The effect of the platelet-rich plasma and ozone therapy on tendon-to-bone healing in the rabbit rotator cuff repair model

Background The aim of this study is to histologically and biomechanically investigate the effects of local PRP and ozone therapy (O2O3) on tendon-to-bone healing in a rabbit model of the supraspinatus tendon tear. Methods Four groups were formed to have seven rabbits in each group: repair, R; repair + PRP, RP; repair + ozone, RO; and repair + PRP + ozone, RPO. The supraspinatus tendon was detached by sharp dissection from the footprint and an acute tear pattern was created. Thereafter, tendon repair was performed with the transosseous technique. In the RP group, PRP, and in the RPO group, PRP + O2O3 mixture was injected to the tendon repair site. In the RO group, O2O3 gas mixture was injected into subacromial space three times a week for a total of 4 weeks. The study was ended at postoperative 6th week. Results When compared with the R group, a statistically significant increase was observed in the biomechanical strength of the RP and RPO groups. The highest increase in biomechanical strength was detected in the RPO group. The histology of the RO and RPO groups showed better collagen fiber continuity and orientation than the R and RP groups. Conclusions The results obtained from this study show that the ozonized PRP can be used as biological support to increase tendon-to-bone healing. However, these results need to be supported by clinical studies.

Pectoralis Major Ruptures: Tear Patterns and Patient Demographic Characteristics

Background: The pectoralis major (PM) is made up of multilaminar muscle segments that form a complex insertion on the proximal humerus; it is composed of an anterior and a posterior tendon layer. The tear patterns and patient characteristics of operatively treated PM ruptures in the general population remain poorly understood. Purpose: To comprehensively report the demographic characteristics of patients who are clinically diagnosed with structurally significant PM ruptures and to describe PM tear patterns identified during surgery. Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis of surgically treated PM tears was performed for a single-surgeon case series between January 1, 2003, and November 1, 2017. Patient demographic characteristics, classification of tear pattern, and treatment (repair/reconstruction) were recorded. Results: A total of 104 surgical cases of PM tendon rupture were identified; 100 patients underwent primary repair and 4 underwent dermal allograft reconstruction. All patients were male, with a mean age of 36.5 ± 9.2 years. Chronic tears (>6 weeks old) accounted for 63.6% of surgical cases, and 96% (n = 100) of tears occurred at or between the musculotendinous junction and tendinous insertion. A partial-thickness, complete-width tear of the posterior tendon layer at this same location was the most common tear pattern identified. Conclusion: PM ruptures occurred almost exclusively at or between the musculotendinous junction and tendinous insertion, with predominant involvement of the posterior tendon layer. Chronic tears can be safely treated with primary repair in the vast majority of cases.

Characterization of Synovial Cytokine Patterns in Bucket-Handle and Posterior Horn Meniscal Tears

The specific etiology of meniscal tears, including the mechanism of lesion, location, and orientation, is considered for its contribution to subsequent joint cytokine responsiveness, healing outcomes, and by extension, appropriate lesion-specific surgical remediation. Meniscal repair is desirable to reduce the probability of development of posttraumatic osteoarthritis (PTOA) which is strongly influenced by the coordinate generation of pro- and anti-inflammatory cytokines by the injured cartilage. We now present biochemical data on variation in cytokine levels arising from two particular meniscal tears: bucket-handle (BH) and posterior horn (PH) isolated meniscal tears. We selected these two groups due to the different clinical presentations. We measured the concentrations of TNF-α, IL-1β, IL-6, IL-8, and IL-10 in knee synovial fluid of 45 patients with isolated meniscal lesions (BH tear, n = 12 ; PH tear, n = 33 ). TNF-α levels were significantly ( p < 0.05 ) greater in the BH group compared with the PH group, whereas IL-1β levels were significantly greater ( p < 0.05 ) in the PH group compared with the BH group. Both BH and PH groups were consistent in presenting a positive correlation between concentrations of IL-6 and IL-1β. A fundamental difference in IL-10 responsiveness between the two groups was noted; specifically, levels of IL-10 were positively correlated with IL-6 in the BH group, whereas in the PH group, levels of IL-10 were positively correlated with IL-1β. Collectively, our data suggest a possible influence of the meniscal tear pattern to the articular cytokine responsiveness. This differential expression of inflammatory cytokines may influence the risk of developing PTOA in the long term.

Magnetic Resonance Imaging of Pectoralis Major Injuries in an Active Duty Military Cohort: Mechanism Affects Tear Location

Background: Pectoralis major (PM) tendon tears are common injuries in athletic patient populations, where operative repair is largely recommended for maximum functional recovery. The repair varies in difficulty and technique based on the location of the tear within the muscle-tendon unit. Magnetic resonance imagining (MRI) has been reported to be sensitive and specific for identifying the tear location, but the effect of injury mechanism on tear pattern has not been previously investigated. Purpose: To examine PM tears in a military patient population and assess the effect of injury mechanism (weightlifting vs high-energy trauma) on the tear pattern and accuracy of MRI interpretation. Study Design: Cohort study; Level of evidence, 3. Methods: Active duty military servicemembers undergoing operative repair of PM tendon tears with corresponding preoperative MRIs from 2 medical centers were identified. Two musculoskeletal fellowship–trained radiologists reviewed imaging studies, reporting the location of the tear within the muscle-tendon unit and the severity of the tear (sternal head vs clavicular head vs both). Radiographic findings were compared against intraoperative findings. Mechanism of injury and timing from injury to imaging and surgery were assessed to determine whether they affected the accuracy of MRI interpretations. Results: A total of 72 patients were included (mean ± SD age, 33.7 ± 7.0 years; 100% male). Mechanisms of injury consisted of 46 weightlifting injuries and 26 high-energy injuries. Interrater reliability was poor for tear location (kappa, 0.162; P = .003) but substantial for extent of tear (kappa, 0.637; P < .0001). MRI had a 51.3% sensitivity and 63.6% specificity for identifying complete tears. MRI had a sensitivity of 73.9% and specificity of 72.2% for avulsion injuries and sensitivity of 75% and specificity of 79.3% for musculotendinous injuries. Mechanism of injury had no effect on extent of the tear but did affect the location of the tear, with a higher rate of avulsion injuries in the high-energy mechanism cohort (81% vs 40%; P = .02). Conclusion: The mechanism of injury was found to significantly affect the location of tendon tears. A higher rate of avulsion injuries was found in high-energy injuries than weightlifting injuries. MRI appeared to be less sensitive and specific than previous reports for traumatic PM tendon injuries.

