Editorial Commentary: Shoulder Stiffness Enhances Repair Integrity After Rotator Cuff Repair.

Shoulder stiffness after rotator cuff repair is relatively common. In the past, this was thought to be a difficult complication, and many suggested manipulation under anesthesia or arthroscopic capsular release early in the postoperative course if a patient developed stiffness after rotator cuff repair. However, recent research shows such stiffness is actually a good thing. If a patient develops stiffness after rotator cuff repair, they have a better chance of healing their repair. Eventually, most of the stiffness resolves, and it may be that shoulder stiffness after rotator cuff repair is part of the natural healing response and not detrimental to repair but rather is beneficial and results in an intact repair.

A Systematic Temporal Assessment of Changes in Tendon Stiffness Following Rotator Cuff Repair.

OBJECTIVES: How the material properties of the human supraspinatus tendon change following arthroscopic rotator cuff repair is undetermined. Shear wave elastography ultrasound is a relatively new, noninvasive measure of tissue stiffness. We aimed to evaluate any temporal changes in stiffness and/or thickness of supraspinatus tendons in humans following primary arthroscopic rotator cuff repair. METHODS: Shear wave elastography was performed at three predetermined regions by a single sonographer at 1-, 6-, 12-, 24-, and 52 weeks postoperatively in 50 consecutive single-row inverted mattress primary arthroscopic rotator cuff repairs. One-way ANOVA with Tukey's correction and Spearman's correlation tests was performed. RESULTS: Of 50 patients, two retore by 1-week and were excluded. Two patients retore at 6 weeks, two at 12 weeks, and one at 24 weeks. The mean tendon stiffness in 48 patients at the tendon footprint increased by 21% (1.32 m/s) at 6 months (P < .001), with the lateral tendon stiffening before the medial tendon. Tendon thickness decreased by 11% (0.6 mm) at 6 weeks (P = .008), then stabilized to 24 weeks. Tendons that were less elastographically stiff at 1 week were more likely to be thinner at 6-weeks (r = .38, P = .010). CONCLUSIONS: The data supports the hypothesis that rotator cuff tendons repaired using the single-row inverted-mattress technique take 6 weeks to heal to bone. Unlike in other tendons, there was no hypertrophic healing response. Prior to 6 weeks, the tendon may stretch/thin-out, particularly if its material properties, as assessed by shear wave elastography, are inferior. The material properties of the tendon improved at the tendon insertion site first, then medially out to 12 months post-repair.

An evaluation of shear wave elastographic characteristics of the supraspinatus tendon after rotator cuff repair.

BACKGROUND: The main complication of rotator cuff repair is retear, which is most common in older patients and patients with greater tear sizes. However, it is unknown why these factors are associated with increased rates of retear. The aim of this study was to determine whether the factors associated with rotator cuff retear (age, tear size, sex, history of trauma, and duration of symptoms) are also associated with decreased mechanical stiffness of the supraspinatus tendon after repair, as assessed by shear wave elastography. METHODS: This was a prospective study of 50 patients undergoing primary rotator cuff repair. A sonographer conducted shear wave elastography ultrasound in all patients at 1, 6, 12, 26, and 52 weeks after repair. The shear wave velocity of the supraspinatus tendon was measured at the tendon-bone interface, 3 mm medial to the interface, and 6 mm medial to the interface. A multiple linear regression analysis was performed with calculation of Cohen F2 values to determine the factors that independently affected supraspinatus tendon stiffness postoperatively. RESULTS: For every decade increase in age, the shear wave velocity of the supraspinatus tendon decreased by 0.5 m/s (P = .004). Greater tear size correlated with reduced supraspinatus shear wave velocity (P < .03 at 6 weeks). Male patients had greater supraspinatus tendon stiffness than female patients (8.2 m/s vs. 6.9 m/s, P = .04). Tendons in patients with a history of trauma were approximately 16% stiffer postoperatively than those in patients with no trauma history (P < .001). Duration of symptoms had no impact on the mechanical stiffness of the supraspinatus tendon. CONCLUSION: Older age, larger tear size, female sex, and nontraumatic tear causation were independently associated with reduced shear wave velocity of the supraspinatus tendon postoperatively. The findings of our study correlate with the results of cohort studies assessing the influence of these variables on rotator cuff retear rates, suggesting that the mechanical stiffness of the supraspinatus tendon, as assessed by shear wave elastography, may have an important association with a successful repair.

