Long head of biceps tendon transposition for massive and irreparable rotator cuff tears:A systematic review and meta-analysis

BACKGROUND Superior capsular reconstruction(SCR)with long head of biceps tendon(LHBT)transposition was developed to massive and irreparable rotator cuff tears(MIRCTs);however,the outcomes of this technique remain unclear.AIM To perform a systematic review of biomechanical outcomes and a meta-analysis of clinical outcomes after LHBT transposition for MIRCTs.METHODS We performed a systematic electronic database search on PubMed,EMBASE,and Cochrane Library.Studies of SCR with LHBT transposition were included according to the inclusion and exclusion criteria.Biomechanical studies were assessed for main results and conclusions.Included clinical studies were evaluated for quality of methodology.Data including study characteristics,cohort demographics,and outcomes were extracted.A meta-analysis was conducted of the clinical outcomes.RESULTS According to our inclusion and exclusion criteria,a total of six biomechanical studies were identified and reported an overall improvement in subacromial contact pressures and prevention of superior humeral migration without limiting range of motion(ROM)after LHBT transposition for MIRCTs.A total of five clinical studies were included in the meta-analysis of LHBT transposition outcomes,consisting of 253 patients.The results indicated that compared to other surgical methods for MIRCTs,LHBT transposition had advantages of more significant improvement in ROM(forward flexion mean difference[MD]=6.54,95%confidence interval[CI]:3.07-10.01;external rotation[MD=5.15,95%CI:1.59-8.17];the acromiohumeral distance[AHD][MD=0.90,95%CI:0.21-1.59])and reducing retear rate(odds ratio=0.27,95%CI:0.15-0.48).No significant difference in American Shoulder and Elbow Surgeons score,visual analogue scale score,and University of California at Los Angles score was demonstrated between these two groups for MIRCTs.CONCLUSION In general,SCR with LHBT transposition was a reliable and economical technique for treating MIRCTs,both in terms of biomechanical and clinical outcomes,with comparable clinical outcomes,improved ROM,AHD,and reduced the retear rates compared to conventional SCR and other established techniques.More high-quality randomized controlled studies on the long-term outcomes of SCR with LHBT transposition are required to further assess.

Comparison with Surgical Findings for the Accuracy of Routine MRI in Rotator Cuff Tears

Objective: To evaluate the diagnostic efficacy of magnetic resonance imaging (MRI) for the detection of partial-thickness rotator cuff tears (PTT) and full-thickness rotator cuff tears(FTT) by comparing its findings with surgical findings as the gold standard and to improve the previous MRI accuracy in diagnosing rotator cuff tears (RCT) considering more variables. Methods: In 45 months, 804 patients underwent MRI shoulder joint. Among them, only 95 cases had undergone both MRI imaging and surgery accordingly. The patient records were evaluated retrospectively if MRI and surgery were performed within 40 days of MRI. MRI findings were categorized into PTT, FTT and no tears which were further divided into different types according to four main nominal data as variables viz. site, size, shape and muscle involvement in RCT and were correlated with surgical findings for statistical calculation by using Kappa coefficient and McNemar Bowker test. Results: 81 patients (86 RCTs) underwent surgery within 40 days. On the basis of site as variable, MRI correctly depicted 100% of full thickness tears(FTT), 85% of bursal partial thickness tears(PTT), 80.4% of articular partial thickness tears(PTT). The consistency in diagnosis of RCT between MRI and surgery was moderate (Kappa coefficient 0.645). Overall sensitivity, specificity and accuracy of MRI for diagnosing PTT was 87.3%, 53.3% and 81.3%;and that for FTT was 100%, 98.7% and 98.8% respectively. Likewise on the basis of size, shape and muscles involved, the consistency between MRI and surgery was poor for size and shape and moderate for muscles involved;and the difference in diagnosing RCT by MRI and surgery was significant for shape (P = 0.002) only, but not significant for size (P = 0.16) and for muscles involved (P = 0.206) respectively. The agreement between MRI and surgery in diagnosing calcific tendinitis and shoulder joint hematoma with Kappa coefficient is (0.577) and (0.556) respectively. Conclusion: MRI has better accuracy for detecting FTT and has high sensitivity and positive predictive value in diagnosing both PTT and FTT. Combining more others variables in addition to RCT, MRI offers a great value in diagnosing RCT.

