This study aims to investigate the mechanical properties of a rotator cuff tear repaired with a polypropylene interposition graft in an ovine infraspinatus ex-vivo model. Twenty fresh shoulders from skeletally mature sheep were used in this study. A tear size of 20 mm from the tendon joint was created in the infraspinatus tendon to simulate a large tear in fifteen specimens. This was repaired with a polypropylene mesh used as an interposition graft between the ends of the tendon. Eight specimens were secured with mattress stitches while seven were secured to the remnant tendon on the greater tuberosity side by continuous stitching. Remaining five specimens with an intact tendon served as a control group. All specimens underwent cyclic loading with a universal testing machine to determine the ultimate failure load and gap distance. Gap distance increased with progressive cyclic loading through 3000 cycles for all repaired specimens. Mean gap distance after 3000 cycles for both continuous and mattress groups are 1.7 mm and 4.2 mm respectively (P = .001). Significantly higher mean ultimate failure load was also observed with 549.2 N in the continuous group, 426.6 N in the mattress group and 370 N in the intact group. The use of a polypropylene mesh as an interposition graft for large irreparable rotator cuff tears is biomechanically suitable and results in a robust repair that is comparable to an intact rotator cuff tendon. When paired with a continuous suturing technique, it demonstrates significantly resultant superior biomechanical properties that may potentially reduce re-tear rates after repairing large or massive rotator cuff tears

Chronic rotator cuff tears are a major problem especially in the elderly population. Refixation is associated with high re-rupture rates. Therefore new implants or healing methods are needed. For a control of success biomechanical characteristics of native as well as treated tendons are of particular importance. Currently, tensile tests with static material testing machines are the most common technique for the biomechanical characterization of tendons. Resulting values are the maximum force (Fmax), stiffness and the Young´s modulus. However, no information is given about the allocation of strains over the tendon area. In addition, the determination of Fmax results in tissue destruction thus foreclosing further evaluation like histology. The Digital Image Correlation (DIC) is a contact-free non-destructive optical measuring method which gives information about distribution of strains by tracking the areal shift of an applied speckle pattern. The needed speckle pattern has to have a high contrast, a homogeneous distribution and a good adhesion to the surface. The method is established for the characterization of construction materials [1] to detect e.g. weak points. The present study examined if DIC is applicable for the complementary biomechanical evaluation of the sheep infraspinatus tendon. Fine ground powder extracted from a printer cartridge was chosen as a starting point. Preliminary to the in vitro experiments, the powder was applied on sheets with different methods: brushing, blowing, sieving and stamping. Stamping showed best results and was used for further in vitro tests on cadaveric native tendons (n=5). First, the toner powder was transferred to coarse-grained abrasive paper using a brush and stamped on the tendon surface. Afterwards DIC analysis was performed. For the in vivo tests, the left infraspinatus tendon of two German black-headed Mutton Sheep was detached and then refixed with bone anchors, the right tendon was used as native control (authorization: AZ 33.19-42502-04-17/2739). 12 weeks after surgery the animals were euthanized, the shoulders were explanted and DIC measurement performed. The speckle pattern could be applied adequately on the smooth tendon surfaces of native tendons. All specimens could be analyzed by DIC with sufficient correlation coefficients. The highest displacements were measured in the peripheral areas, whereas the central part of the tendon showed a low displacement. Repaired left tendons showed obvious differences already macroscopically. The tendons were thicker and showed inhomogeneous surfaces. Application of the toner powder by stamping was distinctly more complicated, DIC analysis could not produce sufficient correlation coefficients. In summary, transfer of DIC to native infraspinatus tendons of sheep was successful and can be further transferred to other animal and human tendons. However, irregular surfaces in tendon scar tissues affect the application of an adequate speckle pattern with a stamp technique. Therefore, further modifications are necessary. This research project has been supported by the German Research Foundation “Graded Implants FOR 2180 – tendon- and bone junctions” WE 4262/6-1

