Scapular morphology does not predict supraspinatus tendon tear propagation following an individualised exercise therapy programme.

Purpose: To determine whether scapular morphology could predict isolated supraspinatus tendon tear propagation after exercise therapy. We hypothesised that a larger critical shoulder angle (CSA) and type III acromial morphology predict a positive change in tear size. Methods: Fifty-nine individuals aged 40-70 years with isolated symptomatic high-grade partial or full-thickness supraspinatus tendon tears were included. Individuals participated in a structured, individualised 12-week exercise therapy programme and underwent ultrasound to measure tear size at baseline and 12 months following therapy. Computed tomography images were segmented to create three-dimensional subject-specific bone models and reviewed by three trained clinicians to measure CSA and to determine acromion morphology based on the Bigliani classification. A binary logistic regression was performed to determine the predictive value of CSA and acromion morphology on tear propagation. Results: The CSA was 30.0 ± 5.4°. Thirty-one individuals (52.5%) had type II acromial morphology, followed by type III and type I morphologies (25.4% and 22.0%, respectively); 81.4% experienced no change in tear size, four (6.8%) individuals experienced tear propagation and seven (11.9%) individuals had a negative change in tear size. No significant difference in tear propagation rates based on CSA or acromion morphology (not significant [NS]) was observed. The model predicted tear size status in 81.4% of cases but only predicted tear propagation 8.3% of the time. Overall, CSA and acromion morphology only predicted 24.3% (R 2 = 0.243) of variance in tear propagation (NS). Conclusions: CSA and acromion morphology were NS predictors of tear propagation of the supraspinatus tendon 12 months following an individualised exercise therapy programme. Level of Evidence: II.

Medial Scapular Body (MSB) Goutallier Classification - MRI based reliability and validity of evaluation of the Goutallier classification for grading fatty infiltration of the rotator cuff.

INTRODUCTION: The degree of atrophy and fatty infiltration of rotator cuff muscle belly is a key predictor for cuff repairability. Traditionally, Goutallier grading of fatty infiltration is assessed at sagittal scapular Y-view. Massive rotator cuff tears are associated with tendon retraction and medial retraction of cuff musculature, resulting in medialization of the muscle bulk. Thus, standard Y-view can misrepresent the region of interest and may misguide clinicians when assessing repairability. It is hypothesized that by assessing the muscle belly with multiple medial sagittal MRI sections at medial scapular body, the Medial Scapular Body - Goutallier Classification (MSB-GC) will improve reliability and repeatability giving a more representative approximation to the degree of fatty infiltration, as compared with original Y-view. METHODS: Fatty infiltration of the rotator cuff muscles were classified based on the Goutallier grade (0 to 4) at three defined sections section 1: original Y-view; section 2: level of suprascapular notch; section 3: three cm medial to suprascapular notch on MRI scans. Six sub-specialist fellowship trained shoulder surgeons, and three musculoskeletal radiologists independently evaluated deidentified MRI scans of included patients. RESULTS: Out of 80 scans, 78% (n=62) were massive cuff tears involving supraspinatus, infraspinatus and subscapularis tendon. Inter-observer reliability (consistency between observers) for Goutallier grade was excellent for all three predefined sections (range:0.87-0.95). Intra-observer reliability (repeatability) for Goutallier grade was excellent for all three sections and four rotator cuff muscles (range:0.83-0.97). There was a moderate to strong positive correlation of Goutallier grades between sections 1 and 3 and between sections 2 and 3 and these were statistically significant (p<0.001). There was a reduction in the severity of fatty infiltration on the Goutallier classification from sections 1 to 3 across all muscles. 42.5% of both supraspinatus and infraspinatus were downgraded by one, 20% of supraspinatus and 3.8% of infraspinatus were downgraded by 2 and 2.5% of supraspinatus were downgraded by 3. CONCLUSION: This study found that applying the Goutallier classification to more medial MRI sections (MSB-GC) resulted in assignment of lower grades for all rotator cuff muscles. Additionally, this method demonstrated excellent test-retest reliability and repeatability. Inclusion of a more medial view or whole scapula on MRI, especially in advanced levels of tear retraction, could be more reliable and representative for assessment of the degree of fatty infiltration within the muscle bulk that could help predict tear repairability and therefore improve clinical decision-making which should be studied further in clinical studies.

