Single knotless-anchor with two ethicon 2# for Ellman grade III bursal-side partial thickness rotator cuff tears: a cadaveric biomechanical study and short-term clinical evaluation.

BACKGROUND: Several surgical techniques are used to treat bursal-side partial thickness rotator cuff tears (PTRCTs). However, use of single knotless-anchor with two Ethicon 2# repair technique for PTRCTs has not been reported. MATERIALS AND METHODS: Bursal-side PTRCTs (Ellman grade III, 75% thickness of tears) were created in the supraspinatus tendon in 16 fresh-frozen cadaveric shoulders. The specimens were randomly assigned to two equal groups: (1) Group A (Transtendon repair), a single knotless-anchor repair with two Ethicon 2#; (2) Group B, Conversion repair (Double-row, DR). Post-repair, each specimen was subjected to cyclic loading test from 5 to 100 N (50 cycles), followed by an ultimate failure test. The displacement of greater tuberosity (mm) and ultimate (N) were recorded. In the clinical study, 12 patients diagnosed with Ellman grade III Bursal-side PTRCTs (using a single knotless anchor with two Ethicon 2# repair techniques) were operated on and analyzed. Visual analog scale (VAS), American Shoulder and Elbow Surgeons Score (ASES), Constant-Murley Score (CMS), and range of motion (ROM) were assessed before surgery and at final minimum follow-up (>1year). RESULTS: There was no significant between-group difference with respect to load-to-failure test (Group A, 359.25 ± 17.91 N; Group B, 374.38 ± 13.75 N, P > 0.05). There were no significant differences with respect to rotator cuff displacement of 10 mm (Group A, 190.50 ± 8.52 N; Group B, 197.25 ± 6.84 N, P > 0.05) and 15 mm (Group A, 282.25 ± 12.20 N; Group B, 291.13 ± 14.74 N, P > 0.05). However, there was significant between-group difference with respect to displacement of 3 and 5 mm (P < 0.05). In the clinical trial, all patients were followed up for an average of 20.4 months (12-29 months). At the last follow-up after surgery(minimum>1year), the VAS score was 0.50 ± 0.67 (0-2), the ASES score was 86.50 ± 3.96 (79-92), the CMS score was 85.08 ± 5.65 (74-93), the mean Forward flexion ROM was 154.00°± 12.48° (131°-169°), and the abduction ROM was 165.00°±13.26° (138°-173°). There was a statistically significant difference between the results of the preoperative and the last postoperative follow-up. The results of the last postoperative follow-up were statistically different from those of the preoperative follow-up (P < 0.05). Regarding complications, stiffness (2 cases) and shoulder impingement (1 case) occurred in 3 cases (25%). CONCLUSION: A single knotless anchor with two Ethicon 2# may provide a biomechanically and clinically feasible option for the treatment of bursal-side Ellman grade III PTRCTs, particularly in resource-constrained settings. MESH KEYWORDS: Bursal-side Ellman Grade III; Single Knotless-anchor; Double-row repair; Biomechanical study; Short-term clinical evaluation.

Magnetic resonance imaging could precisely define the mean value of tendon thickness in partial rotator cuff tears.

PURPOSE: Rotator Cuff (RC) lesions are classified in full-thickness and partial-thickness tears (PTRCTs). To our knowledge, no studies investigated the mean size of shoulder tendons in healthy and PTRCT patients using MRI scans. The aim of the study was to provide data to obtain and compare the mean value of tendon sizes in healthy and PTRCTs groups. METHODS: From 2014 to 2020, 500 were included in the study. They were divided into two groups: Group 1 (100 subjects) was composed of people positive for partial-thickness rotator cuff tears (PTRCTs), while the 400 subjects in Group 2 were negative for PTRCTs. RESULTS: Overall, of the patients included in the study, 231 were females and 269 were males. The mean age of the patients was 49 ± 12.7 years. The mean thickness of the supraspinatus tendon (SSP) was 5.7 ± 0.6 mm in Group 1, 5.9 ± 0.6 mm in Group 2 (p < 0.001). The mean length of the ISP tendon was 27.4 ± 3.2 mm in Group 1, 28.3 ± 3.8 mm in Group 2 (p = 0.004). The mean width of the SSP tendon was 17 ± 1.6 mm in Group 1, 17.6 ± 2 mm in Group 2 (p = 0.004). The mean width of the infraspinatus tendon (ISP) tendon was 17.7 ± 1.4 mm in Group 1, 18.3 ± 2.1 mm in Group 2 (p = 0.02). CONCLUSION: The anatomical data present in this paper may serve as a tool for surgeons to properly manage PTRCTs. The findings of the present study aimed to set the first step towards reaching unanimity to establish international cut-off values to perform surgery. Additionally, they could widely increase diagnostic accuracy, improving both conservative and surgical approaches. Lastly, further clinical trials using more accurate diagnostic MRI tools are required to better define the anatomical differences between PTRCT and healthy patients. LEVEL OF EVIDENCE: Level II, Retrospective Comparative Trial.