Evidence analysis on the utilization of platelet-rich plasma as an adjuvant in the repair of rotator cuff tears

BACKGROUND Platelet-rich plasma has been gaining popularity as an agent for biological augmentation either as the sole treatment modality or as an adjunct to surgical repair.There is substantial discrepancy in the results of the published meta-analyses;and the true efficacy and role of using autologous platelet-rich plasma(PRP)at the time of rotator cuff repair is still ambiguous.AIM To performed this systematic overview on the overlapping meta-analyses that analyzed autologous PRP as an adjuvant in the repair of rotator cuff tears and identify the studies which provide the current best evidence on this subject and generate recommendations for the same.METHODS We conducted independent and duplicate electronic database searches in PubMed,Web of Science,Scopus,Embase,Cochrane Database of Systematic Reviews,Reference Citation Analysis and the Database of Abstracts of Reviews of Effects on September 8,2021 to identify meta-analyses that analyzed the efficacy of PRP as an adjuvant in the repair of rotator cuff tears.Methodological quality assessment was made using Oxford Levels of Evidence,AMSTAR scoring and AMSTAR 2 grades.We then utilized the Jadad decision algorithm to identify the study with the highest quality to represent the current best evidence to generate the recommendation.RESULTS Twenty meta-analyses fulfilling the eligibility criteria were included.The AMSTAR scores of the included studies varied from 6-10(mean:7.9).All the included studies had critically low reliability in their summary of results due to their methodological flaws according to AMSTAR 2 grades.Significant heterogeneity was observed in the reporting of VAS,function outcome scores(longterm UCLA score,ASES score,SST score),operative time and long-term re-tear rates.Recent metaanalyses are more supportive of the role of intra-operative administration of PRPs at the bonetendon interface in improving the overall healing and re-tear rates,functional outcome and pain.The initial size of the tear and type of repair performed do not seem to affect the benefit of PRPs.Among the different preparations used,leucocyte poor(LP)-PRP possibly offers the greatest benefit as a biological augment in these situations.CONCLUSION Based on this systematic overview,we give a level II recommendation that intra-operative use of PRPs at the bone-tendon interface can augment the healing rate,reduce re-tears,enhance functional outcome and mitigate pain in patients undergoing arthroscopic rotator cuff repair.LPPRP possibly offers the greatest benefit in terms of healing rates,as compared with other platelet preparations.

Treatment options for irreparable postero-superior cuff tears in young patients

Rotator cuff tears(RCTs) occur more commonly with advanced age,with most rotator cuff abnormalities in patients less than 30 years old being painful tendinoses or partial-thickness RCTs.Irreparable postero-superior cuff tears has been reported as frequent as 7% to 10% in the general population,and the incidence of irreparable RCTs in young patients is still unknown.Several surgical procedures have been proposed for young patients with irreparable postero-superior RCTs,such as rotator cuff debridement,partial rotator cuff repair,biceps tenotomy/tenodesis,rotator cuff grafting,latissimus dorsi tendon transfer,and reverse shoulder arthroplasty.After being thoroughly investigated in open surgery,arthroscopic techniques for latissimus dorsi tendon transfer have been recently described.They have been shown to be an adequate option to open surgery for managing irreparable postero-superior RCTs refractory to conservative management.

Reporting rotator cuff tears on magnetic resonance arthrography using the Snyder's arthroscopic classification

AIM To determine diagnostic performance of magnetic resonance arthrography(MRA) in evaluating rotator cuff tears(RCTs) using Snyder's classification for reporting.METHODS One hundred and twenty-six patients(64 males, 62 females; median age 55 years) underwent shoulder MRA and arthroscopy, which represented our reference standard. Surgical arthroscopic reports were reviewed and the reported Snyder's classification was recorded. MRA examinations were evaluated by two independent radiologists(14 and 5 years' experience) using Snyder's classification system, blinded to arthroscopy. Agreement between arthroscopy and MRA on partial-and fullthickness tears was calculated, first regardless of their extent. Then, analysis took into account also the extent of the tear. Interobserver agreement was also calculated the quadratically-weighted Cohen kappa statistics.RESULTS On arthroscopy, 71/126 patients(56%) had a fullthickness RCT. The remaining 55/126 patients(44%) had a partial-thickness RCT. Regardless of tear extent, out of 71 patients with arthroscopically-confirmed fullthickness RCTs, 66(93%) were correctly scored by both readers. All 55 patients with arthroscopic diagnosis of partial-thickness RCT were correctly assigned as having a partial-thickness RCT at MRA by both readers. Interobserver reproducibility analysis showed total agreement between the two readers in distinguishing partial-thickness from full-thickness RCTs, regardless of tear extent(k = 1.000). With regard to tear extent, in patients in whom a complete tear was correctly diagnosed, correct tear extent was detected in 61/66 cases(92%); in the remaining 5/66 cases(8%), tear extent was underestimated. Agreement was k = 0.955. Interobserver agreement was total(k = 1.000).CONCLUSION MRA shows high diagnostic accuracy and reproducibility in evaluating RCTs using the Snyder's classification for reporting. Snyder's classification may be adopted for routine reporting of MRA.