Supraspinatus Muscle and Tendon Characteristics 1 Year After Surgical Rotator Cuff Repair Compared With Contralateral Shoulder: Data From the CUT-N-MOVE Trial.

BACKGROUND: It is necessary to better understand the structural characteristics of the supraspinatus tendon and associated muscle after rotator cuff repair and in the event of retear. PURPOSE: To study structural differences between the repaired and contralateral shoulders 1 year after rotator cuff repair in patients who received either progressive exercise therapy (PR) or usual care (UC) in a randomized controlled trial and to investigate whether there was interaction with tendon retear and limb dominance. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients with surgically repaired traumatic full-thickness rotator cuff tears involving the supraspinatus tendon were included. After surgery, they were randomized to PR or UC (active from postoperative week 2 or 6, respectively). The subacromial structures (acromiohumeral distance, supraspinatus tendon thickness, and vascularity) and the supraspinatus muscle thickness were examined with ultrasound at the 1-year follow-up. RESULTS: A total of 79 patients were included. The characteristics of the 2 intervention groups (PR and UC) were comparable, including the Western Ontario Rotator Cuff Index score and number of retears. The authors found significantly thinner supraspinatus tendon (PR, P < .001; UC, P = .003) and reduced acromiohumeral distance (PR, P = .023; UC, P = .025) in the repaired versus the contralateral shoulders in both intervention groups. For neovascularization, there was no interlimb difference in either of the groups or between groups (PR vs UC). In patients with intact tendons, there was no interlimb difference in the muscle thickness, but in patients with tendon retear the muscle was significantly thinner on the repaired side (P = .024 and P < .001, respectively). When the dominant supraspinatus tendon was repaired (both groups), it was significantly thinner than the nondominant healthy tendon, but this difference was not seen when the nondominant supraspinatus tendon was repaired (P = .006). CONCLUSION: One year after rotator cuff surgery, the repaired supraspinatus tendon was significantly thinner and the corresponding acromiohumeral distance was reduced. In patients with retear, the supraspinatus muscle was significantly thinner on the repaired side and early initiation of tendon-loading exercises did not affect these findings. REGISTRATION: NCT02969135 (ClinicalTrials.gov identifier).

Biceps tendon autograft augmentation for rotator cuff and instability procedures: a narrative review.

Rotator cuff tears (RCT) and instability are the most common surgically treated shoulder pathologies. The concept of augmentation using the long head of the biceps tendon (LHBT) autograft was created to improve the results of surgical treatment of these pathologies, especially in cases of chronic and massive injuries. The popularity of using the LHBT for augmentation is evidenced by the significant number of publications on this topic published in the last 3 years; however, only one systematic review has been published regarding only LHBT augmentation for massive RCTs. Several studies comparing partial repair with partial repair and additional LHBT augmentation for RCT showed superior clinical outcomes and lower re-tear rates when LHBT augmentation was performed. There is a rising popularity of using LHBT as an autograft to perform superior capsule reconstruction (SCR) in case of irreparable rotator cuff tears. In recent years, shoulder stabilization by arthroscopic Bankart repair with biceps augmentation has been promoted with very promising short-term results. The evidence provided by studies appears to be sufficient to recommend the use of LHBT for augmentation whenever necessary; however, larger studies with long-term follow-up are needed.

Pectoralis Major Transfer For Anterior Recurrent Dislocation of Reverse Total Shoulder Arthroplasty: A Case Report.

