The effect of continuous interscalene brachial plexus block for arthroscopic rotator cuff repair.

Background: Arthroscopic rotator cuff repair (ARCR) is a minimally invasive surgical technique. However, it is challenging to control postoperative pain. This study aimed to investigate the difference between a single-shot interscalene block and a combined continuous block for ARCR. Methods: Ninety-four patients who underwent ARCR were included in this study. In the preceding period, 43 patients received a single-shot interscalene block and continuous postoperative intravenous opioid infusion (Single group). In the posterior period, 51 patients received a single-shot interscalene block preoperatively and a continuous block postoperatively (Continuous group). Their mean age at surgery was 64.9 years (range, 43-83 years). The mean follow-up period was 25.4 months (range, 24-54 months). The numerical rating scale (NRS) of pain was evaluated immediately after the surgery, at rest, and at night for 1-4 days after the surgery. One day postoperatively, the amount of food taken was assessed from 0 % (no food intake) to 100 % (all food taken). The University of California at Los Angeles (UCLA) shoulder score, range of motion (ROM), and isometric shoulder strength were evaluated. Results: NRS at rest in the Continuous group on the day of surgery was 3.7 ± 2.5. This was significantly lower than in the Single group (5.2 ± 1.8) (P = 0.002). NRS at rest in the Continuous group on the second day after surgery was 3.0 ± 2.1, significantly lower than in the Single group (3.9 ± 1.8) (P = 0.04). The amount of food taken in the morning in the Continuous group was 61 % ± 37 %, which was significantly greater than in the Single group (35 % ± 41 %) (P = 0.004). The ROM of extension at 6 months postoperatively in the Continuous group was 47 ± 7°, which was significantly greater than in the Single group (43 ± 6°) (P = 0.02). The postoperative strength of the external rotator at 6 months in the Continuous group was 95 ± 33 N, significantly greater than in the Single group (78 ± 28 N) (P = 0.01). There was no significant difference in UCLA score at any time. Conclusion: The continuous interscalene block with ultrasound guidance in ARCR effectively relieved pain. The recovery of ROM for extension and the strength of the external rotator was better in the Continuous group.

Patient Sex Is a Significant Factor in Arm Function Recovery After Arthroscopic Rotator Cuff Repair.

Purpose: The purpose of this study was to investigate the impact of patient sex on arm functional recovery after arthroscopic rotator cuff repair (ARCR). Methods: We retrospectively reviewed the clinical records of patients who underwent rehabilitation after ARCR at two affiliated hospitals between January 2014 and December 2019. Patient characteristics included age, sex, type of muscle tear, tear location, muscle strength, Japanese Orthopedic Association (JOA) score, and patient responses to the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. We used mixed-effects regression models with random intercepts to evaluate the QuickDASH scores, JOA scores, and muscle strength relative to the nonoperated side. Results: Of the 124 patients, 82 (66.1%) were 65-year-old men and 42 (33.9%) were 67-year-old women. The preoperative JOA scores (P = .03) and those at 6 months (P < .001) and 12 months (P = .04) after ARCR were significantly greater for men than for women. QuickDASH scores of men were significantly lower at 24 months (P = .02) and all other time points (P < .001) than those of women. The improvement in QuickDASH scores was significantly higher for women than for men (P < .01). The results of the multiple regression analysis showed that patient sex (95% confidence interval, 0.01-0.45; P < .05) had an impact on QuickDASH scores at 24 months after ARCR. Conclusion: In this study, patient sex was a significant factor affecting the recovery and QuickDASH scores of patients who underwent ARCR. Level of Evidence: Level IV, prognostic case series.

Shoulder activity of the contralateral shoulder as a prognostic factor in patients with arthroscopic rotator cuff repair.

Background: This study aimed to investigate the prognosticator of the contralateral rotator cuff in patients who underwent arthroscopic rotator cuff repair (ARCR) for symptomatic rotator cuff tear (RCT). Methods: A total of 104 patients with a mean age of 64.7 years (range, 40-83 years) underwent ARCR and were checked for the presence of a contralateral RCT using preoperative ultrasonography. Preoperative demographic data, including patients' occupations and sports activities, were also evaluated. Results: The mean follow-up period for the operated shoulder was 25.0 months (range, 12-72 months). An RCT of the contralateral shoulder was observed in 40 of the 104 (38.5%) patients. Contralateral shoulder pain was observed in 16 (40%) and 15 (23.1%) patients in the RCT group preoperatively and the non-tear group, respectively. Of the 31 patients with shoulder pain, a poor prognosis was seen in 17 (54.8%). Statistical significance was observed between the active and sedentary groups in the RCT group, with eight patients (30.8%) in the active group and none in the sedentary group having a poor prognosis (P = .02). In contrast, in the non-tear group, a poor prognosis was observed in four patients (10.5%) in the active group, which was not significantly different compared to the five patients (19.2%) in the sedentary group (P = .33). Conclusions: For patients in the active group, RCTs are a risk factor for poor prognosis in the contralateral shoulder of ARCR.

