Editorial Commentary: Postoperative Zoledronic Acid Improves Tendon Healing but Does Not Affect Outcomes in Rotator Cuff Repair Patients With Postmenopausal Osteoporosis.

Understanding the preoperative risk factors for successful rotator cuff repair (RCR) and ways to optimize these factors is an evolving area of study. The Rotator Cuff Healing Index and other proxy risk factors for failed rotator cuff healing have implicated significant fatty infiltration, muscular atrophy, advanced chronological age, tear size and retraction, and ultimately, osteoporosis. Although structural (or biological) augmentation and tendon transfer have been proposed as solutions for the alarmingly high rate of failure after primary RCR, other options may preferentially focus on the enthesis and underlying osseous footprint. Currently, bisphosphonates are frequently used in the treatment of osteoporosis and prevention of fragility fractures. However, burgeoning evidence suggests that postoperative zoledronic acid may have clinical utility after rotator cuff and other tendon repairs. In the cost-conscious world of evidence-based medicine, the added economic burden of additional medications and office visits may or may not improve patient outcomes-much less confer added value. Our advice to fellow shoulder surgeons: Wait for further information, but continue to holistically consider and optimize risk factors for poor soft-tissue healing. Although the addition of postoperative bisphosphonates may improve suture anchor fixation and promote a better foundation for healing, it will not immediately transform your RCR success rates.

Long-Term Follow-Up of Inpatients with Rotator Cuff Tear Who Received Integrative Korean Medicine Treatment: A Retrospective Analysis and Questionnaire Survey.

CONTEXT: Rotator cuff tear is one of the most common causes of shoulder pain and has become a prominent disease most frequently treated by surgery. OBJECTIVES: To investigate the long-term therapeutic effect of integrative Korean medicine (KM) as a conservative treatment in treating rotator cuff tears. DESIGN: A multicenter observational study. SETTINGS: The settings involve four regional network KM hospitals. PATIENTS: The study participants are 288 patients aged 19-70 with rotator cuff tear identified by radiologist based on magnetic resonance imaging who received integrative KM treatment for the chief complaint of shoulder pain between 1 January 2015 and 31 March 2020. INTERVENTION: None. MAIN OUTCOMES: The primary outcome was the pain score in the affected shoulder, measured by the numeric rating scale (NRS). The secondary outcomes were Shoulder Pain and Disability Index (SPADI), 5-Level Quality of life: EuroQol 5-Dimension (EQ-5D-5L), Patient Global Impression of Change (PGIC), and range of motion (ROM) scores. RESULTS: Eligible patients for MCID achievement analysis for minimally clinical important change were 167, and 109 completed the follow-up survey. The mean NRS pain score in the affected shoulder was 5.80 ± 1.27 at admission, 3.50 ± 1.32 at discharge, and 3.83 ± 2.04 at follow-up.The mean SPADI score was 51.48 ± 20.18 at admission, 37.76 ± 19.23 at discharge, and 24.26 ± 21.80 at follow-up. The improvement at discharge (P-value < 0.001) and follow-up (P-value < 0.001) compared to those at admission was statistically significant. The results also presented a significant improvement in ROM for all motions at discharge after treatment (P-value < 0.001). The number of patients who achieved minimal clinically important difference in NRS was 116 (69.5%) at discharge and 71 (65.1%) at follow-up, and in SPADI was 82 (50.9%) at discharge and 77 (70.6%) at follow-up. CONCLUSION: The results of this study suggested that integrative KM treatment can help improve pain, functional impairment, QoL, and ROM in patients with a rotator cuff tear TRIAL REGISTRATION: NCT04566939.

A scoping review and best evidence synthesis for treatment of partial-thickness rotator cuff tears.