Introduction: Reverse total shoulder arthroplasty (RTSA) has revolutionized the treatment landscape for a spectrum of shoulder pathologies, extending its indications from rotator cuff arthropathy to encompass irreparable rotator cuff lesions, fractures, inflammatory arthritis, and tumors. However, the exponential increase in RTSA usage has brought a proportional rise in associated complications, with dislocation being one of the most common early post-operative complications. Case Report: This case report details a 65-year-old right-hand dominant male patient presenting with chronic pain and weakness in the right shoulder, diagnosed with advanced glenohumeral arthritis and massive irreparable rotator cuff tears. The patient underwent a Bony Increased- Offset RTSA (BIO-RTSA) procedure, coupled with subscapularis repair. Postoperatively, the patient experienced pain and instability, culminating in an atraumatic anterior dislocation at 4 months. Despite conservative management, recurrent dislocations persisted. Revision surgery was performed with an increase in the linear component size for containment. About 1 year postoperative of the revision surgery, recurrent dislocation reoccurred. Re-revision surgery was performed with secondary pectoralis major (PM) transfer for subscapularis deficiency due to re-tear from recurrent dislocation, and with an increased humeral tray size for better containment. About 1-year and 6-month post-operative to the re-revision surgery, the patient achieved restored stability, improved range of motion, and reported satisfaction with the outcome. Conclusion: This case report underscores the challenges of managing recurrent anterior dislocation after RTSA. The successful use of secondary PM transfer highlights its efficacy as a salvage procedure in restoring stability for persistent anterior dislocation after RTSA. Yet, further clinical studies are warranted to establish the role of such interventions in the management for RTSA-associated complications. Level of Evidence IV: Case report.

Influence of Frequent Corticosteroid Local Injections on the Expression of Genes and Proteins Related to Fatty Infiltration, Muscle Atrophy, Inflammation, and Fibrosis in Patients With Chronic Rotator Cuff Tears: A Pilot Study.

Background: The effect of local corticosteroid (CS) injections on rotator cuff muscles remains poorly defined, despite the significance of muscle quality as a crucial prognostic factor for patients with rotator cuff tears (RCTs). Purpose: To compare alterations in gene and protein expression patterns in the rotator cuff muscles of patients with RCTs who received frequent joint CS injections with alterations in those without a history of CS injections. Study Design: Controlled laboratory study. Methods: A total of 24 rotator cuff muscle samples with medium-sized tears from 12 patients with a frequent joint CS injection history (steroid group; 7 men and 5 women who had received ≥5 injections with at least 1 within the previous 3 months; mean age, 63.0 ± 7.2 years) and 12 age- and sex-matched control patients without a history of CS injections (no-steroid group) were acquired. Alterations in the expression of genes and proteins associated with adipogenesis, myogenesis, inflammation, and muscle fibrosis were compared between the groups using quantitative reverse transcription-polymerase chain reaction, Western blotting, and immunohistochemistry. Statistical analysis included comparison of group means using the Mann-Whitney U test, chi-square test, or Fisher exact test and logistic regression for multivariate analysis. Results: In the steroid group, the mRNA expression levels of adipogenic CCAAT/enhancer-binding protein alpha (C/EBPα; P = .008) and muscle atrophy-related genes (atrogin; P = .019) were significantly higher, and those of myogenic differentiation 1 (MyoD; P = .035), inflammatory interleukin 6 (IL-6; P = .035), and high mobility group box 1 (P = .003) were significantly lower compared with the no-steroid group. In addition, MyoD (P = .041) and IL-6 (P = .026) expression were decreased in the steroid versus no-steroid group. Immunohistochemistry revealed increased expression of C/EBPα and atrogin and decreased expression of MyoD and IL-6 in the steroid versus no-steroid group. Conclusion: Patients with RCTs and a history of frequent CS injections exhibited an upregulation of adipogenic and muscle atrophy-related genes and proteins within the rotator cuff muscles and a downregulation in the expression of myogenic and inflammatory genes and proteins in the same muscles. Clinical Relevance: These altered gene and protein expressions by frequent local CS injections may cause poor outcomes in patients with RCTs.