Synthetic polytetrafluoroethylene patches for irreparable rotator cuff tears-how are they doing at 5 years?

BACKGROUND: Treating massive and irreparable rotator cuff tears are problematic. Several studies have reported that polytetrafluoroethylene (PTFE) patches demonstrated excellent construct integrity and positive clinical and patient outcomes. However, these studies either had small sample sizes or short follow-up periods. PURPOSE: To determine the survivorship, efficacy, and medium-term (2-19 years) outcomes of PTFE patch repairs. METHODS: This retrospective study used prospectively collected data to establish the medium-term outcomes of PTFE interposition patch repairs for massive rotator cuff tears that could not be repaired by the standard technique. Patients included those who met the ≥2-year follow-up criteria post repair. Standardized assessments of patient-ranked shoulder pain and function and shoulder strength and passive range of motion (ROM) were performed preoperatively and at follow-up visits. Radiographs and ultrasonography were used to evaluate repair integrity, measure proximal humeral head migration, and determine glenohumeral arthritis scores. RESULTS: Forty-one shoulders formed the study cohort at a mean follow-up period of 5 years (range: 2-19 years). The mean age of this group was 72 (standard deviation: 10; range: 50-88) and had 14 cm2 tears at surgery. Twenty-five of 41 (61%) PTFE interposition patch repairs remained intact at an average of 5 years postrepair. Thirteen patches failed at the patch-tendon junction, 1 was removed, and 2 patients underwent reverse total shoulder replacement. Patient-ranked shoulder stiffness (P < .05), frequency of pain during activity and sleep (P < .001), pain levels during overhead activity and rest (P < .001), and overall shoulder function significantly improved from bad preoperatively to fair at the mean 5-year postoperative visit (P < .001). No significant improvements were demonstrated in dynamometer-measured shoulder strength maneuvers and passive ROM. All patients demonstrated proximal humeral head migration on shoulder radiographs regardless of repair integrity (mean Upper Migration Index = 1.2). Failed repairs were associated with higher mean preoperative glenohumeral arthritis grades compared with intact repairs (grade 2 in failed repairs compared with grade 1 in intact repairs) (P < .01). CONCLUSION: PTFE interposition patch repairs for massive and irreparable tears had good construct integrity and clinical outcomes at 2 years. These outcomes were not maintained. PTFE patch repairs often failed at the patch-tendon junction at 4 years and beyond and were ineffective in (1) preventing proximal humeral head migration, (2) stopping progression of glenohumeral arthritis, and (3) improving shoulder strength and ROM.

Fibrillar matrix, Echogenicity, Contour, Thickness, and Suture (FECTS) vs. Global: A comparison of 2 scales developed to assess ultrasound images post rotator cuff repair.

BACKGROUND: Ultrasound is commonly used to assess rotator cuff repair (RCR), but no standardized criterion exists to characterize the tendon. PURPOSE: The aims of this study were to (1) develop content validity for ultrasound specific criteria to grade the postoperative appearance of a tendon after RCR, (2) assess the reliability of the criteria, and (3) assess the feasibility to use these assessments. METHODOLOGY: Following expert consultation and literature review for content validity, 2 scales were created: 1) the Fibrillar matrix, Echogenicity, Contour, Thickness, and Suture (FECTS) scale and 2) the Rotator Cuff Repair-Investigator Global Assessment (RCR-IGA). A prospective cohort study was undertaken on patients who had received a RCR and serial B-mode ultrasound images. Four raters assessed the 64-ultrasound images using the scales created in a blinded fashion using intraclass correlation coefficients. RESULTS: The FECTS scale was a composite score with 5 key parameters and the RCR-IGA scale was a 5-point global score. The intrarater reliability for the FECTS scale was excellent for the most experienced rater (0.92) and fair for the rater with no experience (0.72). The intrarater reliability for the RCR-IGA scale was excellent for 3 of the 4 raters (0.80-0.87) and fair when used by the least experienced rater (0.56). Inter-rater testing for all the FECTS scale parameters had excellent reliability (0.82-0.92) except for Fibrillar matrix (0.73). The average time to complete the FECTS scale per image was 23 seconds and 11 seconds for the RCR-IGA scale. CONCLUSION: The FECTS scale and the RCR-IGA scale are reliable tools to assess the ultrasonic appearance of the repaired rotator cuff tendon. The FECTS scale was more reliable for less experienced assessors. The RCR-IGA scale was easier, more time efficient and reliable for those with experience.