Editorial Commentary: Extreme Medial Repair of Massive Rotator Cuff Tears With Atrophy Warrants Caution: Robbing Peter to Pay Paul.

Medialization of the rotator cuff insertion as a technique to manage massive rotator cuff tears has been described for decades. However, "extreme medialization" as a means to manage massive rotator cuff tears with significant atrophy warrants caution. Nonanatomic reconstruction almost always carries a price. Biomechanical studies show extreme medialization results in significant and obligate restriction of motion, and it is difficult to imagine how extreme medialization would allow normal clinical motion without substantial scapulothoracic compensation. Similarly, obligatory loss of strength could be expected. Based on the current evidence, I will not indicate this technique for my own patients at the present time.

Editorial Commentary: Superior Capsular Reconstruction Is the Treatment of Choice for Massive, Irreparable Rotator Cuff Tears With Pseudoparalysis.

The ideal treatment approach to massive, irreparable rotator cuff tears remains a hot topic of debate. In addition to joint-preserving methods including partial repair and subacromial spacer, techniques such as superior capsular reconstruction and tendon transfers are viable alternatives. These techniques are effective in providing pain relief and-to an extent-functionality during short-term follow-up; however, superior capsular reconstruction (SCR) appears to be the treatment of choice to address the pseudoparalysis.The relatively lower success rates of pseudoparalysis treatment in tendon transfers may be related to (1) the disturbance of the rotator cable, (2) the fact that a single transferred tendon alone may not be good enough to restore the impaired force-coupling mechanism required for overhead motion, and (3) to oppose the forces generated by the deltoid. On the other hand, the SCR graft functions both as a soft tissue augment that restores glenohumeral kinematics by re-establishing the force transmission between the remaining anterior and posterior portions of rotator cuff and as a static depressor of the humeral head during shoulder motion. With adequate graft quality, compatibility (i.e., fascia lata autograft), and thickness (minimum 5 mm), SCR may reliably maintain these functions. Tendon transfers are best reserved for the limited subgroup of patients where active external rotation loss is the primary concern. For the majority of patients with irreparable cuff tears, SCR remains the treatment of choice, particularly for patients with pseudoparalysis.

Secondary Rotator Cuff Insufficiency After Anatomic Total Shoulder Arthroplasty.

¼ Secondary rotator cuff insufficiency is a challenging complication after anatomic total shoulder arthroplasty.¼ Acute tears may be amenable to open or arthroscopic repair in some instances.¼ Chronic attritional tears are best managed with revision to reverse shoulder arthroplasty, especially in the elderly.¼ Increased glenoid inclination, larger critical shoulder angle, oversized humeral components, thicker glenoid components, and rotator cuff muscle fatty infiltration have all shown to contribute to tear risk.

One-stage rotator cuff repair in stiff shoulders shows comparable range of motion, clinical outcome and retear rates to non-stiff shoulders: a systematic review.