Introduction and Objective. In the elderly population, chronic rotator cuff tears are often associated with high re-rupture rates after surgical tendon refixation. Implant materials, especially in combination with additives are supposed to positively influence healing outcome. Furthermore, adequate mechanical properties are crucial. In order to realize degradable implants with high specific surface area, polycaprolactone (PCL) was chosen as basic material and processed by electrospinning to achieve a high surface area for growth factor implementation and subsequent cell attachment. Materials and Methods. PCL (M. n. approx. 80,000 g/mol) was used to generate fibre mats by electrospinning (relative collector velocity 8 m/s; flow rate of 4 ml/h). Mechanical analysis was performed according to EN ISO 527–2:2012 with test specimen 1BA (5 mm in diameter). Maximum force at failure (Fmax) as well as stiffness were evaluated. For preclinical in vivo testing, a coating with CS-g-PCL was performed to increase cellular adhesion and biological integration. Native and TGF-ß3 loaded mats were examined in a chronic rat tendon defect model with dissection of the M. infraspinatus, four week latency and following refixation at the humerus with different PCL-fibre mats (approval Nr. 33.12–42502–04–15/2015). After 8 weeks, rats were finalized and tendon-bone insertions were analyzed biomechanically and via histological methods. Results. Electrospun PCL-fibre mats (n = 6) showed maximum forces of 2.19 ± 0.8 N and a stiffness of 0.38 ± 0.12 N/mm. Native rat infraspinatus tendons showed Fmax values of 28.4 ± 7.2 N and a stiffness of 11.8 ± 4.9 N/mm. After implantation, Fmax of the implant-tendon-regenerate was significantly lower in CS-g-PCL - fibre mat groups compared to native control tendons (mean 52 % of native tendon value). Functionalization with TGF-ß3 led to increased Fmax (78 % of the native tendon value). However, differences were not statistically significant. Histological evaluation revealed no differences between non loaded and TGF-ß3 loaded mats. The implants were strongly disintegrated. Granulation tissue and a high number of foreign body giant cells were present. Conclusions. Although mechanical properties of fabricated mats were low, loading of the fibre mats influenced the biomechanical outcome of refixed tendons, presumably due to their high potential for binding biological active substances like TGF-ß3. However, in ongoing studies these cell reactions, especially regarding polarization of macrophages and foreign body cells need to be characterized. This research project has been supported by the German Research Foundation “Graded Implants FOR 2180 – tendon- and bone junctions” WE 4262/6-2 and parts were published in J Tissue Eng Regen Med. 2020 Jan;14(1):186–197. doi: 10.1002/term.2985

Introduction. Supraspinatus and infraspinatus tears (Massive Rotator Cuff Tear- MRCT) cause compensatory activation of the teres minor (TM) and subscapularis (SubS) to maintain humeral head alignment. This study measures force changes in TM and SubS using a dynamic shoulder testing setup. We hypothesize that combining superior capsule reconstruction (SCR) and lower trapezius tendon (LTT) transfer will correct rotator cuff forces. Methods. Eight fresh-frozen human shoulder specimens from donors aged 55-75 (mean = 63.75 years), balanced for gender, averaging 219.5 lbs, were used. Rotator cuff and deltoid tendons were connected to force sensors through a pulley system, with the deltoid linked to a servohydraulic motor for dynamic force measurement. The system allowed unrestricted humeral abduction from 0 to 90 degrees. Results. Teres Minor (TM):. -. Control: 7.43 N (SD = 1.66). -. SS tear: 5.46 N (SD = 1.45). -. MRCT: 3.94 N (SD = 1.43). -. LTT post-MRCT: 5.85 N (SD = 1.13). -. SCR post-MRCT: 4.68 N (SD = 0.71). -. Combined LTT+SCR: 6.43 N (SD = 1.24). -. TM force reduction: 26.51% post-SS tear, 46.97% from intact to MRCT, 63.20% increase with LTT+SCR. Subscapularis (SubS):. -. Control: -0.73 N (SD = 0.43). -. SS tear: -0.46 N (SD = 0.36), 36.99% increase. -. MRCT: 0.96 N (SD = 0.47), 31.51% increase. -. LTT post-MRCT: -0.32 N (SD = 0.47), 66.67% reduction. -. SCR post-MRCT: -0.28 N (SD = 0.16), 70.83% reduction. -. Combined LTT+SCR: -0.66 N (SD = 0.32), 31.25% reduction. Non-parametric Friedman's ANOVA showed overall statistical significance for TM (P = 1.083×10. -6. ) and SubS (P = 4.77×10. -4. ). Conclusion. The cadaveric model assesses rotator cuff compensations, showing significant TM force reductions following rotator cuff tears and improvements with LTT and SCR, particularly when combined. SubS exhibited negative force during normal abduction but compensated during MRCT, returning to normal values post-LTT and SCR