Stiffness: friend or foe? A cohort study evaluating the effect of early postoperative stiffness on the outcomes of patients who underwent superior labral repair.

BACKGROUND AND HYPOTHESIS: Postoperative stiffness is a commonly reported complication after type II superior labrum anterior-posterior (SLAP) repair. It is unclear whether patients with postoperative stiffness, classified as external rotation to the side of ≤20°, ultimately will have greater functional outcomes at ≥2 years after surgery. We hypothesized that postoperative stiffness would result in improved functional outcomes at ≥2 years after surgery. METHODS: Sixty-five consecutive arthroscopic SLAP repair cases performed by a single surgeon were retrospectively reviewed using prospectively collected patient-ranked outcomes and examiner-determined assessments preoperatively and at 1 week, 6 weeks, 24 weeks, and a minimum of 2 years after surgery. Patients were allocated to the stiff group and the non-stiff group based on their external rotation at 6 weeks after repair. RESULTS: Of the patients, 16 (27%) had ≤20° of external rotation at 6 weeks postoperatively. These patients, comprising the stiff group, had more pain and more difficulty with overhead activities early on than patients in the non-stiff group (very severe vs. severe, P < .05), but by 2 years, they had less difficulty and less pain with overhead activities, less patient-reported stiffness, and less severe pain at night than isolated SLAP repair patients with >20° of external rotation at 6 weeks (P < .05). CONCLUSION: This study suggests that in patients who underwent SLAP repair, early postoperative stiffness (at 6 weeks as assessed by ≤20° of external rotation), while problematic early, is associated with improved functional outcomes in the longer term, with patients in the stiff group reporting less pain and difficulty with overhead activities at ≥2 years after surgery.

Anteroposterior tear size, age, hospital, and case number are important predictors of repair integrity: an analysis of 1962 consecutive arthroscopic single-row rotator cuff repairs.

BACKGROUND: Retear or nonhealing of a surgically repaired rotator cuff is common, but the determinants of retear are poorly understood. We aimed to determine the relationship between preoperative and intraoperative factors and retear rate following rotator cuff repair and to formulate a predictive model based on this relationship, including any interaction effects between tear size, patient age, and surgical experience in contributing to the retear rate. METHODS: We performed a post hoc analysis of prospectively collected data from 1962 consecutive patients who underwent a primary arthroscopic single-row rotator cuff repair performed by the senior author from 2007 through 2018 and postoperatively returned for 6-month follow-up ultrasonography. RESULTS: Multiple logistic regression analysis revealed anteroposterior tear length to be the most important independent predictor of retear (Wald statistic, 90; P < .001). Other independent predictors included case number (Wald statistic, 59; P < .001), patient age at surgery (Wald statistic, 30; P < .001), and type of hospital (public vs. private) (Wald statistic, 17; P < .001). The data indicated that following rotator cuff repair, there was a 4-fold increase in the retear rate as the anteroposterior tear size increased from 1 cm to 3 cm; a 8-fold decrease when comparing case number 1000 with case number 3000; a 2-fold increase as patient age increased from 50 years to 70 years; and a 3-fold increase when comparing surgery performed in a public hospital vs. a private hospital. The area under the receiver operating characteristic curve was 0.81 (95% confidence interval, 0.78-0.84), indicating that our equation could predict 81% of retears. CONCLUSIONS: Anteroposterior tear length was the most important independent predictor of retear or nonhealing. Other predictive factors included case number, patient age at surgery, and hospital type. The predictive effect of anteroposterior tear length, patient age, and case number in contributing to retear was additive. Our regression equation may be used to calculate patient rotator cuff retear risk at 6 months after repair.