BACKGROUND: One-stage treatment involving rotator cuff repair and shoulder capsule release is mainly used to treat patients with rotator cuff tears (RCTs) and concomitant shoulder stiffness. Despite the increasing attention to the efficacy and safety of one-stage treatment, controversy still remains. Therefore, this systematic review aims to summarize the indications, operation procedure and rehabilitation protocol, and compare the range of motions (ROMs), functional outcomes and retear rates of one-stage treatment for RCTs in stiff shoulders and non-stiff shoulders. METHODS: Multiple databases (PubMed, the Cochrane Library, Embase and MEDLINE) were searched for studies that investigated outcomes after one-stage treatment for RCTs concomitant with shoulder stiffness compared with rotator cuff repair for RCTs alone, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Descriptive statistics, including range of motion, patient-reported outcome and retear rate, are presented without meta-analysis due to the heterogeneity and low levels of evidence. RESULTS: A total of 9 cohort studies were included, with 305 patients treated with one-stage treatment involving rotator cuff repair and simultaneous shoulder capsular release and 1059 patients treated with rotator cuff repair alone. Patients in both groups had significant symptom improvement and functional recovery after the one-stage treatment for the stiffness group and standard repair for the non-stiffness group, and most patients could return to normal life and work within 6 months after the operation. The retear rate in the one-stage treatment group was not higher than that in the rotator cuff repair group. No statistically significant differences between the two groups were observed in terms of range of motion and patient-reported outcomes in the vast majority of studies at the final follow-up, including the visual analog scale for pain, the Constant score, the American Shoulder and Elbow Surgeons score, the University of California Los Angeles Shoulder Score, the Oxford shoulder score and the Simple Shoulder Test. CONCLUSION: One-stage treatment for RCTs in stiff shoulders provides comparable ROM and patient-reported clinical outcomes as rotator cuff repair for non-stiff RCTs. In addition, the rate of postoperative retear in stiff shoulder treated with one-stage treatment was not higher than in non-stiff shoulders.

Prospective Randomized Clinical Trial of Arthroscopic Repair Versus Debridement for Partial Subscapularis Tendon Tears More Than Half of the Entire First Facet.

BACKGROUND: Most outcome studies on subscapularis (SSC) tendon tears have focused on large SSC tears rather than partial SSC tendon tears. Therefore, the optimal treatment for partial SSC tendon tears more than half of the first facet of the entire SSC footprint has not yet been clearly defined. PURPOSE: To prospectively investigate the clinical and radiological results between the arthroscopic repair group and the debridement group in SSC partial tear (Yoo and Rhee classification, type 2B: SSC tendon tears of more than half of the entire first facet). STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 65 patients with SSC tendon type 2B tears were randomized to arthroscopic debridement (n = 33) or arthroscopic repair (n = 32). Clinical evaluation of the patients was performed on the day before surgery and 6 months, 1 year, 2 years, and 5 years postoperatively using active range of motion measurements and other validated scores (pain visual analog scale scores, function visual analog scale scores, Constant score, American Shoulder and Elbow Surgeons score). In addition, SSC muscle strength was measured using instruments in the belly-press position. Magnetic resonance imaging (upper and lower SSC muscle diameters, Goutallier grades) was performed on the day before operation as well as 6 months and 2 years postoperatively. RESULTS: There were no clinically or statistically significant differences between the arthroscopic debridement and arthroscopic repair groups with respect to active range of motion, pain visual analog scale scores, function visual analog scale scores, Constant scores, or American Shoulder and Elbow Surgeons scores. There was a statistically significant increase in SSC muscle strength in the repair group compared with the debridement group at 5 years postoperatively (P = .013). Magnetic resonance imaging assessment was also not significantly different between the 2 groups. CONCLUSION: There were no differences in the patient-reported outcomes of patients with partial SSC tears treated with either arthroscopic debridement or repair, although there was an increase in SSC muscle strength associated with repair, the clinical importance of which may warrant further research. REGISTRATION: NCT03183466 (ClinicalTrials.gov identifier).

Prediction of Retear After Arthroscopic Rotator Cuff Repair Based on Intraoperative Arthroscopic Images Using Deep Learning.

BACKGROUND: It is challenging to predict retear after arthroscopic rotator cuff repair (ARCR). The usefulness of arthroscopic intraoperative images as predictors of the ARCR prognosis has not been analyzed. PURPOSE: To evaluate the usefulness of arthroscopic images for the prediction of retear after ARCR using deep learning (DL) algorithms. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 2. METHODS: In total, 1394 arthroscopic intraoperative images were retrospectively obtained from 580 patients. Repaired tendon integrity was evaluated using magnetic resonance imaging performed within 2 years after surgery. Images obtained immediately after ARCR were included. We used 3 DL architectures to predict retear based on arthroscopic images. Three pretrained DL algorithms (VGG16, DenseNet, and Xception) were used for transfer learning. Training and test sets were split into 8:2. Threefold stratified validation was used to fine-tune the hyperparameters using the training data set. The validation results of each fold were evaluated. The performance of each model in the test set was evaluated in terms of accuracy, area under the receiver operating characteristic curve (AUC), F1-score, sensitivity, and specificity. RESULTS: In total, 1138 and 256 arthroscopic images were obtained from 514 patients and 66 patients in the nonretear and retear groups, respectively. The mean validation accuracy of each model was 83% for VGG16, 89% for Xception, and 91% for DenseNet. The accuracy for the test set was 76% for VGG16, 87% for Xception, and 91% for DenseNet. The AUC was highest for DenseNet (0.92); it was 0.83 for VGG16 and 0.91 for Xception. For the test set, the specificity and sensitivity were 0.93 and 0.84 for DenseNet, 0.89 and 0.84 for Xception, and 0.70 and 0.80 for VGG16, respectively. CONCLUSION: The application of DL algorithms to intraoperative arthroscopic images has demonstrated a high level of accuracy in predicting retear occurrences.

