The effect of cuff arthropathy stage on sleep disturbance and kinesiophobia in reverse shoulder arthroplasty patients.

BACKGROUND: The current study aimed to determine the changes in pre-and post-operative Pittsburg sleep quality index (PSQI) and Tampa scale of kinesiophobia (TSK) values ​​according to the Hamada classification in patients who underwent reverse shoulder arthroplasty (RSA) for rotator cuff tear arthropathy (RCTA). METHODS: One hundred and eight patients who underwent RSA for RCTA were reviewed retrospectively. The patients were divided into two groups with low grade (stages 1-2-3) (n = 49) and high grade (stages 4a-4b-5) (n = 59) according to the Hamada classification, which is the radiographic evaluation of RCTA. PSQI and TSK values ​​were calculated preoperatively, and post-operatively at the 6th week, 6th month, and 1st year. The change in PSQI and TSK values ​​between the evaluations and the effect of staging according to the Hamada classification on this change was examined. RESULTS: When compared in preoperative evaluations, PSQI and TSK scores were found to be lower in low-grade group 1 (7.39 ± 1.56, 51.88 ± 4.62, respectively) than in high-grade group 2 (10.47 ± 2.39, 57.05 ± 3.25, respectively) according to Hamada classification (both p < 0.001). In the postoperative evaluations, PSQI and TSK results decreased gradually compared to the preoperative evaluations, and there was a severe decrease in both parameters between the 6th-week and 6th-month evaluations (both p < 0.001). Preoperatively, 102 (95%) patients had sleep disturbance (PSQI ≥ 6), and 108 (100%) patients had high kinesiophobia (TSK > 37). In the 1st year follow-ups, sleep disturbance was observed in 5 (5%) patients and kinesiophobia in 1 (1%) patient. When the Hamada stages were compared, it was seen that there was a significant difference before the operation (both p < 0.001), but the statistically significant difference disappeared in the PSQI value in the 1st year (p = 0.092) and in the TSK value in the 6th month (p = 0.164) post-operatively. It was observed that Hamada staging caused significant differences in PSQI and TSK values ​​in the preoperative period but did not affect the clinical results after treatment. CONCLUSIONS: RSA performed based on RCTA improves sleep quality and reduces kinesiophobia. RCTA stage negatively affects PSQI and TSK before the operation but does not show any effect after the treatment.

Neuropathy of the suprascapular and axillary nerves in rotator cuff arthropathy: a prospective electrodiagnostic study.

PURPOSE: Prevalence of axillary (AN) and/or suprascapular (SSN) neuropathy in rotator cuff tear arthropathy (RCTA) is unknown. We aimed to prospectively evaluate for preoperative neurodiagnostic abnormalities in order to determine their prevalence, location, and influence on reverse shoulder arthroplasty (RSA) outcomes. METHODS: Patients who underwent RSA for RCTA were prospectively included. An electromyography and nerve conduction study were performed pre and post-surgery. Clinical situation: VAS, Relative Constant-Murley Score (rCMS) and ROM over a minimum of two years follow-up. RESULTS: Forty patients met the inclusion criteria; mean follow-up was 28.4 months (SD 4.4). Injuries in RCTA were present in 83.9% (77.4% in AN and 45.2% in SSN). There were no differences on preoperative VAS, ROM, and rCMS between patients with and without preoperative nerve injuries. Four acute postoperative neurological injuries were registered under chronic preoperative injuries. Six months after RSA, 69% of preoperative neuropathies had improved (82.14% chronic injuries and 77.7% disuse injuries). No differences in improvement between disuse and chronic injuries were found, but patients with preoperative neuropathy that had not improved at the postoperative electromyographic study at six months, scored worse on the VAS (1.44 vs 2.66; p .14) and rCMS (91.6 vs 89.04; p .27). CONCLUSIONS: The frequency of axillary and suprascapular neuropathies in RCTA is much higher than expected. Most of these injuries improve after surgery, with almost complete neurophysiological recovery and little functional impact on RSA. However, those patients with preoperative neuropathies and absence of neurophysiological improvement six months after surgery have lower functional results.

Impact of obesity on outcomes of rotator cuff repair: A systematic review and meta-analysis.