Objectives . Rotator cuff tears are among the most common and debilitating upper extremity injuries. Chronic cuff tears result in atrophy and an infiltration of fat into the muscle, a condition commonly referred to as ‘fatty degeneration’. While stem cell therapies hold promise for the treatment of cuff tears, a suitable immunodeficient animal model that could be used to study human or other xenograft-based therapies for the treatment of rotator cuff injuries had not previously been identified. Methods . A full-thickness, massive supraspinatus and infraspinatus tear was induced in adult T-cell deficient rats. We hypothesised that, compared with controls, 28 days after inducing a tear we would observe a decrease in muscle force production, an accumulation of type IIB fibres, and an upregulation in the expression of genes involved with muscle atrophy, fibrosis and inflammation. Results . Chronic cuff tears in nude rats resulted in a 30% to 40% decrease in muscle mass, a 23% reduction in production of muscle force, and an induction of genes that regulate atrophy, fibrosis, lipid accumulation, inflammation and macrophage recruitment. Marked large lipid droplet accumulation was also present. Conclusions . The extent of degenerative changes in nude rats was similar to what was observed in T-cell competent rats. T cells may not play an important role in regulating muscle degeneration following chronic muscle unloading. The general similarities between nude and T-cell competent rats suggest the nude rat is likely an appropriate preclinical model for the study of xenografts that have the potential to enhance the treatment of chronically torn rotator cuff muscles. Cite this article: Bone Joint Res 2014;3:262–72

While the evolution of the bony skeleton of the shoulder girdle is well described, there is little information regarding the soft tissues, in particular of the rotator cuff. We dissected the shoulders of 23 different species and compared the anatomical features of the tendons of the rotator cuff. The alignment and orientation of the collagen fibres of some of the tendons were also examined histologically. The behaviour of the relevant species was studied, with particular reference to the extent and frequency of forward-reaching and overhead activity of the forelimb. In quadrupedal species, the tendons of supraspinatus, infraspinatus and teres minor were seen to insert into the greater tuberosity of the humerus separately. They therefore did not form a true rotator cuff with blending of the tendons. This was only found in advanced primates and in one unusual species, the tree kangaroo. These findings support the suggestion that the appearance of the rotator cuff in the evolutionary process parallels anatomical adaptation to regular overhead activity and the increased use of the arm away from the sagittal plane

We released the infraspinatus tendons of six sheep, allowed retraction of the musculotendinous unit over a period of 40 weeks and then performed a repair. We studied retraction of the musculotendinous unit 35 weeks later using CT, MRI and macroscopic dissection. The tendon was retracted by a mean of 4.7 cm (3.8 to 5.1) 40 weeks after release and remained at a mean of 4.2 cm (3.3 to 4.7) 35 weeks after the repair. Retraction of the muscle was only a mean of 2.7 cm (2.0 to 3.3) and 1.7 cm (1.1 to 2.2) respectively at these two points. Thus, the musculotendinous junction had shifted distally by a mean of 2.5 cm (2.0 to 2.8) relative to the tendon. Sheep muscle showed an ability to compensate for approximately 60% of the tendon retraction in a hitherto unknown fashion. Such retraction may not be a quantitatively reliable indicator of retraction of the muscle and may overestimate the need for elongation of the musculotendinous unit during repair

We reconstructed defects in the infraspinatus tendon using polytetrafluoroethylene (PTFE) felt grafts in 31 beagle dogs and examined the mechanical responses and histocompatibility. Except for one infected specimen, all the reconstructed infraspinatus tendons healed. We examined eight specimens each immediately after surgery and at six and 12 weeks. The ultimate tensile strength of the reconstructed tendons was 60.84 N, 172.88 N, and 306.51 N immediately after surgery and at six and 12 weeks, respectively. The stiffness of the specimens at the PTFE felt-bone interface was 9.61 kN/m, 64.67 kN/m, and 135.09 kN/m immediately after surgery and at six and 12 weeks, respectively. Six tendons were examined histologically at three, six, 12 and 24 weeks. Histological analysis showed that there was ingrowth of fibrous tissue between the PTFE fibres. Foreign-body reactions were found at the margin of the PTFE-bone interface between 12 and 24 weeks. The mechanical recovery and tissue affinity of PTFE felt to bone and to tendon support its use for reconstruction of the rotator cuff. The possible development of a foreign-body reaction should be borne in mind

