Effect of smartphone application-supported self-rehabilitation for frozen shoulder: a prospective randomized control study.

OBJECTIVES:: To evaluate the clinical efficacy of smartphone-assisted self-rehabilitation in patients with frozen shoulder. DESIGN:: A single-center, randomized controlled trial. SETTING:: Orthopedic department of a university hospital. SUBJECTS:: A total of 84 patients with frozen shoulder were recruited. INTERVENTION:: Patients were randomly divided into two groups: a smartphone-assisted exercise group ( n = 42) and a conventional self-exercise group ( n = 42). The study was performed over three months, during which each group performed home-based rehabilitation. MAIN MEASURES:: Visual analogue scale for pain and passive shoulder range of motion were assessed at baseline and after 4, 8, and 12 weeks of treatment. Technology Acceptance Model-2 and Usefulness, Satisfaction, and Ease of Use scores were evaluated in the smartphone group. RESULTS:: Initial visual analogue scale for pain of the smartphone group was 6.0 ± 2.2 and ended up with 1.8 ± 2.5 after 12 weeks, whereas the self-exercise group showed 5.8 ± 2.3 for the baseline visual analogue scale for pain and 2.2 ± 1.7 at the end. Significant time-dependent improvements in all measured values were observed in both groups (all Ps < 0.001), but no significant intergroup difference was observed after 4, 8, or 12 weeks of treatment. In the smartphone group, Technology Acceptance Model-2 and Usefulness, Satisfaction, and Ease of Use scores showed high patient satisfaction with smartphone-assisted exercise. CONCLUSION:: There was no difference between home-based exercise using a smartphone application and a conventional self-exercise program for the treatment of frozen shoulder in terms of visual analogue scale for pain and range of motions.

Outcomes After Limited or Extensive Bursectomy During Rotator Cuff Repair: Randomized Controlled Trial.

PURPOSE: To evaluate the effects of extensive bursectomy (EB) and limited bursectomy (LB) during arthroscopic rotator cuff repair. METHODS: In the EB group (n = 39), subacromial bursae were thoroughly removed from anterior to posterior and lateral to medial. In the LB group (n = 39), bursectomy was minimized to allow torn cuff visualization and tendon repair. Visual analog scale pain scores, passive forward flexion, external rotation at the side (ER), and internal rotation at the back were measured at 5 weeks and 3, 6, and 12 months after surgery. At each time point, bursal thickness was measured and repair integrity was assessed by sonography or magnetic resonance imaging. RESULTS: The analysis included 36 patients in the LB group and 35 in the EB group. Group visual analog scale pain scores were not significantly different at any time (P > .05 for all). Forward flexion and internal rotation at the back showed no intergroup difference during follow-up. However, ER was significantly better in the LB group at 6 months and 1 year postoperatively (31° ± 15° vs 22° ± 16° [P = .020] and 40° ± 19° vs 27° ± 20° [P = .009], respectively). Integrity failures were not significantly different at 5 weeks and at 3, 6, and 12 months (P > .05 for all). Marked bursal thickening (>2 mm) was more frequently observed in the EB group (18 of 32 in the LB group and 27 of 32 in the EB group) at 6 months (P = .014). CONCLUSIONS: EB during arthroscopic rotator cuff repair appears to have no benefit in terms of reducing pain. More adhesions in the subacromial space after EB may result in slower motion recovery, especially in terms of ER. The extent of bursectomy did not affect tendon integrity. However, marked bursal thickening was more frequently observed in the EB group. LEVEL OF EVIDENCE: Level I, randomized controlled study.

Distal Pullout Strengths of the Biceps Long Head Tendon for Different Adjacent Tissue and Tendon Pathologies during Rotator Cuff Repair.

