Risk factors affecting rotator cuff retear after arthroscopic repair: a meta-analysis and systematic review.

Background:Scoring systems integrating possible prognostic factors and predicting rotator cuff healing after surgical repair could provide valuable information for clinical practice.Purpose:To dete...

https://journals.sagepub.com/doi/pdf/10.1177/0363546518810763

The Rotator Cuff Healing Index: A New Scoring System to Predict Rotator Cuff Healing After Surgical Repair:

Background:Platelet-rich plasma (PRP) has been applied as an adjunct to rotator cuff repair to improve tendon-bone healing and potentially reduce the incidence of subsequent tendon retears.Purpose:To investigate whether the midterm clinical and radiographic outcomes of arthroscopic supraspinatus repair are enhanced after repeated postoperative applications of PRP.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:A total of 60 patients (30 control; 30 PRP) were initially randomized to receive 2 ultrasound-guided injections of PRP to the tendon repair site at 7 and 14 days after double-row arthroscopic supraspinatus repair or not. A total of 55 patients (91.7%) underwent a clinical review and magnetic resonance imaging (MRI) at a mean of 3.5 years after surgery (range, 36-51 months). Patient-reported outcome measures (PROMs) included the Constant score, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, Oxford Shoulder Score (OSS), and visual analog scale (VAS) ...

A Midterm Evaluation of Postoperative Platelet-Rich Plasma Injections on Arthroscopic Supraspinatus Repair: A Randomized Controlled Trial.

Context:Posterior shoulder instability has become more frequently recognized and treated as a unique subset of shoulder instability, especially in the military. Posterior shoulder pathology may be more difficult to accurately diagnose than its anterior counterpart, and commonly, patients present with complaints of pain rather than instability. “Posterior instability” may encompass both dislocation and subluxation, and the most common presentation is recurrent posterior subluxation. Arthroscopic and open treatment techniques have improved as understanding of posterior shoulder instability has evolved.Evidence Acquisition:Electronic databases including PubMed and MEDLINE were queried for articles relating to posterior shoulder instability.Study Design:Clinical review.Level of Evidence:Level 4.Results:In low-demand patients, nonoperative treatment of posterior shoulder instability should be considered a first line of treatment and is typically successful. Conservative treatment, however, is commonly unsucces...

Posterior Shoulder Instability.

The long-term success of surgical repair of rotator cuff tears is largely dependent on restoration of a functional tendon-to-bone interface. We implemented micro-precise spatiotemporal delivery of growth factors in three-dimensional printed scaffolds for integrative regeneration of a fibrocartilaginous tendon-to-bone interface. Sustained and spatially controlled release of tenogenic, chondrogenic and osteogenic growth factors was achieved using microsphere-based delivery carriers embedded in thin membrane-like scaffolds. In vitro, the scaffolds embedded with spatiotemporal delivery of growth factors successfully guided regional differentiation of mesenchymal progenitor cells, forming multiphase tissues with tendon-like, cartilage-like and bone-like regions. In vivo, when implanted at the interface between the supraspinatus tendon and the humeral head in a rat rotator cuff repair model, these scaffolds promoted recruitment of endogenous tendon progenitor cells followed by integrative healing of tendon and bone via re-formation of strong fibrocartilaginous interfaces. Our findings demonstrate the potential of in situ tissue engineering of tendon-to-bone interfaces by endogenous progenitor cells. The in situ tissue engineering approach shows translational potential for improving outcomes after rotator cuff repair.

/pdf/in-situ-tissue-engineering-of-the-tendon-to-bone-interface-i38i96o6rm.pdf

In situ tissue engineering of the tendon-to-bone interface by endogenous stem/progenitor cells.