BACKGROUND: Rotator cuff disorders include a broad spectrum of pathological conditions including partial-thickness and full-thickness tears. Studies have shown partial-thickness rotator cuff tear (PTRCT) prevalence to be twice that of full-thickness tears. In the working population, PTRCTs are one of the most common causes of shoulder pain and often result in occupational disability due to pain, stiffness, and loss of shoulder function. Treatment of PTRCTs remains controversial. The purpose of this study was to consolidate the existing high-quality evidence on best management approaches in treating PTRCTs using both nonoperative and operative approaches. METHODS: A scoping review with best evidence synthesis was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. MEDLINE (OVID), EMBASE (OVID), Cochrane Library (Wiley), SCOPUS, Web of Science Core Collection, CINAHL Plus with Full Text (EBSCOhost), PubMed Central, and Science Direct were searched from 2000 to March 3, 2023. Level 1 studies, and systematic reviews and meta-analyses that included level 1 and 2 studies, were included. RESULTS: The search yielded 8276 articles. A total of 3930 articles were screened after removing 4346 duplicates. Application of inclusion criteria resulted in 662 articles that were selected for full-text review. Twenty-eight level 1 studies, 1 systematic review, 4 meta-analyses, and 1 network meta-analyses were included in the best evidence synthesis. Nonoperative strategies included injections (ie, platelet-rich plasma, corticosteroid, prolotherapy, sodium hyaluronate, anesthetic, and atelocollagen), exercise therapy, and physical agents. Operative interventions consisted of débridement, shaving of the tendon and footprint, transtendon repair, and traditional suture anchor repair techniques with and without tear completion. Both nonoperative and operative strategies demonstrated effectiveness at managing pain and functional outcome for PTRCTs. The evidence supports the effectiveness of surgical intervention in treating PTRCTs regardless of arthroscopic technique. CONCLUSION: The results of this scoping review do not support superiority of operative over nonoperative management and suggest that both strategies can be effective at managing pain and functional outcome for PTRCTs. Surgery, however, is the most invasive and costly approach, with the highest risk of complications such as infection. Other variables such as patient expectation, treating practitioner bias, or preference may change which modalities are offered and in what sequence.

Preoperative vitamin D supplementation is a cost-effective intervention in arthroscopic rotator cuff repair.

BACKGROUND: This study investigates the potential role of preoperative 25(OH)D supplementation as a cost-effective strategy to decrease revision rotator cuff repair (RCR) rates and lower the total health care burden from patients undergoing primary arthroscopic RCR. Previous literature has emphasized the importance of vitamin D on bone health maintenance, soft tissue healing, and outcomes in RCR. Inadequate preoperative vitamin D levels may increase revision RCR rates following primary arthroscopic RCR. Although 25(OH)D deficiency is common in RCR patients, serum screening is not routinely performed. METHODS: A cost-estimation model was developed to determine the cost-effectiveness of both preoperative selective and nonselective 25(OH)D supplementation in RCR patients in order to reduce revision RCR rates. Prevalence and surgical cost data were obtained from published literature through systematic reviews. Cost of serum 25(OH)D assay and supplementation were obtained from public-use data. Mean and lower and upper bounds of 1-year cost savings were calculated for both the selective and nonselective supplementation scenarios. RESULTS: Preoperative 25(OH)D screening and subsequent selective 25(OH)D supplementation was calculated to result in a mean cost savings of $6,099,341 (range: -$2,993,000 to $15,191,683) per 250,000 primary arthroscopic RCR cases. Nonselective 25(OH)D supplementation of all arthroscopic RCR patients was calculated to result in a mean cost savings of $11,584,742 (range: $2,492,401-$20,677,085) per 250,000 primary arthroscopic RCR cases. Univariate adjustment projects that selective supplementation is a cost-effective strategy in clinical contexts where the cost of revision RCR exceeds $14,824.69 and prevalence of 25(OH)D deficiency exceeds 6.67%. Additionally, nonselective supplementation is a cost-effective strategy in clinical scenarios where revision RCR cost is ≥$4216.06 and prevalence of 25(OH)D deficiency is ≥1.93%. CONCLUSIONS: This cost-predictive model promotes the role of preoperative 25(OH)D supplementation as a cost-effective mechanism to reduce revision RCR rates and lower the overall health care burden from arthroscopic RCR. Nonselective supplementation appears to be more cost-effective than selective supplementation, likely due to the lower cost of 25(OH)D supplementation compared to serum assays.

Dry needling in a multimodal rehabilitation protocol following rotator cuff repair surgery: study protocol for a double-blinded randomized sham-controlled trial.