Purpose. Pathologies of the long head of the biceps tendon (LHBT) are frequently recognized in cases of rotator cuff tear. Recommendations for managing such pathologies remain debatable, and distal migration of tenotomized biceps is always a concern when only tenotomy is performed. Methods. Seventy patients of mean age 60.4 ± 6.9 years (range: 44 to 82 years) were included in this retrospective study. During subpectoral tenodesis in rotator cuff repair, pullout tensions were measured using a digital tensiometer. Measured tensions obtained were analyzed with respect to sex, tear involvement of the subscapularis, and the presence of a partial tear of LHBT, type II SLAP lesion, subluxation/dislocation of the biceps, or a pulley lesion. Results. Mean LHBT pullout tension for the 70 study subjects was 86.5 ± 42.1 N (26.7-240.5 N). Distal LHBT pullout tension was significantly greater for men than women (93.2 ± 42.7 N versus 73.7 ± 38.7 N, P = 0.041). However, LHBT pullout tensions were not significantly associated with different pathologies of surrounding tissues or of LHBTs (all Ps > 0.05). Conclusion. The study failed to show pullout tension differences associated with pathologies affect distal migration of a tenotomized LHBT. Gender was the only factor found to affect LHBT pullout strength. Risk of distal migration of tenotomized LHBT could not be predicted with intraoperative arthroscopic pathologic findings.

Structural Evolution of Nonoperatively Treated High-Grade Partial-Thickness Tears of the Supraspinatus Tendon.

BACKGROUND: High-grade partial-thickness rotator cuff tears (hPTRCTs) are frequently encountered in the shoulder. However, little information is available on the prevalence or timing of tear progression. Purpose/Hypothesis: The purpose was to prospectively evaluate the structural progression of hPTRCTs with a minimum follow-up of 1 year using magnetic resonance imaging (MRI). The hypothesis was that a substantial portion of hPTRCT patients would experience tear progression or evolution to a full-thickness rotator cuff tear. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between May 2010 and December 2015, 362 patients were diagnosed with hPTRCT (tear involvement >50% of the mediolateral length of the footprint) of the supraspinatus and were treated nonoperatively. Among these patients, 81 underwent follow-up MRI at least 1 year after initial presentation, and these patients were included in the final analysis. Initial and follow-up MRIs were used to determine whether tears had improved, had not changed, or had progressed. A change in tear involvement of >20% was defined as a significant change. Patients were categorized as follows: (1) a decrease in tear involvement of >20% (improved), (2) an increase or decrease of ≤20% (no change), or (3) an increase in tear involvement of >20% (progressed). Demographic data and morphologic data were analyzed to identify variables related to tear progression. Among them, severity of tendinosis was graded using MRIs: grade 1 (mild tendinosis), mild focal increase in tendon signal; grade 2 (moderate tendinosis), moderate focal increase in tendon signal; and grade 3 (marked tendinosis), marked generalized increase in tendon signal. RESULTS: At initial diagnosis, 23 were articular-side (28%) and 58 were bursal-side (72%) hPTRCTs. The study cohort was composed of 51 women and 30 men, and the mean patient age was 62.3 years (range, 41-77 years). Follow-up MRI was performed at a mean 19.9 ± 10.9 months (range, 12-52 months). A significant change in tear involvement was observed at follow-up. In 13 patients (16%, 2 articular-side and 11 bursal-side tears), tears were classified as progressed (the progressed group); in 48 patients (59%), tears exhibited no change (the unchanged group); and in 20 patients (25%, 9 articular-side and 11 bursal-side tears), tears were improved (the improved group). Univariate analysis showed initial tendinosis grade was significantly different in the 3 groups (grade 1, 2, and 3: 5, 4, and 4 in progressed; 36, 11, and 1 in unchanged; 10, 8, and 2 in improved group, respectively, P = .007). CONCLUSION: Although progression of hPTRCT in the long term is uncertain, after 1-year follow-up with MRI, tears progressed in 16% of the tears in this study. Furthermore, some tears were healed or reduced in size, which indicates that decisions to undertake surgical repair at time of presentation may be excessive.

