Rehabilitation following rotator cuff repair: A survey exploring clinical equipoise among surgical members of the British Elbow and Shoulder Society

Background We investigated clinical equipoise across surgical members of the British Elbow and Shoulder Society (BESS) in relation to rehabilitation following rotator cuff repair. Method An online survey explored clinical equipoise regarding early patient-directed versus standard rehabilitation after rotator cuff repair to inform the design of a national randomised controlled trial (RCT). It described different clinical scenarios relating to patient age, tear size, location and whether other patient-related and intra-operative factors would influence equipoise. Results 76 surgeons completed the survey. 81% agreed/ strongly agreed that early mobilisation might benefit recovery; 57% were neutral/ disagreed that this approach risks re-tear. 87% agreed/ strongly agreed that there is clinical uncertainty about the effectiveness of different approaches to rehabilitation. As age of the patient and tear size increased, the proportion of respondents who would agree to recruit and accept the outcome of randomisation reduced, and this was compounded if subscapularis was torn. Other factors that influenced equipoise were diabetes and non-secure repair. Conclusion Surgical members of BESS recognise uncertainty about the effectiveness of different approaches to rehabilitation following rotator cuff repair. We identified a range of factors that influence clinical equipoise that will be considered in the design of a new RCT.

Cotyloid Fossa Coverage Percentages May Be Associated With Alpha Angle, Labral Tear, and Clinical Outcomes in Patients With Femoroacetabular Impingement

Background: Within the hip joint, the anatomy of the acetabulum and cotyloid fossa is well established. There is little literature describing the association between the size of the cotyloid fossa relative to the acetabulum and characteristics of patients with femoroacetabular impingement (FAI). Purpose/Hypothesis: The purpose was to calculate the cotyloid fossa coverage percentage in the acetabulum and determine its association with patient characteristics, radiographic parameters, intra-articular findings, and preoperative patient-reported outcomes in patients with FAI. We hypothesized there is an association between the cotyloid fossa coverage percentage of the acetabulum and characteristics of patients with FAI. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients were included who underwent standard clinical 3-T magnetic resonance imaging of the hip and primary arthroscopic FAI correction surgery during 2015 and 2016. Exclusion criteria were age <18 or >40 years, osteoarthritis, labral reconstruction, previous ipsilateral hip surgery, and hip dysplasia. Measurements of the cotyloid fossa and surrounding lunate cartilage were performed to calculate cotyloid fossa width (CFW) and cotyloid fossa height (CFH) coverage percentages. The relationships between coverage percentages and patient characteristics and intraoperative findings were assessed using independent t tests or Pearson correlations. Results: An overall 146 patients were included. Alpha angle negatively correlated with CFH coverage percentage ( r = −0.19; P = .03) and positively correlated with labral tear size ( r = 0.28; P < .01). CFH coverage percentage was negatively correlated with labral tear size ( r = −0.24; P < .01). Among patients with degenerative tears, CFH was negatively correlated with labral tear size ( r = −0.31; P < .01). However, this association was no longer significant after adjusting for sex (partial r = −0.10; P = .39). Cotyloid fossa coverage was not associated with the condition of the cotyloid fossa synovium (synovitis vs no synovitis). CFW coverage percentage was negatively correlated with the 12-Item Short Form Health Survey (SF-12) physical component summary score ( r = −0.23; P < .01). Conclusion: The CFW and CFH coverage percentages may be associated with alpha angle, labral tear size, and SF-12 physical component summary score in patients with FAI. We may be able to predict the labral condition based on preoperative measurements of CFH and CFW coverage percentages.

Rotator Cuff Tear Size Regulates Fibroadipogenic Progenitor Number and Gene Expression Profile in the Supraspinatus Independent of Patient Age

