Effects of Estrogen-Deficient State on Rotator Cuff Healing.

BACKGROUND: Rotator cuff retears after surgical repair are a concern, despite advances in operative techniques, but few studies have investigated the effects of the estrogen-deficient state on tendon-to-bone healing at the repair site. PURPOSE: We evaluated the effect of the estrogen-deficient state on tendon-to-bone healing after rotator cuff repair in an ovariectomized rat model. STUDY DESIGN: Controlled laboratory study. METHODS: Female Sprague Dawley rats underwent detachment and immediate repair of the supraspinatus tendon. Surgery was performed in 24 rats at 4.5 weeks of age 17 weeks after ovariectomy (OVX group) and in 24 age-matched control rats without ovariectomy (control group). Animals were sacrificed at 2, 4, 8, and 12 weeks after surgery for biomechanical and histological evaluations of reattachment. Bone mineral density (BMD) at the insertion site and cancellous bone in the humeral head was assessed by micro-computed tomography. RESULTS: BMD was significantly lower both at the insertion site and in cancellous area in the OVX group than in the control group at weeks 2 to 12. Ultimate load to failure, ultimate stress, linear stiffness, and the Young modulus were significantly lower in the OVX group than in the control group at 2 and 4 weeks, but the difference was no longer significant at 8 and 12 weeks. At 2 and 4 weeks, relatively immature granulation tissue was observed in the OVX group compared with the control group. At 8 and 12 weeks after surgery, there were differences in the tendon-bone interface in the 2 groups: Direct insertion with well-established chondroid tissue was seen in the control group, and indirect insertion without chondroid tissue was seen in the OVX group. Consistently, the amount of chondroid tissue was greater and collagen organization was better in the control group than in the OVX group. Cells expressing cathepsin K were significantly more numerous both at the insertion site and in cancellous bone in the OVX group than in the control group. CONCLUSION: The estrogen-deficient state by ovariectomy, compared with control rats, led to decreased biomechanical properties and poor development of chondroid tissue that influenced the repair of the tendon insertion after surgery. CLINICAL RELEVANCE: Agents that modulate bone metabolism might improve tendon-to-bone healing in patients with an estrogen-deficient state, such as postmenopausal women who undergo rotator cuff surgery.

Clinical and structural outcomes after arthroscopic rotator cuff repair: a comparison between suture bridge techniques with or without medial knot tying.

PURPOSE: To compare arthroscopic suture bridge (SB) techniques with medial tying to those without tying, considering clinical and structural outcomes. METHODS: We included 124 patients with rotator cuff tears after arthroscopic rotator cuff repair (ARCR). Fifty-three patients with clinical and structural evaluations 3, 12, and 24 months postoperatively were included and divided into 29 patients with medial tying (WMT group) and 24 without tying (WOMT group). Clinical outcomes comprised the University of California Los Angeles (UCLA) and Japanese Orthopaedic Association (JOA) scores. Structural outcomes were evaluated with magnetic resonance images (MRI) using Sugaya classifications. RESULTS: JOA and UCLA scores in the WMT and WOMT groups improved significantly from before surgery to 24 months after surgery (P < 0.01, respectively). No significant difference was noted between groups. No significant postoperative retears (Sugaya types 4 and 5) between WMT and WOMT groups were noted at 3 months (5 vs 3 cases), 12 months (6 vs 5 cases), and 24 months (7 vs 6 cases) postoperatively. Complete healing (Sugaya type 1) was noted at 3 months (8 vs 11 cases), 12 months (10 vs 10 cases), and 24 months (8 vs 13 cases, P = 0.024) postoperatively. Incomplete healing (Sugaya types 2 and 3) were noted at 3 months (16 vs 10 cases), 12 months (13 vs 9 cases), and 24 months (14 vs 5 cases, P = 0.024) postoperatively. CONCLUSION: Clinical outcomes for both techniques were comparable, but the number of incompletely healed tendons in SB with medial tying was significantly larger at 24 months after surgery. LEVEL OF EVIDENCE: This study is a level III, case-control study. CLINICAL RELEVANCE: This study revealed the influence of medial tying in rotator cuff repair.

