Modified margin convergence: over-under lacing suture technique

The principle of margin convergence can be applied to rotator cuff repair to enhance the security of fixation by decreasing the mechanical strain at the margins of the tear. We describe a suture technique, over-under lacing, that reproduces the same margin convergence, with equal tissue tension across the entire surface area of the cuff. A consecutive series of patients affected by massive U-shaped rotator cuff tears were treated by this repair technique. Preoperative diagnosis, tear assessment, and grading of fatty infiltration of the cuff muscles were based on arthro-computed tomography evaluation. The technique passes 2 sutures from the medial to lateral margin of the tear, with a knotless suture anchor for tendon-to-bone fixation. The proposed technique seems to reduce tensile strain on the repaired tendon, can reconstruct the rotator cuff cable, and can attain the balanced pull of the tendon in a medial-to-lateral fashion. The over-under lacing suture technique is both simple and reproducible. This technique may achieve the goals of margin convergence with satisfactory preliminary clinical results for patients with massive rotator cuff tears

Dynamic three-dimensional shoulder MRI during active motion for investigation of rotator cuff diseases

Background MRI is the standard methodology in diagnosis of rotator cuff diseases. However, many patients continue to have pain despite treatment, and MRI of a static unloaded shoulder seems insufficient for best diagnosis and treatment. This study evaluated if Dynamic MRI provides novel kinematic data that can be used to improve the understanding, diagnosis and best treatment of rotator cuff diseases. Methods Dynamic MRI provided real-time 3D image series and was used to measure changes in the width of subacromial space, superior-inferior translation and anterior-posterior translation of the humeral head relative to the glenoid during active abduction. These measures were investigated for consistency with the rotator cuff diseases classifications from standard MRI. Results The study included: 4 shoulders with massive rotator cuff tears, 5 shoulders with an isolated full-thickness supraspinatus tear, 5 shoulders with tendinopathy and 6 normal shoulders. A change in the width of subacromial space greater than 4mm differentiated between rotator cuff diseases with tendon tears (massive cuff tears and supraspinatus tear) and without tears (tendinopathy) (p = 0.012). The range of the superior-inferior translation was higher in the massive cuff tears group (6.4mm) than in normals (3.4mm) (p = 0.02). The range of the anterior-posterior translation was higher in the massive cuff tears (9.2 mm) and supraspinatus tear (9.3 mm) shoulders compared to normals (3.5mm) and tendinopathy (4.8mm) shoulders (p = 0.05). Conclusion The Dynamic MRI enabled a novel measure; ‘Looseness’, i.e. the translation of the humeral head on the glenoid during an abduction cycle. Looseness was better able at differentiating different forms of rotator cuff disease than a simple static measure of relative glenohumeral position

Differences in Risk Factors for Rotator Cuff Tears between Elderly Patients and Young Patients

It has been unclear whether the risk factors for rotator cuff tears are the same at all ages or differ between young and older populations. In this study, we examined the risk factors for rotator cuff tears using classification and regression tree analysis as methods of nonlinear regression analysis. There were 65 patients in the rotator cuff tears group and 45 patients in the intact rotator cuff group. Classification and regression tree analysis was performed to predict rotator cuff tears. The target factor was rotator cuff tears; explanatory variables were age, sex, trauma, and critical shoulder angle≥35°. In the results of classification and regression tree analysis, the tree was divided at age 64. For patients aged≥64, the tree was divided at trauma. For patients aged<64, the tree was divided at critical shoulder angle≥35°. The odds ratio for critical shoulder angle≥35° was significant for all ages (5.89), and for patients aged<64 (10.3) while trauma was only a significant factor for patients aged≥64 (5.13). Age, trauma, and critical shoulder angle≥35° were related to rotator cuff tears in this study. However, these risk factors showed different trends according to age group, not a linear relationship

