Porcine Dermal Xenograft as Augmentation in the Treatment of Large Rotator Cuff Tears: Clinical and Magnetic Resonance Results at 2-Year Follow-Up.

Purpose The aim of the present retrospective study is to describe the results obtained at 2-year follow-up by using a porcine dermis-derived collagen membrane implanted as augmentation to treat large rotator cuff tears. Methods Thirty-five patients in total were included according to the following criteria: large or massive rotator cuff tear, confirmed during surgery, measuring between 3 and 5 cm in width and stage 1 to 2 fatty infiltration documented at magnetic resonance imaging (MRI). Patients underwent arthroscopic repair of the cuff augmented by the implantation of a porcine dermal collagen membrane. Patients were evaluated up to 24 months after surgery by the Constant score and MRI imaging to assess functional outcomes and re-tear rate. The results obtained were compared to those of a matched cohort of 35 patients operated by arthroscopic repair alone by the same surgical team. Results The application of the porcine membrane proved to be safe without scaffold-related adverse events documented. A statistically significant difference in the Constant score in favor of the treatment group was documented at the final evaluation ( p = 0.036 ). Furthermore, a subgroup analysis revealed that patients treated by augmentation and presenting re-tear at MRI showed a significantly higher functional outcome compared with control patients with MRI evidence of re-tear ( p = 0.0136). Conclusion Arthroscopic repair augmented by porcine dermal xenograft for the treatment of chronic and retracted rotator cuff tears with low-grade fatty degeneration proved to be safe and also effective, with higher functional score compared with the arthroscopic repair alone. Level of Evidence This is a Level III, retrospective cohort study.

Is there a difference in clinical outcomes and repair integrity between arthroscopic single-row versus transosseous (anchorless) fixation? A retrospective comparative study.

BACKGROUND: Few studies have investigated clinical and structural outcomes after transosseous (TO) repair. The purpose of this study was to compare structural and clinical outcomes of rotator cuff tear, repaired arthroscopically, with a single row (SR) or transossoeus (TO) anchorless technique. METHODS: 96 patients who underwent an arthroscopic repair for superior or posterosuperior rotator cuff tear using TO (n:54) or a SR (n:42) were retrospectively enrolled in this study after evaluation of clinical and surgical notes. Functional evaluation was performed with the adjusted Constant score, and American Shoulder and Elbow Surgeons (ASES) score. Postoperative cuff integrity was determined through MRI study. RESULTS: Patients were recalled after a minimum follow-up of two years. All the patients were available for the study. In the SR group the Constant rating system showed a significant improvement from a preoperative average rating of 44.8 to an average of 85.7. In the group of TO repair the Constant rating system showed a significant improvement from a preoperative average of 46.1 to an average of 87.6 postoperatively. According to ASES index scores, the average total score improved from 42.8 to 92.0 in the anchor group and from 40.4 to 94.6 in the TO group. There was no statistical difference between the two groups about clinical outcomes. Postoperative MRI revealed no differences in term of complete re-tears between the two techniques. In the SR group at MRI we observe significant more cases of rotator cuff with a Sugaya type III healing. CONCLUSIONS: Arthroscopic rotator cuff repair yielded successful clinical outcomes using SR and TO technique. However using the TO technique we saw less type 3 Sugaya readings on MRI suggesting a possible benefit with TO repair. LEVEL OF EVIDENCE II: Retrospective study.

Intra-articular glenohumeral injections of HYADD®4-G for the treatment of painful shoulder osteoarthritis: a prospective multicenter, open-label trial.