Effect of Anterior Acromial Coverage on Functional and Radiological Outcomes After Arthroscopic Repair of Anteroposterior Massive Rotator Cuff Tears.

BACKGROUND: Rotator cuff tear size, fatty infiltration, and scapular morphology are correlated with tendon healing and functional outcomes after arthroscopic repair; however, the association between anteroposterior acromial coverage and the clinical outcomes of anteroposterior massive rotator cuff tears (AP-MRCTs; involving all 3 tendons) remains unclear. PURPOSE: To identify the association between AP acromial coverage and functional and radiological outcomes after arthroscopic repair of AP-MRCTs. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 98 patients who underwent arthroscopic repair of AP-MRCTs between January 2015 and December 2020 were included in the study and classified according to whether anterior acromial coverage (AAC) was anterior (46 patients; positive AAC group) or posterior (52 patients; negative AAC group) to the scapular line on true lateral shoulder radiographs. Demographic characteristics, surgical details, and functional outcomes were prospectively collected. Acromial morphological features, global tear extension (GTE), the global fatty infiltration index (GFII), tendon integrity after repair, proximal humeral migration, and glenohumeral abduction were measured and calculated on radiographs or magnetic resonance imaging scans preoperatively and at 2 years postoperatively. Multivariate logistic regression was performed to identify the independent risk factors of a rotator cuff retear. RESULTS: The positive AAC group showed larger AAC, posterior acromial tilt, and anterior acromial slope as well as smaller posterior acromial coverage compared with the negative AAC group. Postoperatively, the American Shoulder and Elbow Surgeons score (82.5 ± 8.3 vs 77.2 ± 11.5, respectively; P = .013), active abduction (157.8°± 27.1° vs 142.7°± 39.6°, respectively; P = .048), and glenohumeral abduction (45.6°± 10.4° vs 39.7°± 14.9°, respectively; P = .041) in the positive AAC group were significantly higher than those in the negative AAC group, while the retear rate (23.9% vs 44.2%, respectively; P = .035) and proximal humeral migration (1.7 ± 1.0 vs 2.3 ± 1.2 mm, respectively; P = .006) were significantly lower in the positive AAC group than in the negative AAC group. Smaller AAC (odds ratio [OR], 0.93 [95% CI, 0.87-1.00]; P = .040), larger GTE (OR, 1.03 [95% CI, 1.01-1.06]; P = .017), and a higher GFII (OR, 3.49 [95% CI, 1.09-11.19]; P = .036) were associated with an increased risk of a rotator cuff retear. CONCLUSION: Increased AAC was associated with a lower retear rate and better functional outcomes after arthroscopic repair of AP-MRCTs. A preliminary risk evaluation integrating GTE, the GFII, and AAC is recommended to consider the necessity of additional procedures for patients in need of arthroscopic rotator cuff repair.

Use of Area Deprivation Index to Predict Minimal Clinically Important Difference for Patient Reported Outcomes Measurement Information System After Arthroscopic Rotator Cuff Repair.

