Revision Rotator Cuff Repair With Versus Without an Arthroscopically Inserted Onlay Bioinductive Implant in Workers' Compensation Patients.

Background: The addition of onlay biological grafts to augment difficult rotator cuff repairs has shown encouraging results in a case series. Purpose/Hypothesis: The purpose of this study was to determine whether the addition of an onlay bioinductive implant would improve repair integrity, shear wave elastographic appearance of the repaired tendon and patch, and patient-rated and/or surgeon-measured shoulder function when used in workers' compensation patients undergoing revision arthroscopic rotator cuff repair. We hypothesized that the addition of the bioinductive implant would enhance repair integrity and clinical outcomes compared with standard repair. Study Design: Cohort study; Level of evidence, 3. Methods: A post hoc matched-cohort study was conducted on prospectively recruited workers' compensation patients who received a bioinductive implant for revision rotator cuff repair (n = 19). The control group was selected from consecutive workers' compensation revision rotator cuff repair patients before the introduction of bioinductive implants. Then, they were matched for age and tear size (n = 32). Kaplan-Meier curves were generated to compare the primary outcome of repair integrity between groups. The secondary outcomes were to evaluate the elastographic appearance of the tendon and patch in the bioinductive implant group and to compare patient-rated and surgeon-measured shoulder function between groups preoperatively and at 1 week, 6 weeks, 3 months, and 6 months postoperatively. Results: No major complications associated with the bioinductive implants were identified. Six months after the revision rotator cuff repair, the retear rate in the bioinductive implant group was 16% (3/19), compared with 19% (6/32) in the age- and tear size-matched control group (P = .458). At the final follow-up, the retear rate in the bioinductive implant group was 47% (9/19) at a mean of 14 months compared with 38% (12/32) at a mean of 29 months in the control group (P = .489). The shear wave elastographic stiffness of repaired tendons augmented with the bioinductive implant remained unchanged at 6 m/s from 1 week to 6 months postoperatively, which is lower than the stiffness of 10 m/s in healthy tendons. There were no significant differences in patient-rated or surgeon-measured outcomes between groups 6 months postoperatively. Conclusion: There were no differences in repair integrity or clinical outcomes between workers' compensation patients who underwent revision arthroscopic rotator cuff repair with an onlay bioinductive implant compared to those who underwent standard revision rotator cuff repair.

Reliability of a Novel Preoperative Protocol for Determining Graft Sizes for Superior Capsular Reconstruction Using Plain Film Radiography.

BACKGROUND: Superior capsular reconstruction (SCR) for massive, irreparable rotator cuff tears involves anchoring a graft between the superior glenoid and the greater tuberosity of the humerus. Optimizing the graft size is important. We aimed (1) to evaluate the reliability of plain film radiography in determining graft size for SCR and (2) to create a database to help predict future graft sizes. METHODS: An inter- and intra-rater reliability trial was conducted on 10 and 6 subjects with healthy shoulders, respectively, using plain film radiography to measure the distance between the superior glenoid and the supraspinatus footprint. The subjects were positioned upright with an abduction pillow modified to hold the shoulder at 30° abduction and 45° external rotation, afterwhich a true antero-posterior shoulder radiograph was captured. Thirty subjects were recruited for the database and grouped using the aforementioned protocol. RESULTS: The inter-rater and intra-rater trial agreement was excellent, with intraclass correlation coefficients of 0.94 (95% CI) and 0.76 (95% CI), respectively. Three medio-lateral patch sizes, of 33 mm, 38 mm, and 47 mm, were proposed based on the protocol in 30 subjects. CONCLUSIONS: Plain film radiography demonstrated excellent reliability in measuring the distance between the superior glenoid and the supraspinatus footprint. Three ordinal patch sizes are proposed.

Biomechanical Comparison of Synthetic Polytetrafluoroethylene (PTFE) vs Human Dermal Allograft (HDA), 2 vs 3 Glenoid Anchors, and Suture vs Minitape in Superior Capsule Reconstruction.