BACKGROUND: Rotator cuff tear (RCT) is one of the main causes of shoulder pain and dysfunction. Rotator cuff repair (RCR) is a common surgical procedure for the management of RCTs. Presence of myofascial trigger points (MTrP) as a result of surgical procedure can aggravate postoperative shoulder pain. The purpose of this protocol is to describe a randomized controlled trial design to evaluate the effect of implementing 4 sessions of myofascial trigger point dry needling (MTrP-DN) within a multimodal rehabilitation protocol following RCR surgery. METHODS: Forty-six participants aged 40-75 will be recruited having postoperative shoulder pain after RCR and meeting the inclusion criteria. Participants will be randomly divided into 2 groups: One group will undergo MTrP-DN, manual therapy, exercise therapy and electrotherapy and the other will receive sham dry needling (S-DN), manual therapy, exercise therapy and electrotherapy. This protocol will cover 4 weeks of intervention. The primary outcome measure will be the Numeric Pain Rating Scale (NPRS) for pain. Secondary outcome measures will be Shoulder Pain and Disability Index (SPDI), range of motion (ROM), strength and adverse events. DISCUSSION: This is the first study to investigate the use of 4 sessions of MTrP-DN in combination with a multimodal rehabilitation protocol for postoperative shoulder pain, restriction, weakness and dysfunction following RCR. The results of this study may help to determine the effect of MTrP-DN on various outcomes after RCR surgery. TRIAL REGISTRATION: This trial was registered at the ( https://www.irct.ir ), (IRCT20211005052677N1) on 19/2/2022.

Editorial Commentary: Social Determinants of Health Influence the Success of Shoulder Rotator Cuff Repair Outcomes: When You Do Everything Right, Yet Things Still Go Wrong.

Our ability to perform a technically sound surgery is not sufficient to ensure patients have an excellent clinical outcome. Social determinants of health disparities (SDHDs) profoundly impact health equality. Health disparities that exist in the United States are risk factors for inferior patient-reported outcomes and result in greater complication rates following rotator cuff repair surgery. The presence of SDHDs was associated with an increased risk of revision, stiffness, emergency department visits, medical complications, and costs. Economic and educational SDHDs were associated with the greatest risk of 1-year revision surgery. Improved understanding of these social variables can help with risk identification preoperatively. Surgeons may employ additional, holistic, bio-psycho-social, perioperative resources to provide high-quality, value-based care to at-risk patients who might be marginalized by our health care system.

Muscle-Specific Micro-Ribonucleic Acids miR-1-3p, miR-133a-3p, and miR-133b Reflect Muscle Regeneration After Single-Dose Zoledronic Acid Following Rotator Cuff Repair in a Rodent Chronic Defect Model.

BACKGROUND: Zoledronic acid improves bone microarchitecture and biomechanical properties after chronic rotator cuff repair (RCR) in rats. Besides the positive effects of zoledronic acid on bone mineral density and bone microarchitecture, bisphosphonates have positive effects on skeletal muscle function. PURPOSES/HYPOTHESIS: The purposes of this study were to (1) longitudinally evaluate circulating bone- and muscle-specific serum micro-ribonucleic acids (miRNAs) and (2) investigate supraspinatus muscle tissue after tenotomy and delayed RCR in a rat model. It was hypothesized that zoledronic acid would improve muscle regeneration after chronic RCR in rats. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 34 male Sprague-Dawley rats underwent unilateral (left) supraspinatus tenotomy (time point 1) with delayed transosseous RCR after 3 weeks (time point 2). All rats were sacrificed 8 weeks after RCR (time point 3). Animals were randomly assigned to 2 groups. One day after RCR, the control group was given 1 mL of subcutaneous saline solution, and the intervention group was treated with a subcutaneous single-dose of 100 µg/kg body weight of zoledronic acid. All 34 study animals underwent miRNA analysis at all 3 time points. In 4 animals of each group, histological analyses as well as gene expression analyses were conducted. RESULTS: Circulating miRNAs showed significantly different expressions between both study groups. In the control group, a significant downregulation was observed for muscle-specific miR-1-3p (P = .004), miR-133a-3p (P < .001), and miR-133b (P < .001). Histological analyses showed significantly higher rates of regenerating myofibers on the operated side (left) of both study groups compared with the nonoperated side (right; P = .002). On the nonoperated side, significantly higher rates of regenerating myofibers were observed in the intervention group compared with the control group (P = .031). The myofiber cross-sectional area revealed significantly smaller myofibers on both sides within the intervention group compared with both sides of the control group (P < .001). Within the intervention group, significantly higher expression levels of muscle development/regeneration marker genes embryonal Myosin heavy chain (P = .017) and neonatal Myosin heavy chain (P = .016) were observed on the nonoperated side compared with the operated side. CONCLUSION: An adjuvant single-dose of zoledronic acid after RCR in a chronic defect model in rats led to significant differences in bone- and muscle-specific miRNA levels. Therefore, miR-1-3p, miR-133a-3p, and miR-133b might be used as biomarkers for muscle regeneration after RCR. CLINICAL RELEVANCE: Adjuvant treatment with zoledronic acid may improve muscle regeneration after chronic RCR in humans, thus counteracting fatty muscle infiltration and atrophy.

