Arthroscopic management of massive rotator cuff tears: an evaluation of debridement, complete, and partial repair with and without force couple restoration.

PURPOSE: To evaluate the effectiveness of arthroscopic debridement (DB), partial (PR), and complete repair (CR) for massive rotator cuff tears (mRCT) in terms of functional and subjective parameters, and repair integrity. METHODS: For this single-centre study, 68 consecutive shoulders with mRCT involving at least three tendons and treated with arthroscopic DB (n = 23), PR (n = 22), and CR (n = 23) were included. All patients (52-81 years) were prospectively assessed before and at a mean of 45 months after surgery using functional and subjective parameters. Preoperative tendon rupture pattern and post-operative repair integrity were assessed by MRI. A coding system describing accurately rotator cuff rupture, treatment, and integrity was established. RESULTS: All treatment groups improved significantly from pre- to post-operative (P < 0.01), while preoperative parameters, except fatty degeneration, were not significantly different. However, post-operative comparisons revealed similar scores with DB (constant score, CS 65.8 ± 14.7, qDASH 24.1 ± 20.6) and PR (CS 67.5 ± 9.9, P = n.s.; qDASH 20.5 ± 14.4, P = n.s.), while CR were significantly better (CS 80.3 ± 8.9; qDASH 7.0 ± 8.7; P ≤ 0.001). Force couple restoration of PR did not significantly influence outcome. Re-tear rates with CR (29 %) were lower compared to PR (53 %). Intact CR compared to intact PR showed better CS (83.4 ± 7.3 vs. 68.5 ± 10.6, P = 0.009) and qDASH (5.4 ± 8.3 vs. 21.2 ± 9.5, P = 0.006). The vast majority of patients were satisfied with their arthroscopic procedure (DB 87 %; PR 86 %; CR 91 %). CONCLUSION: Arthroscopic DB, PR, and CR were effective in treating mRCT involving at least three tendons. Reparability of mRCT was influenced by fatty degeneration of the muscles. However, CR showed the most favourable short-term improvements. LEVEL OF EVIDENCE: IV.

Longitudinal Long-term Magnetic Resonance Imaging and Clinical Follow-up After Single-Row Arthroscopic Rotator Cuff Repair: Clinical Superiority of Structural Tendon Integrity.

BACKGROUND: The number of arthroscopic rotator cuff surgeries is consistently increasing. Although generally considered successful, the reported number of retears after rotator cuff repair is substantial. Short-term clinical outcomes are reported to be rarely impaired by tendon retears, whereas to our knowledge, there is no study documenting long-term clinical outcomes and tendon integrity after arthroscopic rotator cuff repair. PURPOSE: To investigate longitudinal long-term repair integrity and clinical outcomes after arthroscopic rotator cuff reconstruction. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Thirty patients who underwent arthroscopic rotator cuff repair with suture anchors for a full-tendon full-thickness tear of the supraspinatus or a partial-tendon full-thickness tear of the infraspinatus were included. Two and 10 years after initial arthroscopic surgery, tendon integrity was analyzed using magnetic resonance imaging (MRI). The University of California, Los Angeles (UCLA) score and Constant score as well as subjective questions regarding satisfaction with the procedure and return to normal activity were used to evaluate short- and long-term outcomes. RESULTS: At the early MRI follow-up, 42% of patients showed a full-thickness rerupture, while 25% had a partial rerupture, and 33% of tendons remained intact. The 10-year MRI follow-up (129 ± 11 months) showed 50% with a total rerupture, while the other half of the tendons were partially reruptured (25%) or intact (25%). The UCLA and Constant scores significantly improved from preoperatively (UCLA total: 50.6% ± 20.2%; Constant total: 44.7 ± 10.5 points) to 2 years (UCLA total: 91.4% ± 16.0% [ P < .001]; Constant total: 87.8 ± 15.3 points [ P < .001]) and remained significantly higher after 10 years (UCLA total: 89.7% ± 15.9% [ P < .001]; Constant total: 77.5 ± 15.6 points [ P < .001]). The Constant total score and Constant strength subscore, but not the UCLA score, were also significantly better at 10 years postoperatively in patients with intact tendons compared with patients with retorn tendons (Constant total: 89.0 ± 7.8 points vs 75.7 ± 14.1 points, respectively [ P = .034]; Constant strength: 18.0 ± 4.9 points vs 9.2 ± 5.2 points, respectively [ P = .006]). The majority of patients rated their satisfaction with the procedure as "excellent" (83.3%), and 87.5% returned to their normal daily activities. CONCLUSION: Arthroscopic rotator cuff repair showed good clinical long-term results despite a high rate of retears. Nonetheless, intact tendons provided significantly superior clinical long-term outcomes, making the improvement of tendon healing and repair integrity important goals of future research efforts.