Background: Fatty infiltration of rotator cuff muscle is a limiting factor in the success of repairs. Fibroadipogenic progenitors (FAPs) are a population of stem cells within the rotator cuff that can differentiate into white adipocytes, fibroblasts, and beige adipocytes. The effects of patient age and rotator cuff tendon tear size on the number, differentiation patterns, and gene expression profiles of FAPs have not yet been analyzed. Purpose: To determine if patient age and rotator cuff tear size independently regulate FAP number, differentiation patterns, and gene expression profiles. Study Design: Controlled laboratory study. Methods: Supraspinatus muscle samples were collected from 26 patients between the ages of 42 and 76 years with partial- or full-thickness rotator cuff tears. FAPs were quantified using fluorescence-activated cell sorting. Gene expression analysis was performed across a custom 96-gene panel using NanoString. In vitro differentiation assays of FAPs were conducted using adipogenic, fibrogenic, and beige-inducing (amibegron-treated) media, and quantitative polymerase chain reaction was used to assess gene expression differences between adipogenic and amibegron media conditions. Multivariable linear regressions were performed using Stata to independently analyze the effects of age and rotator cuff tear size on FAP number, differentiation, and gene expression. Results: Increasing age and tear size were independently correlated with increased FAP number (βage = 0.21, P = .03; βtear size = 3.86, P = .05). There was no clear association between age and gene expression of freshly sorted FAPs. Under adipogenic and fibrogenic media conditions, increasing age and tear size were independently associated with increased adipogenic and fibrogenic differentiation of FAPs. Under amibegron treatment conditions, age positively correlated with increased beige differentiation (β = 1.03; P < .0001), while increasing tear size showed a trend toward decreased beige differentiation (β = −4.87; P = .1). When gene expression patterns between adipogenic and amibegron media conditions were compared, larger tear size strongly inhibited beige gene expression, while advanced age did not. Conclusion: Patient age and rotator cuff tear size independently regulated FAP number, differentiation, and gene expression. Age and tear size were positively correlated with increased FAP number and fibrogenic/adipogenic differentiation. Advancing patient age did not limit FAP beige differentiation and gene expression, while increasing rotator cuff tear size strongly inhibited these processes.

Radiologic Analysis of Causes of Early Recurrence after Percutaneous Endoscopic Transforaminal Discectomy

Objective: To retrospectively analyze causes of, and factors influencing, early recurrence after percutaneous endoscopic transforaminal discectomy (PETD) used to treat lumbar-disc herniation. Methods: We included 285 patients with single-segment lumbar-disc herniation, treated using PETD from January 2017 to December 2019 in the First Affiliated Hospital of the University of South China. Patients were classified into early recurrence and non-early recurrence groups based on clinical symptoms and MRI reexamination. Differences in disc-height index (DHI), sagittal range of motion (sROM), base-width of intervertebral disc degeneration, and postoperative intervertebral annulus-fibrosus tear size were compared using independent-sample t test. Differences in degree of intervertebral disc degeneration and herniation sites were analyzed using rank-sum and chi-square tests. Logistic regression was used for multivariate analysis of factors associated with early recurrence after PETD. Results: Two hundred and eighty five patients completed surgery and underwent clinical follow-up. Mean follow-up duration was 15.5 months (12–24 months). During follow-up, 19 patients relapsed within 6 months post-surgery. Early recurrence rate was 6.7%, and mean recurrence duration was 73.4 days (3–168 days). Differences in DHI, base-width, postoperative annulus-fibrosus tear size, degree of intervertebral disc degeneration, and herniation sites between early recurrence and non-early recurrence groups were statistically significant (P<0.05). Herniation site and base-width of herniation were significantly correlated with early recurrence after PETD. Conclusions: DHI, postoperative annulus-fibrosus tear size, and degree of intervertebral disc degeneration were associated with early recurrence after PETD. Increased base-width of herniation was a risk factor for early recurrence after PETD. Central-herniation patients with were more prone to postoperative early recurrence than paracentral-herniation patients.

Tear size, general health status and smoking influence functional outcome at 5 years following arthroscopic rotator cuff repair

Introduction There is limited medium-term outcome data regarding the predictors of functional outcome and patient satisfaction after arthroscopic rotator cuff repair. Methods 287 patients that underwent arthroscopic rotator cuff repair under a high-volume single surgeon were contacted at a minimum of 4 years following surgery. Patient demographics, tear size and co-morbidities were pre-operatively recorded. The Oxford shoulder score, EuroQol 5-dimensional score and patient satisfaction were recorded at final follow-up. Results 234 (81.5%) patients completed follow-up at a mean of 5.5 (4–9) years. There were 126 males and 108 females with a mean age of 60 (range 25–83) years. The majority of patients ( n = 211, 90%) were satisfied with their final outcome. Multivariate linear regression analysis ( R2 = 0.64) identified that increasing tear size ( p = 0.04), worsening general health assessed by the EuroQol 5-Dimensional ( p < 0.001), and smoking ( p = 0.049) were associated with a worse Oxford shoulder score. Logistic regression analysis ( R2 = 0.13) identified that worsening general health assessed by the EuroQol 5-Dimensional ( p < 0.001), and smoking ( p = 0.01) were associated with an increased risk of patient dissatisfaction. Conclusion General health status and smoking are independent predictors of functional outcome and patient satisfaction at medium-term follow-up following arthroscopic rotator cuff repair.

