Introduction. Differing levels of tendon retraction are found in full-thickness rotator cuff tears. The pathophysiology of tendon degeneration and retraction is unclear. Neoangiogenesis in tendon parenchyma indicates degeneration. Hypoxia inducible factor 1(HIF) and vascular endothelial growth factor (VEGF) are important inducers of neoangiogenesis. Rotator cuff tendons rupture leads to fatty muscle infiltration (FI) and muscle atrophy (MA). The aim of this study is to clarify the relationship between HIF and VEGF expression, neoangiogenesis, FI, and MA in tendon retraction found in full-thickness rotator cuff tears. Methods. Rotator cuff tendon samples of 33 patients with full-thickness medium-sized rotator cuff tears were harvested during reconstructive surgery. The samples were dehydrated and paraffin embedded. For immunohistological determination of VEGF and HIF expression, sample slices were strained with VEGF and HIF antibody dilution. Vessel density and vessel size were determined after Masson-Goldner staining of sample slices. The extent of tendon retraction was determined intraoperatively according to Patte's classification. Patients were assigned to 4 categories based upon Patte tendon retraction grade, including one control group. FI and MA were measured on standardized preoperative shoulder MRI. Results. HIF and VEGF expression, FI, and MA were significantly higher in torn cuff samples compared with healthy tissue (p<0.05). HIF and VEGF expression, and vessel density significantly increased with extent of tendon retraction (p<0.04). A correlation between HIF/VEGF expression and FI and MA could be found (p<0.04). There was no significant correlation between HIF/VEGF expression and neovascularity (p>0.05). Conclusion. Tendon retraction in full-thickness medium-sized rotator cuff tears is characterized by neovascularity, increased VEGF/HIF expression, FI, and MA. VEGF expression and neovascularity may be effective monitoring tools to assess tendon degeneration

The treatment of massive rotator cuff tears remains controversial. There is lack of studies comparing patient-reported outcomes (PROM) of arthroscopic massive rotator cuff repairs (RCR) against large, medium and small RCRs. Our study aims to report the PROM for arthroscopic massive RCR versus non-massive RCR.

Patients undergoing an arthroscopic RCR under a single surgeon over a 5-year period were included. Demographic data were recorded. Pre-operative Quick-DASH and Oxford Shoulder Score (OSS) were prospectively collected pre-operatively and at final review (mean of 18 months post-operatively). The scores were compared to a matched cohort of patients who had large, medium or small RCRs. A post-hoc power analysis confirmed 98% power was achieved.

82 patients were included in the study. 42 (51%) patients underwent massive RCR. The mean age of patients undergoing massive RCR was 59.7 and 55% (n=23) were female. 21% of massive RCRs had biceps augmentation. Quick-DASH improved significantly from a mean of 46.1 pre-operatively to 15.6 at final follow-up for massive RCRs (p<0.001). OSS improved significantly from a mean of 26.9 pre-operatively to 41.4 at final follow up for massive RCRs (p<0.001). There was no significant difference in the final Quick-DASH and OSS scores for massive and non-massive RCRs (p=0.35 and p=0.45 respectively). No revision surgery was required within the minimum one year follow up timescale.

Arthroscopic massive rotator cuff repairs have no functional difference to non-massive rotator cuff repairs in the short term follow up period and should be considered in appropriate patient groups.

Introduction

Massive rotator cuff tears in the patient who is too young for a reverse shoulder replacement are a challenging situation. A technique using a ‘Grammont osteotomy’ of the acromion has been developed to allow a comprehensive approach, the so called “Full Monty”.

