Prognostic factors affecting structural integrity after arthroscopic rotator cuff repair: a clinical and histological study

Background@#Tendon degeneration contributes to rotator cuff tears; however, its role in postoperative structural integrity is poorly understood. The purpose of this study was to investigate the factors associated with postoperative structural integrity after rotator cuff repair, particularly focusing on the histology of tendons harvested intraoperatively. @*Methods@#A total of 56 patients who underwent primary arthroscopic rotator cuff repair between 2009 and 2011 were analyzed. A 3-mm-diameter sample of supraspinatus tendons was harvested en bloc from each patient after minimal debridement of the torn ends. Tendon degeneration was assessed using seven histological parameters on a semi-quantitative grading scale, and the total degeneration score was calculated. One-year postoperative magnetic resonance imaging was used to classify the patients based on retear. @*Results@#The total degeneration scores in the healed and retear groups were 13.93±2.03 and 14.08±2.23 (p=0.960), respectively. Arthroscopically measured anteroposterior (AP) tear sizes in the healed and retear groups were 24.30±12.35 mm and 36.42±25.23 mm (p=0.026), respectively. Preoperative visual analog scale pain scores at rest in the healed and retear groups were 3.54±2.37 and 5.16±2.16 (p=0.046), respectively. Retraction sizes in the healed and retear groups were 16.02±7.587 mm and 22.33±13.364 mm (p=0.037), respectively. The odds of retear rose by 4.2% for every 1-mm increase in AP tear size (p=0.032). @*Conclusions@#The postoperative structural integrity of the rotator cuff tendon was not affected by tendon degeneration, whereas the arthroscopically measured AP tear size of the rotator cuff tendon was an independent predictor of retear.

Florid Reactive Periostitis of the Clavicle: A Case Report

Florid reactive periostitis (FRP) is a rare benign fibro-osseous proliferation, occurring mostly in the short tubular bones of hands and rarely in the long tubular bones. We report a surgically confirmed case of FRP involving the clavicle in a 26-year-old male. On MRI scans, a soft tissue mass with T2 high signal intensity was found that originated from the periosteum of the clavicle and included surrounding a periosteal elevation and perilesional soft tissue edema. Strong contrast enhancement was noted inside the mass and along the periosteum involving more than half of the circumference of the clavicle. Serial radiographs revealed a soft tissue mass without mineralization that turned into an ossified mass with a solid periosteal reaction within a month.

Arthroscopic supraspinatus advancement for retracted rotator cuff tears: a technical note

Irreparable rotator cuffs with retracted torn ends remain a significant challenge for most shoulder surgeons. Since repairs are preferable to reconstruction or replacement whenever possible, studies for anatomical reductions with minimal tension and secure fixation are important. In this study, the authors introduce an arthroscopic supraspinatus advancement (ASSA) procedure for retracted rotator cuff tears that could not be adequately reduced to the original footprint. Using modified long, narrow, curved Cobb elevators, procedures can be performed through lateral portals without any additional skin incision. Following meticulous stepwise three-compartment elevation procedures based on the supraspinatus insertion anatomy, the supraspinatus muscle could be safely elevated from the fossa and sufficiently advanced laterally. The authors suggest that ASSA could be a useful procedure for management of challenging retracted rotator cuff tears by maximizing lateral excursions that could convert irreparable tears to reparable tears in select patients.

What Happens to Rotator Cuff Muscles after Rotator Cuff Repair?

No abstract available.

Characterization of Tendon-Specific Markers in Various Human Tissues, Tenocytes and Mesenchymal Stem Cells

BACKGROUND: Unlike bone, cartilage, or muscle, tendon-specific markers are not well established. The purpose of the study was to investigate expression pattern and level of 6 well-known tendon-specific markers, in various human musculoskeletal tissues, tenocytes, and mesenchymal stem cells (MSCs). METHODS: Musculoskeletal tissue samples of tendon, bone, cartilage, nerve, muscle, and fat were obtained from patients undergoing orthopedic surgery. Tenocytes, MSCs from bone marrow, adipose tissue, and umbilical cord were isolated from each tissue and cultured. Six tendon-specific markers, scleraxis (Scx), tenomodulin (TNMD), thrombospondin-4 (TSP-4), tenascin-C (TNC), type I collagen (Col I), and type III collagen (Col III) were investigated in tendon tissue, tenocytes, and MSCs. RESULTS: mRNA levels of 6 tendon-specific markers were significantly higher in tendon tissue that in other connective tissues levels of Scx, TNMD, TSP-4, and Col III immediately decreased after plating tenocytes in culture dishes whereas those of TNC and Col I did not. In comparison with tendon tissue, mRNA levels pattern of Scx, TNMD, and TSP-4 in tenocytes were significantly higher than that in MSCs, but lower than in tendon tissue whereas expression pattern of TNC, Col I and III showed different pattern with each other. CONCLUSION: This study demonstrated that 6 commonly used tendon-specific markers were mainly expressed in tendon tissue, but that expression level and pattern of the tendon-specific markers with respect to kinds of tissues, culture duration of tenocytes and sources of MSCs.