Functional and Structural Outcomes After Retears of Arthroscopically Repaired Large and Massive Rotator Cuff Tears

Background: Most studies have shown acceptable clinical results in patients with large or massive tears treated by arthroscopic rotator cuff repair (ARCR); however, the effects of retears after surgery in these patients remain unknown. Purpose: To evaluate functional and structural outcomes after retears of large and massive rotator cuff tears treated by ARCR. Study Design: Case series; Level of evidence, 4. Methods: A total of 196 consecutive patients with large to massive rotator cuff tears underwent physical examination and magnetic resonance imaging before and after ARCR at 6, 12, and 24 months. Of these, 9 patients were lost at 6 months after surgery. Therefore, 187 patients were followed up for 24 months after surgery; 148 patients showed no postsurgical ruptures. Consequently, the remaining 39 patients with postsurgical ruptures were included in this study (mean age at surgery, 64.2 ± 8.7 years). Functional outcome measures comprised the University of California, Los Angeles (UCLA) and Japanese Orthopaedic Association (JOA) scores. Structural outcome measures consisted of the global fatty degeneration index (GFDI), mediolateral tear size, and residual tendon attachment area as evaluated by our own scoring system. Results: The mean UCLA and JOA scores significantly improved from 16.3 ± 3.9 and 63.2 ± 10.7 preoperatively to 27.9 ± 5.5 ( P < .0001) and 84.5 ± 9.4 ( P < .0001) at final follow-up, respectively. The mean mediolateral tear size ( P = .03, .02, and .02, respectively) and residual tendon attachment area ( P = .04, .03, and .04, respectively) significantly improved from preoperatively to 6, 12, and 24 months postoperatively. The correlation analysis between the functional and structural variables confirmed significant associations between the residual tendon attachment area, the JOA and UCLA scores at 24 months postoperatively, and the preoperative GFDI ( r = –0.81 to 0.78). Conclusion: The residual tendon attachment area after a retear was significantly larger at 24 months after surgery than before surgery. In addition, significant associations were confirmed between preoperative fatty degeneration, the residual tendon attachment area, and functional outcomes after a retear. These results may explain why functional outcomes significantly improved even after retears in this series.

Analysis of Patient Factors Affecting In Vitro Characteristics of Subacromial Bursal Connective Tissue Progenitor Cells during Rotator Cuff Repair

Unsatisfactory failure rates following rotator cuff (RC) repair have led orthopaedic surgeons to explore biological augmentation of the healing enthesis. The subacromial bursa (SB) contains abundant connective tissue progenitor cells (CTPs) that may aid in this process. The purpose of the study was to investigate the influence of patient demographics and tear characteristics on the number of colony-forming units (CFUs) and nucleated cell count (NCC) of SB-derived CTPs. In this study, we harvested SB tissue over the supraspinatus tendon and muscle in 19 patients during arthroscopic RC repair. NCC of each sample was analyzed on the day of the procedure. After 14 days, CFUs were evaluated under a microscope. Spearman’s rank correlation coefficient was then used to determine the relationship between CFUs or NCC and patient demographics or tear characteristics. The study found no significant correlation between patient demographics and the number of CFUs or NCC of CTPs derived from the SB (p > 0.05). The study did significantly observe that increased tear size was negatively correlated with the number of CFUs (p < 0.05). These results indicated that increased tear size, but not patient demographics, may influence the viability of CTPs and should be considered when augmenting RCrepairs with SB.

Retear rates after rotator cuff surgery: a systematic review and meta-analysis

Background Rotator cuff retear (RCR) is one of the main postoperative drawbacks. RCR can be considered a multifactorial issue, which causes are related either to biological than biomechanical factors. The aim of this study was to define the incidence of RCR after surgical treatment at different time points and to identify the main factors influencing the postoperative rotator cuff (RC) healing. Methods A systematic review and meta-analysis were performed following the PRISMA guidelines. A comprehensive search of the literature was carried out in July 2020, using PubMed and Cochrane Library databases. Only level 1 and 2 clinical evidence studies were included. Studies were included if patients with preoperative repairable full-thickness RC tears were treated surgically, and if studies reported postoperative RCR confirmed by imaging diagnostic. The association between timing of retear and follow-up time points were investigated using an inverse-variance method of pooling data. A subgroup meta-analysis was performed using the DerSimonian and Laird method for the estimation of the between-study variance, i.e., τ2. The association between retear rate after surgery and patients’ age, preoperative tear size, fatty infiltration, postoperative rehabilitation protocol, surgical techniques, and RC repairs was determined by expressing the effect measure in terms of odds ratio (OR) with 95% confidence interval (CI). The Mantel-Haenszel method with 95% CIs was used. Results Thirty-one articles were included in this study. The percentage of RCR after surgery was 15% at 3 months follow-up, 21% at 3–6 months follow-up, 16% at 6–12 months follow-up, 21% at 12–24 months follow-up, 16% at follow-up longer than 24 months. The main factors influencing RC healing are both patient-related (i.e., age, larger tear size, fatty infiltration) and not patient-related (i.e., postoperative rehabilitation protocol, surgical techniques, and procedures). Conclusions Postoperative RC healing is influenced by patient-related and non-patient-related factors. Further high-level clinical studies are needed to provide highly relevant clinical results.