Management of irreparable massive rotator cuff tears: a systematic review and meta-analysis of patient-reported outcomes, reoperation rates, and treatment response.

BACKGROUND: There is no consensus on the treatment of irreparable massive rotator cuff tears. The goal of this systematic review and meta-analysis was to (1) compare patient-reported outcome scores, (2) define failure and reoperation rates, and (3) quantify the magnitude of patient response across treatment strategies. METHODS: The MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and Scopus databases were searched for studies including physical therapy and operative treatment of massive rotator cuff tears. The criteria of the Methodological Index for Non-randomized Studies were used to assess study quality. Primary outcome measures were patient-reported outcome scores as well as failure, complication, and reoperation rates. To quantify patient response to treatment, we compared changes in the Constant-Murley score and American Shoulder and Elbow Surgeons (ASES) score with previously reported minimal clinically important difference (MCID) thresholds. RESULTS: No level I or II studies that met the inclusion and exclusion criteria were found. Physical therapy was associated with a 30% failure rate among the included patients, and another 30% went on to undergo surgery. Partial repair was associated with a 45% retear rate and 10% reoperation rate. Only graft interposition was associated with a weighted average change that exceeded the MCID for both the Constant-Murley score and ASES score. Latissimus tendon transfer techniques using humeral bone tunnel fixation were associated with a 77% failure rate. Superior capsular reconstruction with fascia lata autograft was associated with a weighted average change that exceeded the MCID for the ASES score. Reverse arthroplasty was associated with a 10% prosthesis failure rate and 8% reoperation rate. CONCLUSION: There is a lack of high-quality comparative studies to guide treatment recommendations. Compared with surgery, physical therapy is associated with less improvement in perceived functional outcomes and a higher clinical failure rate.

Risk Factors for Infection After Rotator Cuff Repair.

PURPOSE: To identify risk factors for infection after rotator cuff repair. We hypothesized that patient characteristics and surgical technique would affect the rate of infection. METHODS: The records of 1,824 rotator cuff repairs performed by a single surgeon from 1995 to 2010 were reviewed retrospectively. Fourteen patients had an early deep postoperative wound infection that was treated with surgical irrigation and debridement. One hundred eighty-five control patients who were treated with rotator cuff repair and did not develop an infection were selected randomly for comparison and statistical analysis. Data regarding preoperative and intraoperative risk factors for infection were recorded, and a multiple logistic regression was conducted to investigate predictors of infection. RESULTS: The infection rate was 0.77% (14/1,822). On average 2.1 (range 1 to 4) surgical debridements were performed in addition to treatment with intravenous antibiotics. Patients who had open or miniopen rotator cuff repair had a significantly greater risk of acute postoperative infection (odds ratio [OR] = 8.63, P = .002). Seventy-nine percent of the patients in the infection group had an open or miniopen repair, whereas only 28% of the control group had an open or miniopen repair. Male patients also had a significantly greater risk of acute postoperative infection (OR = 9.52, P = .042). A total of 92% of the infection patients were male compared with 58% of the control group. In addition, as body mass index increased there was a reduction in the odds of infection (OR = 0.81, P = .023). CONCLUSIONS: The results of this case control study demonstrate that open or miniopen surgical technique and male sex are significant risk factors for infection after rotator cuff repair. In our study, arthroscopic rotator cuff repair reduced the risk of infection compared with open techniques. LEVEL OF EVIDENCE: Level IV.

Quantum order-by-disorder near criticality and the secret of partial order in MnSi.

The vicinity of quantum phase transitions has proven fertile ground in the search for new quantum phases. We propose a physically motivated and unifying description of phase reconstruction near metallic quantum-critical points using the idea of quantum order by disorder. Certain deformations of the Fermi surface associated with the onset of competing order enhance the phase space available for low-energy, particle-hole fluctuations and self-consistently lower the free energy. Applying the notion of quantum order by disorder to the itinerant helimagnet MnSi, we show that, near the quantum critical point, fluctuations lead to an increase of the spiral ordering wave vector and a reorientation away from the lattice-favored directions. The magnetic ordering pattern in this fluctuation-driven phase is found to be in excellent agreement with the neutron-scattering data in the partially ordered phase of MnSi.

Dynamics after a sweep through a quantum critical point.

The coherent quantum evolution of a one-dimensional many-particle system after slowly sweeping the Hamiltonian through a critical point is studied using a generalized quantum Ising model containing both integrable and nonintegrable regimes. It is known from previous work that universal power laws of the sweep rate appear in such quantities as the mean number of excitations created by the sweep. Several other phenomena are found that are not reflected by such averages: there are two different scaling behaviors of the entanglement entropy and a relaxation that is power law in time rather than exponential. The final state of evolution after the quench is not characterized by any effective temperature, and the Loschmidt echo converges algebraically for long times, with cusplike singularities in the integrable case that are dynamically broadened by nonintegrable perturbations.