Surgical outcome following rotator cuff tear repair in a low-income population. Impact of obesity and smoking

Background Comorbidities and socioeconomic issues impact outcome of rotator cuff tear (RCT) repair. There are no data on RCT repair outcome from developing regions. We determined the impact of obesity and smoking following RCT repair in a low-income population. Methods This is a retrospective case series. Forty-seven shoulders of 42 patients subjected to open or arthroscopic repair of a RCT with a minimum of 2 years follow-up were cross-sectionally evaluated. Patients were seen in the Orthopaedic Service of the Hospital Geral de Fortaleza-CE, Brazil between March and September 2018. RCT were classified as partial or full-thickness lesions. Fatty infiltration (Goutallier) and tendon retraction (Patte) were recorded as well as obesity (BMI > 30), literacy [>/≤ 8 school years (SY)] and smoking status 6 months prior to surgery (present/absent). Outcomes included pain (visual analogue scale; VAS, 0–10 cm), range of motion [active forward flexion and external rotation (ER)], UCLA and ASES scoring. Results Patients were 59.9 ± 7.4 years-old, 35(74.4%) female with 19 (17.1–30.2 IQR) median of months from diagnosis to surgery and 25 median months of follow-up (26.9–34.0 IQR); over 90% declared < 900.00 US$ monthly family income and two-thirds had ≤8 SY. Forty patients (85.1%) had full-thickness tears, 7 (14.9%) had Goutallier ≥3 and over 80% had < Patte III stage. Outcomes were similar regardless of fatty infiltration or tendon retraction staging. There were 17 (36.1%) smokers and 13 (27.6%) obese patients. Outcome was similar when comparing obese vs non-obese patients. Smokers had more pain (P = 0.043) and less ER (P = 0.029) with a trend towards worse UCLA and ASES scores as compared to non-smokers though differences did not achieve minimal clinically important difference (MCID) proposed for surgical RCT treatment. After adjusting for obesity, VAS and ER values in smokers were no longer significant (P = 0.2474 and 0.4872, respectively). Conclusions Our data document outcomes following RCT repair in a low-income population. Smoking status but not obesity impacted RCT repair outcome though not reaching MCID for surgical treatment.

Good Interrater Reliability for Standardized MRI Assessment of Tendon Discontinuity and Tendon Retraction in Acute Proximal Full-Thickness Hamstring Tendon Injury

Background: Proximal full-thickness free hamstring tendon injury (ie, tendon avulsion or rupture) is a severe injury. Treatment decision making relies on clinical factors and magnetic resonance imaging (MRI) variables; it specifically relies on which tendons are injured as well as the extent of tendon retraction. According to a worldwide evaluation of current practice, discontinuity of both proximal tendons and retraction of >2 cm are used as surgical indications. However, both the diagnosis and the use of MRI variables in decision making may be fraught with uncertainty in clinical practice. A reliable standardized MRI assessment is required. Purpose: To propose an MRI assessment for acute proximal full-thickness free hamstring tendon injury and to evaluate its interater reliability. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: We included 40 MRI scans of patients with acute (≤4 weeks of injury) proximal full-thickness free hamstring tendon injury. Three musculoskeletal radiologists assessed proximal full-thickness free hamstring tendon discontinuity using the novel “dropped ice cream sign” and tendon retraction (in mm). Quantification of tendon retraction (in mm) was performed using 2 different methods: (1) a direct (ie, shortest distance between the center of the hamstring origin and the tendon stump) method and (2) a combined craniocaudal/mediolateral measurement method. Absolute and relative interrater reliability were calculated. Results: We found an almost perfect interrater agreement (kappa = 0.87) for assessment of full-thickness tendon discontinuity using the dropped ice cream sign. Interrater agreement for the direct and craniocaudal retraction measurements was good for both the conjoint (intraclass correlation coefficient [ICC], 0.88 and 0.83) and the semimembranosus tendons (ICC, 0.81 and 0.79). The mediolateral retraction measurement yielded only moderate to poor reliability for the conjoint (ICC, 0.53) and semimembranosus tendons (ICC, 0.41). Conclusion: The standardized MRI assessment to identify proximal hamstring tendon discontinuity and quantify tendon retraction is reliable. We recommend using the novel dropped ice cream sign and the direct retraction measurement in clinical practice and research.

