Primary versus revision arthroscopic bridging reconstruction using dermal allograft: a clinical and radiographic analysis (243)

Objectives: Large or massive rotator cuff tears make up between 10-40% of all rotator cuff tears, yet there is no agreement on the best treatment. Previous studies have shown that acellular human dermal allograft (AHDA) can be used for bridging reconstruction with positive patient outcomes. The use of this surgical technique has not been extensively studied in the primary or revision surgical setting. The main objective of this study was to compare the clinical and radiographic outcomes of patients who received primary or revision arthroscopic bridging reconstruction. Methods: This study is a retrospective review of a sequential series of patients who underwent arthroscopic bridging reconstruction (ABR) using AHDA by the primary author (IW). A total of 130 patients underwent ABR between 2010 and 2018. The inclusion criteria were patients with completed Western Ontario Rotator Cuff (WORC) questionnaire, Disabilities of the Arm, Shoulder, and Hand (DASH) score, or both pre-operatively and at multiple post-operative timepoints. Patients with missing WORC scores were excluded from the study. Eighty-three patients were included following chart review. Patients with available post-operative MRIs were also used for radiological assessment by an independent MSK-trained radiologist. Post-operative MRIs were reviewed to assess for graft integrity and changes to rotator cuff muscle atrophy (using the Warner classification) and fatty degeneration (using the Goutallier classification). Results: There were 46 patients who received primary ABR and 37 who received revision ABR. Forty-eight patients had a post-operative MRI available for review (Primary: 25; Revision: 23). The demographics are summarized in Table 1. Both groups showed a significant improvement in WORC score post-operatively (p<0.001). Primary ABR resulted in higher post-operative WORC scores as compared to revision ABR (p=0.015; Figure 1). The incidence of complete re-tears in the primary group was 8% and 17.4% in the revision group. More than 35% of patients in the primary group showed improvement in fatty infiltration of the infraspinatus and supraspinatus muscles. There was a higher progression in muscle atrophy in the revision group as compared to the primary group (74% and 30%, respectively). Conclusions: Arthroscopic primary arthroscopic bridging reconstruction for large/massive rotator cuff tears using acellular human dermal allograft had better improvement in their WORC scores compared to revision group at the final follow-up. Although the revision group had improved at the two-year follow-up, these changes in WORC score were not sustained at the final follow-up while the improvements were maintained for the primary group. The primary group had a smaller re-tear rate, better fatty infiltration and muscle atrophy as compared to the revision group. This suggests that primary bridging reconstruction provides better outcomes than a revision surgery.

Patient gender and rotator cuff surgery: are there differences in outcome?

Background Although rotator cuff syndrome is common and extensively studied from the perspective of producing healed tendons, influence of gender on patient-reported outcomes is less well examined. As activity and role demands may vary widely between men and women, clarity on whether gender is an important factor in outcome would enhance patient education and expectation management. Our purpose was to determine if differences exist in patient-reported outcomes between men and women undergoing rotator cuff surgery. Methods One hundred forty-eight participants (76 W:72 M) aged 35–75 undergoing surgery for unilateral symptomatic rotator cuff syndrome were followed for 12 months after surgery. Demographics, surgical data, and the Western Ontario Rotator Cuff (WORC) scores were collected. Surgery was performed by two fellowship-trained shoulder surgeons at a single site. Results There were no gender-based differences in overall WORC score or subcategory scores by 12 months post-op. Pain scores were similar at all time points in men and women. Women were more likely to have dominant-arm surgery and had smaller rotator cuff tears than men. Complication rates were low, and satisfaction was high in both groups. Conclusion Patient gender doesn’t appear to exert an important effect on patient-reported rotator cuff outcomes in this prospective cohort. Further work examining other covariates as well as the qualitative experience of going through rotator cuff repair should provide greater insight into factors that influence patient-reported outcomes.