BACKGROUND: To synthesize the existing evidence on the association between obesity and rotator cuff repair outcomes such as pain, shoulder function, range of motion, and complications. METHODS: We searched PubMed, EMBASE, and Scopus databases for relevant observational studies (cohort and case-control) and randomized controlled trials (RCTs). The target population in the included studies comprised adults who had undergone rotator cuff repair procedures. The outcomes of interest were functional outcomes (such as range of motion), pain scores, patient-reported outcome measures, and complication rates (such as re-repair and readmission rates). We applied random-effects models and calculated pooled effect sizes reported as standardized mean differences (SMDs) or relative risks (RRs) with 95% confidence intervals. RESULTS: We analysed data from 11 studies. In most, the follow-up periods ranged from 12 to 60 months. Obese individuals experienced greater pain (SMD 0.30; 95% CI, 0.10, 0.50) and lower shoulder function (SMD -0.33; 95% CI, -0.54, -0.12) than other individuals in the long-term post-operative follow-up. Obese individuals also had higher risks of complications (RR 1.48; 95% CI, 1.11, 1.98) and readmission (RR 1.35; 95% CI, 1.27, 1.43), but a similar likelihood of re-repair (RR, 1.27; 95% CI, 0.82, 1.95) than non-obese/normal BMI individuals. While the forward flexion and external rotation functions were comparable, obese individuals displayed less internal rotation function than other individuals (SMD -0.59; 95% CI, -0.87, -0.30). CONCLUSION: Obesity was associated with unfavourable outcomes after rotator cuff surgery, including increased pain, reduced shoulder function, high risks of complications, and readmission. These findings emphasize the importance of addressing obesity-related factors to improve post-operative outcomes.

The Relationship Among Probable SARCopenia, Osteoporosis and SuprasPinatus Tendon Tears in Postmenopausal Women: The SARCOSP Study.

We aimed to investigate the relationship among probable sarcopenia, osteoporosis (OP) and supraspinatus tendon (SSP) tears in postmenopausal women. Postmenopausal women screened/followed for OP were recruited. Demographic data, comorbidities, exercise/smoking status, and handgrip strength values were recorded. Probable sarcopenia was diagnosed as handgrip strength values < 20 kg. Achilles and SSP thicknesses were measured using ultrasound. Among 1443 postmenopausal women, 268 (18.6%) subjects had SSP tears. Unilateral tears were on the dominant side in 146 (10.1%) and on the non-dominant side in 55 women (3.8%). In contrast to those without, women with SSP tears had older age, lower level of education, thinner SSP and lower grip strength (all p < 0.05). In addition, they had higher frequencies of hypertension, hyperlipidemia, DM, OP and probable sarcopenia, but lower exercise frequency (all p < 0.05). Binary logistic regression modeling revealed that age [odds ratio (OR): 1.046 (1.024-1.067 95% CI)], hypertension [OR: 1.560 (1.145-2.124 95% CI)], OP [OR: 1.371 (1.022-1.839 95% CI)] and probable sarcopenia [OR: 1.386 (1.031-1.861 95% CI)] were significant predictors for SSP tears (all p < 0.05). This study showed that age, presence of hypertension, probable sarcopenia and OP were related with SSP tears in postmenopausal women. To this end, although OP appeared to be related to SSP tears, SSP tear/thickness evaluation can be recommended for OP patients, especially those who have other risk factors such as older age, higher BMI, hypertension, and probable sarcopenia.

[Can a fall onto the shoulder (direct impact) cause a rotator cuff tear?] / Kann ein Sturz auf die Schulter (Direktanprall) einen Riss der Rotatorenmanschette verursachen?

The question of whether a fall directly onto the shoulder can cause a rotator cuff tear has occupied doctors (and courts) for many years. Experts who rely on the medical insurance literature usually reject the causality of the incident. There are no scientific studies on this. The report below describes a typical case in which a fall directly onto the shoulder caused a massive rotator cuff tear.

Reverse Shoulder Arthroplasty for Irreparable Rotator Cuff Tear After Radial to Axillary End-to-Side Transfer: A Case Report.

CASE: A 60-year-old man sustained a massive irreparable rotator cuff tear and axillary nerve palsy with deltoid dysfunction after an anterior shoulder dislocation. He underwent staged reverse end-to-side radial-to-axillary nerve transfer with return of deltoid function allowing for subsequent reverse shoulder arthroplasty. At 1 year postoperatively, he returned to full activity. CONCLUSION: Irreparable rotator cuff tears complicated by axillary nerve palsy can be effectively treated with a staged approach of nerve transfer followed by reverse shoulder arthroplasty.

Patient-reported allergies are associated with increased rate of postoperative stiffness after arthroscopic rotator cuff repair.