Purpose To evaluate whether morphologic characteristics of rotator cuff tear have prognostic value in determining symptomatic structural failure of arthroscopic rotator cuff repair independent of age or gender. Methods Arthroscopic rotator cuff repair cases performed by five fellowship-trained surgeons at our institution from 2006 to 2013 were retrospectively reviewed. Data extraction included demographics, comorbidities, repair technique, clinical examination, and radiographic findings. Failure in symptomatic patients was defined as structural defect on postoperative magnetic resonance imaging or pseudoparalysis on examination. Failures were age and gender matched with successful repairs in a 1:2 ratio. Results A total of 30 failures and 60 controls were identified. Supraspinatus atrophy ( P  = .03) and tear size (18.3 mm failures v 13.9 mm controls; P  = .02) were significant risk factors for failure, as was the presence of an infraspinatus tear greater than 10 mm (62% v 17%, P P  = .06) and simple suture configuration ( P  = .17) were more common but similar between groups. Diabetes mellitus and active tobacco use were not significantly associated with increased failure risk but psychiatric medication use was more frequent in the failure group. Conclusions This study confirms previous suspicions that tear size and fatty infiltration are associated with failure of arthroscopic rotator cuff repair but independent of age or gender in symptomatic patients. There is also a quantitative cutoff on magnetic resonance imaging for the size of infraspinatus involvement that can be used clinically as a predicting factor. Although reported in the literature, smoking and diabetes were not associated with failure. Level of Evidence Level III, retrospective case control.

Morphologic Risk Factors in Predicting Symptomatic Structural Failure of Arthroscopic Rotator Cuff Repairs: Tear Size, Location, and Atrophy Matter

Meniscal tears are present in conjunction with anterior cruciate ligament (ACL) injuries in approximately half of the cases. The menisci serve many important functions in the knee. Specifically in regard to the ACL-injured knee, the lateral meniscus plays a role in rotational loading. It is frequently damaged by the subluxation of the lateral compartment at the time of the ACL rupture. The medial meniscus is a secondary stabilizer to anterior tibial translation and is often torn over time due to accumulated mechanical stress from abnormal knee kinematics in the ACL-deficient knee. With these important functions, meniscal pathology could worsen the already abnormal laxity of the ACL-deficient knee. Surgical treatment aims to preserve as much meniscal structure as possible while removing unstable flaps through meniscectomy or stabilize the meniscus through repair. Loss of normal meniscus function leads to increased articular cartilage degeneration, osteoarthritis (OA), and worse clinical outcomes. Therefore, to improve knee stability and long-term outcomes, meniscal pathology must be carefully considered in the management of patients with ACL ruptures.

http://link.springer.com/content/pdf/10.1007%2F978-3-642-36801-1_88-1.pdf

ACL Injuries with Concomitant Meniscal Pathologies

Revision surgery for reconstruction of failed posterior cruciate and multiple-ligament-injured knees is a difficult problem for knee surgeons. The procedure is required much less commonly than revision anterior cruciate ligament (ACL) reconstructions. One of the key steps in managing this challenging problem is determining the cause of failure for the original procedure. Just as in the case of ACL failures, common causes of failure for posterior cruciate ligament (PCL) and multiple ligament injuries (MLI) reconstructions can be divided into three general categories: iatrogenic, biologic, and traumatic. Often unrecognized combined instability, improper graft technique, and abnormal bony architecture influence the success rate of primary and revision reconstructions. In devising a strategy for revision knee ligament surgery, thorough preoperative planning is essential to success.

Revision Surgery in Posterior Cruciate Ligament Reconstruction

Anterior Cruciate Ligament Injuries with Concomittant Meniscal Pathologies

Causes of knee pain in the unstable knee can be multifactorial and complex and often misdiagnosed. Commonly ligamentous injury, such as anterior cruciate ligament (ACL) tears can lead to knee pain that can be secondary to hemarthrosis, articular injuries, meniscal pathology and/or patellofemoral pain. Controversy exits regarding the role bone bruising plays in ACL injured and knee instability patients. Patient factors such as sex, age, BMI, and type of sport play a role as well. When ligamentous reconstruction is chosen, prehabilitation is essential to decrease the risk of arthrofibrosis which is a common cause of post-operative knee pain. Autograft donor site pain, as well as painful hardware, also is relevant. Post-operative therapies are critical as well. Posterior cruciate ligament (PCL) injury can lead to asymptomatic instability which also can be a cause of pain. As with the ACL, this instability can lead to further cartilage damage and osteoarthritis and subsequently to knee pain. Further, multi-ligamentous knee injuries are complex and causes of knee pain are even more numerous. Special attention must be paid to the vascular and neurologic status of the patient as conditions such as complex regional pain syndrome can be devastating. Commonly, injury and surgical complications, and arthrofibrosis can cause acute and chronic pain and no superior treatment scheme has been well established. The authors recommend an individualized approach with a thorough exam, appropriately indicated treatments, and post-operative care to prevent further injury and debilitating pain to allow the best outcomes.

Pain and the unstable knee

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