Effectiveness of Bone Marrow-Derived Platelet-Rich Fibrin on Rotator Cuff Healing in a Rabbit Degenerative Model.

BACKGROUND: Platelet-rich fibrin (PRF) is a second-generation platelet concentrate. Although peripheral blood-derived PRF (P-PRF) is commonly applied in biological augmentation, there is no report about the therapeutic effect of bone marrow-derived PRF (BM-PRF) for degenerative rotator cuff tears (RCTs). PURPOSE/HYPOTHESIS: To examine the effects of platelet-rich plasma (PRP), P-PRF, and BM-PRF during rotator cuff repair (RCR) in degenerative RCTs in rabbits. We hypothesized that BM-PRF would accelerate the bone-tendon healing after RCR. STUDY DESIGN: Controlled laboratory study. METHODS: Degenerative RCT models were created 2 weeks before beginning the study, and 68 juvenile rabbits were divided into 4 groups: the control, PRP, P-PRF, and BM-PRF groups. RCR without augmentation was done in the control group. PRP was prepared by centrifuging peripheral blood twice using a plastic tube. P-PRF and BM-PRF were prepared by centrifuging peripheral blood and bone marrow, respectively, using a glass tube. Rabbits from PRP, P-PRF, and BM-PRF groups were administered the augmentation in a similar fashion for RCR, between the rotator cuff and the footprint of the humerus. At 4, 8, and 12 weeks, rabbits were euthanized and histologically assessed using hematoxylin and eosin staining, Alcian blue staining, and immunohistochemical staining for type I and III collagen. The sections were also evaluated with immunofluorescence staining of vascular endothelial growth factor (VEGF) at 4 weeks. RESULTS: The continuity was significantly better in the BM-PRF group at 4 weeks (P < .05). Immunofluorescence staining demonstrated that VEGF-positive stained cells were significantly greater in the BM-PRF group than in the control group (P < .01). The modified tendon maturing score was significantly greater in the BM-PRF group than in the control and PRP groups at 12 weeks (P < .05). There was no significant difference in the modified tendon maturing score of the P-PRF group compared with the control group. CONCLUSION: The rabbit model of degenerative RCTs demonstrated that RCR combined with BM-PRF enhanced tendon-bone continuity and increased the VEGF-positive cells at 4 weeks and obtained preferable tendon-bone maturation at 12 weeks. CLINICAL RELEVANCE: RCR augmented with BM-PRF has the potential to improve clinical outcomes for RCTs.

Factors correlated with the optimal tension for arthroscopic rotator cuff repair using Grasper Tensioning Attachment.

BACKGROUND: Little is known about the optimal tension in arthroscopic rotator cuff repair (ARCR). This study aimed to identify preoperative, intraoperative, and postoperative factors that correlate with the tension in ARCR and to determine the optimal intraoperative tension using Grasper Tensioning Attachment, a tension meter attached to the common arthroscopic surgical grasper. METHODS: This study included 63 patients with a mean age at surgery of 65.3 years (range, 45-83 years) who underwent ARCR. The mean follow-up period was 24.1 months (range, 24-28 months). We investigated the patients' demographic data, Japanese Orthopaedic Association score, DeOrio and Cofield classification, and Goutallier stage of the supraspinatus and infraspinatus muscles. We also evaluated cuff integrity based on the Sugaya classification via magnetic resonance imaging. The free edge of the torn retracted tendon was grasped, and the passive tension to the footprint was then measured with Grasper Tensioning Attachment with the arm at the side. The anteroposterior (AP) and mediolateral (ML) diameters were also measured. RESULTS: The preoperative Goutallier stage of the supraspinatus muscle was stage 0 in 7 cases, stage 1 in 34, stage 2 in 20, and stage 3 in 2. The mean intraoperative rotator repair tension was 10.0 ± 2.5 N (range, 7.5-17 N). The mean AP diameter of the rotator cuff tear was 22 ± 10 mm (range, 8-50 mm), and the mean ML diameter was 24 ± 10 mm (range, 10-50 mm). Age, DeOrio and Cofield classification, Goutallier stage, AP diameter, and ML diameter correlated with rotator repair tension. The rotator repair tension in Sugaya classification type III or IV cases (n = 12, 11.4 ± 2.4 N) was significantly larger than that in type I or II cases (n = 51, 9.7 ± 2.4 N; P = .03). Tension ≥ 10 N as a cutoff value from receiver operating characteristic curve analysis was a risk factor for poor cuff integrity (95% confidence interval, 0.53-0.88). CONCLUSIONS: Rotator repair tension ≥ 10 N was a risk factor for poor cuff integrity. Thus, care should be taken when performing intraoperative procedures and administering postoperative regimens.