The fate of sutures post rotator cuff repair.

BACKGROUND: Ultrasonographic imaging has been widely used as a diagnostic tool for rotator cuff tears. Several studies have explored the changes in rotator cuff tendon morphology after arthroscopic cuff repair; however, none have addressed the fate of sutures. The aim of this study was to determine (1) if the sutures migrate through the tendon during the postoperative healing period in patients who have had arthroscopic rotator cuff repair; (2) if the sutures do migrate, the time point at which it does; and (3) if the quality of the tendon, in terms of tendon stiffness, modulus of elasticity, bursal thickness, and anatomic footprint, affects suture migration. METHODS: This was a prospective study involving 21 patients who had primary arthroscopic rotator cuff repair performed by a single surgeon. All patients were assessed at 8 days, 6 weeks, 12 weeks, and 24 weeks postrepair; during each assessment, patients underwent an ultrasonographic examination (using a Siemens ACUSON S3000 ultrasonographic system, following a standardized protocol), where supraspinatus tendon thickness and thickness of tendon tissues below and above the suture were measured. Measurements of anatomic footprint, bursal thickness, tendon stiffness, and modulus of elasticity were obtained to assess tendon quality. RESULTS: Of the 21 participants, 14 (67%) had full-thickness tears and 7 (33%) had partial-thickness tears. Between the 12th- and 24th-week follow-up, 2 patients' tendons were found to be not intact. Within the first 12 weeks of the postrepair healing period, the sutures migrated inferiorly, through to the middle of the tendon at the footprint-articular junction (ie, ratio of tendon tissue thickness below the suture to the total tendon thickness = 0.5) (P = .03). The mean anatomic footprint increased from 8.4 ± 1.6 mm to 9.1 ± 1.2 mm between 8 days and 6 weeks (P = .04); bursal thickness decreased during the 24-week period from 1.5 ± 0.9 mm to 0.7 ± 0.4 mm (P = .005); tendon modulus of elasticity increased from 154 ± 75 kPa to 205 ± 96 kPa between 8 days and 24 weeks (P = .05). DISCUSSION: This is the first study to investigate suture position and migration post arthroscopic rotator cuff repair. The findings of this study suggest that sutures migrating to the middle of the tendon during the postoperative healing process is a normal phenomenon observed on ultrasonography.

Examination of the Shoulder for Beginners and Experts: An Update.

Compared with other joints in the body, examination of the shoulder continues to be a challenge for practitioners, whether they be trainers, physical therapists, primary care physicians, or orthopedic surgeons. There are many reasons for this challenge, the primary being the highly complex architecture of bony and soft-tissue anatomy which allows for the greatest range of motion of any joint of the body. As a result, the clinical examination as Ralph Hertel, MD, has commented "perhaps it is just not easy." His comment reflects that one cannot just expect to understand how to interpret the examination unless the observer has some knowledge of how the shoulder complex works, how to perform the basics of the examination, how to interpret radiographs, and how to integrate these variables into a diagnosis. This chapter will attempt to delineate the principles which make the shoulder examination more attainable, plus highlight the areas where a combination of factors is necessary to arrive at a diagnosis.

Shoulder stiffness after rotator cuff repair: the fate of stiff shoulders up to 9 years after rotator cuff repair.