Effectiveness of measuring tension during arthroscopic rotator cuff repair

Purpose Arthroscopic rotator cuff repair (ARCR) for relatively small rotator cuff tears (RCTs) has shown promising results; however, such surgery for larger tears often results in failure and poor clinical outcomes. One cause of failure is over-tension at the repair site that will be covered with the tendon stump. Reports on the clinical outcomes using ARCR with tension ≤ 30 N are lacking. This study aimed to evaluate ARCR outcomes and failure rates using less tension (30 N) and to assess the prognostic factors for failure. Methods Our study group comprised of 118 patients who underwent ARCR for full-thickness RCTs with full tendon stump coverage of the footprint with a tension of ≤ 30 N, measured using a tension meter; no additional procedures, such as margin convergence or footprint medialisation, were performed. The failure rate was calculated, and the prognostic factor for failure was assessed using multivariate regression analyses. Results There were seven cases of failure in the study group. Postoperatively, flexion and internal rotation ranges of motion, acromiohumeral interval, muscle strength, and clinical results improved significantly. Using multivariate regression analyses, intraoperative concomitant subscapularis tendon lesion and pre-operative infraspinatus tendon retraction, assessed using radial-sequence magnetic resonance imaging, were significantly correlated with post-ARCR failure using less tension (p = 0.030 and p = 0.031, respectively). Conclusion ARCR is likely to succeed for RCTs that can be extracted using tension ≤ 30 N. However, cases with more severe subscapularis tendon lesions and those with high infraspinatus tendon retraction may show surgical failure. Level of evidence LEVEL IV Retrospective case series

Reliability of MRI in Acute Full-thickness Proximal Hamstring Tendon Avulsion in Clinical Practice

In clinically suspected acute full-thickness proximal hamstring tendon avulsions, MRI is the gold standard for evaluating the extent of the injury. MRI variables such as full-thickness free tendon discontinuity, extent of tendon retraction (>20 mm), and continuity of the sacrotuberous ligament with the conjoint tendon (STL-CT) are used in treatment decision-making. The objective was to assess the intra- and inter-rater reliability of these relevant MRI variables after acute full-thickness proximal hamstring tendon avulsion. Three musculoskeletal radiologists assessed MRIs of 40 patients with an acute full-thickness proximal hamstring tendon avulsion. MRI variables included assessment of free tendon discontinuity and continuity of the STL-CT and extent of tendon retraction. Absolute and relative intra- and inter-rater reliability were calculated. Intra- and inter-rater reliability for the assessment of tendon discontinuity was substantial (Kappa [ĸ]=0.78;0.77). For the retraction measurement of the conjoint and semimembranosus tendons, intra-rater reliability was moderate and poor (Intraclass correlation coefficient (ICC)=0.74;0.45), inter-rater reliability was moderate (ICC=0.73;0.57). Intra- and inter-rater reliability of the STL-CT continuity assessment was substantial and fair (ĸ=0.74;0.31). In conclusion, MRI assessment for full-thickness free tendon discontinuity is reliable. However, assessment of extent of tendon retraction and STL-CT continuity is not reliable enough to guide the treatment decision-making process.

The Invisible MGHL Test: Diagnostic Value and Benefits for the Repair of Retracted Subscapularis Tears

Background: Some full-thickness subscapularis tendon tears and partial tears of the deep layer are difficult to characterize, leading to misdiagnosis. Purpose: To evaluate the association between displacement of the middle glenohumeral ligament (MGHL) and retracted tears of the subscapularis tendon as a possible test to improve diagnosis. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Videos (N = 100) recorded during arthroscopic rotator cuff repair involving a torn subscapularis tendon were analyzed retrospectively to assess the association between the MGHL test (nonvisibility of the MGHL) and other objective anatomic criteria. The invisible MGHL test was defined as positive if the MGHL was initially nonvisible in the beach-chair position and appeared only when the subscapularis tendon was pulled back into position by using a 30° arthroscope from the standard posterior portal. The parameters considered during the initial exploration were (1) visibility of the horizontal part of the subscapularis tendon; (2) visibility of the MGHL in its usual position, crossing the superior border of the subscapularis tendon; (3) exposure of the lateral border of the subscapularis tendon (full-thickness retracted tear); and (4) complete or partial exposure of the lesser tuberosity of the humerus. Tendon retraction was evaluated in 3 stages according to the Patte classification. Results: The invisible MGHL test result was positive in 45% of cases. It was positive in 6% of cases (2 of 31) when there was no subscapularis tendon retraction and in 62% of cases (43 of 69) when there was partial or complete retraction ( P < .001). The invisible MGHL test was significantly associated with the width of the tear ( P < .001) and exposure of the lateral border of the subscapularis tendon (full-thickness retracted tear, P = .0002). After repair, the MGHL was visible in its anatomic position in 96% of cases. Conclusion: A positive invisible MGHL test is an alternative indication of subscapularis tendon retraction, and the relocation of the MGHL can also be used after repair to assess the proper anatomic repositioning of the subscapularis tendon.