Outcomes after arthroscopic repair of rotator cuff tears in the setting of mild to moderate glenohumeral osteoarthritis

BACKGROUND Rotator cuff pathology is a very common source of shoulder pain.Similarly,osteoarthritis of the glenohumeral joint can cause shoulder pain and produce similar symptoms.Surgical management can be indicated for both pathologies,however,outcomes data is limited when examining rotator cuff repair(RCR) in the setting of glenohumeral arthritis(GHOA).Thus,this study sought to determine outcomes for patients who undergo RCR in the setting of GHOA.AIM To evaluate if a relationship exists between outcomes of RCR in the setting of GHOA.METHODS This was a retrospective analysis of patients who underwent arthroscopic rotator cuff repair with concurrent glenohumeral osteoarthritis between 2010-2017.Patients were stratified based on rotator cuff tear size and glenohumeral osteoarthritis severity.Cohorts were paired 1:1 with patients without glenohumeral osteoarthritis.Patients included had a minimum two year follow-up.Rate of conversion to total shoulder arthroplasty,complication rates following initial surgery,and patient-reported outcome measures were collected.RESULTS A total of 142 patients were included.The number of patients that required total shoulder arthroplasty within two years after index surgery was low.2/71(2.8%) patients with GHOA,and 1/71(1.4%) without GHOA.Following rotator cuff repair,both groups showed favorable patientreported outcomes.CONCLUSION Patients with glenohumeral osteoarthritis who underwent arthroscopic rotator cuff repair showed comparable outcomes to patients without glenohumeral osteoarthritis.

Assessing the accuracy of arthroscopic and open measurements of the size of rotator cuff tears: A simulation-based study

BACKGROUND Arthroscopic procedures are commonly performed for rotator cuff pathology.Repair of rotator cuff tears is a commonly performed procedure.The intraoperative evaluation of the tear size and pattern contributes to the choice and completion of the technique and the prognosis of the repair.AIM To compare the arthroscopic and open measurements with the real dimensions of three different patterns of simulated rotator cuff tears of known size using a plastic shoulder model.METHODS We created three sizes and patterns of simulated supraspinatus tears on a plastic shoulder model(small and large U-shaped,oval-shaped).Six orthopaedic surgeons with three levels of experience measured the dimensions of the tears arthroscopically,using a 5 mm probe,repeating the procedure three times,and then using a ruler(open technique).Arthroscopic,open and computerized measurements were compared.RESULTS A constant underestimation of specific dimensions of the tears was found when measured with an arthroscope,compared to both the open and computerized measurements(mean differences up to-7.5±5.8 mm,P<0.001).No differences were observed between the open and computerized measurements(mean difference-0.4±1.6 mm).The accuracy of arthroscopic and open measurements was 90.5%and 98.5%,respectively.When comparing between levels of experience,senior residents reported smaller tear dimensions when compared both to staff surgeons and fellows.CONCLUSION This study suggests that arthroscopic measurements of full-thickness rotator cuff tears constantly underestimate the dimensions of the tears.Development of more precise arthroscopic techniques or tools for the evaluation of the size and type of rotator cuff tears are necessary.

Is cellular therapy beneficial in management of rotator cuff tears?Meta-analysis of comparative clinical studies

