Factors affecting rotator cuff integrity after arthroscopic repair for medium-sized or larger cuff tears: a retrospective cohort study

doi:10.1016/j.jse.2017.11.016

Journal of Shoulder and Elbow Surgery

Volume 27, Issue 6, June 2018, Pages 1012-1020

https://doi.org/10.1016/j.jse.2017.11.016 Get rights and content

Background

We wished to identify the preoperative prognostic factors associated with structural integrity after repair of medium-sized and larger rotator cuff tears and to determine the cutoff values using receiver operating characteristic curve analysis.

Methods

The study included 180 patients with medium-sized and larger rotator cuff tears. Each had a minimum 2-year postoperative follow-up by magnetic resonance imaging. We assessed several patient-related and disease-related preoperative factors using univariate and multivariate logistic regression analysis. To determine the cutoff value for the significant variables, receiver operating characteristic curve analysis was performed.

Results

Retears occurred in 28 of the 180 patients (15.6%). Univariate analysis found that retear was significantly affected by the type of work and pattern of tear. The rate of retear was significantly increased in diabetes and with increasing tear size, extent of retraction, delamination, and fatty infiltration. Furthermore, reduced remnant tendon length, distance from the musculotendinous junction to the face of the glenoid, occupation ratio, and acromiohumeral interval were also significant risk factors. In the multivariate analysis, body mass index, diabetes, dyslipidemia, extent of retraction, delamination, distance from musculotendinous junction to face of glenoid, occupation ratio, fatty infiltration of infraspinatus, and acromiohumeral interval remained significant risk factors. The extent of retraction (22.2 mm) and the occupation ratio (53.5%) showed highly accurate cutoff values for predicting retear.

Conclusion

Multiple factors influenced the healing process after rotator cuff repair. The best predictors were the extent of retraction and occupation ratio, which could help assist in determining the prognosis after rotator cuff repairs.

Section snippets

Patient selection

Institutional review board approval was obtained for this study protocol. In this retrospective cohort study, we evaluated 180 consecutive patients with medium-sized or larger RCTs who underwent arthroscopic rotator cuff repair by a single senior surgeon from February 2007 to August 2014 and had a minimum 2-year postoperative follow-up with magnetic resonance imaging (MRI) performed at the final follow-up. The medium-sized or larger cuff tears were defined as over 1 cm, according to Cofield.¹⁰

Results

Retears (Sugaya type IV or type V) occurred in 28 of the 180 patients (15.6%) on follow-up MRI after the rotator cuff repair. The retears of single-row and double-row suture-bridge repairs were 15 (24.6%) and 16 (10.9%) cases, respectively. There was statistically significant difference according to the repair technique (P = .019). In the univariate logistic regression analysis, the result of a retear was significantly affected by the type of work (P = .047) and the pattern of the tear (P

Discussion

The aims of this study were to evaluate preoperative risk factors for retears of medium-sized and larger RCTs and to investigate the cutoff value of each of the significant variables using ROC curve analysis. BMI, DM, dyslipidemia, extent of retraction, delamination, distance from the MTJ to the face of the glenoid, occupation ratio, fatty infiltration of the infraspinatus, and AHI were considered significant risk factors for retear. In addition, there were significantly better cutoff values

Conclusion

Multiple factors can affect the healing process after a rotator cuff repair. In our study on medium-sized and larger RCTs, the best predictors of retear were BMI, DM, dyslipidemia, extent of retraction, delamination, distance from the MTJ to the face of the glenoid, occupation ratio, fatty infiltration of the infraspinatus, and AHI. Furthermore, the extent of retraction and occupation ratio had accurate cutoff values of 22.2 mm and 53.5%, respectively. These cutoff values could be useful in