Floating Subscapularis Tear: A Variation of the Partial Subscapularis Tear

A variation of subscapularis tear has been identified, named floating subscapularis, where the tendon is completely detached from the lesser tuberosity but is continuous with the tissue covering the bicipital groove. An accurate diagnosis can be made using arthroscopic observation with passive external and internal rotation of the affected shoulder, which shows mismatched movement between the humerus and the subscapularis tendon. The purpose of this study is to examine the prevalence of this particular tear pattern. Clinical records during the study period (from January 2011 to December 2017) were retrospectively examined. Overall, 1295 arthroscopic rotator cuff repair procedures were performed. Among these, the subscapularis tendon was repaired in 448 cases, and 27 cases were diagnosed as floating subscapularis. The prevalence of floating subscapularis was 6% in the subscapularis repair population. This particular tear pattern has not previously been described and it seems to be ignored. The floating subscapularis is thought to be the tear of the deep layer preserving the superficial layer connected to the greater tuberosity by fibrous extension of the soft tissue covering the bicipital groove.

Rotating Arm Internally Can Change the Arthroscopic Diagnosis of a Partial-thickness Tear of the Subscapularis

Background: The aims of this study were (1) to examine the footprint of the subscapularis tendon using the traditional posterior portal and 30° arthroscope by simple internal rotation of the arm during surgery, and (2) to classify the pattern of a subscapularis partial-thickness tear.Methods: This study analyzed a total of 231 patients with a partial-thickness subscapularis tear from 550 consecutive patients undergoing an arthroscopic operation who had a visualization of the subscapularis tendon footprint by internal rotation of the arm. First, the patients were classified into four categories according to the tear pattern: (1) stable lamination, (2) unstable lamination, (3) avulsion, and (4) laminated avulsion. Randomized arthroscopic videos were reviewed blindly by two independent orthopedic surgeons. The pattern of the tear of the subscapularis at the neutral position and after internal rotating the arm were assessed and compared with the treatment decision (level IV case series).Results: Stable lamination, unstable lamination, avulsion, and laminated avulsion were observed in 9.1% (n=21), 20.8% (n=48), 41.1% (n=95), and 29.0% (n=67) of cases, respectively. In 145 out of 231 cases (62.8%), the decision was changed after inspecting the footprint after internal rotation of the arm, and the treatment method was changed in 116 (50.2%) cases.Conclusions: In a subscapularis tendon partial-thickness tear, inspecting the footprint of the subscapularis tendon is essential to diagnosing and deciding on the appropriate treatment. In addition, simply internal rotating the arm during surgery when using the traditional posterior portal and 30° arthroscope can be a valuable method.

Association of Rotator Cuff Tear Patterns and Intramuscular Fatty Infiltration on Magnetic Resonance Imaging

Objective: The impact of rotator cuff (RC) tear pattern on intramuscular fatty infiltration (FI) is not well understood. The purpose of our study is to determine if differing RC tear patterns are associated with discordant presentations of intramuscular FI. Methods: Fifty-one adults with full-thickness tear of the posterosuperior RC on shoulder magnetic resonance imaging (MRI) were identified retrospectively. The study subjects were stratified by RC tear pattern: (1) L-shaped tear cohort, (2) crescent-/U-shaped tear cohort, and (3) complete tear cohort. Clinical information pertaining to age, sex, tear size, trauma history, and length of clinical symptoms was recorded from the institution’s picture archiving and communication system. Goutallier grade was assessed on oblique sagittal T1-weighted MRI by two orthopedic surgeons and one orthopedic resident. A musculoskeletal radiologist recorded the shape and size of full-thickness RC tears. Descriptive, correlation, and reliability analyses were performed. Results: The L-shaped, crescent-/U-shaped, and compete tear cohorts demonstrated significant differences pertaining to tear size (P < 0.001) and infraspinatus Goutallier grade (P = 0.024), but not supraspinatus Goutallier grade (P = 0.370). Age had strong correlation to supraspinatus Goutallier grade (rs = 0.712, P = 0.031) and infraspinatus Goutallier grade (rs = 0.712, P = 0.029) in the crescent-/U-shaped tear cohort. Tear size had strong correlation to supraspinatus Goutallier grade (rs = 0.796, P = 0.001) and infraspinatus Goutallier grade (rs = 0.793, P = 0.001) in the complete tear cohort. Moderate interobserver agreement was present for supraspinatus (kappa, 0.484) and infraspinatus (kappa, 0.427) Goutallier grade. Conclusion: RC tear pattern is associated with different presentations of intramuscular FI at the posterosuperior RC. Full-thickness tears involving the crescent region of the RC cuff are associated with age. Intramuscular FI is associated with RC tear size.