BACKGROUND: Stiffness and retear are 2 common complications of rotator cuff repair. McNamara et al found that postoperative stiffness was associated with lower retear rates at 6 months. This study aimed to determine if stiffness after rotator cuff repair protects the individual from retear up to 9 years after surgery. MATERIALS AND METHODS: Two groups of patients, 69 with stiff and 63 with nonstiff shoulder, who underwent arthroscopic rotator cuff repair were created based on external rotation measurements at 6 weeks postoperatively. Patients had regular follow-up assessments at 6, 12, and 24 weeks and were instructed to return for a follow-up at least 2 years after surgery. Patients were assessed for range of motion, shoulder function, strength, and rotator cuff integrity using ultrasound. RESULTS: For patients with postoperative stiffness at 6 weeks, the retear rate at 6 months was 3%, whereas the rate for nonstiff patients was 19% (P = .004). This protective effect of postoperative stiffness persisted up to 9 years after surgery (P = .002). Postoperative stiffness resolved by 5 years after surgery for all measurements except external rotation (50° vs. 61°) (P = .006). Patients with postoperative stiffness had continued improvements in abduction (P < .001), internal rotation (P = .020), and all patient-ranked measurements from the 6-month follow-up to 5 years after surgery. Patients with stiff shoulder had greater overall satisfaction by the final follow-up (P = .028). CONCLUSIONS: In patients experiencing stiffness after rotator cuff surgery, the repair is less likely to fail at 6 months. Although the stiffness generally resolves by 5 years, this protective effect still persists at 9 years after surgery.

Can handheld dynamometry predict rotator cuff tear size? A study in 2100 consecutive patients.

BACKGROUND: This study aimed to determine whether handheld dynamometry measurements could predict rotator cuff tear size in patients who required surgical treatment of their shoulder pathology. METHODS: Handheld dynamometer readings were collected prior to surgery and analyzed retrospectively for 2100 consecutive patients. Post hoc, the cohort was divided into patients with rotator cuff tears (n = 1747) and those without rotator cuff tears (n = 353). The tear group was stratified into partial- vs. full-thickness tears and into 4 groups based on tear size area. RESULTS: Patients with partial-thickness tears had greater internal rotation (P = .03), external rotation (P < .001), and supraspinatus (P < .001) strength than patients with full-thickness tears. Patients with tears had lower supraspinatus strength than patients without tears (r = -0.82, P < .001). Patients with a larger tear size had lower values of external rotation (r = -1.46, P < .001) and supraspinatus (r = -1.18, P < .001) strength. A model involving internal rotation and supraspinatus strength could predict the presence of a tear with a sensitivity of 82% and specificity of 29%. The correct prediction rate was 73% overall (82% in tear group and 29% in no-tear group). The following formula was found to predict rotator cuff tear size, showing modest correlation with our raw data (r = 0.25, P < .001): Tear size = 482.8 + (3.9 × Internal rotation strength) + (1.6 × Adduction strength) - (7.2 × External rotation strength) - (2.0 × Supraspinatus strength). CONCLUSIONS: Handheld dynamometer readings could not reliably predict rotator cuff tear size, showing only modest correlation with our raw data. Handheld dynamometry readings could predict the presence of a tear, although tears in the intact cohort were overestimated (a specificity of 29% and negative predictive value of 25%).

Counterforce bracing of lateral epicondylitis: a prospective, randomized, double-blinded, placebo-controlled clinical trial.

BACKGROUND: Counterforce bracing is one of the common treatment modalities for tennis elbow. The objective of this study was to determine whether counterforce bracing offers any additional benefit over placebo bracing in the treatment of tennis elbow. METHODS: This prospective, randomized, double-blinded, placebo-controlled clinical trial investigated the use of counterforce bracing (n = 17) compared with placebo bracing (n = 14) in the management of acute tennis elbow. Outcome measures included patient-rated pain and functional outcomes, epicondyle tenderness, and strength at 6 months and long term. Follow-up occurred at 2, 6, 12, and 26 weeks, as well as long term (mean follow-up, 3 years). The study duration was 5 years. RESULTS: The 2 groups, counterforce and placebo, were similar in age, sex, hand dominance, and duration of symptoms. Both braces improved patient-rated pain frequency and severity (P < .01), difficulty with picking up objects and twisting motions, and overall elbow function (P < .001) at 6 months and 3 years. Both braces also improved lateral epicondyle tenderness, grip strength (P < .01), and modified ORI-TETS (Orthopaedic Research Institute-Tennis Elbow Testing System) force (P < .05) at 6 months. Significant intergroup differences were detected for frequency of pain at rest at 6 and 12 weeks (P < .05), level of pain at rest at 2 weeks (P < .001), and patient-rated overall elbow function at 26 weeks (P = .041). CONCLUSION: The counterforce brace provides significant reduction in the frequency and severity of pain in the short term (2-12 weeks), as well as overall elbow function at 26 weeks, compared with the placebo brace.