Maximum in-vivo joint contact forces double during active compared to assisted motion in the glenohumeral joint and decline long-term due to rotator cuff pathologies.

Rehabilitation programs advocate early passive and assisted motion after rotator cuff repair to induce healing und maintaining range of motion while avoiding excessive strain on the repaired tendons. In-vivo glenohumeral joint contact forces reflect the compressive forces generated by the rotator muscles. In the present study, maximum in-vivo joint contact forces (FresMax) were determined to compare active and assisted execution of a single movement and the long-term development of joint compression forces. FresMax were measured in six patients who received instrumented, telemetric modified anatomical hemi endoprostheses of the shoulder joint between 2006 and 2008. Data were gathered 23 months postoperatively (2006-2010), were analysed and compared with measurements 133 months postoperatively. Additional imaging was obtained as x-rays and ultrasound examination. Data analysis was conducted by synchronizing video tapes and measured force curves. New imaging showed a rupture of the M. supraspinatus and progressive joint degeneration. FresMax nearly doubled during active compared to assisted execution of each of the four chosen movements. Over the course of 133 months post-surgery, the studied movements showed a decrease of active compression force, probably due to a ruptured supraspinatus, resulting in a lower active/assisted ratio. A long term follow up after eleven years, eight out of ten measured movements showed a decrease of FresMax. These results support current rehabilitation protocols recommending early passive and assisted motion to limit activation of the rotator muscles generating compressive forces. Following degeneration of the rotator cuff, active joint contact forces decrease over time.Level of evidence: III.

Evaluation of Shoulder Injuries: A Comparative Study of Imaging by Magnetic Resonance Imaging (MRI) and Magnetic Resonance Arthrography (MRA).

Background: In contrast to the standard shoulder arthroscopy, current radio-diagnostic techniques like magnetic resonance arthrography (MRA), and magnetic resonance imaging (MRI) provide less invasive intricate structural detail of shoulder anatomy. Objectives: Comparison of efficacy of MRA and MRI for diagnosing suspected rotator cuff injury. Materials and Methods: Over the course of 4 years (from June 2017 to June 2021), a comparative study, including 100 individuals with suspected rotator cuff pathology, was conducted. For the evaluation of shoulder injuries, the assessment and comparison of MRA and MRI were done in terms of sensitivity (Sn), positive predictive value (PPV), and diagnostic accuracy (DA). Results: MRI and MRA were positive in 76 (76%) and 98 (98%) patients, respectively. The Sn and PPV of MRI for diagnosing the shoulder injury were 76% and 100%, respectively, whereas the Sn and PPV of MRA were 98% and 100%, respectively. MRA was better than MRI in terms of diagnostic accuracy (98% vs. 76%, P = 0.03). Conclusion: MRA is a nonsurgical effective method in evaluating and diagnosing rotator cuff injuries in comparison to MRI.

3-Dimensional Bioprinting of a Tendon Stem Cell-Derived Exosomes Loaded Scaffold to Bridge the Unrepairable Massive Rotator Cuff Tear.