Subacromial bursa fibrosis are linked to rotator cuff lesion with shoulder stiffness; however, the mechanism underlying this shoulder disorder remain elusive. MicroRNA-29s (miR-29s) are emerging fibrosis inhibitor targeting fibrogenic matrices during tissue fibrosis. This study is aimed to investigate clinical relevance and function of miR-29 signalling to subacromial bursa homeostasis in shoulder stiffness. Subacromial bursa in patients with rotator cuff lesion with or without shoulder stiffness who required open acromioplasty were harvested for assessing fibrosis histopathology using Manson's trichrome staining. Expressions of proinflammatory cytokines, fibrotic matrices, and miR-29s were quantified using RT-PCR and in situ hybridization. Range of motion and pain scores of the stiffness group were higher than those of non-stiffness group. Upregulated proinflammatory cytokines (IL-1β, IL-6, and TNF-α) and fibrotic matrices (collagen 1α1, 3α1, and 4α1) but decreased miR-29a and b expression existed in the stiffness group. Affected tissues exhibited severe fibrotic matrix accumulation, synovial hyperangiogenesis, hyperplasia, and strong miR-29a transcripts. In vitro, IL-1β rather than IL-6 and TNF-α decreased miR-29a expression of subacromial bursa fibroblasts. miR-29a knockdown escalated fibrotic matrix expression, whereas forced miR-29a expression alleviated the IL-1β-induced fibrotic matrix expression. Of interest, miR-29a transgenic mice displayed moderate responses to supraspinatus and infraspinatus tenotomy-induce fibrosis and gait irregularity of affected shoulders. Weak miR-29 signalling causes excessive fibrosis and remodelling in subacromial bursa and ultimately increases the prevalence of shoulder stiffness. This study reveals a new mechanistic underlying shoulder stiffness and highlights that sustained miR-29a potentially ameliorates the severity and function of stiff shoulder

Disturbed muscular architecture, fatty infiltration and muscular atrophy remain irreversible in chronic rotator cuff tears (RCT) even after repair. Poly-[ADP-ribose]-polymerase 1 (PARP-1), a nuclear factor involved in DNA damage repair, has shown to be a key element in the up-regulation of early muscle inflammation, atrophy and fat deposition. We therefore hypothesized that the absence of PARP-1 would lead to a reduction in muscular architectural damage, early inflammation, atrophy and fatty infiltration subsequent to combined tenotomy and neurectomy in a PARP-1 knock-out mouse model. PARP-1 knock-out (KO group) and standard wild type C57BL/6 (WT group) mice were randomly allocated into three different time points (1, 6 and 12 weeks, total n=72). In all mice the supraspinatus (SSP) and infraspinatus (ISP) tendons of the left shoulder were detached and the SSP muscle was denervated according to a recently established model. Macroscopic muscle weight analysis, retraction documentation using macroscopic suture, magnetic resonance imaging, immunohistochemistry gene expression analysis using real time qPCR (RTqPCR) and histology were used to assess the differences in muscle architecture, early inflammation, fatty infiltration and atrophy between knock out and wild type mice in the supraspinatus muscle. The SSP did retract in both groups, however; the KO muscles and tendons retracted less than the WT muscles (2.1±21mm vs 3.4±0.41mm; p=0.02). Further assessment of muscle architecture demonstrated that the pennation angle was significantly higher in the KO groups at 6 and 12 weeks (28±5 vs 36±5 and 29±4 vs 34±3; p<0.0001). Combined Tenotomy and neurectomy resulted in a significant loss of muscle mass in both groups compared to the contralateral unoperated side (KO group 62±11% and WT group 52±11%, p=0.04) at 6 weeks. But at 12 weeks postoperatively, there was a significant increase in muscle mass to near normal levels in KO group compared to the WT group (14±6% and 42±7% lower muscle mass respectively; p<0.0001) and less fatty infiltration (12.5 ± 1.82% and 19.6 ± 1.96%, p=0.027). Immunohistochemistry revealed a significant decrease in the expression of inflammatory, apoptotic, adipogenic and muscular atrophy genes at both the 1 week and 6 weeks time points, but not at 12 weeks in the KO group compared to the WT group. This was confirmed by histology. Our study is the first to show that knocking out PARP-1 leads to decreased loss of muscle architecture, early inflammation, fatty infiltration and atrophy after combined tenotomy and neurectomy of the rotator cuff muscle. Although the macroscopic muscles reaction to injury is similar in the first 6 weeks, its ability to regenerate is much greater in the PARP-1 group leading to a near normalization of the muscle substance and muscle weight, less retraction, and less fatty infiltration after 12 weeks