BACKGROUND: Several risk factors have been identified for the development of postoperative shoulder stiffness, and there has been increasing interest in orthopedic literature regarding patient-reported allergy (PRA) as an identifiable risk factor for adverse outcomes. The purpose of this study is to determine whether PRAs are associated with subsequent rates of diagnosis of adhesive capsulitis (AC) or return to the operating room for postoperative shoulder stiffness within 2 years after arthroscopic rotator cuff repair (ARCR). METHODS: Current Procedural Terminology surgical billing codes were used to retrospectively identify patients who underwent ARCR at a single urban academic institution from January 2012 to December 2020 with minimum 2-year follow-up. Lysis of adhesions (LOA), manipulation under anesthesia (MUA), and AC of the shoulder were further queried within 2 years postoperatively for the ipsilateral shoulder. Patients were excluded if they had undergone ipsilateral MUA/LOA or received a diagnosis of AC before the index procedure. Demographic characteristics and medical comorbidities (hypertension, diabetes, hyperlipidemia, and hypothyroidism) were extracted from electronic medical records. Baseline characteristics were compared between patients with and without PRAs. Multivariate logistic regression analyses were performed to determine the association of the presence of PRAs overall, as well as the presence of 1, 2, or 3 or more PRAs, with subsequent MUA/LOA or diagnosis of AC within 2 years postoperatively. RESULTS: Of 7057 patients identified in the study period, 6583 were eligible for the final analysis. The mean age was 56.6 ± 11.7 years, and the mean body mass index was 29.1 ± 5.6. Overall, 19.3% of patients (n = 1271) reported at least 1 allergy, and 7.1% (n = 469) had >1 PRA. A total of 44 patients (0.7%) underwent subsequent ipsilateral MUA/LOA within 2 years postoperatively, whereas 93 patients (1.4%) received a diagnosis of ipsilateral AC in the same time frame. PRAs were significantly associated with subsequent diagnosis of AC (odds ratio [OR]: 2.39; 95% confidence interval [CI]: 1.45-3.92; P < .001), but not MUA/LOA (OR: 1.97, 95% CI: 1.26-3.61; P = .133). Patients with 2 PRAs had greater odds of being diagnosed with AC than patients with 1 PRA (OR: 2.74; 95% CI: 1.14-5.99; P = .012). Although this association was nonsignificant for MUA/LOA, patients with 2 PRAs (OR: 2.67; 95% CI: 0.96-8.80; P = .059) demonstrated a similar statistical trend. CONCLUSION: PRAs are associated with increased odds of receiving a diagnosis of AC within 2 years after ARCR but were not found to be associated with return to the operating room for postoperative stiffness.

Lower Trapezius Transfer Improves Clinical Outcomes With a Rate of Complications and Reoperations Comparable to Other Surgical Alternatives in Patients with Functionally Irreparable Rotator Cuff Tears: A Systematic Review.

PURPOSE: To analyze the clinical outcomes of lower trapezius transfer (LTT) for patients with functionally irreparable rotator cuff tears (FIRCT) and summarize the available literature regarding complications and reoperations. METHODS: After registration in the International prospective register of systematic reviews (PROSPERO [CRD42022359277]), a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Inclusion criteria were English, full-length, peer-reviewed publications with a level of evidence IV or higher reporting on clinical outcomes of LTT for FIRCT. Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus via Elsevier databases were searched. Clinical data, complications and revisions were systematically recorded. RESULTS: Seven studies with 159 patients were identified. The mean age range was 52 to 63 years, 70.4% of the patients included were male, and the mean follow-up time ranged between 14 and 47 months. At final follow-up, LTT lead to improvements in range of motion, with reported forward elevation (FE) and external rotation (ER) mean gains of 10° to 66° and 11° to 63°, respectively. ER lag was present before surgery in 78 patients and was reversed after LTT in all shoulders. Patient-reported outcomes were improved at final follow-up, including the American Shoulder and Elbow Society score, Shoulder Subjective Value and Visual Analogue Scale. The overall complication rate was 17.6%, and the most reported complication was posterior harvest site seroma/hematoma (6.3%). The most common reoperation was conversion to reverse shoulder arthroplasty (5%) with an overall reoperation rate of 7.5%. CONCLUSIONS: Lower trapezius transfer improves clinical outcomes in patients with irreparable rotator cuff tears with a rate of complications and reoperations comparable to other surgical alternatives in this group of patients. Increases in forward flexion and ER are to be expected, as well as a reversal of ER lag sign when present before surgery. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

Pseudoparesis and pseudoparalysis in the setting of massive irreparable rotator cuff tear: demographic, anatomic, and radiographic risk factors.