BACKGROUND: Socioeconomic disparities correlate with worse outcomes after arthroscopic rotator cuff repair. However, use of a surrogate to describe socioeconomic disadvantage has been a challenge. The Area Deprivation Index (ADI) is a tool that encompasses 17 socioeconomic variables into a single metric based on census location. HYPOTHESIS: Higher ADI would result in a worse minimal clinically important difference (MCID) for the Patient Reported Outcomes Measurement Information System (PROMIS) and have less improvement in range of motion (ROM) following arthroscopic rotator cuff repair (ARCR). STUDY DESIGN: Cohort study; Level of evidence, 3. METHOD: A retrospective review was performed for patients who underwent arthroscopic rotator cuff repair. Patients in the most socioeconomically disadvantaged quartile (ADIHigh) were compared with the least disadvantaged quartile (ADILow) in the ability to reach MCID. Demographic and surgical features were assessed for attainment of MCID. RESULTS: In total 1382 patients were identified who underwent ARCR, of which a total of 306 patients met final inclusion criteria. A higher percentage of patients within the ADIHigh cohort identified as "Black" or "other" race and had government-issued insurance compared with the ADILow cohort (P < .05). The ADIHigh cohort had significantly worse postoperative forward flexion compared with the ADILow cohort (145.0°± 32.5° vs 156.3°± 23.4°; P = .001) despite starting with comparable preoperative ROM (P = .17). Logistic regression showed that ADI was the only variable significant for predicting achievement of MCID for all 3 PROMIS domains, with the ADIHigh cohort having significantly worse odds of achieving MCID Physical Function (odds ratio [OR], 0.31; P = .001), Pain Interference (OR, 0.21; P = .001), and Depression (OR, 0.28; P = .001). Meanwhile, age, sex, body mass index, and smoking history were nonsignificant. Moreover, "other" for race and Medicare insurance were significant for achievement of MCID Depression but not Physical Function or Pain Interference. Finally, ADI was the main feature for predictive logistic regression modeling. CONCLUSION: ADI served as the only significant predictor for achieving MCID for all 3 PROMIS domains after arthroscopic rotator cuff repair. Patients who face high levels of socioeconomic disadvantage have lower rates of achieving MCID. In addition, patients with greater neighborhood disadvantage demonstrated significantly worse improvement in active forward flexion. Further investigation is required to understand the role of ADI on physical therapy compliance and to identify the barriers that prevent equitable postoperative care.

Microfracture Lateral to the Greater Tuberosity of the Humerus Enhances Tendon-to-Bone Healing in a Rat Rotator Cuff Model.

BACKGROUND: Microfracture at the rotator cuff insertion is an established surgical marrow-stimulation technique for enhancing rotator cuff healing. However, the effect of lateralized or medialized microfracture on the insertion is unknown. PURPOSE: To compare the biomechanical and histologic effects of microfracture at 3 different regions for rotator cuff repair in a rat model. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 72 Sprague-Dawley rats with bilateral supraspinatus tendon insertion detachment were allocated into 4 groups with 4 different interventions: no microfracture at the humeral head as a control group (Con), traditional microfracture at the footprint area (MFA), and medialized microfracture to the footprint area (MMFA) on the articular surface of the humerus or lateralized microfracture to the footprint area at the greater tuberosity (LMFA). All underwent immediate repair. Tendon-to-bone healing was assessed by biomechanical and histologic tests 4 and 8 weeks postoperation. RESULTS: At 4 weeks, the LMFA group showed a significantly superior failure load compared with the other groups (all P < .05). The LMFA and MFA groups showed significantly superior stiffness compared with the Con and MMFA groups (all P < .01). At 8 weeks, superior failure load and stiffness were observed in the LMFA group compared with the control group (all P < .05). Histologic examination revealed that the LMFA group had superior collagen composition and tendon-to-bone maturation at the interface at 4 and 8 weeks compared with the Con group (all P < .05). CONCLUSION: Lateralized microfracture at the greater tuberosity improved the histologic quality of repair tissue and biomechanical strength at the tendon-to-bone insertion after rotator cuff repair in a rat model. CLINICAL RELEVANCE: Microfracture lateral to the footprint area might be a better way to enhance rotator cuff healing clinically.

Engineered Tissue Graft for Repair of Injured Infraspinatus Rotator Cuff Tendon.