Platelet-rich plasma for the treatment of partial rotator cuff tears

Rotator cuff tears are a common injury impacting a large and diverse group of patients and refer to a partial or full discontinuation of one or more of the muscles or tendons comprising the shoulder complex. It may occur as a result of traumatic injury, applied weight, overuse, or intrinsic degeneration over a period of years. The incidence of rotator cuff tears has been found to increase with age. Though not a life-threatening condition, rotator cuff tears adversely affect the quality of one's lifestyle causing significant pain, weakness, and limitation of motion that hinders a person from performing routine daily activities as adequately and frequently as desired. Data from cadaveric studies suggest that as many as 65% of individuals over the age of 70 have a partial-thickness rotator cuff tear. Oftentimes, rotator cuff tears are asymptomatic which can make diagnosis and early treatment challenging. The decision to pursue operative versus conservative management is often controversial. Though surgical intervention may provide more immediate pain relief and functional improvement, it portends a higher risk of morbidity than conservative measures, particularly with an older demographic of patients. Moreover, surgical repair is often followed by long recovery periods and has variable outcomes. A number of conservative treatment options are currently being utilized for the management of partial rotator cuff tears including oral medication, corticosteroid injection, and targeted physical therapy. This review seeks to assess an innovative, biologic approach to treating partial rotator cuff tears using autologous platelet-rich plasma (PRP). The use of PRP for the conservative management of both degenerative and acutely injured tissues is quickly becoming a more popular option within the clinical community. PRP treatment has received significant attention from the media and has been used by several professional athletes as a means of expediting the healing process. The appeal of PRP stems from the fact that it is produced from a patient's own blood. After a blood sample is obtained, it is placed into a centrifuge, a tool used to separate the blood into its many components. A large concentration of platelet-enriched plasma can then be collected and augmented before administration to an injured area of bone or soft tissue, such as a tendon or ligament. Platelets contain an abundance of growth factors essential for cellular recruitment, proliferation, and specialization required for the healing process. PRP is given to a patient via an injection, often under ultrasound assistance for more precise placement. This study reviewed a collection of current literature on the efficacy of PRP in rotator cuff repair. Published studies have generally illustrated a general trend towards effectiveness, suggesting PRP may improve patient outcomes and prevent the need for surgery in patients with partial rotator cuff tears. Study designs and results have proved to be inconsistent at times. However, further clinical investigation is required to validate the use of PRP as an additional non-surgical treatment option

Double-Row Repair Technique for Bursal-Sided Partial-Thickness Rotator Cuff Tears

Rotator cuff pathology is a common cause of shoulder pain in the athletic and general population. Partial-thickness rotator cuff tears (PTRCT) are commonly encountered and can be bursal-sided, articular-sided, or intratendinous. Various techniques exist for the repair of bursal-sided PTRCTs. The 2 main distinctions when addressing these lesions include tear completion versus preservation of the intact fibers, and single- versus double-row suture anchor fixation. We present our method for addressing bursal-sided PTRCTs using an in situ repair technique with double-row suture anchors. © 2017 Arthroscopy Association of North Americ

A multi-center, double-blind, randomized, placebo-controlled trial protocol to assess Traumeel injection vs dexamethasone injection in rotator cuff syndrome : the TRAumeel in ROtator cuff syndrome (TRARO) study protocol

Background: Shoulder pain is a common musculoskeletal symptom with a wide range of potential causes; however, the majority of conditions can be managed with conservative treatment. The aim of this study is to assess the efficacy and safety of Traumeel injections versus corticosteroid injections and placebo in the treatment of rotator cuff syndrome and bursitis and expand the current evidence base for the conservative treatment of rotator cuff syndrome. Methods/Design: This is a multi-center, randomized, double-blind, 16-week, three-arm, parallel-group, active-and placebo-controlled trial to assess the efficacy and safety of Traumeel 2 ml injection versus dexamethasone 8 mg injection versus placebo (saline solution). Patients will be randomly allocated to Traumeel, dexamethasone or placebo in a 2: 2: 1 randomization. After 1 week screening, patients will receive 3 injections at weekly intervals (days 1, 8 and 15) with additional follow-up assessments on day 22, a telephone consultation in week 9 and a final visit at week 15. Male and female patients aged 40 to 65 years, inclusive, will be recruited if they have acute episodes of chronic rotator cuff syndrome and/or bursitis. Patients with calcifications in the shoulder joint or a complete rotator cuff tear will be excluded. At least 160 patients will be recruited. All subacromial injections will be performed under ultrasound guidance utilizing a common technique. The only rescue medication permitted will be paracetamol (acetaminophen), with usage recorded. The primary endpoint is change from baseline in abduction-rotation pain visual analog scale (0-100 mm scale, 0 corresponds to no pain and 100 to extreme pain) at day 22 (Traumeel injections versus dexamethasone injections) for active external rotation. Secondary efficacy parameters include range of motion, disability of arm, shoulder, hand score and patient's/investigator's global assessment. Clinical efficacy will be assessed as non-inferiority of Traumeel with respect to dexamethasone regarding the primary efficacy parameter. Discussion: It is hoped that the results of this trial will expand the treatment options and evidence base available for the management of rotator cuff disease

Rotator cuff related shoulder pain: Assessment, management and uncertainties.