BACKGROUND Mesenchymal stromal cell(MSC)-based cellular therapy promotes type I collagen production,enhance mechanical strength of tissues,and enhance biology at the bone-tendon interface,which primarily explains their potential clinical utility in rotator cuff(RC)tears.AIM To analyze the efficacy and safety of cellular therapy utilizing MSCs in the management of RC tears from clinical studies available in the literature.METHODS We conducted independent and duplicate electronic database searches including PubMed,Embase,Reference Citation Anallysis,Web of Science,and Cochrane Library in August 2021 for studies analyzing the efficacy and safety of cellular therapy(CT)utilizing MSCs in the management of RC tears.Visual Analog Score(VAS)score for pain,American Shoulder and Elbow Surgeons(ASES)score,Disability of the Arm,Shoulder,and Hand score,Constant score,radiological assessment of healing,and complications such as retear rate and adverse events were the outcomes analyzed.Analysis was performed in R-platform using OpenMeta[Analyst]software.RESULTS Six studies involving 238 patients were included for analysis.We noted a significant reduction in VAS score for pain at 3 mo(weighed mean difference[WMD]=-2.234,P<0.001)and 6 mo(WMD=-3.078,P<0.001)with the use of CT,which was not maintained at long-term follow-up(WMD=-0.749,P=0.544).Concerning functional outcomes,utilization of CT produced a significant shortterm improvement in the ASES score(WMD=17.090,P<0.001)and significant benefit in functional scores such as Constant score(WMD=0.833,P=0.760)at long-term follow-up.Moreover,we also observed significantly improved radiological tendon healing during the longterm follow-up(odds ratio[OR]=3.252,P=0.059).We also noted a significant reduction in the retear rate upon utilization of CT in RC tears both at short-(OR=0.079,P=0.032)and long-term(OR=0.434,P=0.027)follow-ups.We did not observe any significant increase in the adverse events directly related to cellular therapy,as compared with the control group(OR=0.876,P=0.869).CONCLUSION Based on our comprehensive and critical review,we could observe that the utilization of CT in RC tear significantly reduced pain severity at 3 and 6 mo,improved short-term functional outcome,enhanced radiological tendon healing,and mitigated retear rates at both short-and long-term follow-ups.The literature also confirmed the relative safety of using MSC therapy in patients presenting with RC tears.

Predictors of clinical outcomes after non-operative management of symptomatic full-thickness rotator cuff tears

BACKGROUND Previous studies have shown that non-surgical management can be an effective treatment strategy for many patients with rotator cuff tears.Despite the prevalence of rotator cuff disease,few studies have examined the patient and tear related factors that predict outcomes of nonsurgical management in this cohort of patients.AIM To identify factors that are associated with changes in patient reported outcomes over time in individuals with full-thickness rotator cuff tears treated without surgery.METHODS A cohort of 59 patients who underwent non-surgical management of full thickness rotator cuff tears with a minimum of 1-year follow-up were identified from our institutional registry.Patient demographics,comorbidities and tear characteristics were collected at initial presentation.Outcome measures were collected at baseline and at each clinical follow-up,which included Western Ontario Rotator Cuff(WORC)index,American Shoulder and Elbow Surgeons score,Visual Analog Scale for pain and Single Assessment Numerical Evaluation.Multi-and univariate regression analyses were used to determine the impact of each patient and tear related variable on final WORC scores and change in WORC scores throughout the study.RESULTS In this non-surgical cohort,all patient-reported outcome measures significantly improved compared to baseline at 1 and 2-year follow-up.There was no significant difference in outcomes between 1 and 2 years.The average improvement surpassed the published minimal clinically important differences values for WORC,American Shoulder and Elbow Surgeons,Visual Analog Scale pain and Single Assessment Numerical Evaluation scores.Regression analysis identified female gender(β=-19.88,P=0.003),smoking(β=-29.98,P=0.014)and significant subscapularis fatty infiltration(β=-15.35,P=0.024)as predictors of less favorable WORC scores at 1 year,and female gender(β=-19.09,P=0.015)alone as a predictor of lower WORC scores at 2 years.Patients with symptom duration greater than 1 year at presentation reported less improvement in WORC scores at 1-year follow-up(β=-14.63,P=0.052)and patients with traumatic tears reported greater improvements in WORC scores at 2-year follow-up(β=17.37,P=0.031).CONCLUSION Patients with full thickness rotator cuff tears can achieve and maintain clinically meaningful benefit from non-surgical management through 2-year follow-up.Female patients,smokers,and those with significant subscapularis fatty infiltration tend to have lower overall WORC scores at 1-year follow-up,and females also have lower WORC scores at 2-year follow-up.Patients presenting with symptoms greater than 1 year had less clinical improvement at 1-year follow-up,and those with traumatic tears had greater clinical improvement at 2-year follow-up.