Background: Superior capsule reconstruction (SCR) is an option for the treatment of massive, irreparable rotator cuff tears. However, which materials yield the strongest constructs remains undetermined. Purposes: We sought to investigate whether SCR with polytetrafluoroethylene (PTFE) or human dermal allograft (HDA), 2 or 3 glenoid anchors, and suture or minitape resulted in better failure load properties at the patch-glenoid interface. Methods: We conducted a biomechanical study in 30 glenoid-sided SCR repairs in Sawbones models divided into 5 groups. Each was pulled to failure to assess mode of failure, peak load (N), stiffness (N/mm), yield load (N), peak energy (N m), and ultimate energy (N m). The 5 groups were as follows: group 1-PTFE, 2 anchors, and suture; group 2-PTFE, 2 anchors, and minitape; group 3-HDA, 2 anchors, and suture; group 4-HDA, 2 anchors, and minitape; group 5-PTFE, 3 anchors, and minitape. Results: Repairs failed by button-holing of suture/minitape. Group 5 had greater peak load, stiffness, yield load, and peak energy (384 ± 62 N; 24 ± 3 N/mm; 343 ± 42 N; 4 ± 2 N m) than group 3 (226 ± 67 N; 16 ± 4 N/mm; 194 ± 74 N; 2 ± 1 N m) or group 4 (274 ± 62 N; 17 ± 4 N/mm; 244 ± 50 N; 2 ± 1 N m) and greater ultimate energy (8 ± 3 N m) than all other groups. Conclusions: This biomechanical study of SCR repairs in Sawbones models found that yield load was greater in PTFE than HDA, 3 anchors were better than 2, and minitape was no better than suture.

Predictors of Return to Work Following Primary Arthroscopic Rotator Cuff Repair: An Analysis of 1502 Cases.

BACKGROUND: It is undetermined which factors predict return to work after arthroscopic rotator cuff repair. PURPOSE: To identify which factors predicted return to work at any level and return to preinjury levels of work 6 months after arthroscopic rotator cuff repair. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Multiple logistic regression analysis of prospectively collected descriptive, preinjury, preoperative, and intraoperative data from 1502 consecutive primary arthroscopic rotator cuff repairs, performed by a single surgeon, was performed to identify independent predictors of return to work at 6 months postoperatively. RESULTS: Six months after arthroscopic rotator cuff repair, 76% of patients had returned to work, and 40% had returned to preinjury levels of work. Return to work at 6 months was likely if patients were still working after their injuries but before surgery (Wald statistic [W] = 55, P < .0001), were stronger in internal rotation preoperatively (W = 8, P = .004), had full-thickness tears (W = 9, P = .002), and were female (W = 5, P = .030). Patients who continued working postinjury but presurgery were 1.6 times more likely to return to work at any level at 6 months compared to patients who were not working (P < .0001). Patients who had a less strenuous preinjury level of work (W = 173, P < .0001), worked at a mild to moderate level post injury but presurgery, had greater preoperative behind-the-back lift-off strength (W = 8, P = .004), and had less preoperative passive external rotation range of motion (W = 5, P = .034) were more likely to return to preinjury levels of work at 6 months postoperatively. Specifically, patients who worked at a mild to moderate level postinjury but presurgery were 2.5 times more likely to return to work than patients who were not working, or who were working strenuously postinjury but presurgery (p < 0.0001). Patients who nominated their preinjury level of work as "light" were 11 times more likely to return to preinjury levels of work at 6 months compared to those who nominated it as "strenuous" (P < .0001). CONCLUSION: Six months after rotator cuff repair, patients who continued to work after injury but presurgery were the most likely to return to work at any level, and patients who had less strenuous preinjury levels of work were the most likely to return to their preinjury levels of work. Greater preoperative subscapularis strength independently predicted return to work at any level and to preinjury levels.

Biomechanical and morphological comparison of two interposition graft rotator cuff repair techniques.

BACKGROUND: Interposition graft rotator cuff repair is one option for the treatment of massive, otherwise irreparable rotator cuff tears. It is undetermined how different suturing techniques influence morphology at the patch-tendon interface in interposition rotator cuff repairs, particularly with respect to increased cross-sectional area at the repair site post-exposure to cyclic loading, which may influence healing. We aimed to analyze how the morphology of the grafts used in polytetrafluoroethylene (PTFE) interposition rotator cuff repairs differed according to whether the graft was secured using the multiple mattress technique or the weave technique respectively. METHODS: Twelve PTFE interposition rotator cuff repairs (two groups, n = 6) were cyclically loaded. The thickness, width, cross-sectional area at the individual patches and at the repair site, and patch elongation were compared between repairs using the 'multiple mattress' technique and repairs that used the 'weave' technique. RESULTS: At all loads, repair site cross-sectional area and thickness was greater in the weave group than in the multiple mattress group (P<0.05), despite repair site width being greater in the multiple mattress group (P<0.05). No significant differences in elongation were found between the multiple mattress and weave groups. CONCLUSION: Greater repair site cross-sectional area under cyclic loading was observed in polytetrafluoroethylene interposition rotator repairs that used the weave technique than in those that used the multiple mattress technique. Increased repair site cross-sectional area in the weave group occurred due to increased thickness and decreased width relative to the multiple mattress group. No differences in cross-sectional area were found between groups at the individual patches.