The aim is to evaluate the effectiveness of pericardium patch as a tendon augmentation graft in the repair of massive rotator cuff tear. This is prospective study analysis of a consecutive series of 60 patients who underwent open repair of a massive rotator cuff tear with patch between 1999 and 2007. The inclusion criteria were: symptomatic with pain, deficit of elevation, not responsive to the physiotherapy, tear size (massive: 2 or more tendons), minimum follow-up of 2 years since surgery, active and motivated patients. All were assessed preoperatively with plain radiographs (anteroposterior and axillary views), ultrasound and NMR of the shoulder. The study group consistent of 60 patients (39 men and 21 women) with the mean age of was 66 years (range, 46–81). The mean duration of symptoms before repair was 18 months (range 3–48). Patients were assessed with UCLA score, visual analog scale (Vas scale) and ultrasound preoperatively, at 1 year, and at 3 years. The change in UCLA scores, Vas scale were analyzed with the paired Student's test, assuming a normal distribution of the total score. Satisfactory results were achieved in 49 patients: mean preoperative UCLA score improved from 9.3 to 16.9 at final follow-up.

For pain, the mean preoperative value of Vas scale was 9,1, postoperative mean value was 4.9. Range of motion and abduction power improved not significantly after surgery, although patients satisfaction levels were high. Imaging studies identified intact patch in 15 patients and patch detachment in 45. No adverse side effects (infection, rejection, allergy) were reported during the study period.

The results of our study suggest that patients (appropriately selected) with a massive full-thickness rotator cuff tear can be expected to have a pain relief after repair, but not a significantly improved of functional outcome.

Shoulder pain or loss of normal range of motion is a frequent complaint in the outpatient clinic. Of these presentations, rotator cuff injury is a common cause. This can range from mild, transient inflammation of the tendons, to partial tears of tendons, or even full thickness tears. Disruption of the tendons can occur from forceful forward throwing actions undertaken in some sports, for example baseball pitching, more commonly in the UK however, chronic impingement can lead eventually to a tendon tear-usually seen in an older population. Current methods of investigation of such injuries after clinical history and examination, includes plain film radiography, ultrasonography, magnetic resonance imaging and arthrography. We decided to look at how ultrasound can be used in the district general hospital for investigation of such injuries.

INTRODUCTION

This study describes the prevalence of pain, functional loss and rotator cuff tears (RCTs) in a general population cohort. It is the first multidisciplinary assessment in such a cohort.

Management of irreparable rotator cuff tears is challenging and controversial. Surgeons have been utilising biological tissue scaffolding to augment repairs, but there are concerns regarding viability and function. We wished to investigate this viability and clinical outcome in a small group of patients.

All procedures were performed by a single surgeon over a three-year period. Inclusion criteria were patients with large cuff tears and failure of non-operative treatment. Exclusion criteria were patients with glenohumeral arthritis and where cuff repair could not be successfully performed. Open rotator cuff repair followed by augmentation with Graft Jacket® Regenerative Tissue Matrix (Wright Medical) was performed in all patients. A structured cuff repair physiotherapy protocol was then followed. Follow-up was at six months and at minimum twenty-four months post-operatively where Constant scores (CS) and Oxford Shoulder scores (OSS) were noted and a repeat ultrasound performed.

Fourteen patients underwent the procedure. No patient was lost to follow-up. There were seven males and seven females with a mean age of 63 years (range 31–77). At minimum twenty-four month follow-up, thirteen patients had flexion and abduction above 90 degrees and symmetrical external rotation. Mean CS was 81 (range 70–91) and mean OSS was 46 (range 41–48). Shoulder ultrasound revealed an intact Graft Jacket® in all thirteen patients. The final patient had lower functional movement and lower CS (34) and OSS (25) and ultrasound identified a re-rupture.

This study indicates that augmentation of large rotator cuff repairs with biological tissue scaffolding is a viable option and has good functional results.

INTRODUCTION

There is increasing evidence for a multi-stage model of rotator cuff (RC) tendon tears, wherein healing is affected by tear size. The underlying pathophysiology however is not fully understood. Changes in the production and remodeling of the RC extracellular matrix (ECM) are likely to be important determinants of RC tendinopathy as they affect healing and the ability to bear loads. This study aimed to gain greater insight into size related tear pathogenesis by analyzing gene expression profiles from normal, small and massive RC tears.