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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To investigate the effect of the antiosteoporotic agent zoledronic acid (ZA) on rotator cuff healing and clinical outcomes in patients with postmenopausal osteoporosis.
We prospectively enrolled 138 female patients with postmenopausal osteoporosis who were scheduled to undergo arthroscopic rotator cuff repair (ARCR) from March 2020 to March 2021. Patients were randomly allocated to the ZA group (ARCR followed by intravenous ZA infusions at postoperative Day 1 and 1 year later) and the control group (ARCR alone). All patients were followed up for 24 months. Tendon healing was evaluated by ultrasonography at 6 weeks and 24 months after surgery. The American Shoulder and Elbow Surgeons (ASES) score, Western Ontario Rotator Cuff (WORC) index, and Numeric Rating Scale (NRS) for pain were recorded at each follow-up, and the minimal clinically important difference (MCID) was calculated.
A total of 124 patients were included in the final analysis, 61 in the ZA group and 63 in the control group. There was no statistically significant difference in participant characteristics between the 2 groups. The ZA group had a significantly higher tendon healing rate than the control group at 2 years after surgery (odds ratio = 5.0; 95% confidence interval [CI], 1.4-18.7; P = .014). Regarding clinical outcomes, 100% of patients exceeded the MCID in both groups, and no significant differences were found at 2 years after surgery between the 2 groups (ASES: 2.5 [95% CI, −2.2 to 7.2; P = .291]; WORC index: 4.5 [95% CI, −0.117 to 9.117; P = .056]; NRS: −0.1 [95% CI, −0.3 to 0.1; P = .394]).
Antiosteoporotic treatment with ZA reduced the retear rate but did not significantly influence the clinical outcomes after ARCR in female patients with postmenopausal osteoporosis. Outcomes of ARCR showed good results in both groups and exceeded the MCID.
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Greater Socioeconomic Disadvantage as Measured by the Area Deprivation Index Is Associated With Failure of Healing Following Arthroscopic Repair of Massive Rotator Cuff Tears but Not With Clinical Outcomes
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To analyze the relationship between Area Deprivation Index (ADI) and preoperative status and short-term postoperative clinical outcomes among patients who underwent arthroscopic rotator cuff repair (ARCR) of massive rotator cuff tears (MRCTs).
A retrospective review was conducted on prospectively maintained data on patients who underwent ARCR of MRCTs defined as tear size ≥5 cm or complete tear of at least 2 tendons, with a minimum 2-year follow-up and a valid home address between January 2015 and December 2018. Each patient’s home address was mapped to the ADI to determine neighborhood disadvantage. This composite index is composed of 17 census-based indicators, including income, education, employment, and housing quality to quantify the level of socioeconomic deprivation. Ratings were recorded and categorized based on the sample’s percentile. Patients were then divided into 2 groups: upper quartile (ie, most disadvantaged [≥75th percentile]) and lower 3 quartiles (ie, least disadvantaged [<75th percentile]). Bivariate analysis was performed to associate ADI with patient-reported outcomes (PROs) and range of motion pre- and postoperatively, as well as complications, healing rate, satisfaction, and return to work. Patients reaching or exceeding the minimal clinically important difference for visual analog scale (VAS), American Shoulder and Elbow Surgeons, Veterans Rand 12-Item questionnaire, and subjective shoulder value were recorded for both cohorts.
Ninety-nine patients were eligible for study analysis. Preoperative PROs and range of motion were similar, except for a greater VAS for pain (6.3 vs 4.3; P < .01) and lower American Shoulder and Elbow Surgeons score (32.2 vs 45.1; P = .01) in the most disadvantaged group. Both groups showed similar postoperative PROs scores, but greater VAS improvement was seen in the upper quartile group (Δ 4.2 vs Δ 3.0; P = .04). In contrast, only the least-disadvantaged group significantly improved in internal rotation (P = .01) and forward flexion (18°; P < .01) from baseline. Although satisfaction, complications, and return to work were comparable (P > .05), failure of healing occurred more frequently in the most disadvantaged group (21% vs 6%; P = .03).
Patients with MRCTs residing in the most disadvantaged neighborhoods as measured by the ADI have more pain and functional limitations before undergoing ARCR but demonstrate similar postoperative functional improvements to patients from other socioeconomic backgrounds. Failure of healing of MRCTs may be more common in disadvantaged groups. Furthermore, both groups reported similar rates of clinically important functional improvement.
Level III, retrospective cohort comparison.
Contrast-Enhanced Ultrasound–Assessed Supraspinatus Muscle Perfusion Indicates Better Tissue Vitality and Outcome After Supraspinatus Tendon Repair and Subacromial Decompression
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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.
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.
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).
CEUS can visualize SSP muscle perfusion as a surrogate for tissue vitality and tendon healing, which is associated with better post-operative shoulder function.
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Healing failure after rotator cuff repair is a challenging problem. Acute, trauma-related tears are considered a separate entity and are often treated surgically. The aim of this study was to identify factors associated with healing failure in previously asymptomatic patients with trauma-related rotator cuff tears treated with early arthroscopic repair.
This study included 62 consecutively recruited patients (23% women; median age, 61 years; age range, 42-75 years) with acute symptoms in a previously asymptomatic shoulder and a magnetic resonance imaging–verified full-thickness rotator cuff tear after shoulder trauma. All patients were offered, and underwent, early arthroscopic repair, during which a biopsy specimen was harvested from the supraspinatus tendon and analyzed for signs of degeneration. Of the patients, 57 (92%) completed 1-year follow-up and underwent assessment of repair integrity on magnetic resonance images according to the Sugaya classification. Risk factors for healing failure were investigated using a causal-relation diagram where age, body mass index, tendon degeneration (Bonar score), diabetes mellitus, fatty infiltration (FI), sex, smoking, tear location regarding integrity of the rotator cable, and tear size (number of ruptured tendons and tendon retraction) were included and analyzed.
Healing failure at 1 year was identified in 37% of patients (n = 21). A high degree of FI of the supraspinatus muscle (P = .01), a tear location including disruption of rotator cable integrity (P = .01), and old age (P = .03) were associated with healing failure. Tendon degeneration as determined by histopathology was not associated with healing failure at 1-year follow-up (P = .63).
Older age, increased FI of the supraspinatus muscle, and a tear including disruption of the rotator cable increased the risk of healing failure after early arthroscopic repair in patients with trauma-related full-thickness rotator cuff tears.
Scaffold- and graft-based biological augmentation of rotator cuff repair: an updated systematic review and meta-analysis of preclinical and clinical studies for 2010-2022
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Despite advancements in the surgical techniques of rotator cuff repair (RCR), there remains a high retear rate. Biological augmentation of repairs with overlaying grafts and scaffolds may enhance healing and strengthen the repair construct. This study aimed to investigate the efficacy and safety of scaffold-based (nonstructural) and overlay graft–based (structural) biological augmentation in RCR (excluding superior capsule reconstruction and bridging techniques) in both preclinical and clinical studies.
This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, as well as guidelines outlined by The Cochrane Collaboration. A search of the PubMed, Embase, and Cochrane Library databases from 2010 until 2022 was conducted to identify studies reporting the clinical, functional, and/or patient-reported outcomes of ≥1 biological augmentation method in either animal models or humans. The methodologic quality of included primary studies was appraised using the Checklist to Evaluate a Report of a Non-pharmacological Trial (CLEAR-NPT) for randomized controlled trials and using the Methodological Index for Non-randomized Studies (MINORS) for nonrandomized studies.
A total of 62 studies (Level I-IV evidence) were included, comprising 47 studies reporting outcomes in animal models and 15 clinical studies. Of the 47 animal-model studies, 41 (87.2%) demonstrated biomechanical and histologic enhancement with improved RCR load to failure, stiffness, and strength. Of the 15 clinical studies, 10 (66.7%) illustrated improvement in postoperative clinical, functional, and patient-reported outcomes (eg, retear rate, radiographic thickness and footprint, and patient functional scores). No study reported a significant detriment to repair with augmentation, and all studies endorsed low complication rates. A meta-analysis of pooled retear rates demonstrated significantly lower odds of retear after treatment with biological augmentation of RCR compared with treatment with non-augmented RCR (odds ratio, 0.28; P < .00001), with low heterogeneity (I² = 0.11).
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There were no treatment specimens that exhibited histologic signs of a significant infection, inflammatory infiltrate, or foreign body reaction such as granuloma or fibrous capsule formation. Histologic scores in all categories were not significantly different at all time points, including the primary end point mean cumulative inflammatory score (control: 3.66 ± 1.21 vs treated: 4.33 ± 1.51, P = .42), when comparing the treatment and control RCR groups. In general, the degree of tendon healing and host tissue response was essentially equivalent between the 2 groups with observation of low overall levels of inflammation and progressive improvements in collagen organization, reduced tenocyte activity, and fibrocartilaginous enthesis reformation.
This histologic study demonstrated the use of a biphasic interpositional allograft for RCR augmentation in an ovine model does not generate an inflammatory response or foreign body reaction. Use of the biphasic interpositional allograft resulted in a histological profile that was essentially equivalent to that of a standard RCR at 3-, 6-, and 12-week postoperative timepoints. These findings suggest that a biphasic interpositional allograft is safe for further clinical investigation in humans before broader clinical application.
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: This study was approved by the Institutional Review Board at the Gil Medical Center, Gachon University: GCIRB2017-175.