Factors influencing clinical outcomes in superior capsular reconstruction: A scoping review.

Background: It is undetermined how effective superior capsule/capsular reconstruction (SCR) is, and which factors influence clinical outcomes. Questions/purposes: (1) To identify which factors influence outcomes in SCR, (2) to evaluate the effect of graft integrity on clinical outcomes, and (3) to compare SCR to other procedures for irreparable rotator cuff tears. Methods: PubMed and EMBASE databases were searched for clinical SCR studies. Data on specific factors that influenced outcomes, that compared outcomes between intact/torn graft groups, or compared SCR to alternative treatments for irreparable tears were extracted by two investigators. Random-effects meta-analysis was performed to compare outcomes between intact vs torn SCR grafts. Results: 394 articles were identified. 100 full-text articles were screened. 13 studies were included for scoping review. Eight studies were meta-analyzed. Better clinical scores were found in younger patients, with intact/repairable subscapularis, without acetabulization/arthritis, who played sports. In patients with irreparable tears without arthritis, SCR produced similar clinical scores at 2 years as shoulder arthroplasty and partial infraspinatus repair, and greater improvements in ASES and Constant scores than latissimus dorsi tendon transfer. Intact grafts produced better VAS (mean difference [MD] = 0.97, 95% confidence interval [-1.45-0.50], P < 0.0001, I 2 = 67%, n [patients] = 261), ASES (MD = 8.29, [2.89-13.70], P = 0.003, I 2 = 74%, n = 281), external rotation (MD = 4.49, [0.36-8.61], P = 0.03, I 2 = 0%, n = 240), and acromiohumeral distance (MD = 2.45, [0.96-3.94], P = 0.001, I 2 = 92%, n = 260) than torn grafts. Conclusions: Patients who underwent SCR for irreparable rotator cuff tears were more likely to have better clinical outcomes if they were younger, had intact/repairable subscapularis, without acetabulization/arthritis, played sports and had intact grafts.

Sports Participation After Reverse Total Shoulder Replacement.

Background: Reverse total shoulder replacement (RTSR) is becoming a popular and reliable treatment for rotator cuff arthropathy. However, little is known about the ability to participate in sports after surgery. Purpose: To determine to what extent RTSR will allow patients to participate in sporting activities and identify the associated factors that could affect postoperative sports participation. Study Design: Case series; Level of evidence, 4. Methods: Data were collected prospectively from patients who underwent RTSR over a 10-year period from April 2009 to May 2019. Patients were assessed before surgery, at 6 months after surgery, and at the final follow-up. Patients were asked within a validated shoulder questionnaire to rank their current highest level of sports participation, overall shoulder status, frequency of pain, level of pain, and functional levels. Their shoulder range of motion and strength were assessed before surgery and at 6 months after surgery. Results: The study included 108 shoulders (106 patients). The mean age was 74 years (range, 51-88 years), with 44 men and 64 women. The mean follow-up was 4 years. Overall shoulder satisfaction, frequency and levels of pain, and shoulder function improved significantly at 6 months and 4 years (P < .0001). External rotation, abduction, and forward flexion range of motion improved significantly at 6 months (P < .05 for all). The strength of internal rotation, external rotation, abduction, and adduction improved significantly at 6 months (P < .001 for all). The rate of return to sports was 67% at 6 months and 48% at 4 years. Multiple significantly associated factors were identified with return to sports at 6 months, including sex and age. Conclusion: The rate of return to sports after RTSR is high. Around two-thirds of patients can return to sports at 6 months postoperatively, although the results slightly deteriorate over time (48% at 4 years).

Ultrasound-guided repair of the distal biceps tendon.

Surgical repair of the distal biceps tendon rupture can be a challenge, especially when patients present with a retracted tendon. The tendon stump is often difficult to find and retrieve. In this aticle, we described a technique using ultrasound imaging at the start of the procedure. Under ultrasound guidance, a breast biopsy needle is used to help localize and mark the retracted tendon edge as well as the distal rupture site. Ultrasound is also used to mark important neurovascular structures at risk to help speed up exposure and avoid complications.