Are psychosocial variables, sleep characteristics or central pain processing prognostic factors for outcome following rotator cuff repair? A protocol for a prospective longitudinal cohort study.

INTRODUCTION: Prognosis following surgical rotator cuff repair (RCR) is often established through the assessment of non-modifiable biomedical factors such as tear size. This understates the complex nature of recovery following RCR. There is a need to identify modifiable psychosocial and sleep-related variables, and to find out whether changes in central pain processing influence prognosis after RCR. This will improve our knowledge on how to optimise recovery, using a holistic rehabilitation approach. METHODS AND ANALYSIS: This longitudinal study will analyse 141 participants undergoing usual care for first time RCR. Data will be collected 1-21 days preoperatively (T1), then 11-14 weeks (T2) and 12-14 months (T3) postoperatively. We will use mixed-effects linear regression to assess relationships between potential prognostic factors and our primary and secondary outcome measures-the Western Ontario Rotator Cuff Index; the Constant-Murley Score; the Subjective Shoulder Value; Maximal Pain (Numeric Rating Scale); and Quality of Life (European Quality of Life, 5 dimensions, 5 levels). Potential prognostic factors include: four psychosocial variables; pain catastrophising, perceived stress, injury perceptions and patients' expectations for RCR; sleep; and four factors related to central pain processing (central sensitisation inventory, temporal summation, cold hyperalgesia and pressure pain threshold). Intercorrelations will be assessed to determine the strength of relationships between all potential prognostic indicators.Our aim is to explore whether modifiable psychosocial factors, sleep-related variables and altered central pain processing are associated with outcomes pre-RCR and post-RCR and to identify them as potential prognostic factors. ETHICS AND DISSEMINATION: The results of the study will be disseminated at conferences such as the European Pain Congress. One or more manuscripts will be published in a peer-reviewed SCI-ranked journal. Findings will be reported in accordance with the STROBE statement and PROGRESS framework. Ethical approval is granted by the Ethical commission of Canton of Zurich, Switzerland, No: ID_2018-02089 TRIAL REGISTRATION NUMBER: NCT04946149.

The investigation of acute effects of fascial release technique in patients with arthroscopic rotator cuff repair: A randomized controlled trial.

BACKGROUND: Fascial release technique is used for releasing fascial tissue to decrease pain, to increase range of motion, and to improve functional level. OBJECTIVE: To investigate the acute effects of fascial release technique on pain, range of motion, upper extremity functional level, and fear of movement in individuals with arthroscopic rotator cuff repair. METHODS: Thirty volunteers with an arthroscopic rotator cuff repair were included in the study. The individuals were randomly divided into two groups. One group received only conventional physiotherapy including hot pack, interferential current, and exercise program, while the fascial release technique was applied to the other group in addition to the conventional physiotherapy program for 2 weeks with 2 sessions per week. Individuals were assessed for pain intensity, range of motion, functional level, fear of movement before and after treatment, and satisfaction level after treatment. RESULTS: Demographic and clinical characteristics of the groups were similar (p > 0.05). Both groups showed improvement in pain, range of motion, and upper extremity functions (p < 0.05). Improvements in the treatment group were better than the conventional physiotherapy group (p < 0.05). Fear of movement was significantly decreased in the treatment group (p < 0.05). Both groups were similar in terms of satisfaction level (p > 0.05). CONCLUSION: Fascial release technique is acutely effective on the pain, joint range of motion and upper extremity functions in the treatment of individuals with arthroscopic rotator cuff repair and more successful results can be obtained by including it in the early rehabilitation program after arthroscopic rotator cuff surgery.

Does vitamin C supplementation improve rotator cuff healing? A preliminary study.