Differences in the Length and Thickness of the Coracoacromial Ligament between Normal Shoulders and Shoulders with Rotator Cuff Tears

Although the relationship between the material properties of the coracoacromial ligament and rotator cuff tears has been clarified, it is difficult to evaluate these properties in the clinical setting. The purpose of this study was to clarify the relationship between rotator cuff tears and the length and thickness of the coracoacromial ligament in living shoulders, in order to assess the potential use of these parameters as clinical indicators of the possible risk or progression of rotator cuff tears. Thirty-five volunteers (46 shoulders, mean age: 52 years) were enrolled. The presence or absence of rotator cuff tears and the length and thickness of the coracoacromial ligament were evaluated by ultrasonography. Longitudinal images of the coracoacromial ligaments with the acromion and coracoid process as landmarks were obtained, and the lengths of the ligaments were measured using acoustic shadows as the index. On the same screens, the thicknesses at the center of the ligaments were measured. Ligaments in shoulders with a rotator cuff tear were significantly shorter than ligaments in shoulders without a rotator cuff tear (25.9 ± 2.5 mm vs. 28.6 ± 1.7 mm, respectively;P < 0.0001). There was no significant difference in the thicknesses of the ligaments. The length and thickness of the coracoacromial ligament of living shoulders were easily evaluated with ultrasonography in the present study, and the coracoacromial ligament was found to be significantly shorter in shoulders with a rotator cuff tear. The risk and progression of rotator cuff tears can be evaluated clinically by measuring the length of the coracoacromial ligament.

MORPHOLOGICAL AND SIGNAL CHARACTERISTICS OF ROTATOR CUFF TEARS ON CONVENTIONAL MRI AND MR ARTHROGRAPHY:COMPARING WITH GROSS ANATOMY AND HISTOPATHOLOGY

Objective To study the MR characterizations of supraspinatus and infraspinatus tendon lesions by comparing with gross anatomy and histopathology. Methods The study group consisted of 20 cadaver shoulders which were underwent the same imaging protocols of conventional MRI and MR arthrography. Results SET2WI images or MR arthrography respectively possessed of high specificity （95. 6% , 100% ）, but low sensitivity （70. 6% , 58. 8% ） for diagnosing rotator cuff tears. By uniting two images techniques, could remedy its limitations and would markedly increase the sensitivity （88.2% ）. There were many factors influencing the visualizations of partial thickness tears of rotator cuff on MR images, from which uppermost factors are tear extent, ruptured synovial capsule, scar and synovial proliferation. Conclusion MR1 diagnoses of rotator cuff lesions （ especially partial thickness tears） must carefully be estimated by combining T2WI images and MR arthrography.

Effects of different positions on rehabilitation after rotator cuff repair under shoulder arthroscopy

Objective Shoulder arthroscopic rotator cuff tear repair is currently the main treatment for full-thickness rotator cuff tears,and postoperative rehabilitation training is essential.However,pain and limitation of activity during the rehabilitation process will lead to poor results.Hence,identifying rehabilitation approaches is crucial.This study aimed to compare patient's rehabilitation outcomes and experience between rehabilitation in the supine position and in the standing position.Methods This prospective study included patients diagnosed with full-thickness rotator cuff tears who underwent shoulder arthroscopic double-row rivet repair at Sir Run Run Shaw Hospital,Zhejiang University School of Medicine from March 2019 to September 2021.The patients were randomly assigned to the standing rehabilitation exercise group(group A)and the supine rehabilitation exercise group(group B).All patients were followed up for 6 months to record and compare the visual analog scale(VAS)scores,shoulder range of motion,and rehabilitation compliance.Results Altogether,86 patients participated in the study,of whom 79 patients completed the 6-month follow-up.Groups A and B had 39 and 40 patients,respectively.Before operation,the VAS score,forward flexion and extension angle,and abduction angle were comparable between groups A and B.After operation,the patients in groups A and B all experienced a significant improvement in the VAS score,forward flexion and extension angle,and abduction angle(p<0.05).In addition,patients in group B had better VAS score(4.58±0.87 vs.5.21±1.13,p=0.0068;2.15±0.66 vs.2.51±0.51,p=0.0078;0.78±0.86 vs.1.33±0.81,p=0.0015),forward flexion and extension angle(109.30±2.87°vs.102.33±3.74°,p=0.0001;109.53±3.39°vs.104.18±2.76°,p=0.0001;125.22±6.05°vs.117.59±2.27°,p=0.0001),and abduction angle(91.78±2.77°vs.82.92±2.12°,p=0.0001;91.62±2.78°vs.82.82±1.45°,p=0.0001;109.48±3.37°vs.100.10±2.94°,p=0.0001)at 2 wk,6 wk and 6 m postoperatively.Conclusion After 6 months of follow-up,the patients who performed rehabilitation exercises in the supine position achieved better rehabilitation outcomes than those who performed rehabilitation exercises while standing.

