Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient Acceptable Symptomatic State After Arthroscopic Rotator Cuff Repair

Background: Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) are emerging criteria for patient-based treatment assessments. However, few studies have investigated these measures after rotator cuff repair. Purpose: (1) To determine MCID, SCB, and PASS values for pain visual analog scale (pVAS), Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) score, and University of California, Los Angeles (UCLA) score after arthroscopic rotator cuff repair. (2) To determine factors for achieving the MCID, SCB, and PASS. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: We analyzed prospectively collected data from a rotator cuff surgery registry between March 2018 and February 2019. Eighty-two patients were included, and anchor questions for deriving MCID, SCB, and PASS values were applied at 1-year follow-up after the surgery. The MCID and SCB for the pVAS, ASES, SANE, and UCLA scores were then derived via 2 methods: a sensitivity- and specificity-based approach, which was used alone to derive PASS values, and a between-patients approach. Additionally, univariable and multivariable logistic regression analyses were performed to determine factors for achieving the MCID, SCB, and PASS. Results: All 4 scores showed acceptable areas under the curve. MCID, SCB, and PASS values for the pVAS were 1.5, 2.5, and 1.7; for ASES scores, 21.0, 26.0, and 78.0; for SANE, 13.0, 20.0, and 71.0; and for UCLA scores, 6.0, 8.0, and 23.0, respectively. Poor preoperative scores demonstrated significantly higher odds ratios (ORs) for achieving the MCID and SCB and lower ORs for achieving the PASS. Retear, large to massive tear, and older age showed lower ORs for achieving the MCID or SCB. For PASS items, male sex and biceps tenodesis had higher ORs, and older age had lower ORs. MCID, SCB, and PASS values per the sensitivity- and specificity-based approach were applied in factor analyses. Conclusion: Reliable MCID, SCB, and PASS values were obtained from patient evaluations 1 year after arthroscopic rotator cuff surgery. Poor preoperative score (MCID and SCB), male sex, and biceps tenodesis showed higher ORs, whereas poor preoperative score (PASS), retear, large to massive tear, and older age demonstrated lower ORs.

Associations of Preoperative Patient Mental Health and Sociodemographic and Clinical Characteristics With Baseline Pain, Function, and Satisfaction in Patients Undergoing Rotator Cuff Repairs

Background: Shoulder pain and dysfunction are common indications for rotator cuff repair surgery, yet the factors that are associated with these symptoms are not fully understood. Purpose/Hypothesis: This study aimed to investigate the associations of patient and disease-specific factors with baseline patient-reported outcome measures (PROMs) in patients undergoing rotator cuff repair. We hypothesized that tear size and mental health status, as assessed by the Veterans RAND 12-Item Health Survey mental component score (VR-12 MCS), would be associated with baseline total Penn Shoulder Score (PSS) and its pain, function, and satisfaction subscale scores. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We prospectively identified 12 patient factors and 12 disease-specific factors as possible statistical predictors for baseline PROMs in patients undergoing surgical repair of superior-posterior rotator cuff tears at a single institution over a 3-year period. Multivariable statistical modeling and Akaike information criterion comparisons were used to investigate the unique associations with, and relative importance of, these factors in accounting for variation in baseline PSS and its subscale scores. Results: A total of 1442 patients who had undergone surgery by 23 surgeons met inclusion criteria, with a baseline median total PSS of 38.5 (pain, 12; function, 24.2; satisfaction, 2). Adjusted R2 in multivariable models demonstrated that the 24 general patient and disease-specific factors accounted for 22% to 24% of the variability in total PSS and its pain and function subscale scores. Large/massive tear size was significantly associated with worse PSS total score and function score but not pain or satisfaction scores. Lower VR-12 MCS was significantly associated with worse total PSS and all 3 subscale scores. Among other factors significantly associated with baseline PROMs were sex, race, preoperative opioid use, years of education, employment status, acromion status, and adhesive capsulitis. Lower VR-12 MCS, preoperative opioid use, female sex, and black race were the factors most strongly associated with baseline PROMs. Conclusion: Large/massive tear size, lower VR-12 MCS, and several additional patient and disease-specific factors are associated with baseline PROMs in patients undergoing rotator cuff repair. Further studies are needed to investigate whether these factors will also predict poor postoperative PROMs.