PURPOSE: numerous experimental and clinical studies in osteoarthritis (OA) have demonstrated that intra-articular (IA) administration of hyaluronic acid can improve the altered rheological properties of the synovial fluid and exert protective and reparative effects on the joint structure. The objective of this study was to evaluate the safety and performance of HYADD®4-G (Hymovis®) in patients with glenohumeral joint OA. METHODS: forty-one patients with shoulder pain and limited shoulder function resulting from concentric glenohumeral joint OA were enrolled in a multicenter clinical trial. Patients received two HYADD®4-G injections administered one week apart. The main outcome measure was improvement in shoulder pain on movement at six months as assessed through a 100-mm visual analog scale (VAS), range of motion (ROM) values, and Constant-Murley Shoulder Outcome Score (CS). RESULTS: two IA injections of HYADD®4-G (Hymovis®) significantly decreased pain and improved shoulder function for up to six months from the first injection. The VAS score decreased (from 66.1 mm to 37.7 mm at six months) and improvements were recorded in the total CS and in the ROM values ( rotation decreased from a mean value of 54.2° at baseline to 63.2° at six months and internal rotation from a mean value of 44.0° at baseline to 45.7° at 26 weeks). No serious adverse events occurred. CONCLUSIONS: the study results demonstrated that two IA injections of HYADD®4-G (Hymovis®) may be a safe and effective treatment option for shoulder pain associated with glenohumeral OA and that the effects of the injections are still present for up to six months after the treatment. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Deep partial rotator cuff tear: transtendon repair or tear completion and repair? A randomized clinical trial.

PURPOSE: The purpose of this study is to compare the clinical and subjective difference between transtendon repair or complete/repair in two homogeneous groups of patients affected by deep partial articular supraspinatus tear. METHODS: Seventy-four patients were randomized in two groups of 37 patients each. The first group (A) was treated with arthroscopic transtendon repair while the second group (B) was treated with an arthroscopic completion of the tear and formal repair. All the patients were revaluated at a minimum 2 years of follow-up with Constant score and Visual Analogic Scale (VAS). RESULTS: Constant score improved by a mean value of 25 (95 % CI 21-28) (p < 0.0001) and of 29 (95 % CI 26-31) (p < 0.0001), respectively; VAS score decreased by a mean value of 3.4 (95 % CI 2.9-3.9) (p < 0.0001) and of 3.6 (95 % CI 3.3-4.0) (p < 0.0001), respectively. The improvement was higher in both groups for the ADL, and in Group B, the improvement in strength was higher than in Group A. There were no statistical differences between the two different techniques. CONCLUSION: Both repairing techniques of deep partial supraspinatus tear provide good results in terms of function and pain. There were no statistically significant differences between the two techniques. LEVEL OF EVIDENCE: Prospective comparative study, Level II.

Can arthroscopic revision surgery for shoulder instability be a fair option?

BACKGROUND: the aim of this study was to evaluate the role of arthroscopic capsuloplasty in the treatment of failed primary arthroscopic treatment of glenohumeral instability. METHODS: we retrospectively examined at a minimum of 3-years follow-up 22 patients who underwent arthroscopic treatment between 1999 and 2007 who had recurrent anterior shoulder instability with a post-surgical failure. A statistical analysis was performed to evaluate which variable could influence the definitive result and clinical outcomes at final follow-up. A p value of less than 0.05 was considered significant. RESULTS: we observed after revision surgery an overall failure rate of 8/22 (36.4%) including frank dislocations, subluxations and also apprehension that seriously inhibit the patient's quality of life. No significant differences were observed in the examined parameters. CONCLUSIONS: according to our outcomes we generally do not recommend an arthroscopic revision procedure for failed instability surgery.

No prosthetic management of massive and irreparable rotator cuff tears.

A massive rotator cuff tear is not necessarily irreparable. Number of tendons involved, muscle-tendon unit quality, and decreased acromionhumeral distance (AHD) are as important as tear size in determining reparability of lesion. Massive and irreparable rotator cuff tears cannot be anatomically repaired to the bone and are a common source of pain and disability even in middle-aged patients. In these patients when conservative management has failed, it is possible to perform different surgical techniques. A functional repair can help to restore the horizontal force couple of the cuff on the humeral head and to increase the AHD. Debridement of irreparable tears and biceps tenotomy or tenodesis can have a role in low functional demand patients but results deteriorate over time. Recently, several commercially available tissue-engineered biological and synthetic scaffolds have been developed to augment rotator cuff repairs. The aim is to provide a mechanical improvement in case of poor quality tissue at time zero and give a support to have a better cuff healing. In selected cases, the scaffold can be used also to bridge tendon defect. Patients who not have pseudoparalysis, cuff tear arthropathy and with intact deltoid function can benefit from tendon transfers with satisfactory outcomes. These different procedures should be chosen for each patient with selected criteria and after a satisfactory explanation about the really possible expectation after surgery.