BACKGROUND: The primary purpose of this study was to identify demographic, anatomic, and radiographic risk factors for active forward elevation (AFE) <90° in the setting of massive, irreparable rotator cuff tear (miRCT). The secondary purpose was to identify characteristics differentiating between patients with pseudoparalysis (AFE <45°) and pseudoparesis (AFE >45° but <90°). METHODS: This was a retrospective case-control study reviewing patients with miRCTs at a single institution between January 12, 2016 and November 26, 2020. Patients were separated into 2 cohorts based on presence or absence of preoperative AFE <90° with maintained passive range of motion. Demographics, RCT pattern, and radiographic parameters were assessed as risk factors for AFE <90°. A secondary analysis was conducted to compare patients with pseudoparalysis and pseudoparesis. RESULTS: There were 79 patients in the AFE <90° cohort and 50 patients in the control cohort. Univariate analysis confirmed significant differences between the AFE <90° and control cohort in age (71.9 ± 11.0 vs. 65.9 ± 9.1 years), arthritis severity (34.2% vs. 16.0% grade 3 Samilson-Prieto), acromiohumeral distance (AHD; 4.8 ± 2.7 vs. 7.6 ± 2.6 mm), fatty infiltration of the supraspinatus (3.3 ± 0.9 vs. 2.8 ± 0.8) and subscapularis (2.0 ± 1.2 vs. 1.5 ± 1.0), and proportion of subscapularis tears (55.7% vs. 34.0%). On multivariate analysis, age (odds ratio [OR] 1.08, P = .014), decreased AHD (OR 0.67, P < .001), severe arthritis (OR 2.84, P = .041), and subscapularis tear (OR 6.29, P = .015) were independent factors predictive of AFE <90°. Secondary analysis revealed tobacco use (OR 3.54, P = .026) and grade 4 fatty infiltration of the supraspinatus (OR 2.22, P = .015) and subscapularis (OR 3.12, P = .042) as significant predictors for pseudoparalysis compared to pseudoparesis. CONCLUSIONS: In patients with miRCT, increased age, decreased AHD, severe arthritis, and subscapularis tear are associated with AFE <90°. Furthermore, patients with AFE <90° tend to have greater supraspinatus and subscapularis fatty infiltration. Lastly, among patients with AFE <90°, tobacco use and grade 4 fatty infiltration of the supraspinatus and subscapularis are associated with pseudoparalysis compared with pseudoparesis.

Elevated HbA1c is not associated with reoperation following arthroscopic rotator cuff repair in patients with diabetes mellitus.

BACKGROUND: Hyperglycemia is a known risk factor for tendon degeneration due to oxidative stresses from production of advanced glycosylation end products. In patients with diabetes mellitus (DM), analysis of glycated hemoglobin (HbA1c) provides a 3-month window into a patient's glucose control. No guidelines exist for ideal preoperative HbA1c and glucose control prior to arthroscopic rotator cuff repair. This study evaluated if a critical HbA1c level is associated with reoperation following arthroscopic rotator cuff repair. METHODS: We retrospectively evaluated patients with DM who underwent primary arthroscopic rotator cuff repair from January 2014 to December 2018 at a single institution. Patients required a preoperative HbA1c within 3 months of surgery. Medical records were queried to evaluate for reoperation and identify the subsequent procedures performed. Univariate statistical analysis was performed to assess factors associated with reoperation (P < .05 considered significant). Threshold, area under the curve (AUC), analysis was performed to assess if a critical HbA1c value was associated with reoperation. RESULTS: A total of 402 patients met inclusion criteria. Patients had an average age of 65.5 years (range 40-89) at time of surgery; 244 (60.6%) patients were male; and average body mass index was 32.96 ± 5.81. Mean HbA1c was 7.36 (range 5.2-12). Thirty-three patients (8.2%) underwent subsequent reoperation. Six patients (1.5%) underwent capsular release and lysis of adhesions, 20 patients (5.0%) underwent a revision rotator cuff surgery, combination revision rotator cuff repair and lysis of adhesions, graft-augmented revision repair, or superior capsular reconstruction, and 7 patients (1.7%) underwent revision to reverse shoulder arthroplasty (1.7%). There were no cases of reoperation for infection. On AUC analysis, no critical HbA1c value was identified to predispose to reoperation. Interestingly, elevated preoperative American Society of Anesthesiologists (ASA) physical status classification score (2.8 vs. 2.28, P = .001) was associated with a higher reoperation rate. DISCUSSION: In patients with DM, preoperative HbA1c is not a predictive factor for surgical failure requiring reoperation. Stable glycemic control is important to a patient's overall health and may play a role in minimizing postoperative medical complications, but an elevated preoperative HbA1c should not be a strict surgical contraindication for arthroscopic rotator cuff repair. In patients with DM, an elevated ASA score is associated with an increased rate of subsequent reoperation; diabetic patients should be counseled accordingly.

Superior humeral head osteophytes are associated with rotator cuff insufficiency in glenohumeral osteoarthritis: a retrospective analysis.

PURPOSE: The primary goal of this study was to investigate whether superior humeral head osteophyte (SHO) size is associated with rotator cuff insufficiency, including rotator cuff tear (RCT), supraspinatus tendon thickness, and fatty infiltration of the rotator cuff muscles. METHODS: Patients ≥ 18 years who were diagnosed with glenohumeral osteoarthritis were retrospectively reviewed. SHO size was determined by radiograph. MRI measured SHO and RCT presence, type, and size; supraspinatus tendon thickness; and fatty infiltration of rotator cuff musculature. RESULTS: A total of 461 patients were included. Mean SHO size was 1.93 mm on radiographs and 2.13 mm on MRI. Risk ratio for a RCT was 1.14. For each 1-mm increase in SHO size on radiograph, supraspinatus tendon thickness decreased by 0.20 mm. SHO presence was associated with moderate-to-severe fatty infiltration of the supraspinatus with a risk ratio of 3.16. CONCLUSION: SHOs were not associated with RCT but were associated with higher risk of supraspinatus FI and decreased tendon thickness, which could indicate rotator cuff insufficiency. LEVEL OF EVIDENCE: IV.