Summary Statement. A novel biomimetic polydioxanone tendon patch with woven and electrospun components is biocompatible, recapitulates native tendon architecture and creates a tissue-healing microenvironment directed by a subpopulation of regenerative macrophages. The woven component provides tensile strength while the tendon heals. Introduction. There is great interest in the use of biomimetic devices to augment tendon repairs. Ideally, implants improve healing without causing adverse local or systemic reactions. Biocompatibility remains a critical issue prior to implantation into humans, as some implants elicit a foreign body response (FBR) involving inflammation, poor wound healing and even fistulae formation. Additionally, the effect on articular cartilage locally or systemically with placement of a juxta-articular implant has not been examined. The purpose of this study is to test the in vivo biocompatibility of a novel hybrid woven and electrospun polydioxanone patch in a rat tendon transection model. Patients and Methods. Sixty Lewis rats were divided into 4 groups in which the infraspinatus was surgically transected 3 mm from its insertion. Tendons were repaired with a woven and electrospun polydioxanone patch (PDOe) and 5-0 Prolene sutures. Vicryl and Silk patches or a simple Prolene suture repair served as comparators. Animals were sacrificed at 1, 2, 4, 6 and 12 weeks to examine the biocompatibility of the implants. Immunohistochemistry was used to examine macrophage subpopulations and hematoxylin and eosin staining was used to assess foreign-body giant cells and both analyzed with a one-way ANOVA with significance set at p<.05. Articular cartilage was scrutinised with semi-quantitative analysis. Hind paw inflammatory indices were used to determine the systemic effects and biomechanical testing the tensile strength of the materials over time. Results. The PDOe patch remained grossly quiescent at all time-points. There was a severe inflammatory reaction to Vicryl at one and 2-week time-points with gross exudate. Silk patches were associated with larger fibrous capsules at each time point. There were no adverse systemic effects and articular cartilage remained normal with no differences between materials to controls. Immunohistochemistry showed a significantly higher ratio of regenerative to inflammatory macrophages for the PDOe patch compared to other constructs at each time-point and similar to controls. Silk and Vicryl patches had a greater than 10-fold increase in foreign-body giant cells compared to the PDOe patch and controls (p<.05) suggesting incorporation rather than rejection and walling off of the biomaterial. Tensile strength of the PDOe patch increased in the first 2 weeks to greater than 90 N and gradually declined to a mean of 22 N at 12 weeks. Discussion/Conclusion. The novel PDOe patch appears to be biocompatible and illicit very little FBR in this rat tendon injury model. Importantly, there was no joint reaction to the biomaterial which has not been addressed previously. We believe the electrospun component of the patch recapitulates native tendon architecture creating a tissue healing microenvironment directed by a regenerative macrophage subpopulation. These results corroborate earlier in vitro work that showed incorporation of tenocytes within the electrospun scaffold. The woven component of the scaffold provides tensile strength as the tendon heals and begins to degrade after healing is underway making it less likely to elicit a FBR. Based on these and earlier in vitro data we believe this implant shows excellent biocompatibility and is ready to proceed to human trials