This document is the Accepted Manuscript version of the following article: Jeremy Lewis, ‘Rotator cuff related shoulder pain: Assessment, management and uncertainties’, Manual Therapy, Vol. 23: 57-68, June 2016, DOI: https://doi.org/10.1016/j.math.2016.03.009. This manuscript version is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.Rotator cuff related shoulder pain (RCRSP) is an over-arching term that encompasses a spectrum of shoulder conditions including; subacromial pain (impingement) syndrome, rotator cuff tendinopathy, and symptomatic partial and full thickness rotator cuff tears. For those diagnosed with RCRSP one aim of treatment is to achieve symptom free shoulder movement and function. Findings from published high quality research investigations suggest that a graduated and well-constructed exercise approach confers at least equivalent benefit as that derived from surgery for; subacromial pain (impingement) syndrome, rotator cuff tendinopathy, partial thickness rotator cuff (RC) tears and atraumatic full thickness rotator cuff tears. However considerable deficits in our understanding of RCRSP persist. These include; (i) cause and source of symptoms, (ii) establishing a definitive diagnosis, (iii) establishing the epidemiology of symptomatic RCRSP, (iv) knowing which tissues or systems to target intervention, and (v) which interventions are most effective.Peer reviewedFinal Accepted Versio

Acute rotator cuff tendinopathy: does ice, low load isometric exercise, or a combination of the two produce an analgaesic effect?

This document is the Accepted Manuscript version of the following article: Parle PJ, Riddiford-Harland DL, Howitt CD, et al. 'Acute rotator cuff tendinopathy: does ice, low load isometric exercise, or a combination of the two produce an analgaesic effect?.' Br J Sports Med 2017;51:208-209, doi: http://dx.doi.org/10.1136/bjsports-2016-096107.Rotator cuff tendinopathies are the most commonly diagnosed musculoskeletal shoulder conditions and are associated with pain, weakness and loss of function.1 Tendon swelling may be associated with tendinopathy and may result from acute overload.2–3 An increase in tendon cells (tenocytes) and upregulation of large molecular weight proteoglycans, such as aggrecan, may increase tendon water content.2 There is uncertainty as to whether the swelling is related to the pain or is instead an observed but unrelated phenomenon. Weakness detected clinically may be due to pain inhibition.4–5 Early treatment of acute rotator cuff tendinopathy involves patient education and relative rest, and may include non-steroidal anti-inflammatory drugs (NSAIDs) to reduce pain, swelling and inflammation. Subacromial corticosteroid injections are also used to achieve the same purpose. These techniques show low to moderate evidence of reducing short-term pain but they do not improve function.6 The medications have side effects such as gastrointestinal tract complaints,7 and corticosteroids may damage tendon tissue.8 Identifying alternative ways to control pain and inflammation may be warranted. Two clinical procedures to manage RC tendinopathy include ice wraps and isometric exercise, however, there are no empirical data supporting their use. This pilot study, conducted at the Illawarra Sports Medicine Clinic, NSW, Australia, was designed to test (1) the short term analgaesic effect of these interventions and (2) the feasibility of a larger clinical trial for adults diagnosed with acute rotator cuff tendinopathy (<12 weeks).Peer reviewe

Arthroscopic transosseous rotator cuff repair: A prospective study on cost savings, surgical time, and outcomes

Objectives: Health expenditures in the United States are outpacing national income, and affordability has become a major policy issue. Over 500,000 rotator cuff repairs (RCR) are performed annually in the United States making RCR a potential source of cost savings. Arthroscopic trans-osseous equivalent (TOE) repair using a double row of anchors has shown superior biomechanical strength compared to other techniques, but at a higher cost. The arthroscopic transosseous (TO) repair is a novel technique allowing arthroscopic rotator cuff repair to be performed without suture anchors. Arthroscopic TO repair may be a means to provide similarly excellent patient outcomes while lowering the cost of care. The primary purpose is to compare the price differential and time of surgery for an arthroscopic rotator cuff repair using anchorless TO repair verses an anchor trans-osseous equivalent (TOE) repair. A secondary purpose of the study was to evaluate outcomes at 6 months postoperatively. Methods: A prospective, case-controlled study evaluating arthroscopic rotator cuff repair using two techniques was performed. The study group consisting of 21 patients undergoing TO repair was compared to a control group consisting of 22 patients undergoing TOE repair. The groups were controlled for size of tear, biceps treatment, acromioplasty, distal clavicle excision, and labral pathology. The primary outcome measures were surgical time as well as total cost of implants and equipment for each surgery, determined by an independent third party, Atlanticare Hospital. Secondary outcomes were changes in the SST, VAS, and SANE scores. Results: Mean total surgical implant/equipment cost per procedure for TOE repair was $2348.03 (SD 490.30) and for TO repair was$1204.97 (SD 330.69; p\u3c0.0001). Mean cut to close time for TOE repair was 85 minutes (95% CI is 77-90) verses 74 (95% CI = 71-98) for TO repair. A log rank test revealed no difference in time (p =0.95). A linear regression model was developed to evaluate the change in SST, VAS, and SANE scores from pre-op to 6 months follow-up. Our study was underpowered but no difference in outcome was observed. Conclusion: Arthroscopic TO rotator cuff repair is a cost savings and time neutral technique compared to TOE repair. A mean of $1100 can be saved in surgical cost per case. In a country that performs over 500,000 RCRs annually, utilizing a TO repair technique can provide substantial cost savings to the healthcare system. © The Author(s) 2015