PURPOSE: One of the complications after rotator cuff repair is a tendon non-healing. It has already been posited in the literature that vitamin C (VC) promotes tendon healing through its antioxidant properties and its role as a cofactor in collagen synthesis. The aim of this study was to evaluate the effect of postoperative VC supplementation on the tendon healing following repair. METHODS: This randomized monocentric prospective study included 98 patients who underwent arthroscopic rotator cuff repair in 1-year period and follow-up ultrasound 6 months postoperatively. The cohort was divided into two groups: the VC+ group (500 mg/day PO for 45 days postoperatively) and the VC- group (no supplementation). The evaluation criterion was tendon healing at 6 months postoperatively according to the Sugaya ultrasound classification. Preoperative and postoperative clinical evaluations were based on active mobilities, the Constant score and the subjective shoulder value. RESULTS: There was no difference in term of postoperative outcomes between the two groups. At an average follow-up of 6.3 months, the non-healing rate in the overall population was 17%. This rate was higher in VC- compared to VC+, respectively, 23% vs. 11%), p = 0.2. CONCLUSION: This study showed a trend to improve tendon healing after rotator cuff repair with VC supplementation. However, a prospective study with a larger patient population should be conducted to confirm this finding.

Prevalence and Clinical Impact of Acromial Cupping after Arthroscopic Rotator Cuff Repair: Does Acromioplasty Matter?

BACKGROUND: Although the effectiveness of acromioplasty is controversial, it is commonly performed during rotator cuff repair to reduce external impingement. During follow-up, osteolysis under the acromion (acromial cupping) could be observed. However, this phenomenon has been rarely addressed in the literature. The purpose of this study was to compare the prevalence and severity of acromial cupping after rotator cuff repair depending on the concomitant performance of acromioplasty and evaluate the influence of acromial cupping on clinical and radiological outcome. METHODS: This is a retrospective study involving patients who underwent arthroscopic rotator cuff repair for small-to-large full-thickness rotator cuff tears from October 2015 to March 2019 and clinical follow-up and magnetic resonance imaging at least 1 year postoperatively. A total of 110 patients were enrolled and divided into two groups depending on whether acromioplasty had been performed (group A) or not (group N). The prevalence of acromial cupping was evaluated in each group. In addition, we stratified patients according to the severity of acromial cupping to investigate its influence on healing and functional scores (visual analog scale [VAS], American Shoulder and Elbow Surgeons [ASES] score, simple shoulder test [SST], and Constant-Murley score). RESULTS: There were 85 patients in group A and 25 patients in group N. The prevalence of acromial cupping and acromial cysts was as follows: 36.4% (40 patients) and 6.4% (7 patients), respectively, in the total subjects; 43.5% (37/85) and 5.9% (5/85), respectively, in group A; and 12.0% (3/25) and 8.0% (2/25), respectively, in group N. The prevalence of acromial cupping was significantly different between the two groups (p = 0.012). However, functional outcomes were not significantly different between groups stratified by the severity of acromial cupping (VAS, p = 0.464; ASES score, p = 0.902; SST, p = 0.816; and Constant-Murley score, p = 0.117). The difference in healing rate was statistically insignificant between groups (p = 0.726). CONCLUSIONS: The incidence and severity of acromial cupping were significantly greater in patients who underwent rotator cuff repair with acromioplasty. It was a relatively common phenomenon, especially after acromioplasty. However, neither the existence nor the severity of acromial cupping affected functional outcomes or healing.

Clinical Observation on the Treatment of Rotator Cuff Injury with Modified Buyang Huanwu Decoction and Rotator Cuff Repair.

In this paper, we have evaluated the clinical efficacy of rotator cuff surgery combined with Chinese medicine Buyang Huanwu Decoction (adding medicine) in the treatment of patients with rotator cuff injury. For this purpose, sixty patients with rotator cuff injury and shoulder arthroscopic surgery were selected in this hospital (where 57 cases were finally screened). The patients were divided into a control group (28 cases) and a study group (29 cases) by the envelope method. The control group received conventional treatment after the operation, whereas the study group was combined with Buyang Huanwu Decoction after the operation. The clinical efficacy of the two groups, particularly after treatment, was compared in terms of self-care ability and Constant-Murley scores before and after treatment, that is, 4 w, 8 w, and 12 w. The total effective rate of treatment in the study group was significantly higher than that of the control group after 4 weeks of treatment (P < 0.05). There was no significant difference in the FIM self-care scores of the two groups before treatment (P > 0.05). In the study group patients, after treatment for 4 w and 8 w, the FIM self-care score was significantly improved (P < 0.05). The FIM self-care score of the patients in the study group, after 12 w of treatment, had no significant difference compared with the control group (P > 0.05). The Constant-Murley scores of the two groups were compared before treatment where no significant difference is observed (P > 0.05) and the Constant-Murley score of the study group patients was significantly higher than that of the control group, after 4 w and 8 w treatment (P < 0.05). Additionally, Constant-Murley score of the study group was not significantly higher than that of the control group after 12 w of treatment difference (P > 0.05). The proposed combined treatment program has value of promotion and implementation in the clinical treatment of patients with rotator cuff injury.