Rotator cuff tears constitute a vast majority of shoulder-related injuries, occurring in a wide population range and increasing in incidence with age. Current treatments for full thickness tears use suture to secure the ruptured tendon back to its native attachment site and often retear due to improper enthesis regeneration. To reduce the occurrence of retear, our laboratory developed an engineered tendon graft for rotator cuff repair (ETG-RC) to serve as an underlayment to traditional suture repair. We hypothesize the ETG-RC will aid in the repair of the torn rotator cuff tendon by promoting the regeneration of a functional enthesis. This devitalized graft fabricated from ovine-derived bone marrow stromal cells was evaluated for biomechanical and histomorphology properties in an ovine infraspinatus rotator cuff repair model. Compared with a current standard practice Suture-Only model, the ETG-RC repair showed comparable high strain-to-failure forces, greater fibrocartilage deposition, regeneration of zonal gradients, and Shapey's fibers formation, indicative of enthesis regeneration. Enthesis regeneration after rotator cuff repair should repair mechanical properties and alleviate the need for subsequent surgeries required due to retear. The ETG-RC could potentially be used for repairing other tendon injuries throughout the body.

Contrast-Enhanced Ultrasound-Assessed Supraspinatus Muscle Perfusion Indicates Better Tissue Vitality and Outcome After Supraspinatus Tendon Repair and Subacromial Decompression.

OBJECTIVE: Supraspinatus tendon (SSP) tears are a frequent indication for shoulder surgery. Therapy options include physiotherapy, tendon repair and less invasive surgical options like subacromial decompression (SAD). The selection of the most appropriate treatment depends on the specific characteristics and needs of each patient subgroup. Typically, physically active patients are candidates for tendon repair, while a conservative approach is preferred for individuals with severe muscle degeneration or low physical demands. The goal of this study was to assess the impact of contrast-enhanced ultrasound (CEUS)-assessed SSP muscle perfusion on post-operative shoulder function and tendon healing in patients undergoing SSP repair or SAD, thereby enhancing personalized therapy for SSP tendon tears. METHODS: Two cohorts of patients with SSP tendon tears were treated either by SAD or tendon repair. Pre-operative and 6-month post-operative SSP muscle perfusion was quantified using CEUS and investigated as a surrogate for tissue vitality. The magnetic resonance imaging-derived parameters fatty infiltration and tendon retraction and established shoulder function scores were assessed pre- and post-operatively. RESULTS: Thirty-five SSP repair patients were compared with 20 SAD patients. Pre-operative perfusion was comparable in the SAD and SSP repair cohorts when a re-tear occurred (wash-in perfusion index = 103.8 ± 124.0 vs. 114.6 ± 155.0, p = 0.83), while being significantly higher among patients with an intact repair (103.8 ± 124 vs. 325.4 ± 388.6, p = 0.006). Below-median pre-operative muscle perfusion was associated with lower post-operative shoulder function (Constant score: 59 ± 28 vs. 78 ± 19, p = 0.012). CONCLUSION: CEUS can visualize SSP muscle perfusion as a surrogate for tissue vitality and tendon healing, which is associated with better post-operative shoulder function.

Editorial Commentary: A Biphasic (Calcified and Demineralized), Cancellous, Interpositional Allograft Augmenting Rotator Cuff Repair in an Ovine Model Does Not Show Harmful Inflammation or Foreign Body Reaction.

To improve the outcomes of arthroscopic rotator cuff (RC) repair, it is important to achieve tendon-to-bone healing at the repair site. Healed repairs are more likely to restore shoulder strength and lead to higher magnitudes of satisfaction. Patches or grafts that can be either secured to the bursal surface of the RC or interposed between the RC tendon and greater tuberosity at the time of repair have been described as adjuncts to RC repair. A cancellous, biphasic allograft tissue composed of 2 layers (calcified to promote osseointegration and demineralized to support soft-tissue ingrowth) has been shown to be safe in an ovine model, without a harmful inflammatory or foreign body response. Human trials may be a reasonable next step.

Partial Articular Supraspinatus Tendon Avulsion Repair and Patch: A Technical Note for Augmenting the Supraspinatus Reinsertion with the Long Head of the Biceps Tendon.

BACKGROUND: There is no clear consensus on the treatment of partial articular-sided supraspinatus tendon avulsions. Debridement alone might not be sufficient to prevent further tendon degradation or alleviate patient complaints. Direct repair using a suture anchor without treating the concomitant conditions of the long head of the biceps tendon might come with residual anterior shoulder pain or even further loss of function in cases of failed repair. The purpose of the present study is to describe an arthroscopic technique by which the long head of the biceps tendon can be included in the partial articular-sided supraspinatus tendon avulsion repair. TECHNIQUE PRESENTATION WITH VIDEO: In this technical note we describe the arthroscopic repair and augmentation with tenotomized biceps of partial supraspinatus tendon tears to address three main concepts for successful rotator cuff repairs, namely rotator cuff biologic augmentation, tendon to bone healing and postoperative pain prevention. CONCLUSION: The biceps tendon is a mechanically robust, locally available autograft that can be used in borderline partial articular-sided supraspinatus tendon avulsions in order to biologically augment healing at the tendon-bone interface without any immunogenic reactions or morbidity following harvesting.

