by comparing them with magnetic resonance ones in healthy controls as well as in patients referred to us between 1991 and 2004. In this period, we studied 436 newborns: 88 without any suspicion of disease as normal controls, and 348 with suspected congenital diseases or in order to screen the children of diabetic mothers, a group that has shown an increased incidence of dysraphism. After explaining normal sonograms, we describe the pathological pictures observed in the 12 pathological cases in our series: conus hypomobility in five cases; lack of visualization of the conus medullaris in one case; and an enlarged ependymal canal in six cases. Four cases presented all three pathological conditions, and seven the association of two pathologies. All of these patients also underwent magnetic resonance imaging (MRI), which confirmed the ultrasound findings in four cases: three cases of enlarged ependymal canal and one of tethered cord hypomobility of the roots with an associated lipoma; the MRI findings were normal in the other seven cases. Sonography was highly specific but not very sensitive, because it is partially conditioned by patient collaboration. Nevertheless, subsequent MRI confirmed 37% of the suspected pathological cases. The ultrasound resolution of both normal and pathological spinal cord structures was particularly clear. The images were similar, easily comparable and often identical to the MRI results, although MRI was certainly more sensitive. The advantages of sonography are its non-invasiveness, low cost, the virtually ubiquitous availability of ultrasound equipment, the simplicity and rapidity of the examination, and its specificity. We believe that the indications for its use are lumbo-sacral skin alterations, neurological disorders caused by congenital malformations, traumas due to childbirth or a lumbar puncture, occult dysraphism, all of the compressive spinal cord neo-formations involving nerves, the dura mater and vertebral bone and joint structures, and the screening of the newborns of diabetic mothers.