Matrix metalloproteases and their inhibitors are altered in torn rotator cuff tendons, but also in the macroscopically and histologically intact portion of those tendons.

We evaluated whether matrix metalloproteases and their inhibitors are involved in extracellular matrix remodelling and degradation of chronic rotator cuff tears. Tendon samples were harvested from 13 patients who underwent arthroscopic repair of a rotator cuff tear. Supraspinatus specimens were harvested en bloc from the arthroscopically intact middle portion of the tendon, more than 1 cm lateral to the torn edge, from the lateral edge of the tear, and from the superior margin of the macroscopically intact subscapularis tendon, used as control. The collagenases, the stromelysins, and the tissue inhibitors of metalloprotease arrays were analyzed blindly by multiplex sandwich ELISA in each specimen. Histological evidence of tendinopathy was present in all patients with a rotator cuff tear, but not in the macroscopically intact subscapularis tendon. There were significantly increased levels of MMP 1, MMP 2, MMP 3, TIMP-1, and TIMP-2 in all specimens examined, including the macroscopically intact portion of the supraspinatus tendon and the subscapularis (control specimens). The levels of specific matrix metalloproteases and their inhibitors are altered in torn rotator cuff tendons, but also in the macroscopically and histologically intact tendons. These changes extended medially to the site of tendon tear, and to other tendons.

Role of metalloproteinases in rotator cuff tear.

The role of matrix metalloproteinases (MMPs) and their inhibitors (TIMPS) in the pathophysiology of rotator cuff tears has not been established yet. Recent advances empathize about the role of MMPs and TIMPS in extracellular matrix (ECM) remodeling and degradation in rotator cuff tears pathogenesis and healing after surgical repair. An increase in MMPs synthesis and the resulting MMPs mediated alterations in the ECM of tendons have been implicated in the etiopathogenesis of tendinopathy, and there is an increase in the expression of MMPs and a decrease in TIMP messenger ribonucleic acid expression in tenocytes from degenerative or ruptured tendons. Importantly, MMPs are amenable to inhibition by cheap, safe, and widely available drugs such as the tetracycline antibiotics and bisphosphonates. A better understanding of relationship and activity of these molecules could provide better strategies to optimize outcomes of rotator cuff therapy.

Subcoracoid impingement syndrome: a painful shoulder condition related to different pathologic factors.

Subcoracoid impingement syndrome represents a rare cause of shoulder pain. To date, there are a few papers in literature that have addressed specifically the subcoracoid impingement. We reviewed 13 consecutive patients suffering from this syndrome who underwent an arthroscopic treatment. There were 4 men and 9 women with a mean age of 45 years (range, 23-58 years). The diagnosis of subcoracoid impingement was carried out on the basis of clinical examination and magnetic resonance imaging finding. Arthroscopic surgery consisted of a coracoplasty alone in 2 patients, coracoplasty and acromioplasty in 2 patients, coracoplasty and subscapularis tendon repair in 4 patients, and in the last 5 patients no coracoplasty was done and surgery consisted in treating a minor shoulder instability. Patients were reviewed at a mean follow-up of 2.4 ± 0.7 years. We evaluated the difference between preoperative and final postoperative range of motion, VAS, UCLA, SST and Constant score using a Student's t test. At follow-up, we observed a significant improvement in range of motion and shoulder scores; moreover, clinical findings of subcoracoid impingement were negative in all patients. Different pathological shoulder conditions can be responsible for a subcoracoid impingement that can be primary or secondary to factors different from mechanic attrition against the coracoid because of its morphology. In case of primary impingement, coracoplasty is a good treatment to relieve clinical symptoms. In patients suffering from an associated minor shoulder instability with MGHL capsulolabral lesion, surgical treatment of this lesion without coracoplasty led to the improvement in symptoms.

Partial repair of irreparable supraspinatus tendon tears: clinical and radiographic evaluations at long-term follow-up.