Preventing brachial plexus injury during shoulder surgery: a real-time cadaveric study.

BACKGROUND: Brachial plexopathy is not uncommon after shoulder surgery. Although thought to be due to stretch neuropathy, its etiology is poorly understood. This study aimed to identify arm positions and maneuvers that may risk causing brachial plexopathy during shoulder arthroplasty. METHODS: Tensions in the cords of the brachial plexuses of 6 human cadaveric upper limbs were measured using load cells while each limb was placed in different arm positions and while they underwent shoulder hemiarthroplasty and revision reverse arthroplasty. Arthroplasty procedures in 4 specimens were performed with standard limb positioning (unsupported), and 2 specimens were supported from under the elbow (supported). Each cord then underwent biomechanical testing to identify tension corresponding to 10% strain (the stretch neuropathy threshold in animal models). RESULTS: Tensions exceeding 15 N, 11 N, and 9 N in the lateral, medial, and posterior cords, respectively, produced 10% strain. Shoulder abduction >70° and combined external rotation >60° with extension >50° increased medial cord tension above the 10% strain threshold. Medial cord tensions (mean ± standard error of the mean) in unsupported specimens increased over baseline during hemiarthroplasty (sounder insertion [4.7 ± 0.6 N, P = .04], prosthesis impaction [6.1 ± 0.8 N, P = .04], and arthroplasty reduction [5.0 ± 0.7 N, P = .04]) and revision reverse arthroplasty (retractor positioning [7.2 ± 0.8 N, P = .02]). Supported specimens experienced lower tensions than unsupported specimens. CONCLUSIONS: Shoulder abduction >70°, combined external rotation >60° with extension >50°, and downward forces on the humeral shaft may risk causing brachial plexopathy. Retractor placement, sounder insertion, humeral prosthesis impaction, and arthroplasty reduction increase medial cord tensions during shoulder arthroplasty. Supporting the arm from under the elbow protected the brachial plexus in this cadaveric model.

The effect of rotator cuff repair on early overhead shoulder function: a study in 1600 consecutive rotator cuff repairs.

BACKGROUND: Rotator cuff tears are often surgically repaired, generally with good results. However, repairs not infrequently retear, and how important repair integrity is with respect to early functional outcomes after rotator cuff repair is unclear. Thus, the purpose of this study was to determine the effect of a retear on overhead activities in a large cohort of patients after rotator cuff repair. METHODS: This was a retrospective cohort study of prospectively collected data from 1600 consecutive rotator cuff repairs. Outcomes were based on patient responses to the L'Insalata Shoulder Questionnaire and findings on examination preoperatively and at 6 months of follow-up. Repair integrity was determined by ultrasound imaging at the 6-month follow-up visit. RESULTS: The 1600 patients (885 men, 715 women) were a mean age of 58 years. Postoperative ultrasound imaging found 13% (211 of 1600) of repairs had retorn. Significant improvements were seen irrespective of rotator cuff integrity in pain levels with overhead activity (P < .0001) and range of motion in forward flexion (P < .001) and abduction (P < .01). Patients with intact repairs had 9.5 N greater supraspinatus strength (P < .0001) and 6.9 N greater external rotation strength (P < .01) than those with a retear. CONCLUSION: To our knowledge, this is the largest study to evaluate the effect of rotator cuff repair integrity on shoulder function. Patients who had an arthroscopic rotator cuff repair reported significant improvements in overhead pain levels irrespective of the repair integrity at 6 months. Repair integrity influenced supraspinatus and external rotation power, where patients with intact repairs were stronger than those with a retear.