Patients with rotator cuff tears present a psychological impairment, not only a functional deficit: a systematic review.

INTRODUCTION: Psychological factors impact patients with rotator cuff tears (RCT) in terms of pain level, shoulder function, sleep disturbance, and quality of life (QoL). The aim of this study was to quantify the prevalence of psychological factors in those patients, evaluate their influence on patient-reported outcomes (PROMs), and assess the possible improvement with surgical treatment. METHODS: The literature search was performed on PubMed, Web of Science, Wiley Cochrane Library up to January, 2023. INCLUSION CRITERIA: RCT treated with arthroscopic rotator cuff reconstruction (ARCR), description of psychological variables evaluated with validated questionnaires, descriptions of PROMs. RESULTS: Thirty-nine studies included 7021 patients. Depression was found in eight studies (19.2%), anxiety in 6 (13.0%), sleep disturbance in seven (71.3%), and distress in three studies (26.4%). Studies evaluating the relationship between psychological impairment and pain documented more pain and impaired shoulder function before and after ARCR in patients with altered psychological status. DISCUSSION: An impaired psychological status has an important impact on patients' perception of their disease. RCT patients with psychological alterations often experience more pain and reduced shoulder function, thus having worse QoL. CONCLUSION: This study underlines that psychological impairment largely affects RCT patient condition and treatment outcome, which underlines the importance of a multidisciplinary biopsychosocial intervention to achieve better results.

Influence of body mass index on severity of rotator cuff tears.

BACKGROUND: Research on the relationship between obesity and rotator cuff tears (RCTs) has been limited to the impact of obesity on the results of arthroscopic repair of RCTs; thus, a need for rigorous research controlling for other factors affecting RCTs is warranted, especially to better understand the impact of body mass index (BMI) on RCT severity. METHODS: A retrospective study of admission records contained in electronic medical records pertaining to patients who were admitted for RCT repair on 1 shoulder between January 2018 and July 2022 was conducted. In total, 386 patients were included. In accordance with guidance regarding obesity from Taiwan's Ministry of Health and Welfare, patients were divided into three groups: underweight or normal weight (BMI <24.0 kg/m2), overweight (BMI 24.0-26.9 kg/m2), or obese (BMI ≥27.0 kg/m2). Magnetic resonance imaging was used to assess RCT severity in terms of four parameters: Patte stage (PS), fatty infiltration (FI), anteroposterior tear size (AP), and retraction size. Multinomial logistic regression analysis was performed on PS and FI grade data, and multiple linear regression analysis was performed on AP tear size and retraction size in order to analyze impact. RESULTS: Our results revealed that the average age of the 386 patients was 63.41 years (SD = 9.29) and the mean BMI was 25.88 (SD = 3.72) kg/m2. We found significant differences in PS (P = .003), FI (P < .001), retraction size (P = .001), and AP tear size (P = .001) among patients who were underweight or normal weight, overweight, and obese. After controlling for other risk factors, including age, gender, RCT-prone occupation, duration of shoulder pain prior to surgery, history of shoulder injury, and tobacco use, we found that obese patients had higher severity levels in PS (B = 1.21, OR = 3.36, P = .029), FI (B = 1.38, OR = 3.96, P < .001), retraction size (ß = 0.18, P = .001), and AP tear size (ß = 0.18, P = .001) compared to underweight or normal weight patients. CONCLUSIONS: Our study demonstrates that a correlation exists between BMI-measured obesity and RCT severity. We therefore suggest that adults control their weight given that maintaining a healthy weight is highly associated with better shoulder health.

Reverse shoulder arthroplasty for primary glenohumeral osteoarthritis: significantly different characteristics and outcomes in shoulders with intact vs. torn rotator cuff.