Psychometric Evaluation of the Taiwanese Version of the Western Ontario Rotator Cuff Index

Background: The Western Ontario Rotator Cuff (WORC) index is a self-report questionnaire that measures the disease-specific quality of life in patients with rotator cuff injuries. The aim of this study was to evaluate the psychometric properties of the Taiwanese version of WORC (T-WORC) in patients with rotator cuff tear (RCT) before surgery. Methods: A cross-sectional study design was used. The study was composed of two phases: translation of the WORC into Taiwanese version of WORC, and 210 patients with rotator cuff tear before surgery completed the questionnaire twice within 2 weeks. The main outcome measures included reliability and validity. Reliability was assessed with internal consistency and test-retest. Internal consistency was assessed using the Cronbach’s alpha and test-retest reliability was assessed using the intraclass correlation coefficient (ICC). Construct validity was evaluated by examining convergent, divergent, known-group validity, and exploratory factor analysis (EFA). Results: The T-WORC demonstrated satisfactory reliability with the Cronbach's alpha of .94, and ICC (2 week-interval) of .79. The convergent validity showed that the T-WORC was significantly positively correlated with the disability of the arm, shoulder, and hand and numerical rating scales of pain, but negatively correlated with the Short Form-12. The divergent validity was shown by the low correlation between T-WORC and state anger scale. The known-group validity showed a significant difference between the high pain group and the low pain group. The EFA revealed 4 factors, daily activities and function, physical symptoms, emotion, and shoulder clicking and recreation, which explained 66.13 % of the variance. Conclusions: The findings of this study did not support the 5-domain structure proposed by the original version. Nevertheless, the T-WORC still demonstrated adequate psychometric properties and could be a useful instrument for assessing the RCT patients' quality of life before surgery.

Comparison of sleep quality, shoulder function, and quality of life in patients with different-sized rotator cuff tears

Background: Many patients with rotator cuff tears suffer from nocturnal shoulder pain resulting in sleep disturbance, inability on shoulder function, and reduced quality of life. Aims and Objective: This study aimed to compare patients with different sizes of rotator cuff tears (RCTs) concerning sleep quality, shoulder function, quality of life, and emotional state. Materials and Methods: Forty-four patients (mean age 49.43±10.71) with different size of RCT were included in this prospective cross-sectional study. Patients were divided into two groups according to RCT size diagnosed with magnetic resonance imaging. Patients were evaluated with Pittsburgh Sleep Quality Index (PSQI), Constant Murley (CM) score, Western Ontario Rotator Cuff Index (WORC), and Beck Depression Inventory (BDI). Results: There was no significant difference between patients with small and large size RCT in terms of sleep quality, shoulder functionality, quality of life and emotional state (p=0.841, p=0.258, p=0.916, p=0.936, respectively). Conclusion: We demonstrated that patients with RCT had poor sleep quality, decreased shoulder function, poor quality of life, and normal emotional status, regardless of the tear size.