Short-term outcomes after arthroscopic capsular release for adhesive capsulitis.

BACKGROUND: Little is known about the short-term temporal outcomes of an arthroscopic capsular release for adhesive capsulitis (frozen shoulder). Specifically, it is not known how immediate the improvements are and how quickly patients return to normal function after an arthroscopic release. METHODS: The study included 140 shoulders in 133 patients with idiopathic adhesive capsulitis who underwent a complete arthroscopic release of the shoulder capsule, performed by a single surgeon in a day surgery setting. Patient-reported pain and shoulder function were evaluated with the use of Likert scales, and an independent examiner assessed shoulder strength and range of motion preoperatively and at 1 week, 6 weeks, 12 weeks, and 24 weeks postoperatively. RESULTS: Arthroscopic capsular release resulted in immediate improvements in pain, functional outcomes, and range of motion (P < .0001). External rotation increased from 21° ± 17° (mean ± standard deviation) to 76° ± 17° at 1 week. Passive range of shoulder motion improved at 1 week, deteriorated slightly at 6 weeks, and then continued to improve at 12 and 24 weeks. Before surgery, 38% of patients reported that they "always" experienced extreme pain. This proportion reduced to 30% (P < .0001) at 1 week postoperatively and 2% (P < .0001) at 24 weeks postoperatively. There were no complications. CONCLUSIONS: Patients who underwent an arthroscopic capsular release for idiopathic adhesive capsulitis experienced significant reductions in pain, improvements in range of motion, and improvements in overall shoulder function in the first postoperative week. These immediate improvements in pain and function continue to improve at 6, 12, and 24 weeks postoperatively.

Effect of surgeon-sonographer interaction on ultrasound diagnosis of rotator cuff tears: a five-year cohort study in 775 shoulders.

BACKGROUND: Ultrasonography for the diagnosis of rotator cuff tears has been a topic of debate for years. The literature shows promising results for the diagnostic utility of ultrasonography for rotator cuff tears. This study assessed the effect of a surgeon-sonographer interaction on the ability of ultrasonography to predict the presence or absence of rotator cuff tears. METHODS: This study was a temporal cohort analysis of 775 patients to detect the diagnostic accuracy of ultrasonography at predicting a rotator cuff tear. The surgeon-sonographer interaction had three components: (1) presence of an ultrasound machine and ultrasonographer within a shoulder clinic, (2) the ultrasonographer attends shoulder operations, (3) and the ultrasonographer reviews patients preoperatively and postoperatively. Comparisons of 2 variables-presence and size of a tear-were made between the preoperative ultrasonographic findings with arthroscopic findings (gold standard). RESULTS: The diagnostic utility for the detection of rotator cuff tears by ultrasonography at the start of the study was 93% sensitive and 68% specific, and at the end of the study was 99% sensitive and 93% specific. There was an improvement in the correlation of the ability to estimate the size of rotator cuff tears from ultrasonography to surgery in both full- and partial-thickness tears. CONCLUSIONS: The surgeon-sonographer interaction improved the diagnostic utility of an office-based ultrasonographer over time, particularly with respect to the overall accuracy of ultrasonography for the detection of rotator cuff tears and for the ability to predict the size of full- and partial-thickness rotator cuff tears.

Trauma versus no trauma: an analysis of the effect of tear mechanism on tendon healing in 1300 consecutive patients after arthroscopic rotator cuff repair.

BACKGROUND: Patients with rotator cuff tears often recall a specific initiating event (traumatic), whereas many cannot (nontraumatic). It is unclear how important a history of trauma is to the outcomes of rotator cuff repair. METHODS: This question was addressed in a study cohort of 1300 consecutive patients who completed a preoperative questionnaire regarding their shoulder injury and had a systematic evaluation of shoulder range of motion and strength, a primary arthroscopic rotator cuff repair performed by a single surgeon, an ultrasound scan, and the same subjective and objective measurements made of their shoulder 6 months after surgery. Post hoc, this cohort was separated into 2 groups: those who reported no history of trauma on presentation (n = 489) and those with a history of traumatic injury (n = 811). RESULTS: The retear rate in the group with no history of trauma was 12%, whereas that of the group with a history of trauma was 14% (P = .36). Those patients with a history of shoulder trauma who waited longer than 24 months had higher retear rates (20%) than those who had their surgery earlier (13%) (P = .040). CONCLUSION: Recollection of a traumatic initiating event had little effect on the outcome of arthroscopic rotator cuff repair. Duration of symptoms was important in predicting retears if patients recalled a specific initiating event but not in patients who did not recall any specific initiating event. Patients with a history of trauma should be encouraged to have their rotator cuff tear repaired within 2 years.