PURPOSE: To compare outcomes of reverse shoulder arthroplasty (RSA) for primary osteoarthritis (OA) with and without rotator cuff (RC) tears to those with secondary OA due to RC tears. METHODS: We reviewed records of all patients who received RSA for primary OA or secondary OA. All patients had preoperative radiographs, computed tomographic arthrography (CTA), and/or magnetic resonance imaging (MRI) scans of their shoulders to assess their etiology, glenoid morphology, and fatty infiltration. Pre- and postoperative (at minimum follow-up of 2 years) Constant scores and range of motion were compared between patients who had RSA for primary OA with and without RC tears to those with secondary OA due to RC tears. RESULTS: Of the initial cohort of 605 shoulders (583 patients), 153 were lost to follow-up (25.3%), 25 required revision with implant removal (4.1%), and 13 died of causes unrelated to the surgery (2.1%), and left a final cohort of 414 patients. Of the final cohort, 97 had primary OA with intact RC, 62 had primary OA with RC tears, and 255 had secondary OA. Postoperative Constant scores were significantly higher for primary OA with intact RC (73.8 ± 14.3), compared with both primary OA with RC tears (66.1 ± 14.6, P < .001) and secondary OA (64.1 ± 14.8, P < .001). There were no differences in pre- or postoperative scores between primary OA with RC tears and secondary OA. CONCLUSION: At 2 or more years following RSA, Constant scores were significantly higher for primary OA with intact RC, compared to either primary OA with RC tears or secondary OA, whereas there were no differences in pre- or postoperative scores of shoulders that had primary OA with RC tears vs. secondary OA. The authors recommend distinguishing primary OA with intact RC from primary OA with RC tears, as the two have considerably different characteristics and prognosis following RSA.

Predictors of pain development for contralateral asymptomatic degenerative rotator cuff tears based on features of an ipsilateral painful cuff tear: a prospective longitudinal cohort study.

BACKGROUND: Prior rotator cuff disease natural history studies have focused on tear-related factors that predict disease progression within a given shoulder. The purpose of this study was to examine both patient- and tear-related characteristics of a painful rotator cuff tear that predict future pain development and functional impairment in a shoulder with a contralateral asymptomatic cuff tear. METHODS: This was a prospective longitudinal cohort study of patients aged ≤65 years who underwent surgery for a painful degenerative rotator cuff tear and possessed an asymptomatic contralateral tear. Patients were followed up prospectively by shoulder ultrasound, physical examination, and functional score assessment. The primary outcome was change in the American Shoulder and Elbow Surgeons (ASES) score at 2 years. Secondary outcomes included the Western Ontario Rotator Cuff Index (WORC) score, Patient-Reported Outcomes Measurement Information System (PROMIS) score, Hospital Anxiety Depression Scale (HADS) depression and anxiety scores, and Veterans RAND-12 (VR-12) mental component score (MCS). RESULTS: Sixty-five patients were included, with a mean follow-up period of 37 months (range, 24-42 months). In 17 patients (26%), contralateral shoulder pain developed at a median of 15.2 months (interquartile range [IQR], 10.5 months). No difference in age, sex, Charlson Comorbidity Index, or occupational demand was noted between patients in whom pain developed and those in whom pain did not develop. In the presenting painful shoulder, there was no difference in baseline tear size, muscle degeneration, or biceps pathology between groups. The mean baseline tear length (8.6 mm vs. 3.8 mm, P = .0008) and width (8.4 mm vs. 3.2 mm, P = .0004) were larger in asymptomatic shoulders in which pain subsequently developed compared with those in which pain did not develop. However, there was no difference in mean tear enlargement (P = .51 for length and P = .90 for width). There were no differences in baseline ASES, WORC, Patient-Reported Outcomes Measurement Information System (PROMIS), or HADS depression and anxiety scores between shoulders in which pain developed and those in which pain did not develop; however, patients in whom pain developed reported a lower baseline VR-12 MCS (53.3 vs. 57.6, P = .04). Shoulders in which pain developed had higher visual analog scale pain scores (2.9 [standard deviation (SD), 2.5] vs. 0.6 [SD, 1.0]; P = .016), lower ASES scores 75 [SD, 33] vs. 100 [SD, 11.6]; P = .001), and significant changes in all WORC scales with pain onset compared with those that remained asymptomatic. The study showed no significant difference in changes in the HADS anxiety and depression scores but found a significant increase in the VR-12 MCS in patients in whom pain developed (7.1 [interquartile range, 12.6] vs. -1.9 [interquartile range, 8.7]; P = .036). CONCLUSION: In one-quarter of patients with painful cuff tears, pain developed in a contralateral asymptomatic cuff tear that resulted in a measurable decline in function within 3 years. Our analysis showed that only the baseline tear size of the asymptomatic shoulder was predictive of pain development. There were no tear-related features of the presenting painful rotator cuff tear or indices of mental health and physical function or occupational demand that were predictive of future pain development at short-term follow-up.

The effect of concurrent cervical spine degenerative disease on the outcome of rotator cuff repair: a national database study.