Do Relaxation Exercises Decrease Pain After Arthroscopic Rotator Cuff Repair? A Randomized Controlled Trial.

BACKGROUND: Pain after rotator cuff repair is commonly managed with opioid medications; however, these medications are associated with serious adverse effects. Relaxation exercises represent a potential nonpharmacologic method of pain management that can be easily implemented without substantial adverse effects; however, the effects of relaxation exercises have not been studied in a practical, reproducible protocol after arthroscopic rotator cuff repair. QUESTIONS/PURPOSES: (1) Does performing relaxation exercises after arthroscopic rotator cuff repair (ARCR) decrease pain compared with standard pain management medication? (2) Does performing relaxation exercises after ARCR decrease opioid consumption? (3) What proportion of patients who used the relaxation techniques believed they decreased their pain level, and what proportion continued using these techniques at 2 weeks? (4) Does performing relaxation exercises after ARCR affect shoulder function? METHODS: During the study period, 563 patients were eligible for inclusion; however, only 146 were enrolled, randomized, and postoperatively followed (relaxation group: 74, control group: 72); 68% (384 of 563) of patients were not contacted due to patient and research staff availability. Thirty-three patients were unenrolled preoperatively or immediately postoperatively due to change in operative procedure (such as, only debridement) or patient request; no postoperative data were collected from these patients. Follow-up proportions were similar between the relaxation and control groups (relaxation: 80%, control: 81%; p = 0.90). The relaxation group received and reviewed educational materials consisting of a 5-minute video and an educational pamphlet explaining relaxation breathing techniques, while the control group did not receive relaxation education materials. Patients recorded their pain levels and opioid consumption during the 5 days after ARCR. Patients also completed the American Shoulder and Elbow Surgeons shoulder score preoperatively and 2, 6, 13, 18, and 26 weeks postoperatively. Linear mixed models were created to analyze postoperative pain, opioid consumption measured in morphine milligram equivalents (MMEs), and shoulder function outcomes. A per-protocol approach was used to correct for patients who were enrolled but subsequently underwent other procedures. RESULTS: There was no difference in pain scores between the relaxation and control groups during the first 5 days postoperatively. There was no difference in pain scores at 2 weeks postoperatively between the relaxation and control groups (3.3 ± 3 versus 3.5 ± 2, mean difference -0.22 [95% CI -1.06 to 0.62]; p = 0.60). There was no difference in opioid consumption during the first 5 days postoperatively between the relaxation and control groups. The use of relaxation exercises resulted in lower 2-week narcotics consumption in the relaxation group than in the control group (309 ± 241 MMEs versus 442 ± 307 MMEs, mean difference -133 [95% CI -225 to -42]; p < 0.01). Sixty-two percent (41 of 66) of patients in the relaxation group believed the relaxation exercises decreased their pain levels. Fifty-two percent (34 of 66) were still performing the exercises at 2 weeks postoperatively. During the 6-month follow-up period, there was no difference in shoulder function between the relaxation and control groups. CONCLUSION: The preoperative administration of quick, basic relaxation exercises allowed patients to use appreciably lower opioid analgesic doses over the first 2 weeks after ARCR, without any worsening of pain scores. We consider this result promising but preliminary; it is possible that a more intense mindfulness intervention-the one we studied here was disseminated using only a 5-minute video-would deliver reductions in pain and further reductions in opioid usage. LEVEL OF EVIDENCE: Level II, therapeutic study.

Platelet-Rich Product Supplementation in Rotator Cuff Repair Reduces Retear Rates and Improves Clinical Outcomes: A Meta-analysis of Randomized Controlled Trials.