HUBUNGAN GLENOHUMERAL INSTABILITY TERHADAP TERJADINYA SWIMMER’S SHOULDER PADA KLUB RENANG DI KABUPATEN BADUNG

Swimmer’s Shoulder menggambarkan kondisi nyeri bahu yang dialami oleh perenang, salah satu faktor resikonya yaitu glenohumeral instability yang merupakan kondisi ketidakstabilan bahu. Kondisi bahu yang tidak stabil dapat menurunkan performa atlet yang dapat meningkatkan resiko terjadinya swimmer’s shoulder. Penelitian ini bertujuan untuk mengetahui hubungan glenohumeral instability terhadap terjadinya swimmer’s shoulder pada klub renang di Kabupaten Badung. Penelitian ini menggunakan rancangan observasional analytic dengan pendekatan metode cross sectional study dan teknik nonprobability sampling dengan jenis purposive sampling dalam. Sampel berjumlah 67 orang, yang diukur glenohumeral instability nya menggunakan tes spesifik yaitu apprehension test dan sulcus sign test dengan skala Visual Analog Scale (VAS) dan swimmer’s shoulder menggunakan kuesioner Western Ontario Rotator Cuff (WORC). Analisis data yang digunakan yaitu teknik spearman’s rho dengan nilai p=0,001, sampel dengan kondisi bahu yang stabil berjumlah 50 orang (74,6%) dan dominan berpotensi rendah terjadinya swimmer’s shoulder (74,6%) sedangkan kondisi bahu yang tidak stabil 17 orang (25,4%) dan dominan berpotensi sedang terjadinya swimmer’s shoulder (25,4%). Hasil analisis data ini menunjukkan bahwa terdapat hubungan yang signifikan antara glenohumeral instability dengan swimmer’s shoulder pada klub renang di Kabupaten Badung. Kata Kunci: perenang, swimmer’s shoulder, glenohumeral instability

Validity and Reliability of the Turkish Version of Western Ontario Osteoarthritis of the Shoulder Index

Objectives: This study aims to adapt the Western Ontario Osteoarthritis of the Shoulder (WOOS) index specific to shoulder osteoarthritis into Turkish and to evaluate its validity and reliability. Patients and methods: The WOOS index was translated and culturally adapted into Turkish, systematically. It was applied to a total of 68 patients (17 males, 51 females; mean age: 61.5±8.7 years; range, 45 to 80 years) with osteoarthritis of the shoulder treated conservatively. The reliability of the scale was checked through internal consistency and test-retest methods. Internal consistency was analyzed with Cronbach alpha value. Test-retest reliability was assessed using an intraclass correlation coefficient (ICC) with 25 patients. The Western Ontario Rotator Cuff (WORC), the Shoulder Pain and Disability Index (SPADI), and the Society of American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (ASES) scores were used to conduct concurrent validity. Results: The Cronbach alpha value of the scale was found to be excellent as 0.92 (p<0.001). The ICC value was also excellent as 0.97 (p<0.001). There was an excellent positive correlation with WORC (0.847; p<0.001) and a very good positive correlation with SPADI (0.788; p<0.001). It was also negatively very good to correlate with the ASES (-0.754; p<0.001). Additionally, subsections of WOOS had a good correlation with the corresponding subsections of WORC (0.779-0.664; p<0.001). Conclusion: The Turkish version of the WOOS index is a valid and reliable tool and is recommended for use in the assessment of patients with osteoarthritis of the shoulder.

Comparison of Superior Capsular Reconstruction and Partial Infraspinatus Repair: A Matched-Pair Analysis of Irreparable Rotator Cuff Tears

Background: Superior capsular reconstruction (SCR) represents a new option for the treatment of irreparable rotator cuff tears. Purpose/Hypothesis: This study aimed to evaluate the clinical and radiologic outcomes of SCR and compare them with the outcomes of partial repair (PR) of the infraspinatus tendon. The hypothesis was that there would be no significant differences between the clinical and radiologic outcome parameters of SCR and PR after a minimum follow-up of 2 years. Study Design: Cohort study; Level of evidence, 3. Methods: Of 21 patients who underwent SCR, 20 patients were matched in a 1:1 ratio according to sex, age, and tear configuration with 20 of 60 patients who had undergone PR; all patients were prospectively evaluated for a minimum follow-up of 2 years. The investigated outcome measures included the Constant score; Western Ontario Rotator Cuff (WORC) index; Disabilities of the Arm, Shoulder and Hand (DASH) score; and radiologic analysis of acromiohumeral distance (AHD) and humeral head centralization (HHC). Results: There were no differences in the demographic data between the SCR and PR groups. The mean age of both groups was 62.3 years (range, 47-79 years), the mean tear configuration was Bateman 3.0 and Patte 2.8, and the mean follow-up period was 29.4 months (range, 24-53 months). At final follow-up, no significant differences were seen between the SCR and PR groups with regard to Constant score (77.1 vs 82.7), age- and sex-adapted Constant score (85.5% vs 91.4%), DASH score (15.6 vs 7.8), or WORC index (81.1 vs 90.4). No significant differences in the AHD or HHC were seen between the groups. The reoperation rate was 4.8% (1/21) in the SCR cohort and 15% (9/60) in the PR cohort. Conclusion: Both SCR and PR resulted in significant improvements in patient-reported outcomes at 2-year follow-up, with no significant differences in clinical outcomes between the 2 techniques. Further follow-up is needed to determine whether there are long-term differences in HHC and development of cuff tear arthropathy. Further investigations should also focus on the cost-effectiveness of the respective procedures.