The effect of concomitant glenohumeral joint capsule release during rotator cuff repair--a comparative study.

BACKGROUND: There is debate as to whether to operate or to defer surgery on patients with concomitant rotator cuff tear and shoulder stiffness. The purpose of this study was therefore to compare the outcomes in those patients who had both their rotator cuff tear and shoulder stiffness treated with the outcomes of patients who had a rotator cuff repair but no stiffness. METHODS: Twenty-five patients formed the stiffness group (receiving a concomitant rotator cuff repair and manipulation under anesthesia ± arthroscopic capsular release for preoperative ipsilateral stiffness), and a chronologically matched group of 170 rotator cuff repair-only patients formed the nonstiffness group. Patients ranked their pain and function scores preoperatively and at 1 week, 6 weeks, 12 weeks, 6 months, and 2 years postoperatively; examiners recorded range of motion, strength, and presence of impingement signs. Repair integrity was determined using ultrasound. RESULTS: Patients from both groups had significantly improved clinical outcomes at the 2-year follow-up compared with preoperative values. Range of motion was similar between groups at 2 years for forward flexion, abduction, and external rotation, whereas the nonstiffness group had a superior range of internal rotation (P = .014). Stiffness patients had 0 of 25 (0%) retears at 2 years compared with 34 of 170 (20%) in the nonstiffness group (P = .009). CONCLUSIONS: The good outcomes of rotator cuff repair with glenohumeral capsular release disproved our hypothesis and suggest that there is no advantage in delaying repair of a rotator cuff tear to allow stiffness to resolve and that stiffness confers an advantage in terms of repair integrity. LEVEL OF EVIDENCE: Level III; Retrospective Cohort Design; Treatment Study.

Advanced glycation end products in idiopathic frozen shoulders.

BACKGROUND: The pathophysiologic mechanisms behind proliferation of fibroblasts and deposition of dense collagen matrix in idiopathic frozen shoulder remain unclear. Accumulation of advanced glycation end products (AGEs) with cross-linking and stabilization of collagen has been hypothesized to contribute to this pathophysiologic process. This study investigated whether the immunoreactivity of AGEs is higher in patients with idiopathic frozen shoulder than in the control groups. METHODS: Shoulder capsule samples were collected from 8 patients with idiopathic frozen shoulder, 6 with unstable shoulders (control 1), and 8 with rotator cuff tears (control 2). The samples were hematoxylin and eosin stained and analyzed by immunohistochemistry using antibodies against AGEs. Immunoreactivities were rated in a blinded fashion from none (0) to strong (3). Immunohistochemical distribution within the capsule was noted. RESULTS: Frozen shoulder patients had greater frequency and severity of self-reported pain (P = .02) than rotator cuff tear patients and more restricted range of motion in all planes (P < .05) than patients of the instability and rotator cuff tear groups. Hematoxylin and eosin-stained capsular tissue from frozen shoulder showed fibroblastic proliferation, increased numbers of adipocytes, and increased subsynovial vascularity. Immunoreactivity of AGEs was stronger in frozen shoulder capsules (2.8) than in instability (0.3; P = .0001) and rotator cuff tear (1.1; P = .016) capsules. CONCLUSION: This study highlights a potential role for AGEs in the pathogenesis of frozen shoulder. The overexpression of AGEs may explain the fibroblastic proliferation and deposition of collagen matrix in idiopathic frozen shoulder. LEVEL OF EVIDENCE: Basic Science Study; Histology.