Biomodulating healing after arthroscopic rotator cuff repair: the protocol of a randomised proof of concept trial (BIOHACK).

PURPOSE/INTRODUCTION: Over the last decades, there has been increasing interest in biological stimulation or bioaugmentation after rotator cuff repair. So far, there is no consensus on the appropriate composition of biologicals or which patients would benefit most, and moreover, these biologicals are often expensive. However, there are other, non-pharmacological strategies that are also believed to achieve biological stimulation. This randomised controlled trial evaluates the possible cumulative effect of pragmatic application of cryobiomodulation, photobiomodulation and electrobiomodulation-collectively called biomodulation-on the bone-to-tendon healing process after rotator cuff repair. METHODS: In this randomised, controlled proof of concept study, 146 patients undergoing arthroscopic repair of a full thickness posterosuperior or anterosuperior rotator cuff tear will be 1:1 randomly assigned to either a control group or to the additional biomodulation protocol group. The adjuvant biomodulation protocol consists of seven self-applicable therapies and will be administered during the first 6 weeks after surgery. Primary outcome will be healing of the rotator cuff as evaluated by the Sugaya classification on MRI at 1-year postoperatively. ETHICS AND DISSEMINATION: This study has been accepted by the National Ethical Review Board CPP Sud-Est IV in France and has been registered at Clinicaltrials.gov. The results of this study will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT04618484.

Similar outcomes between transtendon repair and tear completion repair techniques for partial articular-sided supraspinatus tendon avulsion lesions: a systematic review and meta-analysis.

PURPOSE: This study aimed to review studies comparing transtendon repair (TTR) with tear completion repair (TCR) techniques for partial articular-sided supraspinatus tendon avulsion (PASTA) lesions according to postoperative patient-reported outcomes and complications. METHODS: Databases, including PubMed, Embase, Scopus, and Cochrane, were searched for studies published between 2008 and 2022 that directly compared the postoperative patient-reported outcomes and complications of the TTR and TCR techniques for PASTA lesions. Odds ratios (ORs) were calculated for dichotomous outcomes, while mean differences (MDs) were calculated for continuous outcomes. RESULTS: A total of seven studies (497 shoulders) were analysed. No statistically significant differences in the postoperative clinical outcomes at the final follow-up were observed between the TTR and TCR techniques for PASTA lesions. The overall retear rates of the TTR and TCR techniques were 7.7% and 11.6%, respectively (corresponding healing rates were 92.3% and 88.4%), whereas the overall occurrence rates of adhesive capsulitis were 4.7% and 3.3%, respectively. Furthermore, no significant difference was observed in postoperative range of motion (forward flexion, MD = - 1.22, 95% confidence interval (95%CI) - 5.28 to 3.34, n.s.; external rotation, MD = - 1.39, 95% CI - 3.19 to 0.42, n.s.), overall retear rate (OR 0.72, 95% CI 0.29-1.08, n.s.), and occurrence rate of adhesive capsulitis (OR 1.11, 95% CI 0.35-3.52, n.s.) between the two techniques. CONCLUSION: Both techniques improve clinical outcomes while having a low complication rate and a high rate of healing. No significant difference in clinical outcomes was observed between the two techniques. LEVEL OF EVIDENCE: III.

Gender and degree of tendon healing are independent predictive factors for clinical outcome in successfully healed rotator cuff tears.