Optimizing Recovery Following Mihata Superior Capsular Reconstruction Surgery with Tensor Fascia Lata Auto Graft: A Comprehensive Rehabilitation Protocol

Objective: Superior Capsular Reconstruction (SCR) using a Tensor Fascia Lata (TFL) autograft is an evolving technique for treating irreparable rotator cuff tears. The Mihata technique, initially developed in Japan, has shown promising long-term results. However, a standardized post-operative rehabilitation protocol for this procedure in the USA is lacking. Purpose: This study aims to evaluate the outcomes of a comprehensive rehabilitation protocol following SCR with TFL autograft in a cohort of nine patients. Participants and Methods: A prospective observational study was conducted at Concentra Urgent Care, San Francisco. Nine patients, aged 55 - 65 years, underwent SCR with TFL autograft performed by a specialized orthopedic surgeon. Post-operative rehabilitation was managed using a structured protocol, divided into three phases focusing on passive exercises, progressive range of motion, and strengthening. Outcomes were measured using the Visual Analogue Scale (VAS) for pain, forward flexion range of motion (FF-ROM), and Single Assessment Numeric Evaluation (SANE) scores over a six-month period. Results: Significant improvements were observed in pain reduction (mean VAS decrease of −3.67 points, p = 0.01), ROM (mean FF increase of 41.11 degrees, p = 0.014), and SANE scores (mean improvement of 42.11%, p = 0.009), indicating the efficacy of the rehabilitation protocol. Conclusion: The comprehensive rehabilitation protocol following SCR with TFL autograft significantly improved pain, range of motion, and shoulder function in patients, suggesting its potential utility in clinical practice.

Fracture of the scapular neck combined with rotator cuff tear:A case report

BACKGROUND Scapular fracture has a low incidence rate, accounting for 0.4%-0.9% of allfractures, and scapular neck fractures are extremely rare, comprisingapproximately 7%-25% of all scapular fractures. Scapular neck fractures are oftenstudied as case reports mostly accompanied by other injuries, thus leading toconfusion. All previous cases of scapular neck fractures are not associated withrotator cuff injuries.CASE SUMMARY A 62-year-old man was admitted to our emergency department 6 h after his rightshoulder and back were impacted by heavy objects. The patient presented chesttightness and shortness of breath. Chest computed tomography (CT) showedpneumohemothorax, multiple rib fractures, and right scapula fractures. ThreedimensionalCT reconstruction of the right shoulder joint showed a trans-spinousscapular neck fracture with a glenohumeral joint dislocation. Rotator cuff injurywas suspected because the patient had a glenohumeral joint dislocation and wasthen confirmed by shoulder magnetic resonance imaging. A staged surgery wasperformed, including open reduction and internal fixation of the right scapulafracture and repairing of rotator cuff by right shoulder arthroscopy. At the 5-mofollow-up, the fracture line was blurred and the shoulder joint function was good.CONCLUSION Fracture of the scapular neck combined with rotator cuff tear is rare and therotator cuff injury should not be ignored in clinical work. Stable internal fixationcombined with secondary arthroscopic repair of rotator cuff tear can achieve goodresults.

Role of biomechanical assessment in rotator cuff tear repair: Arthroscopic vs mini-open approach

BACKGROUND Rotator cuff(RC)tears are one of the most frequent pathologies within the shoulder girdle.Hand dominance and older age are associated with RC tears.Two different surgical procedures,the mini-open(MO)and all-arthroscopic(AA)approach,represented the standard of treatment.AIM To compare the clinical and biomechanical outcomes of two surgical techniques(AA vs MO procedure)performed to address the painful shoulder syndrome with partial or total supraspinatus tendon tear.METHODS Eighty-eight participants,50 following RC repair with AA and 38 with MO approach,were recruited in the present cross-sectional case-control study(ORTHO-SHOULDER,Prot.0054602).All patients underwent postoperative clinical evaluation for pain(Visual analogic scale),impairment,and disability(disability of the arm,shoulder,and hand)and limitation in daily activity(Constant-Murley score).Patients’shoulder mobility was also assessed in our Laboratory of Functional Movement through a wearable inertial sensor and surface electromyography to monitor kinematics and muscle activity during the movement on the frontal(abduction/adduction)and sagittal(flexion-extension)planes.RESULTS No statistically significant differences between the two procedures were observed in either main clinical score or range of motion.A significant increase in velocity during the movement execution and a higher contribution of upper trapezius muscles were found in the AA group compared with MO patients.CONCLUSION In terms of clinical scores,our findings were in line with previous results.However,the use of technology-based assessment of shoulder mobility has revealed significant differences between the two techniques in terms of mean velocity and pattern of muscle activation.