Evaluation of Repair Tension in Arthroscopic Rotator Cuff Repair: Does It Really Matter to the Integrity of the Rotator Cuff?

BACKGROUND: Repair tension of a torn rotator cuff can affect healing after repair. However, a measurement of the actual tension during arthroscopic rotator cuff repair is not feasible. The relationship between repair tension and healing of a rotator cuff repair remains unclear. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the effect of repair tension on healing at the repair site. The hypothesis was that repair tension would be a major factor in determining the anatomic outcome of rotator cuff repair. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Arthroscopic rotator cuff repairs (132 patients) for full-thickness rotator cuff tears were analyzed. An intraoperative model was designed for the estimation of repair tension using a tensiometer. Magnetic resonance imaging (MRI) was performed approximately 1 year (mean [±SD], 12.7 ± 3.2 months) postoperatively for the evaluation of healing at the repair site. Multivariable analysis was performed for tear size, amount of retraction, and fatty degeneration (FD) of rotator cuff muscles. RESULTS: The mean repair tension measured during the arthroscopic procedure was 28.5 ± 23.1 N. There was a statistically significant correlation between tension and tear size (Pearson correlation coefficient [PCC], 0.529; P < .001), amount of retraction (PCC, 0.619; P < .001), and FD of the supraspinatus (Spearman correlation coefficient [SCC], 0.308; P < .001) and infraspinatus (SCC, 0.332; P < .001). At the final follow-up (12.7 ± 3.2 months), healing failure was observed in 18.2% (24/132), and repair tension also showed a significant inverse correlation with healing at the repair site (SCC, 0.195; P = .025). However, when sex, age, tear size, amount of retraction, tendon quality, and FD of rotator cuff muscles were included for multivariable logistic regression analysis, only FD of the infraspinatus showed an association with the anatomic outcome of repair (Exp(B) = 0.596; P = .010). CONCLUSION: Our intraoperative model for the estimation of rotator cuff repair tension showed an inverse correlation of repair tension with healing at the repair site, suggesting that complete healing is less likely with high-tension repairs. A significant association was observed on MRI between a high level of FD of the infraspinatus and repaired tendon integrity.

Healing disturbance with suture bridge configuration repair in rabbit rotator cuff tear.

BACKGROUND: Medial row failure has been reported in the suture bridge technique of rotator cuff repair. This study compared the healing response of suture bridge configuration repair (SBCR) and parallel type transosseous repair (PTR). METHODS: Acute rotator cuff repair was performed in 32 rabbits. Both shoulders were repaired using PTR or SBCR. In PTR, simple PTR was performed through 2 parallel transosseous tunnels created using a microdrill. In SBCR, 2 additional crisscross transosseous tunnels were added to mimic arthroscopic SBCR. At 1, 2, and 5 weeks postoperatively, comparative biomechanical testing was performed in 8 rabbits, and histologic analysis, including immunohistochemical staining for CD31, was performed in 4 rabbits. RESULTS: Failure loads at 1 week (38.12 ± 20.43 N vs 52.00 ± 27.23 N; P = .284) and 5 weeks (97.93 ± 48.35 N vs 119.60 ± 60.81 N; P = .218) were not statistically different between the SBCR and PTR groups, respectively, but were significantly lower in the SBCR group than in the PTR group (23.56 ± 13.56 N vs. 44.25 ± 12.53 N; P = .009), respectively, at 2 weeks. Markedly greater fibrinoid deposition was observed in the SBCR group than in the PTR group at 2 weeks. For vascularization, there was a tendency that more vessels could be observed in PTR than in SBCR at 2 weeks (15.9 vs 5.6, P = .068). CONCLUSIONS: In a rabbit acute rotator cuff repair model, SBCR exhibited inferior mechanical strength, and fewer blood vessels were observed at the healing site at 2 weeks postoperatively. Medial row tendon failure was more common in SBCR. Surgeons should consider the clinical effect of SBCR when performing rotator cuff repair.