BACKGROUND: Irreparable rotator cuff tears are a common source of pain and disability even in middle-aged patients. Although most rotator cuff tears can be completely repaired to bone, a significant proportion of these cannot be sutured by traditional methods. In these cases it is possible to perform a functional repair of the cuff to help restore the force couple of the cuff on the humeral head and to increase the acromion-humeral distance (AHD). This technique provides peripheral repair of the cuff tear without complete closure of the cuff defect. Our hypothesis was that arthroscopic partial suture of the cuff leads to pain relief and functional improvement for the patients while restoring the AHD. MATERIALS AND METHODS: All patients (67 cases) were arthroscopically treated with functional repair of the posterior cuff. The follow-up was at least 5 years. All the patients had clinical and radiographic evaluations and assessment with the Simple Shoulder Test and Constant score. RESULTS: The mean Constant score increased from 44 points to a mean of 73 points, the mean Simple Shoulder Test score increased from 4.6 to 9.0, and the mean AHD increased from 6.1 mm to 9.1 mm. DISCUSSION AND CONCLUSION: Functional repair of the infraspinatus, leaving the greater tuberosity uncovered, in patients with irreparable cuff tears gives good results in terms of patient satisfaction and in restoring the AHD even at long-term follow-up. Complications were rare and in line with the usual sequelae of a rotator cuff repair.

Anterior-superior internal impingement of the shoulder: an evidence-based review.

PURPOSE: Internal impingement syndrome is a painful shoulder condition related to the impingement of the soft tissue, including the rotator cuff, joint capsule and the long head of the biceps tendon and glenoid labrum. Two types of internal impingement syndrome can be differentiated: posterior-superior impingement and anterior-superior impingement (ASI). The aetiology of ASI in particular is not clear. The purpose of this paper is to discuss the different aetiological theories relating to ASI, try to clarify the clinical, radiological and arthroscopic findings and, finally, suggesting treatment for this complex shoulder syndrome. METHODS: The article is based on own research and clinical experience, as well as a non-systematic search in the PubMed database. RESULTS: The aetiology of ASI appears to be related to the pulley lesion and instability of the long head of the biceps tendon. It can be caused by trauma or degenerative factors, which produces anterior shoulder pain in middle-aged patients, particularly when performing overhead activities. CONCLUSION: The ASI is probably more frequent than previously reported. There is no evidence to prove the efficacy of a specific rehabilitative protocol, and the gold standard of surgical management has to be ascertained. However, in patients with a pulley lesion, there is some evidence that early surgical management, when minor soft injury lesions are present, produces better clinical outcomes.

Posterior superior internal impingement: an evidence-based review [corrected].

Over the last decade, the concept of internal impingement has continued to evolve, and the frequency with which this condition is recognised continues to increase. This syndrome should be clearly differentiated from the classical (external) impingement that is thought to be caused by compression of the subacromial bursa, long head of the biceps tendon and rotator cuff (RC) by the coraco-acromial arch. Internal (posterosuperior) impingement syndrome is typified by a painful shoulder due to impingement of the soft tissue, including the RC, joint capsule and the posterosuperior part of the glenoid. The aetiology of this syndrome is unclear, but hypotheses include anterior shoulder instability or micro-instability, contracture of the posterior capsule, reduced humeral retroversion and scapular dyskinesis. Non-operative therapy represents the first line of treatment for this syndrome and includes the management of pain, stretching of the posterior capsule and a muscle strengthening programme. Surgical treatment should only be considered when conservative management fails. A number of different surgical procedures have been proposed, but the results are variable. The success rate is generally improved when the subtle instability, associated with internal impingement, is also addressed.

Collagen I membranes for tendon repair: effect of collagen fiber orientation on cell behavior.

Tendons have poor spontaneous regenerative capabilities, and complete regeneration is never achieved despite intensive remodeling. In this in vitro study, we characterized two multilamellar collagen I membranes differing in the arrangement of collagen fiber deposition (oriented vs. nonoriented) and compared their mechanical properties. Human dermal fibroblasts and tenocytes were seeded on the two membranes to evaluate the effect of fiber orientation on cell viability and cytoskeletal organization. Results demonstrate that the multilamellar collagen I membrane with oriented fibers has the better mechanical properties and affords optimum cell proliferation and adhesion. Its fiber arrangement provides an instructive pattern for cell growth and may serve to guide the alignment of cells migrating from the ends of a crushed or frayed tendon to obtain a strong, correctly structured tendon, thus providing a viable clinical option for tendon repair.