Platelet-Rich Plasma Injection / 대한정형외과학회잡지

Platelet-rich plasma (PRP) supplies numerous growth factors from concentrated platelets required to promote the healing process of injured or degenerated tissue. PRP is already a popular option to treat a variety of musculoskeletal injuries and diseases, even though the precise mechanism of action is not completely understood. Varying outcomes, from favorable to poor, after PRP injection may arise from interstudy differences with respect to 4Ds (Drug [PRP], Delivery [application method], Donor [patients], and Disease [stage of rotator cuff disease]). In addition, there is no standard treatment regimen (injection location, number, interval, volume). Therefore, precise outcome measures as well as long-term follow-up are required to accurately evaluate the efficacy.

Comparative Analysis of Platelet-rich Plasma Effect on Tenocytes from Normal Human Rotator Cuff Tendon and Human Rotator Cuff Tendon with Degenerative Tears

BACKGROUND: Platelet-rich plasma (PRP) stimulates cell proliferation and enhances matrix gene expression and synthesis. However, there have been no comparative study of the PRP effect on the normal and degenerative tenocytes. The purpose of this study was to compare the effect of PRP on tenocytes from normal and degenerative tendon. METHODS: Tendon tissues were obtained from patients undergoing arthroscopic repair (n=9) and from healthy donors (n=3). Tenocytes were cultured with 10% (vol/vol) platelet-poor plasma, PRP activated with calcium, and PRP activated with calcium and thrombin. The total cell number was assessed at days 7 and 14. The expressions of type I and III collagen, decorin, tenascin-C, and scleraxis were evaluated by quantitative real-time reverse transcriptase polymerase chain reaction. The total collagen and glycosaminoglycan (GAG) synthesis was evaluated at days 7 and 14. RESULTS: No differences were observed between the groups at day 7, but cell proliferation was remarkably increased in tenocytes from the degenerative tendon at day 14. In both tenocyte groups, the gene expressions of type I and III collagen were up-regulated. GAG synthesis was greater in the normal tendon, whereas the expressions of decorin and tenascin-C were increased in tenocytes from the degenerative tendon. Tenocytes from the degenerative tendon had higher fold-change of GAG synthesis and a lower collagen III/I ratio than normal tenocytes. CONCLUSIONS: PRP promoted the cell proliferation and enhanced the synthesis of tendon matrix in both groups. PRP has a greater positive effect on cell proliferation, matrix gene expression and synthesis in tenocytes from degenerative tendon.

Clinical and Radiological Results after Arthroscopic Superior Capsular Reconstruction in Patients with Massive Irreparable Rotator Cuff Tears

BACKGROUND: Massive, irreparable rotator cuff tears (RCTs) are a challenging clinical problem in young patients. In recent years, arthroscopic superior capsular reconstruction (ASCR) is a popular treatment in the massive, irreparable RCTs. However, studies reporting clinical results of ASCR are rare in the literature. METHODS: Between 2013 and 2015, six patients underwent ASCR. One patient treated with dermal allograft, while five patients with autogenous fascia lata graft. Demographic data, as well as preoperative and last follow-up clinical data including pain, range of motion (ROM), strength, American Shoulder and Elbow Surgeons system, the Constant system, the University of California at Los Angeles system, the Simple Shoulder Test, and the Shoulder Pain and Disability Index system were obtained. Acromiohumeral distances and Hamada classification were measured on standard anteroposterior x-ray. RESULTS: All patients were men, and the average age was 59.5 ± 4.18 years (range, 53–65 years).The minimum follow-up was 18 months with a mean follow-up was 27.33 ± 7.58 months (range, 18–36). All patients had postoperative improvement in pain scores and functional scores. The ROM and strength did not improve after surgery. The Hamada score progressed of radiographic stage in 2 patients. In the case of dermal allograft, there was graft failure 6 weeks after ASCR. CONCLUSIONS: Our results support the ASCR as a viable treatment for surgical salvage in massive, irreparable RCTs. This treatment option may provide patients with decreased pain and increased function. And studying our case of dermal allograft failure provides opportunities to decrease graft failure in ASCR using dermal allograft.