Introduction

Latissimus dorsi transfer is a procedure used in massive irreparable posterosuperior rotator cuff tears, in young patient with severe pain and significant functional impairment. The purpose of this retrospective study was to evaluate its clinical, radiological and electromyographic results.

Summary

Strong mechanical fixation is critical to the success of rotator cuff repairs. In this comparative study in cadaveric shoulders, single-tendon full-thickness supraspinatus tears were repaired using two different types of PEEK knotless suture anchors-ReelX STT (Stryker) and Opus Magnum PI (Arthrocare)-using a single-row technique in both instances. Cyclic testing was performed followed by loading until mechanical failure. No significant difference was observed in gap formation, measured as the distance between the supraspinatus tendon and bone at the repair site, during cyclic loading. However, the maximum load was statistically higher for repairs with the ReelX anchor.

INTRODUCTION

In order to address high failure rates following rotator cuff repairs, a greater understanding is required of the underlying structural changes so that treatments can be appropriately targeted and biomarkers of failure can be identified. As collagen is the primary constituent of tendon and determines force transmission, collagen structural changes may affect responses to loading. For example changes in collagen 1 and 5 are associated with the hyperelastic Ehlers-Danlos syndrome, which is diagnosed by looking for pathopneumonic altered collagen fibres or ‘collagen flowers’ in skin using transmission electron microscopy (TEM). To date no study has been performed on the microstructure of torn human rotator cuff tendons using TEM.

It was hypothesized that normal, small and massive human rotator cuff tendons tears will have altered microscopic structures. The unique study aimed to use TEM to compare the ultrastructure of small and massive rotator cuff tears, to normal rotator cuff tendons.

Introduction

Following tear of its tendon, the muscle undergoes retraction, atrophy and fatty infiltration. These changes are inevitable and considered irreversible and limit the potential of successful repair of musculotendinous units. It was the purpose of this study to test the hypothesis that administration of anabolic steroids can prevent these muscular changes following experimental supraspinatus tendon release in the rabbit.

Antegrade nailing of proximal humeral fractures using a straight nail can damage the bony insertion of the supraspinatus tendon and may lead to varus failure of the construct. In order to establish the ideal anatomical landmarks for insertion of the nail and their clinical relevance we analysed CT scans of bilateral proximal humeri in 200 patients (mean age 45.1 years (sd 19.6; 18 to 97) without humeral fractures. The entry point of the nail was defined by the point of intersection of the anteroposterior and lateral vertical axes with the cortex of the humeral head. The critical point was defined as the intersection of the sagittal axis with the medial limit of the insertion of the supraspinatus tendon on the greater tuberosity. The region of interest, i.e. the biggest entry hole that would not encroach on the insertion of the supraspinatus tendon, was calculated setting a 3 mm minimal distance from the critical point. This identified that 38.5% of the humeral heads were categorised as ‘critical types’, due to morphology in which the predicted offset of the entry point would encroach on the insertion of the supraspinatus tendon that may damage the tendon and reduce the stability of fixation.

We therefore emphasise the need for ‘fastidious’ pre-operative planning to minimise this risk.

Cite this article: Bone Joint J 2014;96-B:249–53.

Introduction

The pathophysiology of high failure rates following rotator cuff tendon repairs, particularly massive tears, is not fully understood. Collagen structural changes have been shown to alter tendon thermal and mechanical properties. Thermal changes in small biopsies, detected by differential scanning calorimetry (DSC) can help to quantify collagen structural differences in torn rotator cuff tendons. This study aimed to form a quantitative rather than qualitative assessment, of whether differences in collagen structure and integrity existed between small biopsies of normal, small and massive rotator cuff tears using DSC.

Aims

There is no consensus on the treatment of proximal humeral fractures. Hemiarthroplasty has been widely used in patients when non-surgical treatment is not possible. There is, despite extensive use, limited information about the long-term outcome. Our primary aim was to report ten-year patient-reported outcome after hemiarthroplasty for acute proximal humeral fractures. The secondary aims were to report the cumulative revision rate and risk factors for an inferior patient-reported outcome.