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.

Exosomes derived from tendon stem/progenitor cells enhance tendon-bone interface healing after rotator cuff repair in a rat model

The rate of retear after surgical repair remains high.Mesenchymal stem cells(MSCs)have been extensively employed in regenerative medicine for several decades.However,safety and ethical concerns constrain their clinical application.Tendon Stem/Progenitor Cells(TSPCs)-derived exosomes have emerged as promising cellfree therapeutic agents.Therefore,urgent studies are needed to investigate whether TSPC-Exos could enhance tendon-bone healing and elucidate the underlying mechanisms.In this study,TSPC-Exos were found to promote the proliferation,migration,and expression of fibrogenesis markers in BMSCs.Furthermore,TSPC-Exos demonstrated an ability to suppress the polarization of M1 macrophages while promoting M2 macrophage polarization.In a rat model of rotator cuff repair,TSPC-Exos modulated inflammation and improved the histological structure of the tendon-bone interface,the biomechanical properties of the repaired tendon,and the function of the joint.Mechanistically,TSPC-Exos exhibited high expression of miR-21a-5p,which regulated the expression of PDCD4.The PDCD4/AKT/mTOR axis was implicated in the therapeutic effects of TSPC-Exos on proliferation,migration,and fibrogenesis in BMSCs.This study introduces a novel approach utilizing TSPC-Exos therapy as a promising strategy for cell-free therapies,potentially benefiting patients with rotator cuff tear in the future.

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.

Rotator cuff repair with an interposition polypropylene mesh:A biomechanical ovine study

BACKGROUND Chronic large to massive rotator cuff tears are difficult to treat and re-tears are common even after surgical repair.We propose using a synthetic polypropylene mesh to increase the tensile strength of rotator cuff repairs.We hypothesize that using a polypropylene mesh to bridge the repair of large rotator cuff tears will increase the ultimate failure load of the repair.AIM To investigate the mechanical properties of rotator cuff tears repaired with a polypropylene interposition graft in an ovine ex-vivo model.METHODS A 20 mm length of infraspinatus tendon was resected from fifteen fresh sheep shoulders to simulate a large tear.We used a polypropylene mesh as an interposition graft between the ends of the tendon for repair.In seven specimens,the mesh was secured to remnant tendon by continuous stitching while mattress stitches were used for eight specimens.Five specimens with an intact tendon were tested.The specimens underwent cyclic loading to determine the ultimate failure load and gap formation.RESULTS The mean gap formation after 3000 cycles was 1.67 mm in the continuous group,and 4.16 mm in the mattress group(P=0.001).The mean ultimate failure load was significantly higher at 549.2 N in the continuous group,426.4 N in the mattress group and 370 N in the intact group(P=0.003).CONCLUSION The use of a polypropylene mesh is biomechanically suitable as an interposition graft for large irreparable rotator cuff tears.

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.

Rotator cuff tears: An evidence based approach

Lesions of the rotator cuff(RC) are a common occurrence affecting millions of people across all parts of the globe. RC tears are also rampantly prevalent with an agedependent increase in numbers. Other associated factors include a history of trauma, limb dominance, contralateral shoulder, smoking-status, hypercholesterolemia, posture and occupational dispositions. The challenge lies in early diagnosis since a high proportion of patients are asymptomatic. Pain and decreasing shoulder power and function should alert the heedful practitioner in recognizing promptly the onset or aggravation of existing RC tears. Partial-thickness tears(PTT) can be bursalsided or articular-sided tears. Over the course of time, PTT enlarge and propagate into full-thickness tears(FTT) and develop distinct chronic pathological changes due to muscle retraction, fatty infiltration and muscle atrophy. These lead to a reduction in tendon elasticity and viability. Eventually, the glenohumeral joint experiences a series of degenerative alterations- cuff tear arthropathy. To avert this, a vigilant clinician must utilize and corroborate clinical skill and radiological findings to identify tear progression. Modern radio-diagnostic means of ultrasonography and magnetic resonance imaging provide excellent visualization of structural details and are crucial in determining further course of action for these patients. Physical therapy along with activity modifications, antiinflammatory and analgesic medications form the pillars of nonoperative treatment. Elderly patients with minimal functional demands can be managed conservatively and reassessed at frequent intervals. Regular monitoring helps in isolating patients who require surgical interventions. Early surgery should be considered in younger, active and symptomatic, healthy patients. In addition to being costeffective, this helps in providing a functional shoulder witha stable cuff. An easily reproducible technique of maximal strength and sturdiness should by chosen among the armamentarium of the shoulder surgeon. Grade 1 PTTs do well with debridement while more severe lesions mandate repair either by trans-tendon technique or repair following conversion into FTT. Early repair of repairable FTT can avoid appearance and progression of disability and weakness. The choice of surgery varies from surgeon-to-surgeon with arthroscopy taking the lead in the current scenario. The double-row repairs have an edge over the single-row technique in some patients especially those with massive tears. Stronger, costeffective and improved functional scores can be obtained by the former. Both early and delayed postoperative rehabilitation programmes have led to comparable outcomes. Guarded results may be anticipated in patients in extremes of age, presence of comorbidities and severe tear patters. Overall, satisfactory results are obtained with timely diagnosis and execution of the appropriate treatment modality.