Patch Reinforcement, Interposition or Augmentation?

No abstract available.

Similar Degree of Degeneration in the Articular and Bursal Layers of Delaminated Rotator Cuff Tear

BACKGROUND: The purpose of the study was to compare the degree of degeneration of the articular and bursal layers of delaminated supraspinatus tendons based on histological examination. METHODS: Fifty-four patients with a full-thickness rotator cuff tear were included in the study. Tendon specimens were harvested during arthroscopic rotator cuff repair from the lateral torn edges of the articular and bursal layers of the delaminated tear. Harvested samples were stained with H&E dye and evaluated based on a semi-quantitative grading scale. RESULTS: There were no significant differences in the seven histological characteristics of tendon degeneration: fiber structure, fiber arrangement, round nuclei, regional variations in cellularity, vascularity, collagen stainability, and hyalinization between the articular and bursal layers of the delaminated rotator cuff tear (all p>0.05). Total degeneration scores of articular and bursal sides were 13.1 ± 3.85 points and 13.2 ± 3.42 points, respectively, and were not significantly different (p=0.958). CONCLUSIONS: The study demonstrates that tendon degeneration was similar in the articular and bursal sides of the delaminated fullthickness rotator cuff tear, suggesting that degeneration would be a main etiology for the rotator cuff tear not only in the articular side but also in the bursal side. Considering potential disadvantages of subacromial decompression, this study tentatively suggests routine use of subacromial decompression as well as the need for halting or recovery from rotator cuff degeneration for better rotator cuff repair.

Patch Reinforcement, Interposition or Augmentation?

No abstract available.

Similar Degree of Degeneration in the Articular and Bursal Layers of Delaminated Rotator Cuff Tear

BACKGROUND: The purpose of the study was to compare the degree of degeneration of the articular and bursal layers of delaminated supraspinatus tendons based on histological examination. METHODS: Fifty-four patients with a full-thickness rotator cuff tear were included in the study. Tendon specimens were harvested during arthroscopic rotator cuff repair from the lateral torn edges of the articular and bursal layers of the delaminated tear. Harvested samples were stained with H&E dye and evaluated based on a semi-quantitative grading scale. RESULTS: There were no significant differences in the seven histological characteristics of tendon degeneration: fiber structure, fiber arrangement, round nuclei, regional variations in cellularity, vascularity, collagen stainability, and hyalinization between the articular and bursal layers of the delaminated rotator cuff tear (all p>0.05). Total degeneration scores of articular and bursal sides were 13.1 ± 3.85 points and 13.2 ± 3.42 points, respectively, and were not significantly different (p=0.958). CONCLUSIONS: The study demonstrates that tendon degeneration was similar in the articular and bursal sides of the delaminated fullthickness rotator cuff tear, suggesting that degeneration would be a main etiology for the rotator cuff tear not only in the articular side but also in the bursal side. Considering potential disadvantages of subacromial decompression, this study tentatively suggests routine use of subacromial decompression as well as the need for halting or recovery from rotator cuff degeneration for better rotator cuff repair.

Animal Models for Tendon and Ligament / 대한정형외과연구학회지

Tendon and ligament disorders are common and lead to significant disability, pain, healthcare cost, and lost productivity. To study the pathogenesis and management strategies of tendon and ligament injury, appropriate choice and analysis of research models is essential. A number of animal models for tendon and ligament injuries are designed to mimic distinct clinical diseases to better evaluate underlying mechanisms and potential treatments. In this review, we discuss the common methods used for inducing animal models related to tendon and ligament injury as well as the variables for assessing outcome that may be used in animal researchs.