PURPOSE: The purpose of this study was to conduct a comprehensive systematic review and meta-analysis to investigate the clinical and imaging outcomes of all 4 types of platelet-rich therapies (pure platelet-rich plasma [P-PRP], leukocyte and platelet-rich plasma, pure platelet-rich fibrin, and leukocyte and platelet-rich fibrin) in rotator cuff repairs. METHODS: A systematic literature search was performed to identify rotator cuff tears comparing any of the 4 types of platelet-rich products (PRP) to a control in rotator cuff repair. Data extracted from the studies included retear rates diagnosed with imaging studies, as well as outcome scores such as Constant, American Shoulder and Elbow Surgeons (ASES), University of California Los Angeles (UCLA), Simple Shoulder Test (SST), and visual analog scale (VAS). Meta-analyses compared postoperative outcome scores and retear rates between the control and study groups. RESULTS: Seventeen studies were included in the meta-analysis. When pooling data from all studies, retear rate for the treatment group was 19.3%, compared to 25.4% for the control group (odds ratio [OR] 0.59, P = .0037). When stratified based on PRP type, only P-PRP resulted in a significant reduction in retear rate (OR 0.26, P = .0005). Overall, treatment with PRP significantly improved Constant scores when compared to controls (mean difference [MD] 2.41, P =.0027), as well as VAS scores (MD -0.12, P = .0014), and SST scores (MD 0.41, P = .0126). There was no significant difference in ASES scores (MD 0.37, P = .7762) or UCLA scores (MD 0.76, P =0.2447) between treatment and controls when pooling data from all studies. CONCLUSIONS: This analysis demonstrates significant reductions in retear rates when rotator cuff repair is augmented with PRP. P-PRP appears to be the most effective formulation, resulting in significantly improved retear rates and clinical outcome scores when compared with controls.

The effect of the platelet-rich plasma and ozone therapy on tendon-to-bone healing in the rabbit rotator cuff repair model.

BACKGROUND: The aim of this study is to histologically and biomechanically investigate the effects of local PRP and ozone therapy (O2O3) on tendon-to-bone healing in a rabbit model of the supraspinatus tendon tear. METHODS: Four groups were formed to have seven rabbits in each group: repair, R; repair + PRP, RP; repair + ozone, RO; and repair + PRP + ozone, RPO. The supraspinatus tendon was detached by sharp dissection from the footprint and an acute tear pattern was created. Thereafter, tendon repair was performed with the transosseous technique. In the RP group, PRP, and in the RPO group, PRP + O2O3 mixture was injected to the tendon repair site. In the RO group, O2O3 gas mixture was injected into subacromial space three times a week for a total of 4 weeks. The study was ended at postoperative 6th week. RESULTS: When compared with the R group, a statistically significant increase was observed in the biomechanical strength of the RP and RPO groups. The highest increase in biomechanical strength was detected in the RPO group. The histology of the RO and RPO groups showed better collagen fiber continuity and orientation than the R and RP groups. CONCLUSIONS: The results obtained from this study show that the ozonized PRP can be used as biological support to increase tendon-to-bone healing. However, these results need to be supported by clinical studies.

Conservative management in an elderly woman with proximal humeral head fracture and massive rotator cuff tear who refused surgery: A case report.

BACKGROUND: Proximal humerus fractures (PHFs) account for between 4% and 10% of all fractures in the elderly people and osteoporosis is frequently related to PHF. Furthermore, rotator cuff (RC) tears are also extremely common, affecting at least 10% of people aged over 60 in the United States. Among shoulder pathologies, the periarticular soft tissue disorders, including the RC, this is considered to be the most common. The incidence of full thickness RC tears increases with age. An aggressive surgical approach is often required for patients with massive RC tear and PHFs to restore the patients' functional daily living activities. To the best of the authors' knowledge, this is the first case report describing a successful conservative management in an elderly patient with a full thickness RC tear and PHF that refused surgery. CASE DESCRIPTION: This report describes the case of a 90-year-old woman with a massive RC tear who fell over on the sidewalk and sustained a PHF. The patient refused surgery even though it was recommended and prescribed by an orthopaedic surgeon. INTERVENTION: After having her shoulder immobilized with a brace as prescribed by the orthopaedic physician, the patient began a shoulder rehabilitation program with progressive work load exposure, functional movements and a pain and kinesiophobia education program. OUTCOMES: After 3 and a half months, the patient achieved full recovery to her pre-injury level of function. Such outcome was assessed using the Numeric Pain Rating Scale (NPRS), the Disability of the Arm, Shoulder and Hand (DASH) scale, the Fear-Avoidance Beliefs Questionnaire (FABQ), the Pain Catastrophysing Scale (PCS), and the Global Rating of Change (GROC) scale. DISCUSSION AND CONCLUSION: In an elderly patient with a massive RC tear and an undisplaced PHFs, patient education, pain reconceptualization and change of beliefs in combination with progressive work load exposure appeared to be an effective management strategy to achieve a return to the pre-injury level of function.