BACKGROUND: Cervical spine degenerative disease (CSD) can cause shoulder pain, potentially confounding the management of patients with rotator cuff tears. This study aimed to investigate the relationships between CSD and rotator cuff repair (RCR). METHODS: A national administrative database (PearlDiver) was used to study 4 patient cohorts: (1) RCR only (RCRo), (2) RCR with concurrent CSD (RCRC), (3) RCR after a cervical spine procedure (RCRA), and (4) RCR before a cervical spine procedure (RCRB). The outcomes of RCR were compared using multivariable logistic regression, controlling for age, sex, and Elixhauser Comorbidity Index, as well as preoperative opioid utilization in the analysis of opioid use. RESULTS: Between 2010 and 2021, a total of 889,977 patients underwent RCR. Of these patients, 784,230 (88%) underwent RCRo whereas 105,747 (12%) underwent RCRC, of whom 21,585 (2.4%) underwent cervical spine procedures (RCRA in 9670 [1.1%] and RCRB in 11,915 [1.3%]). At 2 years after RCR, compared with RCRo patients, RCRC patients had an increased risk of surgical-site infection (adjusted odds ratio [aOR] = 1.25, P = .0004), deep vein thrombosis (aOR = 1.17, P = .0002), respiratory complications (aOR = 1.19, P = .0164), and ipsilateral shoulder reoperations (débridement [aOR = 1.66, P < .0001], manipulation under anesthesia or arthroscopic lysis of adhesions [aOR = 1.23, P < .0001], distal clavicle excision [aOR = 1.78, P < .0001], subacromial decompression [aOR = 1.72, P < .0001], biceps tenodesis [aOR = 1.76, P < .0001], incision and drainage [aOR = 1.34, P = .0020], synovectomy [aOR = 1.48, P = .0136], conversion to shoulder arthroplasty [aOR = 1.62, P < .0001], revision RCR [aOR = 1.77, P < .0001], and subsequent contralateral RCR [aOR = 1.71, P < .0001]). At 2 years, compared with RCRC patients who did not undergo cervical spine procedures, RCRC patients who underwent cervical spine procedures had an increased risk of incision and drainage (aOR = 1.50, P = .0255), conversion to arthroplasty (aOR = 1.40, P < .0001), and revision RCR (aOR = 1.11, P = .0374), as well as a lower risk of contralateral RCR (aOR = 0.89, P = .0469). The sequence of cervical spine procedures did not affect the risk of shoulder reoperations. At 1 year, the risk of opioid use after RCR was less for RCRA patients compared with RCRB patients (aOR = 1.71 [95% confidence interval, 1.61-1.80; P < .0001] vs. aOR = 2.01 [95% confidence interval, 1.92-2.12; P < .0001]). CONCLUSION: Concurrent CSD has significant detrimental effects on RCR outcomes. Patients with concurrent CSD undergoing cervical spine procedures have a greater risk of ipsilateral shoulder reoperations but a decreased risk of contralateral RCR. The risk of prolonged opioid use was lower if RCR followed a cervical spine procedure. Concurrent CSD must be considered and possibly treated to optimize the outcomes of RCR.

Significant Association between a Diagnosis of Hypovitaminosis D and Rotator Cuff Tear, Independent of Age and Sex: A Retrospective Database Study.

PURPOSE: As high rates of vitamin D deficiency have been demonstrated in orthopedic patient cohorts, this study aimed to characterize the association between a diagnosis of hypovitaminosis D and primary rotator cuff tear (RCT), primary rotator cuff repair (RCR), and postoperative complications in different sex and age cohorts. METHODS: In this retrospective cohort study using PearlDiver, a nationwide administrative claims database, records for all patients aged 30 to 89 yr who received a diagnosis of hypovitaminosis D between January 1, 2011, and October 31, 2018, were queried. Rates of primary RCT, primary RCR, and postoperative complications including subsequent surgery were calculated within sex- and age-specific cohorts and compared with matched control cohorts using multivariable logistic regression. RESULTS: Among the 336,320 patients included in the hypovitaminosis D cohort, these patients were significantly more likely to experience an RCT (odds ratio (OR), 2.70; 95% confidence interval (CI), 2.55-2.85) as well as a full-thickness RCT (OR, 2.36; 95% CI, 2.17-2.56) specifically within 2 yr of their diagnosis. Women with hypovitaminosis D were more likely to undergo surgery to address their full-thickness tears (OR, 1.37; 95% CI, 1.09-1.74). There was no difference in the rates of revision RCR or irrigation and debridement. However, women with hypovitaminosis D were significantly more likely to undergo manipulation under anesthesia (OR, 1.16; 95% CI, 1.03-1.31). CONCLUSIONS: Patients diagnosed with hypovitaminosis D were significantly more likely to suffer from a primary RCT and to undergo manipulation under anesthesia within a year of their RCR. Although many risk factors for RCT are unmodifiable, vitamin D deficiency is a readily modifiable risk factor with several treatment regimens demonstrating positive effects on musculoskeletal health.

Interventions used to mitigate muscle fatty degeneration following the repair of massive rotator cuff tears. A systematic review of animal studies.