Degeneration Exists along the Entire Length of the Supraspinatus Tendon in Patients with a Rotator Cuff Tear

BACKGROUND: The purposes of the study were to examine rotator cuff tendon degeneration with respect to harvesting location, to determine a rationale for debridement of the torn end, and thus, to determine adequate debridement extent. METHODS: Twenty-four patients with a full-thickness rotator cuff tear were included in the study. Tendon specimens were harvested during arthroscopic rotator cuff repair from three locations; from torn ends after minimal regularization of fraying (native end group, NE group), from torn ends after complete freshening of the frayed end (freshened end group, FE group), and from the macroscopically intact portion just distal to the musculotendinous junction (musculotendinous junction group, MTJ group). Control samples were harvested from patients admitted for surgery for proximal humerus fracture. Harvested samples were evaluated using a semi-quantitative grading scale. RESULTS: Mean total degeneration scores in the NE group (13.3 +/- 3.21), the FE group (12.5 +/- 2.30), and in the MTJ group (10.8 +/- 3.10) were significantly higher than those in the normal control group (5.0 +/- 2.87; all P>0.001). Mean total degeneration score in the NE group was significantly higher than that in the MTJ group (p=0.012), but was not from that of the FE group. Mean total degeneration score in the FE group was not significantly different from that of the MTJ group. CONCLUSIONS: Tendon degeneration exists throughout the entire tendon to the macroscopically intact portion of full-thickness rotator cuff tear. Therefore, aggressive debridement to grossly normal appearing, bleeding tendon is unnecessary for enhancing healing after repair.

Degeneration Exists along the Entire Length of the Supraspinatus Tendon in Patients with a Rotator Cuff Tear

BACKGROUND: The purposes of the study were to examine rotator cuff tendon degeneration with respect to harvesting location, to determine a rationale for debridement of the torn end, and thus, to determine adequate debridement extent. METHODS: Twenty-four patients with a full-thickness rotator cuff tear were included in the study. Tendon specimens were harvested during arthroscopic rotator cuff repair from three locations; from torn ends after minimal regularization of fraying (native end group, NE group), from torn ends after complete freshening of the frayed end (freshened end group, FE group), and from the macroscopically intact portion just distal to the musculotendinous junction (musculotendinous junction group, MTJ group). Control samples were harvested from patients admitted for surgery for proximal humerus fracture. Harvested samples were evaluated using a semi-quantitative grading scale. RESULTS: Mean total degeneration scores in the NE group (13.3 +/- 3.21), the FE group (12.5 +/- 2.30), and in the MTJ group (10.8 +/- 3.10) were significantly higher than those in the normal control group (5.0 +/- 2.87; all P>0.001). Mean total degeneration score in the NE group was significantly higher than that in the MTJ group (p=0.012), but was not from that of the FE group. Mean total degeneration score in the FE group was not significantly different from that of the MTJ group. CONCLUSIONS: Tendon degeneration exists throughout the entire tendon to the macroscopically intact portion of full-thickness rotator cuff tear. Therefore, aggressive debridement to grossly normal appearing, bleeding tendon is unnecessary for enhancing healing after repair.

The Outcome of Total Knee Arthroplasty in Diabetics / 대한정형외과학회잡지

PURPOSE: To analyze the results of total knee arthroplasty (TKA) in patients with diabetes mellitus (DM). MATERIALS AND METHODS: Between 1996 and 2001, 601 TKAs in 373 patients were performed by a single surgeon. From this series, 45 patients (74 knees) were diagnosed as type II DM and osteoarthritis of the knee. The mean follow-up was 49 months (6-108 months), and the mean age was 68.6 years (54-83 years). The clinical outcome of the diabetic and non diabetic group was compared using the Hospital for special surgery score (HSS) and the Knee society clinical and radiological scoring system. The radiological loosening and perioperative complications were evaluated. The plasma Hemoglobin A1c (HbA1c) level of the diabetes patients was examined pre and postoperatively. RESULTS: The knee and pain scores were higher in the diabetes group postoperatively (p=0.040, p=0.039, respectively), whereas the HSS scores and overall function scores were lower in the diabetes group postoperatively (p=0.021, p=0.016, respectively). The rate of superficial wound problems was greater in the diabetes group (8.1% versus 2.4%, p=0.032). However the incidence of a deep infection was similar in the diabetic and non diabetic group (2.7% versus 0.9%). The mean HbA1c level was significantly higher in the diabetic patients with a superficial and deep infection than in the remaining diabetic patients (p=0.033). CONCLUSION: The HbA1c level might be a valuable predictor of superficial wound complications and deep infection. Although the clinical results were similar in the diabetes and non diabetes groups, special precautions should be taken for diabetic patients undergoing TKA to minimize complications.