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.

Elasticity of the Coracoacromial Ligament in Shoulders with Rotator Cuff Tears: Measurement with Ultrasound Elastography

Background: The symptoms of rotator cuff tear vary and may even be absent. Thus, the symptoms cannot be explained solely by the presence of rotator cuff tear, and other factors are thought to be involved. Because the rotator cuff comes in contact with the coracoacromial ligament, the elasticity of the ligament may be a factor of the symptoms. The purpose of this study was to clarify the elasticity of the coracoacromial ligament in live shoulders with rotator cuff tears. Methods: Forty-one shoulders in 24 persons were enrolled in this study. The average age was 52 years old (range, 15 - 84 years old). We investigated the presence of rotator cuff tear and measured the elasticity of the coracoacromial ligament by ultrasound elastography (EUB-7500, HITACHI, Japan). Ultrasound elastography was a useful method to quantify the strain of soft tissue when pressure was added. The strain ratio (the ratio of strain of the coracoacromial ligament to that of the rotator cuff) was used as the index of the elasticity of coracoacromial ligament. Thus, the higher the strain ratio was, the softer the ligament was. Results: The strain ratio of the coracoacromial ligaments without rotator cuff tear showed a negative correlation to the age (r = ﹣0.825, P 0.01). The strain ratio of the ligaments with rotator cuff tear (23.75 ± 15.05, 69.6 years old) was higher than that of the older ligaments without cuff tear (12.62 ± 7.94, 64.6 years old) (P = 0.0486). In shoulders with rotator cuff tear, the strain ratio of the ligaments with pain (14.37 ± 10.15, 66.7 years old) was lower than that of ligaments without pain (33.12 ± 13.59, 69.1 years old) (P = 0.0221). Conclusions: The coracoacromial ligament became stiffened with aging but softened with the existence of rotator cuff tear. The ligaments with symptomatic cuff tear are more stiffened than the ligaments with asymptomatic cuff tear.

Surgeon-Operated In-Office Ultrasonography for the Diagnosis of Rotator Cuff Tears: A Comparison with Magnetic Resonance Imaging

Objective: Few investigators have evaluated whether ultrasonography operated by a surgeon during a patient’s clinic visit is capable of obtaining a similar degree of accuracy as magnetic resonance imaging in regard to the diagnosis of rotator cuff tears and lesions of the biceps tendon. The purpose of this study was to clarify the accuracy of in-office ultrasonography for the diagnosis of rotator cuff tears in comparison to magnetic resonance imaging. Methods: One hundred and three patients (105 shoulders) with a clinical diagnosis of impingement and suspected rotator cuff tear, who subsequently underwent arthroscopic surgery were retrospectively enrolled in this study, including 7 males with 89 shoulders, and 33 females with 33 shoulders, and their mean age was 60.9 years (range, 30 to 83 years). The subjects were examined using ultrasonography and magnetic resonance imaging within three months pre-operatively per normal practice of the outpatient clinic. The two modalities were then compared to the reference standard, arthroscopic findings. Results: Intra-operatively, 79 full-thickness and 15 partial-thickness rotator cuff tears were found. The agreement between ultrasonography and magnetic resonance imaging for diagnosis of rotator cuff tears was statistically good;observed degree of agreement was 87% with Kappa coefficient of 0.73. Ultrasonography showed a sensitivity of 94% and a specificity of 100% for full-thickness tears, and a sensitivity of 80% and a specificity of 91% for partial-thickness tears. The agreement of the two modalities for diagnosis of lesions of the biceps tendon was also good;observed degree of agreement was 93% with Kappa coefficient of 0.76. In addition, ultrasonography showed comparable accuracy for classifying the size of rotator cuff tears to that of magnetic resonance imaging. Conclusion: Surgeon-operated in-office ultrasonography is an appropriate technique for the assessment of rotator cuff tears with a comparable sensitivity and specificity to that of magnetic resonance imaging.

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.

Differential mRNA Expression of <i>COX</i>-2 and Proinflammatory Mediators in Patients with Rotator Cuff Tears and Osteoarthritis of the Hip

Purpose: Bursal inflammation is thought to be a major cause of pain in degenerative rotator cuff tears (RCTs). While the expression of proinflammatory mediators, such as COX-2, TNF-α, IL-1β, and IL-6, is crucial for the pathophysiology of osteoarthritis (OA), their role in degenerative RCTs remains unknown. The aim of this study was to determine the expression of COX-2 and proinflammatory mediators in the development of RCT-induced pain by comparing their levels in patients with hip OA or RCTs. Methods: We included samples obtained from 31 shoulders of 31 patients with RCTs and samples from 30 hips of 27 patients with hip OA. The mRNA levels of COX-2, TNF-α, IL-1β, and IL-6 were determined using RT-PCR, and were compared between the subacromial bursa and hip joints. We also analyzed IL-1β-induced COX-2 expression in the subacromial bursa and synovial blast of the hip. Results: COX-2, IL-1β, and IL-6 expression levels were significantly lower in the subacromial bursa of RCTs than in hip OA samples, while no significant difference was observed for TNF-α. No significant difference in the fold increase was observed between subacromial bursa and hip OA samples, even though IL-1β-induced COX-2 expression increased in both samples. Conclusion: Our findings suggest that the main mechanism underlying pain development differs between patients with RCTs and those with hip OA.