Molecular mechanisms of osteoporotic hip fractures in elderly women.

A common manifestation of age-related bone loss and resultant osteoporosis are fractures of the hip. Age-related osteoporosis is thought to be determined by a number of intrinsic factors including genetics, hormonal changes, changes in levels of oxidative stress, or an inflammatory status associated with the aging process. The aim of this study was to investigate gene expression and bone architecture in bone samples derived from elderly osteoporotic women with hip fractures (OP) in comparison to bone samples from age matched women with osteoarthritis of the hip (OA). Femoral heads and adjacent neck tissue were collected from 10 women with low-trauma hip fractures (mean age 83±6) and consecutive surgical hip replacement. Ten bone samples from patients undergoing hip replacement due to osteoarthritis (mean age 80±5) served as controls. One half of each bone sample was subjected to gene expression analysis. The second half of each bone sample was analyzed by microcomputed tomography. From each half, samples from four different regions, the central and subcortical region of the femoral head and neck, were analyzed. We could show a significantly decreased expression of the osteoblast related genes RUNX2, Osterix, Sclerostin, WNT10B, and Osteocalcin, a significantly increased ratio of RANKL to Osteoprotegerin, and a significantly increased expression of the enzymes superoxide dismutase 2 (SOD2) and glutathione peroxidase GPX3, and of the inflammatory cytokine IL6 in bone samples from hip fracture patients compared to controls. Major microstructural changes in OP bone were seen in the neck and were characterized by a significant decrease of bone volume, trabecular number, and connectivity density and a significant increase of trabecular separation. In conclusion, our data give evidence for a decreased expression of osteoblast related genes and increased expression of osteoclast related genes. Furthermore, increased expression of SOD2 and GPX3 suggest increased antioxidative activity in bone samples from elderly osteoporotic women with hip fractures.

Molecular evidence of osteoblast dysfunction in elderly men with osteoporotic hip fractures.

Osteoporosis is extremely frequent in post-menopausal women; nevertheless, osteoporosis in men is also a severe and frequently occurring but often underestimated disease. Increasing evidence links bone loss in male idiopathic osteoporosis and age related osteoporosis to osteoblast dysfunction rather than increased osteoclast activity as seen in postmenopausal osteoporosis. The aim of this study was to investigate gene expression of osteoblast related genes and of bone architecture in bone samples derived from elderly osteoporotic men with hip fractures (OP) in comparison to bone samples from age matched men with osteoarthritis of the hip (OA). Femoral heads and adjacent neck tissue were collected from 12 men with low-trauma hip fractures and consecutive surgical hip replacement. Bone samples of age matched patients undergoing hip replacement due to osteoarthritis served as controls. One half of the bone samples was subjected to RNA extraction, reverse transcription, and real-time polymerase chain reactions. The second half of the bone samples was analyzed by static histomorphometry. From each half samples from four different regions, the central and subcortical region of the femoral head and neck, were analyzed. OP patients displayed a significantly decreased RUNX2, Osterix and SOST expression compared to OA patients. Major microstructural changes in OP bone were seen in the subcortical region of the neck and were characterized by a significant decrease of bone volume, and a significant increase of trabecular separation. In conclusion, decreased local gene expression of RUNX2 and Osterix in men with hip fractures strongly supports the concept of osteoblast dysfunction in male osteoporosis. Major microstructural changes in the trabecular structure associated with osteoporotic hip fractures in men are localized in the subcortical region of the femoral neck.