Accuracy of the rotator cuff reparability score

BACKGROUND The reparability of large or massive rotator cuff tears is difficult to determine preoperatively.We previously identified age≥65 years,acromiohumeral interval≤6 mm,and anteroposterior tear size≥22 mm as risk factors for rotator cuff repair failure.We therefore developed a rotator cuff reparability score where each of the above risk factors is assigned a score of one point.AIM To determine the accuracy of a rotator cuff reparability score.METHODS This was a retrospective cohort study of recruited patients with large or massive rotator cuff tears treated at our institution between January 2013 and December 2019.Exclusion criteria were revision surgery and patients with contraindications for surgery.All patients underwent arthroscopic rotator cuff repair and were categorized into either complete or partial rotator cuff repair.Rotator cuff reparability scores were calculated for each patient.The sensitivity,specificity,positive and negative predictive value,and positive and negative likelihood ratio were assessed.A receiver operating characteristic curve was plotted to determine the optimal cut-off rotator cuff reparability score.RESULTS Eighty patients(mean age,61 years;range,25–84 years;41 females and 39 males)were recruited.Intra-and inter-observer reliabilities were good to excellent.The number of patients with 0,1,2,and 3 risk factors for rotator cuff repair failure were 24,33,17,and 6,respectively.Complete repair was performed in all patients without risk factors.Two of the 33 patients with one risk factor and seven of the 17 patients with two risk factors underwent partial repair.One of the six patients with three risk factors underwent complete repair.The area under the curve was 0.894.The optimal cut-off score was two points with a sensitivity of 85.71%and a specificity of 83.33%.CONCLUSION A rotator cuff reparability score of two was determined to be the optimal cut-off score for predicting the reparability of large or massive rotator cuff tears.

Application of Tranexamic Acid in Shoulder Arthroscopic Surgery:A Randomised Controlled Trial

Objective To explore the optimal administration route of tranexamic acid(TXA)in shoulder arthroscopic surgery.Methods Patients undergoing arthroscopic rotator cuff repair were randomly divided into four groups:control group(without TXA treatment),intravenous group(TXA was intravenously administered 10 minutes before surgery),irrigation group(TXA was added to the irrigation fluid during subacromial decompression and acromioplasty),and intravenous plus irrigation group(TXA was applied both intravenously and via intra-articular irrigation).The primary outcome was visual clarity assessed with visual analog scale(VAS)score,and the secondary outcomes included irrigation fluid consumption and time to subacromial decompression and acromioplasty procedure.Results There were 134 patients enrolled in the study,including 33 in the control group,35 in the intravenous group,32 in the irrigation group,and 34 in the intravenous plus irrigation group.The median and interquartile range of VAS scores for the intravenous,irrigation,and intravenous plus irrigation groups were 2.70(2.50,2.86)(Z=-3.677,P=0.002),2.67(2.50,2.77)(Z=-3.058,P<0.001),and 2.91(2.75,3.00)(Z=-6.634,P<0.001),respectively,significantly higher than that of the control group[2.44(2.37,2.53)].Moreover,the control group consumed more irrigation fluid than the intravenous group,irrigation group,and intravenous plus irrigation group(all P<0.05).The intravenous plus irrigation group consumed less irrigation fluid than either the intravenous group or the irrigation group(both P<0.001).There was no difference in subacromial decompression and acromioplasty operative time among the four groups.Conclusion TXA applied both topically and systematically can improve intraoperative visual clarity,and the combined application is more effective.

Usefulness of computed tomography based three-dimensional reconstructions to assess the critical shoulder angle