Summary Statement. Demineralised bone matrix augmented tendon-bone fixations in the animal model show less scar tissue and an enthesis morphology closer to the physiologic one which may lead to a more resistant repair construct. Introduction. Rotator cuff repair is one of the most common operative procedures in the shoulder. Yet despite its prevalence recurrent tear rates of up to 94% have been reported in the literature. High failure rates have been associated with tendon detachment from bone at the tendon – bone interface. Exogenous agents as biological strategies to augment tendon – bone healing in the shoulder represent a new area of focus to improve patient outcomes. Demineralised bone matrix (DBM) contains matrix bound proteins, exposed through acid demineralization step of DBM manufacture, and has long been recognised for its osteoinductive and osteoconductive properties. We hypothesised that DBM administered to the bone bed prior to the reattachment of the tendon, will upregulate healing and result in enhanced tissue morphology that more closely resembles that of a normal enthesis. An established ovine transosseous equivalent rotator cuff model was used. Methods. Following ethics approval, 10 adult wethers (18 months) were randomly allocated to control, n=4 (without DBM) or DBM, n=6 (DBM administered to bone bed) groups. The infraspinatus tendon was detached from its insertion and repaired in a transosseous equivalent fashion using PEEK suture anchors. In treatment animals 0.25cc of ovine DBM, previously prepared using a modified Urist protocol, was injected into two drill holes within the bony tendon footprint. Animals were culled at 4 weeks following surgery and processed for tissue histology and microcomputed tomography (μCT) endpoints. Results. No infection or tendon detachment following repair was noted in either group. 3D reconstructed images of μCT scans verified correct DBM and suture anchor placement. Histological images demonstrated distinct differences in tissue morphology between the two groups; however there was no evidence of the four – zoned structure characteristic of a healthy tendon bone insertion, in any specimens. In the control group specimens, the tendon midsubstance was highly disorganised with randomly arranged collagen fibres and diminutive areas of fibrocartilage. In the treatment group, large regions between tendon and bone were occupied by fibrocartilage. Within the fibrocartilage region, insertional collagen fibres appeared organised and chondrocytes were orientated in the direction of the insertional collagen fibres. Organised collagen fibre orientation within the tendon midsubstance was observed, though this was not consistent throughout all the specimens. DBM particles were resorbed and trabecular bone occupied the DBM holes. The PEEK anchors were all in direct contact with the ongrowing bone indicating good quality integration and fixation. Discussion. This study showed that DBM augmented tendon to bone repair leads to an upregulated cellular activity resulting in increased amounts of fibrocartilage between the repaired tendon and underlying bone. The upshot of this is an improved tissue organization which more closely resembles the morphology of the normal enthesis. Introduction of osteoinductive DBM at the tendon – bone interface during surgery may reduce failure rates associated with rotator cuff repair and improve clinical outcomes

Summary Statement. Reverse shoulder design philosophy can impact external rotation moment arms. Lateralizing the humerus can increase the external rotator moment arms relative to normal anatomy. Introduction. The design of reverse shoulders continues to evolve. These devices are unique in that they are not meant to reproduce the healthy anatomy. The reversal of the fulcurm in these devices impacts every muscle that surrounds the joint. This study is focused on analyzing the moment arms for the rotator cuff muscles involved in internal and external rotation for a number of reverse shoulder design philosophies. Methods. Four of the most common design philosophies were chosen. The first, a Grammont style prosthesis, with a center of rotation (COR) on the glenoid face and a humeral cup countersunk into the proximal humerus (MGMH). The second concept is the MGMH design lateralised by a 10mm bone graft (BIO). The third concept has a lateralised glenosphere COR and a humeral component inside the proximal humerus (LGMH). The fourth design has a medialised COR with a humeral component placed on top of the humerus (MGLH). This places the humerus further lateral than the previous designs. For each component set, a representative implant was modeled based on published specifications. Each design was implanted into the same digital bone models (consisting of a humerus, scapula, clavicle, and ribcage) following the manufacturer's recommended surgical technique. The muscles analyzed were the posterior-deltoid (PD), subscapularis (SSC), infraspinatus (IS), and teres minor (TM). These muscles were allowed to wrap around the bone of the scapula and proximal humerus through the range of motion. All muscle origin and insertion points were kept constant throughout the analysis. The assemblies were externally rotated from an initial position of 45° internal rotation to 45° of external rotation of the humerus with the arm at 0° of abduction. The moment arms for all muscles were compared to those calculated for the anatomic shoulder. Results. All the rotator cuff muscles displayed a similar trend with the reverse shoulder. The external rotators all had similar moment arm values at neutral (IS∼22mm, TM∼20mm), but increased at rates proportional to their humeral offsets with external rotation (IS-MGLH 32.3mm, LGMH 27.5mm, MGMH and BIO 26.25mm; TM-MGLH 31.3mm, LGMH 27.8mm, MGMH and BIO 26.5mm). The SSC internal rotation moment arm remains roughly constant at 20mm for the anatomic shoulder, but varies widely from 45° external to 45° internal rotation with the different designs (MGLH 31.4mm to 6.7mm; MGMH 25.1mm to 11.2mm; LGMH 26.2mm to 10.8mm; BIO 25.4mm to 4.8mm). The PD moment arm is increased relative to the anatomic shoulder during external rotation for the MGLH design (9.3mm vs. 7.4mm). The other designs exhibit a decrease in the moment arm of this muscle relative to the anatomic design (LGMH 7.3mm, MGMH 5.8mm, BIO 6.4mm). Discussion. The lateral offset between the center of humeral axis and the muscle insertion on the humerus dominates the external rotation moment arm value through this range of motion. This is evident by the increase in the moment arms with external rotation for the different reverse shoulder designs. The increase in external rotation efficiency for the external rotators and PD could play a critical role in post-operative external rotation strength and motion