Risk factors related to complications of the fingers and hand after arthroscopic rotator cuff repair - carpal tunnel syndrome, flexor tenosynovitis, and complex regional pain syndrome.

HYPOTHESIS/BACKGROUND: Complications involving the fingers and hand after arthroscopic rotator cuff repair (ARCR) include complex regional pain syndrome, carpal tunnel syndrome (CTS), and flexor tenosynovitis (TS). The aims of this study were to diagnose the complications after ARCR and investigate the risk factors that could predispose individuals to these finger and hand complications. METHODS: Fifty patients (50 shoulders) who underwent ARCR participated in this study. The patients' ages ranged from 36 to 84 years (mean, 63 years). Before ARCR, we determined the disease history of the fingers and hand (CTS or TS) and subjectively assessed their symptoms using a questionnaire that included a scale ranging from 1 (no symptoms or no disability) to 5 (the worst symptoms or severest disability). ARCR was performed in all patients using suture anchors. The mean observation period after surgery was 15.5 months (range, 12-48 months). We diagnosed complications involving the fingers and hand after ARCR and investigated the preoperative, intraoperative, and postoperative risk factors that could predispose patients to these complications using univariable and multivariable analyses. RESULTS: After ARCR, 20 patients (20 hands) (40%) had complications of the fingers and hand. Among them, the diagnosis was CTS in 2 hands, TS in 15 hands, and both CTS and TS in 3 hands. None of the hands exhibited complex regional pain syndrome. These complications occurred at an average of 1.8 months (range, 0.1-4 months) after ARCR. In the 47 patients who did not have symptoms just before the operation, both univariable and multivariable analyses between the complication group (n = 17) and the no-complications group (n = 30) showed a significant difference in the presence of a past history of CTS or TS (complication frequency: past history: 88%, no past history: 25%) (P < .05) and the preoperative subjective assessment for edema of the fingers and hand (complication frequency: edema ≥ 2 points: 89%, edema < 2 points: 24%) (P < .05). There were no relationships between the other candidate intraoperative and postoperative factors and complications. CONCLUSION: In all 20 hands with complications of the fingers and hand after ARCR, the diagnosis was CTS or TS. Complications of the fingers and hand after ARCR easily occurred in patients with a past history of CTS or TS and in patients with edema as per a subjective assessment. We speculate that the ARCR triggered the occurrence of CTS and TS postoperatively in patients who had subclinical CTS or TS before surgery.

Contractile property measurement of the torn supraspinatus muscle using real-time tissue elastography.

HYPOTHESIS: In the restoration of shoulder abduction, decreased contractility of the torn rotator cuff muscle may be a cause of a poor result. The aim of this study was to investigate the relationship between the contractile property of the torn supraspinatus muscle measured by real-time tissue elastography and the Goutallier stage as modified by Fuchs et al. METHODS: The muscular hardness of the torn supraspinatus muscle was measured in 32 patients at rest and during isometric contraction with the shoulder abducted to 60° in the scapular plane. The muscular hardness was calculated as the strain ratio. Fatty degeneration was assessed according to the modified Goutallier stage. Because the activity value (defined as the difference between the strain ratio at rest and the strain ratio during isometric contraction) estimated the contractile property of the muscle, stepwise multiple regression analysis was used to compare the activity value with age, sex, side, time from injury onset to obtaining the measurements, and modified Goutallier stage. RESULTS: The mean activity value was 0.26 ± 0.16. Fatty degeneration of the supraspinatus muscle was grade 0 in 5 patients, grade 1 in 16, grade 2 in 10, and grade 3 in 1. The activity value was significantly correlated only with the modified Goutallier stage (r = -0.78, P < .001). CONCLUSION: The contractile property of the supraspinatus muscles decreased with an increase in the modified Goutallier stage. Real-time tissue elastography can measure the contractile property of the muscles before surgery and thus may be a predictor for the resulting restoration of lost muscle function.