Characteristics of the patients with delaminated rotator cuff tear

Purpose: The purpose of this study was to analyze factors relating to delamination in full-thickness rotator cuff tears. Methods: 126 patients with full-thickness rotator cuff tears treated by arthroscopic rotator cuff repair were the subjects of this study. There were 52 females and 74 males whose average age was 64.2 years. Fifty-three patients had history of trauma. The average duration of disorder was 29.5 weeks. Nineteen patients were diagnosed with diabetes. On types of the tears, small tear was observed in 59 patients, medium tear in 47 patients, large tear in 6 patients, and massive tear in 14 patients. The average size of tear was 1.98 cm. Delamination of the torn cuff was observed in 45 patients. Factors compared between the patients without delamination and those with delamination were as follows: gender and age of the patients, history of trauma, duration of disorder, diabetes, smoking, size and number of rotator cuff tears. Results: The delamination rate of the smoking patients was significantly higher than non-smoking patients. The delamination rate of patients with more than two tendon tears was significantly higher than those with only one tendon tear. The average size of tear with delamination was significantly larger than that of tear without delamination. The other factors were not related to delamination. Conclusions: This study suggests that smoking, size of tear and number of torn cuffs are associated with delamination. The progression of torn cuff, anatomical features and nicotine of smoking affect the causes of delaminated tear of rotator cuff.

IRREPARABLE ROTATOR CUFF TEAR; A SURGICAL DILEMMA

Rotator cuff tear are common injuries in modern day orthopedic practice. Irreparable rotator cuff tear are those massive tear which cannot be repaired primarily. Their management depends on several factors like symptoms, age of patient, location of tear and examination findings. However, most chronic rotator cuff tear especially in older age group can be treated conservatively, when shoulder has reasonably good range of movement.

Restoration of Shoulder Biomechanics According to Degree of Repair Completion in a Cadaveric Model of Massive Rotator Cuff Tear

Background: Complete repair in massive rotator cuff tear may not be possible, allowing for only partial repair. However, the effect of partial repair on glenohumeral biomechanics has not been evaluated. Therefore, the purpose of this study was to compare the rotational range of motion (ROM), glenohumeral kinematics, and gap formation at the repaired tendon edge following massive cuff tear and repair according to the degree of repair completion. Hypothesis: Posterior fixation will restore the altered biomechanics of massive rotator cuff tear. Study Design: Controlled laboratory study. Methods: Eight cadaveric shoulders were tested at 0°, 30°, and 60° of abduction in the scapular plane. Muscle loading was applied based on physiological muscle cross-sectional area ratios. Maximum internal (MaxIR) and external rotations (MaxER) were measured. Humeral head apex (HHA) position and gap formation at the repaired tendon edge were measured using a MicroScribe from MaxIR to MaxER in 30° increments. Testing was performed for intact, massive cuff tear, complete repair, and 4 types of partial repair. A repeated-measures analysis of variance was used to determine significant differences. Results: Massive tear significantly increased ROM and shifted HHA superiorly in MaxIR at all abduction angles ( P < .05). The complete repair restored ROM to intact ( P < .05), while all partial repairs did not. Abnormal HHA elevation due to massive tear was restored by all repairs ( P < .05). Release of the anterior single row alone and release of the marginal convergence significantly increased gap formation at the anterior tendon edge ( P < .05). Conclusion: This study emphasizes the importance of anterior fixation in massive cuff tear to restore rotational range of motion and decrease gap formation at the repaired tendon edge and of posterior fixation to restore abnormal glenohumeral kinematics due to massive cuff tear. Clinical Relevance: If complete repair of massive cuff tear is not possible, posterior cuff (infraspinatus) repair is necessary to restore abnormal glenohumeral kinematics, and margin convergence anteriorly is recommended to decrease gap formation of the repaired tendon edge, which may provide a better biomechanical environment for healing.