Background. High re-rupture rates following repairs of rotator cuff tears (RCTs) have resulted in the increased use of repair grafts to act as temporary scaffolds to support tendon healing. It has been estimated that thousands of extracellular matrix repair grafts are used annually to augment surgical repair of rotator cuff tears. The only mechanical assessment of the suitability of these grafts for rotator cuff repair has been made using tensile testing only, and compared grafts to canine infraspinatus. As the shoulder and rotator cuff tendons are exposed to shearing as well as uniaxial loading, we compared the response of repair grafts and human rotator cuff tendons to shearing mechanical stress. We used a novel technique to study material deformation, dynamic shear analysis (DSA). Methods. The shear properties of four RCT repair grafts were measured (Restore, GraftJacket, Zimmer Collagen Repair and SportsMesh). 3mm-sized biopsy samples were taken and subjected to DSA using oscillatory deformation under compression to calculate the storage modulus (G') as an indicator of mechanical integrity. To assess how well the repair grafts were matched to normal rotator cuff tendons, the storage modulus was calculated for 18 human rotator cuff specimens which were obtained from patients aged between 22 and 89 years (mean age 58.8 years, with 9 males and 9 females). Control human rotator cuff tendons were obtained from the edge of tendons during hemiarthoplasties and stabilisations. A 1-way ANOVA of all of the groups was performed to compare shear properties between the different commercially available repair grafts and human rotator cuff tendons to see if they were different. Specific comparison between the different repair grafts and normal rotator cuff tendons was done using a Dunn's multiple comparison test. Results. We report a significant difference in the shear moduli of all four rotator cuff repair grafts (P<0.0001, 1 way ANOVA, Kruskall-Wallis test). 2 of the grafts, Zimmer Collagen Repair and SportMesh, were not significantly different when compared to rotator cuff tendons and were found to have comparable shear mechanical properties (P > 0.05, Dunn's multiple comparison test). The other repair grafts, GraftJacket and Restore, had a significantly lower storage modulus when compared to human rotator cuff tendons. Conclusions. With increasing numbers of repairs of rotator cuff tears, and augmentation of these repairs, there is a need to understand the mechanical and biological properties of the both repair grafts and the tendons they are designed to augment. At present there is no clear definition of the ideal mechanobiological properties of rotator cuff repair patches. Current rotator cuff repair grafts display a wide variation in their shear mechanical properties, and how closely they are matched to the mechanical properties of human rotator cuff tendons. It is hoped that this study may help to guide surgeons in deciding on the most appropriate rotator cuff tendon repair graft

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The establishment of a suitable animal model of repair of the rotator cuff is difficult since the presence of a true rotator cuff anatomically appears to be restricted almost exclusively to advanced primates. Our observational study describes the healing process after repair of the cuff in a primate model. Lesions were prepared and repaired in eight ‘middle-aged’ baboons. Two each were killed at four, eight, 12 and 15 weeks post-operatively. The bone-tendon repair zones were assessed macroscopically and histologically.

Healing of the baboon supraspinatus involved a sequence of stages resulting in the reestablishment of the bone-tendon junction. It was not uniform and occurred more rapidly at the sites of suture fixation than between them. Four weeks after repair the bone-tendon healing was immature. Whereas macroscopically the repair appeared to be healed at eight weeks, the Sharpey fibres holding the repair together did not appear in any considerable number before 12 weeks. By 15 weeks, the bone-tendon junction was almost, but not quite mature.