Role of shoulder gradient in the pathogenesis of rotator cuff tears

BACKGROUND Shoulder gradient has been associated with shoulder pathologies such as shoulder impingement syndrome.AIM To investigate if there is an association between shoulder gradient and incidence of rotator cuff tear(RCT).METHODS A total of 61 patients with a confirmed diagnosis of RCT were included in this retrospective study.The anteroposterior radiograph of the shoulder was used to measure shoulder gradient in adduction and neutral rotation positions.The pain level was assessed with the visual analog scale for pain.RESULTS The mean age of the patients was 55.7±12.3 years.The mean visual analog scale of the patients was 4.1±1.2.The mean shoulder gradient was 14.11 ±2.65 for the affected shoulder and 15.8 ±2.2 for the unaffected shoulders.This difference was not statistically significant(P=0.41).A difference of 1.15 ±1.82 was found between the injured and non-injured shoulder.No significant association was found between the gradient difference of the shoulder and demographic and clinical characteristics of the patients.CONCLUSION Shoulder gradient is not associated with the pathology of RCT.Yet,future studies with more standardization and a larger sample size are needed to investigate the role of shoulder gradient in RCT pathogenesis further.

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.

Arthroscopic Subacromial Decompression for Small and Medium Size Tears of Rotator Cuff without Tendon Repair

According to our previous clinical impression, we hypothesized that patients who had symptomatic rotator cuff tendon tear in a diamemter below 3 cm would benefit from arthroscopic subacromial decompression only, without the need for the repair of the thorn tendon. From 1998 to 2003, 160 patients (168 shoulders) had arthroscopic subacromial decompression for impingement syndrome with a torn rotator cuff without repairing the tear of the cuffs (120 males and 40 females). The average patient age was 64 years and the average follow up was 30 months. At follow up, 96 patients (60%) had full recovery;55 patients (35%) had residual low grade shoulder pain on effort and 7 patients (5%) had poor outcome. In the last group of patients with unsatisfactory outcome, the postoperative Constant score was only 64 points. In 95% of patients, the average Constant score values raised from average preoperative value of 62 to postoperative average score of 82. According to these results, there is an indication that in patients in the seventh decade of life or older with symptomatic rotator cuff tear, pain relief and good shoulder function can be achieved by more conservative approach of subacromial decompression alone, providing a clear diagnosis that the diameter of the tear in the supraspinatus and infraspinatus tendons is below 3 cm.

Rotator Cuff Reconstruction and Humeral Head Replacement Using Smaller Humeral Prostheses in Cuff Tear Arthropathy Patients under 70 Years of Age

Background: Most reverse shoulder arthroplasty (RSA) studies have shown good improvement in arm elevation without improvements in external rotation (ER). In addition, high rates of complications after long-term RSA have been reported, suggesting that RSA should be limited to elderly patients, especially those who are older than 70 years old. Since 2001, we have developed a strategy of rotator cuff reconstruction with muscle transfer and humeral head replacement (HHR), using smaller humeral prostheses, in cuff tear arthropathy patients. The aim of the present study was to investigate the clinical outcome of our strategy in patients under 70 years of age who had irreparable rotator cuff tears and osteoarthritis. Materials and Methods: A total of 25 shoulders of 25 patients under 70 years of age (males, 15;females, 10) with irreparable cuff tears were treated with HHR and cuff reconstruction. The average age at the time of surgery was 64.3 years (range, 55 - 69) and the average follow-up period was 38.7 months (range, 24 - 72). The cuff defect was repaired using a partial subscapularis transfer in 14 shoulders;nine shoulders required a latissimus dorsi transfer, one required a pectoralis major transfer, and one required both a latissimus dorsi and a pectoralis major transfer. Clinical outcomes were assessed with the range of motion (ROM), UCLA score, Japanese Orthopaedic Association (JOA) score and postsurgical complications. Results: Shoulder pain was diminished in all patients after surgery. The preoperative UCLA and JOA scores were 13.1 and 47.0 respectively, improving to 28.6 and 81.5 respectively after surgery. Active forward flexion has improved from an average of 89.0° to 138.8°, and the ER improved from an average of 16.2° to 33.2°. No complications occurred after surgery. Conclusion: Anatomical reconstruction using smaller head humeral prostheses yielded favorable results and less complication, compared with RSA. Considering another advantage of ability to retain glenoid bone stock, the current procedure can be a useful option for irreparable rotator cuff tears with OA in patients under 70 years old.

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.