PURPOSE: Arthroscopic rotator cuff repair (aRCR) is a commonly performed procedure and has been reported to be a successful treatment. Successful healing has traditionally been considered to be associated with good outcome; however, knowledge on predictive factors affecting final outcome other than tendon healing is limited. This study aims to investigate predictive factors influencing clinical outcome following aRCR in patients with successfully healed tears. METHODS: This retrospective case-control study was conducted in a single center with 135 patients who had successfully healed tendons based on Sugaya classification (grades I-III) on postoperative magnetic resonance imaging (MRI) scans following aRCR. Clinical outcome measures included Constant-Murley score (CMS), range of motion (ROM), pain score. Various preoperative, intraoperative factors and degree of postoperative tendon healing were assessed to identify independent predictive factors for final clinical outcome. RESULTS: Mean age of patients was 55.9 ± 9.0 years and mean follow-up duration was 46.8 ± 14.9 months. There were 50 (37%) male and 85 (63.0%) female patients. At final follow-up, mean CMS was 85.7 ± 12.0. Considering mean postoperative CMS and the minimal clinically important difference (MCID) of 10 points for CMS, a cutoff level of 75 points for CMS was set (85-10 = 75) and study population was divided into two study groups (group I, poor outcome, CMS ≤ ;75, and group II, good outcome, CMS > 75). There were 24 (17.8%) patients in group I and 111 (82.2%) patients in group II. Univariate analysis revealed that gender, body mass index (BMI) and degree of tendon healing (Sugaya classification) differed significantly between two groups (p < 0.05). Multivariate logistic regression analysis which was conducted with these variables showed that female gender (odds ratio 3.65) and Sugaya grade III (odds ratio 8.19) were independent predictive factors which were significantly associated with poor outcome (p < 0.05). CONCLUSIONS: This study showed that despite achieving a successful healing, considerable amount of patients (17.8%) have ended up with poor outcome. Female gender and degree of tendon healing were identified as independent predictive factors for poor outcome. These data would help surgeons during decision-making, risk assessment and patient counseling. LEVEL OF EVIDENCE: III.

Reverse shoulder arthroplasty renders better clinical scores at a minimum follow-up of two years for patients with no rotator cuff deficiency operated by the deltopectoral approach.

PURPOSE: The purpose of this multi-centre study was to report outcomes of a large cohort of reverse shoulder arthroplasty (RSA) at a minimum follow-up of two years and to determine patient and surgical factors that influence postoperative outcomes. The hypothesis was that surgical indication, surgical approach, and implant design would affect clinical outcomes significantly. METHODS: The authors reviewed records of 743 RSAs in patients with primary osteoarthritis (OA) with or without rotator cuff (RC) tears, secondary OA due to RC tears, and irreparable massive rotator cuff tears (mRCT). The deltopectoral (DP) approach was used in 540 and the anterosuperior (AS) approach in 203. Pre- and postoperative Constant scores (CS) were recorded. Multivariable linear analyses were performed to determine if CS was associated with indications for surgery, surgical approach, or implant design. RESULTS: Of the 743 shoulders, 193 (25.7%) were lost to follow-up, 16 (2.1%) died, and 33 (4.4%) were revised, leaving 501 for analysis. At a mean follow-up of 3.2 ± 0.9 years, net improvement in CS was 29.2 ± 17.0. Multivariable analyses revealed that postoperative CS decreased with age and was worse in shoulders that had preoperative rotator cuff deficiency and in shoulders operated by the AS approach. Multivariable analyses also revealed worse net improvement in shoulders operated for secondary OA due to RC tears or for irreparable mRCT, as well as shoulders operated by the AS approach. CONCLUSION: This large multi-centre study confirms that, at two or more years following RSA, Constant scores are not associated with implant design, but rather with rotator cuff deficiency and surgical approach. Multivariable analysis revealed that postoperative CS was worse for shoulders with preoperative rotator cuff deficiency and for shoulders operated by the AS approach. Multivariable analysis also revealed that net improvement in CS was worse in shoulders treated for secondary OA due to RC tears and for shoulders with irreparable mRCT, as well as for shoulders operated by the AS approach.

Editorial Commentary: Superior Capsular Reconstruction Hybrid Grafts Include Autograft for Healing Plus Synthetics for Structural Integrity to Improve Outcomes.

Superior capsular reconstruction is a viable option for select patients with massive irreparable rotator cuff tears. Graft integrity at short- and mid-term follow-up directly correlates with range of motion, functional outcome, and radiographic outcome. Historically, various graft options have been proposed, including dermal allograft, fascia lata autograft, and synthetic graft choices. With a traditional dermal allograft and fascia lata autograft, the graft retear rates have been variably reported. Because of this uncertainty, newer techniques using the healing capabilities of autografts in conjunction with the structural integrity of synthetic materials have emerged in an effort to decrease graft failure rates. Preliminary results are promising; however, longer-term follow-up with head-to-head comparison with traditional techniques is required to understand their true efficacy.