Our results support the use of a post-operative rehabilitation programme in man which protects the surgical repair for at least 12 to 15 weeks in order to allow maturation of tendon-to-bone healing.

We compared time-dependent changes in the biomechanical properties of single-and double-row repair of a simulated acute tear of the rotator cuff in rabbits to determine the effect of the fixation techniques on the healing process.

A tear of the supraspinatus tendon was created in 80 rabbits which were separated into two equal groups. A single-row repair with two suture anchors was conducted in group 1 and a double-row repair with four suture anchors in group 2. A total of ten intact contralateral shoulder joints was used as a control group. Biomechanical testing was performed immediately post-operatively and at four and eight weeks, and histological analysis at four and eight weeks.

The mean load to failure in group 2 animals was greater than in group 1, but both groups remained lower than the control group at all intervals. Histological analysis showed similar healing properties at four and eight weeks in both groups, but a significantly larger number of healed tendon-bone interfaces were identified in group 2 than in group 1 at eight weeks (p < 0.012).

The ultimate load to failure increased with the number of suture anchors used immediately post-operatively, and at four and eight weeks. The increased load to failure at eight weeks seemed to be related to the increase in the surface area of healed tendon-to-bone in the double-row repair group.

Our aim was to determine the most repeatable three-dimensional measurement of glenoid orientation and to compare it between shoulders with intact and torn rotator cuffs. Our null hypothesis was that glenoid orientation in the scapulae of shoulders with a full-thickness tear of the rotator cuff was the same as that in shoulders with an intact rotator cuff.

We studied 24 shoulders in cadavers, 12 with an intact rotator cuff and 12 with a full-thickness tear. Two different observers used a three-dimensional digitising system to measure glenoid orientation in the scapular plane (ie glenoid inclination) using six different techniques. Glenoid version was also measured. The overall precision of the measurements revealed an error of less than 0.6°.

Intraobserver reliability (correlation coefficients of 0.990 and 0.984 for each observer) and interobserver reliability (correlation coefficient of 0.985) were highest for measurement of glenoid inclination based on the angle obtained from a line connecting the superior and inferior points of the glenoid and that connecting the most superior point of the glenoid and the most superior point on the body of the scapula. There were no differences in glenoid inclination (p = 0.34) or glenoid version (p = 0.12) in scapulae from shoulders with an intact rotator cuff and those with a full-thickness tear. Abnormal glenoid orientation was not present in shoulders with a torn rotator cuff.

We used demineralised bone matrix (DBM) to augment re-attachment of tendon to a metal prosthesis in an in vivo ovine model of reconstruction of the extensor mechanism at the knee. We hypothesised that augmentation of the tendon-implant interface with DBM would enhance the functional and histological outcomes as compared with previously reported control reconstructions without DBM. Function was assessed at six and 12 weeks postoperatively, and histological examination was undertaken at 12 weeks.

A significant increase of 23.5% was observed in functional weight-bearing at six weeks in the DBM-augmented group compared with non-augmented controls (p = 0.004). By 12 weeks augmentation with DBM resulted in regeneration of a more direct-type enthesis, with regions of fibrocartilage, mineralised fibrocartilage and bone. In the controls the interface was predominantly indirect, with the tendon attached to the bone graft-hydroxyapatite base plate by perforating collagen fibres.

Wear of polyethylene is associated with aseptic loosening of orthopaedic implants and has been observed in hip and knee prostheses and anatomical implants for the shoulder. The reversed shoulder prostheses have not been assessed as yet. We investigated the volumetric polyethylene wear of the reversed and anatomical Aequalis shoulder prostheses using a mathematical musculoskeletal model. Movement and joint stability were achieved by EMG-controlled activation of the muscles. A non-constant wear factor was considered. Simulated activities of daily living were estimated from in vivo recorded data.

After one year of use, the volumetric wear was 8.4 mm³ for the anatomical prosthesis, but 44.6 mm³ for the reversed version. For the anatomical prosthesis the predictions for contact pressure and wear were consistent with biomechanical and clinical data. The abrasive wear of the polyethylene in reversed prostheses should not be underestimated, and further analysis, both experimental and clinical, is required.