BACKGROUND: Unrepairable massive rotator cuff tears (UMRCTs) are challenging to surgeons owing to the severely retracted rotator cuff musculotendinous tissues and extreme defects in the rotator cuff tendinous tissues. PURPOSE: To fabricate a tendon stem cell-derived exosomes loaded scaffold (TSC-Exos-S) and investigate its effects on cellular bioactivity in vitro and repair in a rabbit UMRCT model in vivo. STUDY DESIGN: Controlled laboratory study. METHODS: TSC-Exos-S was fabricated by loading TSC-Exos and type 1 collagen (COL-I) into a 3-dimensional bioprinted and polycaprolactone (PCL)-based scaffold. The proliferation, migration, and tenogenic differentiation activities of rabbit bone marrow stem cells (BMSCs) were evaluated in vitro by culturing them in saline, PCL-based scaffold (S), COL-I loaded scaffold (COL-I-S), and TSC-Exos-S. In vivo studies were conducted on a rabbit UMRCT model, where bridging was repaired with S, COL-I-S, TSC-Exos-S, and autologous fascia lata (FL). Histological and biomechanical analyses were performed at 8 and 16 weeks postoperatively. RESULTS: TSC-Exos-S exhibited reliable mechanical strength and subcutaneous degradation, which did not occur before tissue regeneration. TSC-Exos-S significantly promoted the proliferation, migration, and tenogenic differentiation of rabbit BMSCs in vitro. In vivo studies showed that UMRCT repaired with TSC-Exos-S exhibited significant signs of tendinous tissue regeneration at the bridging site with regard to specific collagen staining. Moreover, no significant differences were observed in the histological and biomechanical properties compared with those repaired with autologous FL. CONCLUSION: TSC-Exos-S achieved tendinous tissue regeneration in UMRCT by providing mechanical support and promoting the trend toward tenogenic differentiation. CLINICAL RELEVANCE: The present study proposes a potential strategy for repairing UMRCT with severely retracted musculotendinous tissues and large tendinous tissue defects.

Muscle and joint function in the rotator cuff deficient shoulder.

Full-thickness rotator cuff tears can lead to poor coaptation of the humeral head to the glenoid, disrupting muscle forces required for glenohumeral joint stability, ultimately leading to joint subluxation. The aim of this study was to evaluate muscle forces and glenohumeral joint translations during elevation in the presence of isolated and combined full-thickness rotator cuff tears. Eight fresh-frozen upper limbs were mounted to a computer-controlled testing apparatus that simulated joint motion by simulated muscle force application. Scapular-plane abduction was performed, and glenohumeral joint translations were measured using an optoelectronic system. Testing was performed in the native shoulder, a following an isolated tear to the supraspinatus, as well as combined tears involving the supraspinatus and subscapularis, as well as supraspinatus, infraspinatus, and teres minor. Rotator cuff tears significantly increased middle deltoid force at 30°, 60°, and 90° of abduction relative to that in the native shoulder (p < 0.05). Significantly greater superior translations were observed relative to the intact shoulder due to combined tears to the supraspinatus and infraspinatus at 30° of abduction (mean increase: 1.6 mm, p = 0.020) and 60° of abduction (mean increase: 4.8 mm, p = 0.040). This study illustrates the infraspinatus-teres minor complex as a major humeral head depressor and contributor to glenohumeral joint stability. An increase in deltoid force during abduction occurs in the presence of rotator cuff tears, which exacerbates superior migration of the humeral head. The findings may help in the development of clinical tests in rotator cuff tear diagnostics, in surgical planning of rotator cuff repair, and in planning of targeted rehabilitation.

Defining Pseudoparalysis & Pseudoparesis - A Consensus Study.

PURPOSE: The purpose of this study was to establish consensus statements via a modified Delphi process on the definition of shoulder pseudoparalysis and pseudoparesis. METHODS: A consensus process on the definition of a diagnosis of pseudoparalysis utilizing a modified Delphi technique was conducted, and 26 shoulder/sports surgeons from 11 countries, selected based on their level of expertise in the field, participated in these consensus statements. Consensus was defined as achieving 80-89% agreement, whereas strong consensus was defined as 90-99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: Three statements regarding the diagnosis of pseudoparalysis reached strong (>89%) consensus: passive range of motion (ROM) should be unaffected, the passive range of abduction should not be considered and diagnosis should be excluded if lidocaine injection produces a substantial improvement in range of motion. Additionally, consensus (>79%) was reached that the active range of external rotation should not be considered for diagnosis, pain as a cause of restricted motion must be excluded, and that distinctions between restricted active flexion and external rotation should be made by ROM rather than tear characteristics. No consensus could be reached on statements regarding the size, number of tendons or chronicity of cuff tears. Nor was there agreement on the active range of flexion permitted or on the difference between pseudoparalysis and pseudoparesis. CONCLUSION: A modified Delphi process was utilized to establish consensus on the definition of shoulder pseudoparalysis and pseudoparesis. Unfortunately, almost half of the statements did not reach consensus, and agreement could not be reached across all domains for a unifying definition for the diagnosis of pseudoparalysis in the setting of RCTs. Furthermore, it was not agreed how or whether pseudoparalysis should be differentiated from pseudoparesis. Based on the lack of a consensus for these terms, studies should report explicitly how these terms are defined when they are used.