Short-term effects of high-intensity laser therapy on frozen shoulder: A prospective randomized control study.

BACKGROUND: Frozen shoulder, which is characterized by shoulder pain and limitation of the range of motion (ROM), is a common disorder. High-intensity laser therapy (HILT) was recently introduced in the musculoskeletal therapeutic field. OBJECTIVE: The objective of this study is to evaluate the clinical efficacy of HILT in patients with frozen shoulder. DESIGN: A prospective randomized controlled study. METHOD: Patients with frozen shoulder were randomly divided into 2 groups: a HILT group (n = 33) and a placebo group (n = 33). The treatment was administered 3 times per week on alternate days for 3 weeks. For all patients, the visual analog scale (VAS) for pain, VAS for satisfaction, and passive ROM were measured at baseline and 3, 8, and 12 weeks after the treatment. RESULTS: The HILT group had a lower pain VAS score at 3 weeks (3.2 ± 1.7 vs. 4.3 ± 2.2, p = 0.033) and 8 weeks (2.2 ± 2.0 vs. 3.4 ± 2.7, p = 0.042), however, no statistically significant difference in the pain VAS was observed between the two groups at the final follow-up (12 weeks). No statistical difference in the ROM and the satisfaction VAS was observed between the 2 groups at serial follow-ups. CONCLUSIONS: In management of frozen shoulder, HILT provided significant pain relief at 3 and 8 weeks, but not at the final follow-up time point. HILT is a noninvasive adjuvant treatment that can reduce pain in frozen shoulders. Further study is needed in order to optimize the dose and duration of HILT.

Postoperative imaging of bioabsorbable anchors in rotator cuff repair.

BACKGROUND: Bioabsorbable anchors may lead to osteolysis and cyst formation. However, the prevalence of these outcomes is not known for rotator cuff repairs. PURPOSE: To evaluate cyst formation after placement of bioabsorbable anchors for rotator cuff repairs and to verify whether bioabsorbable anchors degraded as intended and preserved bone stock for possible revision compared with metal anchors. The null hypothesis was that the rate and severity of cyst formation around the anchor are negligible. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between April 2008 and November 2011, a total of 209 patients (85 men, 124 women) underwent rotator cuff repair with bioabsorbable suture anchors (113 with polylactic acid enantiomers [PLLA] and 96 with poly-D,L-lactide from L-lactide and D-lactide [PLDLA]); the patients underwent magnetic resonance imaging (MRI) evaluation more than 10 months after surgery. The fluid signal around the anchor on T2-weighted MRI scans was graded as follows: grade 0, no fluid around anchor; grade 1, minimal fluid around anchor; grade 2, local fluid around anchor; grade 3, fluid collection around entire length of anchor with cyst diameter less than twice the anchor diameter; and grade 4, cyst diameter larger than grade 3. The integrity of repairs was also evaluated. RESULTS: Cysts were observed in 97 instances (46.4%). There were 41 grade 1 cases (19.6%), 16 grade 2 (7.7%), 22 grade 3 (10.5%), and 18 grade 4 (8.6%). Healing of repaired tendon was observed in 131 patients (62.7%). There was no statistical difference in healing rate between patients with and without cyst formation (66.1% vs 58.8%; P = .276). Altered anchor shape and absorption were not observed in most of the patients. However, in 12 patients (6 with PLLA and 6 with PLDLA anchors), T2-weighted scans showed that the signal intensity of anchors had changed since surgery, which could indicate that absorption had taken place; nonetheless, even in these 12 patients, anchors were clearly visible on T1-weighted scans. CONCLUSION: Osteolysis and cyst formation are common complications following the use of bioabsorbable anchors in rotator cuff repairs. Considering that adequate absorption of anchors and preservation of bone stock are the reasons for using bioabsorbable anchors, use of these anchors should be reconsidered because of possible interference with revision surgery.