Platelet-Rich Plasma versus Corticosteroid Injections in Rotator Cuff Related Shoulder Pain: A Comparative Study with Up to 18 Months of Follow-Up

Purpose: Given the complications involved in corticosteroid (CS) injections, subacromial platelet-rich plasma (PRP) injections may provide a valid alternative to CS in the treatment of rotator cuff related shoulder pain (RCRSP).Methods: We retrospectively reviewed a total of 98 patients affected by RCRSP who were treated with either subacromial injection of PRP or CS. The PRP group received three injections of autologous PRP at two weeks interval, and the CS group received one injection of CS. Western Ontario Rotator Cuff Index (WORC) was the primary outcome measure, while secondary outcome measures were the Visual Analogue Scale (VAS), Range of Motion (ROM) and need for cuff repair surgery, which were analyzed at interval of 6, 12, and 18 months.Results: A total of 75 patients were included in the analysis (PRP n = 35, CS n = 40). Mean follow-up was (PRP 21.1 ± 8.7 months vs CS 33.6 ± 16.3 months, p <0.001). Both groups showed improvement in WORC, VAS and ROM. No significant differences were detected between the two groups in any of the primary (WORC) or secondary outcomes during 6, 12 and 18 months (all p > 0.05). No adverse events were detected.Conclusion: Both treatments improve RCRSP patient’s symptoms, but none of them seems to result in a significant better outcome in this series of patients. PRP can be a safe and feasible alternative to CS in treatment of RCRSP even at long follow-up, to reduce local and systemic effects involved with CS injections.

What is better for rotator cuff tendinopathy: dextrose prolotherapy, platelet-rich plasma, or corticosteroid injections? A randomized controlled study

Background Rotator cuff tendinopathy (RCT) is a leading cause of shoulder pain and disability. Management is mainly conservative, but the limited ability of tendons to regenerate is the main cause of unsatisfactory results. So, we conducted our study to compare the efficacy of deep prolotherapy (glucose 25%), platelet-rich plasma (PRP), and betamethasone corticosteroid for treatment of RCT to find the most effective one based on clinical, functional, and radiological assessment. Results Regarding visual analog scale (VAS), it was significantly (p < 0.001) improved after injection among group 1 (prolotherapy group) and group 3 (steroid group) patients, while no significant improvement was noted among group 2 (PRP group) (p = 0.212) patients. The Western Ontario Rotator Cuff (WORC) Index significantly improved among the studied groups (p < 0.001, p = 0.049, and p < 0.001, respectively) after injection. Regarding the range of motion (ROM), a significant improvement (p = 0.029) was achieved in group 1 after injection but no significant improvements were noted among group 2 and 3 patients (p = 0.529 and 0.121, respectively). There was a significant improvement among group 1 and 2 patients (p < 0.001 and p = 0.020, respectively) regarding the grade of tendon lesions but no improvement occurred among group 3 patients (p = 0.470). Conclusion Prolotherapy injections improve shoulder ROM, VAS, WORC index, and rotator cuff tendon healing while PRP injections improve WORC index and tendon healing but steroid injection has no effect on healing. Trial registration PACTR202005610509496. Retrospective registration on May 25, 2020, Pan African Clinical Trial Registry.