BACKGROUND The critical shoulder angle(CSA)is a radiographic measurement that provides an assessment of both glenoid inclination and acromial length.Higher values may correlate with the presence of rotator cuff tears.However,it is difficult to obtain a high-quality true anteroposterior(AP)radiograph of the shoulder,with any excess scapular version or flexion/extension resulting in deviation from the true CSA value.Three-dimensional(3D)bony reconstructions of computed tomography(CT)shoulder scans may be able to be rotated to obtain a similar view to that of true AP radiographs.AIM To compare CSA measurements performed on 3D bony CT reconstructions,with those on corresponding true AP radiographs.METHODS CT shoulder scans were matched with true AP radiographs that were classified as either Suter-Henninger type A or C quality.3D bony reconstructions were segmented from the CT scans,and rotated to replicate an ideal true AP view.Two observers performed CSA measurements using both CT and radiographic images.Measurements were repeated after a one week interval.Reliability was assessed using intraclass correlation coefficients(ICCs)and Bland-Altman plots[bias,limits of agreement(LOA)].RESULTS Twenty CT shoulder scans were matched.The mean CSA values were 32.55°(±4.26°)with radiographs and 29.82°(±3.49°)with the CT-based method[mean difference 2.73°(±2.86°);P<0.001;bias+2.73°;LOA-2.17°to+7.63°].There was a strong correlation between the two methods(r=0.748;P<0.001).Intra-observer reliability was similar,but the best intra-observer values were achieved by the most experienced observer using the CT-based method[ICC:0.983(0.958-0.993);bias+0.03°,LOA-1.28°to+1.34°].Inter-observer reliability was better with the CT-based method[ICC:0.897(0.758-0.958),bias+0.24°,LOA-2.93°to+3.41°].CONCLUSION The described CT-based method may be a suitable alternative for critical shoulder angle measurement,as it overcomes the difficulty in obtaining a true AP radiographic view.

First immunohistochemical evidence of human tendon repair following stem cell injection: A case report and review of literature

BACKGROUND Current clinical treatment options for symptomatic,partial-thickness rotator cuff tear(sPTRCT)offer only limited potential for true tissue healing and improvement of clinical results.In animal models,injections of adult stem cells isolated from adipose tissue into tendon injuries evidenced histological regeneration of tendon tissue.However,it is unclear whether such beneficial effects could also be observed in a human tendon treated with fresh,uncultured,autologous,adipose derived regenerative cells(UA-ADRCs).A specific challenge in this regard is that UA-ADRCs cannot be labeled and,thus,not unequivocally identified in the host tissue.Therefore,histological regeneration of injured human tendons after injection of UA-ADRCs must be assessed using comprehensive,immunohistochemical and microscopic analysis of biopsies taken from the treated tendon a few weeks after injection of UA-ADRCs.CASE SUMMARY A 66-year-old patient suffered from sPTRCT affecting the right supraspinatus and infraspinatus tendon,caused by a bicycle accident.On day 18 post injury[day 16 post magnetic resonance imaging(MRI)examination]approximately 100 g of abdominal adipose tissue was harvested by liposuction,from which approximately 75×10^(6) UA-ADRCs were isolated within 2 h.Then,UA-ADRCs were injected(controlled by biplanar X-ray imaging)adjacent to the injured supraspinatus tendon immediately after isolation.Despite fast clinical recovery,a follow-up MRI examination 2.5 mo post treatment indicated the need for open revision of the injured infraspinatus tendon,which had not been treated with UAADRCs.During this operation,a biopsy was taken from the supraspinatus tendon at the position of the injury.A comprehensive,immunohistochemical and microscopic analysis of the biopsy(comprising 13 antibodies)was indicative of newly formed tendon tissue.CONCLUSION Injection of UA-ADRCs can result in regeneration of injured human tendons by formation of new tendon tissue.

Crimped nanofiber scaffold mimicking tendon-to-bone interface for fatty-infiltrated massive rotator cuff repair

Electrospun fibers,with proven ability to promote tissue regeneration,are widely being explored for rotator cuff repairing.However,without post treatment,the microstructure of the electrospun scaffold is vastly different from that of natural extracellular matrix(ECM).Moreover,during mechanical loading,the nanofibers slip that hampers the proliferation and differentiation of migrating stem cells.Here,electrospun nanofiber scaffolds,with crimped nanofibers and welded joints to biomimic the intricate natural microstructure of tendon-to-bone insertion,were prepared using poly(ester-urethane)urea and gelatin via electrospinning and double crosslinking by a multi-bonding network densification strategy.The crimped nanofiber scaffold(CNS)features bionic tensile stress and induces chondrogenic differentiation,laying credible basis for in vivo experimentation.After repairing a rabbit massive rotator cuff tear using a CNS for 3 months,the continuous translational tendon-to-bone interface was fully regenerated,and fatty infiltration was simultaneously inhibited.Instead of micro-CT,μCT was employed to visualize the integrity and intricateness of the three-dimensional microstructure of the CNS-induced-healed tendon-to-bone interface at an ultra-high resolution of less than 1μm.This study sheds light on the correlation between nanofiber post treatment and massive rotator cuff repair and provides a general strategy for crimped nanofiber preparation and tendon-to-bone interface imaging characterization.