Hand lesion after arthroscopic rotator cuff repair: Association with complex regional pain syndrome.

BACKGROUND: It is known that complex regional pain syndrome (CRPS) occurs after arthroscopic rotator cuff repair (ARCR); however, few studies have investigated this complication. Therefore, the purpose of the present study was to evaluate CRPS after ARCR. METHODS: A total of 182 patients who underwent ARCR were enrolled in this study. The average age of patients was 62.8 ± 10.0 years, with an average follow-up period of 21.5 ± 38.1 months. CRPS criteria outlined by the Ministry of Health, Labor, and Welfare study team for CRPS in Japan (MHLWJ) and International Association for the Study of Pain (IASP 2005) were utilized for diagnosis. There are two rating systems for the "clinical purpose" and "research purpose" in both criteria, respectively. Clinical outcomes, including Japanese Orthopedic Association (JOA) and University of California, Los Angeles scores, were evaluated using univariate and multivariate analysis. RESULTS: CRPS exclusively occurred in the hand of the operated limb, developing within 3 months of surgery. Two or more of the following symptoms were noted in patients with the hand lesion associated with CRPS: edema (93.4%), restricted range of motion (83.4%), hyperalgesia (30.1%), paridrosis (20.4%), and atrophic change (12.2%). Under these conditions, the incidences of CRPS were 24.2% (44/182) when evaluated by the MHLWJ rating system for the "clinical purpose;" 11% (22/182) by the MHLWJ rating system for the "research purpose;" 6% (11/182) by the IASP 2005 for the "clinical purpose;" and 0.5% (1/182) by the IASP 2005 for the "research purpose." Results of multivariate analysis demonstrated that "Function" in the JOA score was a risk factor for the development of CRPS after ARCR, when evaluated by a system for the "clinical purpose" of the MHLWJ. CONCLUSION: Following ARCR, CRPS-induced hand lesions occur more frequently than is generally believed, thereby suggesting that its impact on surgical outcomes should be clarified in the future.

Hypersensitivity to suture anchors.

Hypersensitivity to suture anchor is extremely rare. Herein, we present a case in which hypersensitivity to suture anchor was strongly suspected. The right rotator cuff of a 50-year-old woman was repaired with a metal suture anchor. Three weeks after the surgery, she developed erythema around her face, trunk, and hands, accompanied by itching. Infection was unlikely because no abnormalities were detected by blood testing or by medical examination. Suspicious of a metallic allergy, a dermatologist performed a patch testing 6 months after the first surgery. The patient had negative reactions to tests for titanium, aluminum, and vanadium, which were the principal components of the suture anchor. The anchor was removed 7 months after the first surgery, and the erythema disappeared immediately. When allergic symptoms occur and persist after the use of a metal anchor, removal should be considered as a treatment option even if the patch test result is negative.

Calcific tendonitis of the rotator cuff: an unusual case.

Few case reports have described the surgical treatment of calcifying tendonitis of the subscapularis tendon. We present a case of symptomatic diffuse calcifying tendonitis involving the subscapularis and infraspinatus insertions that was difficult to detect arthroscopically. The patient was treated with arthroscopic incision of the tendinous insertions thorough removal of the calcific deposits and subsequent repair using a suture-anchor technique. Two years after the surgical procedure, the patient was completely pain-free and attained full range of motion. Radiographic evaluation performed 2 years after the procedure revealed no calcific deposits. We conclude that the combination of incision of the subscapularis and infraspinatus insertions, complete removal of the calcific deposits, and subsequent suture-anchor repair in an all-arthroscopic manner can lead to an excellent clinical outcome without compromising the functional integrity of the rotator cuff tendons.