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Factors affecting rotator cuff integrity after arthroscopic repair for medium-sized or larger cuff tears: a retrospective cohort study

Background

Methods

Results

Conclusion

Section snippets

Patient selection

Results

Discussion

Conclusion

Disclaimer

J Shoulder Elbow Surg

Arthroscopy

Arthroscopy

J Shoulder Elbow Surg

Orthop Traumatol Surg Res

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Semin Nucl Med

Arthroscopy

Arthroscopy

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Arthroscopy

J Shoulder Elbow Surg

Arthroscopy

J Shoulder Elbow Surg

J Shoulder Elbow Surg

The effect of hypercholesterolemia on rotator cuff disease

Clin Orthop Relat Res

Factors affecting healing after arthroscopic rotator cuff repair

World J Orthop

Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies

Lancet

Results of the surgical repair of the rotator cuff. Radio-clinical correlation

Rev Chir Orthop Reparatrice Appar Mot

Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal?

J Bone Joint Surg Am

Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function

Am J Sports Med

Factors affecting rotator cuff healing after arthroscopic repair: osteoporosis as one of the independent risk factors

Am J Sports Med

Quality of life after arthroscopic rotator cuff repair evaluation using SF-36 and an analysis of affecting clinical factors

Am J Sports Med

Subscapular muscle transposition for repair of chronic rotator cuff tears

Surg Gynecol Obstet

Arthroscopic rotator cuff repair: impact of diabetes mellitus on patient outcomes

Phys Sportsmed