[Electro-acupuncture promotes repair of rotator cuff injury in rats].

OBJECTIVE: To observe the therapeutic effect of electro-acupuncture on tendon healing and functional recovery of rotator cuff injury in rats and explore the therapeutic mechanism of electro-acupuncture. METHODS: Ninety SD rats were randomly divided into electro-acupuncture group, model group and blank control group, and models of rotator cuff injury were established in the former two groups.The rats in electro-acupuncture group was treated with electro-acupuncture after the operation, and those in the other two groups received no treatment.The right forefoot thermal withdrawal latency (TWL), the contents of IL-1ß, IL-6 and TNF-α in the synovial fluid and the maximum tension load of supraspinatus tendon were measured at 2, 4 and 8 weeks after the operation. RESULTS: TWL in the model group was significantly lower than that in the blank control group and electro-acupuncture group at 2, 4 and 8 weeks after the operation (P < 0.05).At all these time points, the contents of IL-1ß, IL-6 and TNF-α in the synovial fluid were significantly higher in the model group than in the blank control group and electro-acupuncture group (P < 0.05).At 2 weeks, the maximum load in electro-acupuncture group and model group were significantly lower than that in the blank control group (P < 0.05).At 4 and 8 weeks after the operation, the maximum pull load was significantly greater in electro-acupuncture group than in the model group (P < 0.05). CONCLUSIONS: Electro-acupuncture treatment not only effectively reduces the expression of inflammatory factors to relieve pain, but also promotes the repair of damaged tissue to improve the biomechanical properties of rotator cuff in the rat models.

Electro-acupuncture promotes repair of rotator cuff injury in rats / 南方医科大学学报

OBJECTIVE@#To observe the therapeutic effect of electro-acupuncture on tendon healing and functional recovery of rotator cuff injury in rats and explore the therapeutic mechanism of electro-acupuncture.@*METHODS@#Ninety SD rats were randomly divided into electro-acupuncture group, model group and blank control group, and models of rotator cuff injury were established in the former two groups.The rats in electro-acupuncture group was treated with electro-acupuncture after the operation, and those in the other two groups received no treatment.The right forefoot thermal withdrawal latency (TWL), the contents of IL-1β, IL-6 and TNF-α in the synovial fluid and the maximum tension load of supraspinatus tendon were measured at 2, 4 and 8 weeks after the operation.@*RESULTS@#TWL in the model group was significantly lower than that in the blank control group and electro-acupuncture group at 2, 4 and 8 weeks after the operation (@*CONCLUSIONS@#Electro-acupuncture treatment not only effectively reduces the expression of inflammatory factors to relieve pain, but also promotes the repair of damaged tissue to improve the biomechanical properties of rotator cuff in the rat models.

Immediate Effects of Thoracic Spine Manipulation Upon Shoulder Functionality in Patients With Sutured Rotator Cuff Repair: A Prospective Study.

OBJECTIVES: The purpose of this study was to evaluate the immediate effect of thoracic spine manipulation upon active flexion and abduction mobility of the shoulder, spine temperature, and the size of the subacromial space as measured by ultrasound in 3 positions (internal, neutral, and external rotation) of the glenohumeral joint in patients who have undergone surgery because of subacromial impingement. METHODS: Quasi-experimental, prospective, short-term effect study with consecutively sampled participants. Thirty-two patients had undergone subacromial decompression together with supraspinatus tendon suture. The following variables were studied: age, sex, dominant shoulder, presurgery evolution time, working status, surface temperature of dorsal segment with limited mobility, premanipulation functional assessment using the Spanish version of the Upper Limb Functional Index Scale, goniometric range of motion measurement at glenohumeral joint before and after manipulation, and ultrasound measurement of subacromial space before and after manipulation. RESULTS: Significant differences and small effect size were found in measurements for flexion and abduction movements after thoracic spine manipulation (P > .001; ES > 0.2) and subacromial space measurements in neutral rotation and external rotation (P > .001), but without clinical relevance effect size (<0.2). CONCLUSIONS: Active shoulder flexion and abduction mobility increase after manipulation of thoracic spine in patients who have undergone surgery for rotator cuff suture. Subacromial space increases significantly with shoulder in neutral and external rotation position after manipulation. No differences were found regarding surface temperature of manipulated area.