BACKGROUND: Muscle fatty degeneration following rotator cuff tears has been unequivocally associated with poorer functional outcomes and increased risk for retear following rotator cuff repair. Promising results have emerged from animal studies, with the implementation of various interventions for biologic inhibition of this fatty muscle degeneration. The lack of high quality randomized human evidence on this topic, increases the impact of pooled results from animal literature. The aim of the present study was to systematically review the available published literature for animal studies evaluating the ability of several interventions used to mitigate muscle fatty degeneration following the repair of massive rotator cuff tears. PATIENTS AND METHODS: A comprehensive search was conducted on Pubmed, Scopus and Google Scholar, covering the period from conception until 16th April 2022. Datasets were stratified based on the type of intervention performed. SYRCLE risk of bias instrument was implemented for quality assessment of the included studies. RESULTS: Rotator cuff repair augmentation with Adipose derived stem cells (ADSC's), Mesenchymal stem cells (MSC's) and Nandrolone was effective against fatty infiltration, but less effective against muscle atrophy. More beneficial effect was shown by the utilization of Beige adipose tissue - Fibroadipogenic progenitors (BAT-FAP) stimulation, using either Amibregon or BAT-FAPs transplantation. Both provided good results in mitigating muscle atrophy, fatty infiltration and fibrosis. DISCUSSION: ADSC's, MSC's, Nandrolone and BAT-FAP stimulation may have a role in mitigating muscle fatty degeneration following rotator cuff tears. Large scale human studies are required to further elucidate their role in the clinical setting. LEVEL OF EVIDENCE: V; systematic review of pre-clinical studies.

Local Injection of Rapamycin-Loaded Pcl-Peg Nanoparticles for Enhanced Tendon Healing in Rotator Cuff Tears via Simultaneously Reducing Fatty Infiltration and Drug Toxicity.

As a common cause of shoulder pain, rotator cuff tears (RCTs) are difficult to treat clinically because of their unsatisfactory prognosis due to the fatty infiltration caused by muscle-derived stem cells (MDSCs). Previous studies have found that rapamycin (RAPA) can inhibit fatty infiltration. However, systemic administration of RAPA may cause complications such as infection and nausea, while local administration of RAPA may lead to the cytotoxicity of tendon cells, affecting the healing of rotator cuffs. In this study, biocompatible and clinically approved polycaprolactone-polyethylene glycol (PCL-PEG) is formulated into an injectable nanoparticle for the sustained release of RAPA. The results indicate that the RAPA/PCL-PEG nanoparticles (NPs) can efficiently prolong the release of RAPA and significantly reduce the cytotoxicity of tendon cells caused by RAPA. The study of the fatty infiltration model in rats with delayed rotator cuff repair shows that weekly intraarticular injection of RAPA/PCL-PEG NPs can more effectively reduce the fatty infiltration and muscle atrophy of rat rotator cuffs and leads to better mechanical properties and gait improvements than a daily intraarticular injection of RAPA. These findings imply that local injection of RAPA/PCL-PEG NPs in the shoulder joints can be a potential clinical option for RCTs patients with fatty infiltration.

Does body mass index affect outcomes following arthroscopic superior capsular reconstruction using fascia lata autograft for massive irreparable rotator cuff tear?

PURPOSE: This study aimed to evaluate the effect of increased body mass index (BMI) on patient-reported outcomes (PROs) and clinically significant outcomes (CSOs) obtained > two years postoperatively following arthroscopic superior capsular reconstruction (ASCR). METHODS: A retrospective study was conducted on patients who underwent ASCR with a minimum two year follow-up. All patients were divided into normal (BMI < 25.0), overweight (BMI 25-30.0), and obese (BMI ≥ 30) according to preoperative BMI. Patients were assessed using the PROs preoperatively and at six months, one year, and two years postoperatively, including the visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES), and Constant-Murley scores. The time required to achieve each CSO was analyzed and compared. Multivariate analyses evaluated the predictor variables and time required to achieve CSOs. RESULTS: This study included 63 patients with a mean age of 64.8 ± 8.6 years, including 31 normal BMI, 25 overweight, and seven obese patients. Significant improvements in VAS and ASES scores after ASCR were observed in all three groups. Normal and overweight patients had significant improvements in the Constant score; however, no difference was observed in obese patients. No significant difference was observed in the probability distributions of CSOs between the BMI groups. Similarly, no significant differences were observed in the probability distributions of the CSOs, ASES, and Constant scores at each time point, among the BMI groups. CONCLUSION: Patients in the normal and overweight groups had significant improvements in the VAS, ASES, and Constant scores after ASCR. Patients in the obese group had a significant improvement in VAS score; however, there is no difference for the ASES and Constant scores in the obese group. However, no differences were observed in all PROMs and the likelihood of achieving CSOs among the different BMI groups.