Severity of rotator cuff disorders and additional load affect fluoroscopy-based shoulder kinematics during arm abduction.

BACKGROUND: Rotator cuff disorders, whether symptomatic or asymptomatic, may result in abnormal shoulder kinematics (scapular rotation and glenohumeral translation). This study aimed to investigate the effect of rotator cuff tears on in vivo shoulder kinematics during a 30° loaded abduction test using single-plane fluoroscopy. MATERIALS AND METHODS: In total, 25 younger controls, 25 older controls and 25 patients with unilateral symptomatic rotator cuff tears participated in this study. Both shoulders of each participant were analysed and grouped on the basis of magnetic resonance imaging into healthy, rotator cuff tendinopathy, asymptomatic and symptomatic rotator cuff tears. All participants performed a bilateral 30° arm abduction and adduction movement in the scapular plane with handheld weights (0, 2 and 4 kg) during fluoroscopy acquisition. The range of upward-downward scapular rotation and superior-inferior glenohumeral translation were measured and analysed during abduction and adduction using a linear mixed model (loads, shoulder types) with random effects (shoulder ID). RESULTS: Scapular rotation was greater in shoulders with rotator cuff tendinopathy and asymptomatic rotator cuff tears than in healthy shoulders. Additional load increased upward during abduction and downward during adduction scapular rotation (P < 0.001 in all groups but rotator cuff tendinopathy). In healthy shoulders, upward scapular rotation during 30° abduction increased from 2.3° with 0-kg load to 4.1° with 4-kg load and on shoulders with symptomatic rotator cuff tears from 3.6° with 0-kg load to 6.5° with 4-kg load. Glenohumeral translation was influenced by the handheld weights only in shoulders with rotator cuff tendinopathy (P ≤ 0.020). Overall, superior glenohumeral translation during 30° abduction was approximately 1.0 mm with all loads. CONCLUSIONS: The results of glenohumeral translation comparable to control but greater scapular rotations during 30° abduction in the scapular plane in rotator cuff tears indicate that the scapula compensates for rotator cuff deficiency by rotating. Further analysis of load-dependent joint stability is needed to better understand glenohumeral and scapula motion. LEVEL OF EVIDENCE: Level 2. TRIAL REGISTRATION: Ethical approval was obtained from the regional ethics committee (Ethics Committee Northwest Switzerland EKNZ 2021-00182), and the study was registered at clinicaltrials.gov on 29 March 2021 (trial registration number NCT04819724, https://clinicaltrials.gov/ct2/show/NCT04819724 ).

Bioactive Patch for Rotator Cuff Repairing via Enhancing Tendon-to-Bone Healing: A Large Animal Study and Short-Term Outcome of a Clinical Trial.

Tissue engineering has demonstrated its efficacy in promoting tissue regeneration, and extensive research has explored its application in rotator cuff (RC) tears. However, there remains a paucity of research translating from bench to clinic. A key challenge in RC repair is the healing of tendon-bone interface (TBI), for which bioactive materials suitable for interface repair are still lacking. The umbilical cord (UC), which serves as a vital repository of bioactive components in nature, is emerging as an important source of tissue engineering materials. A minimally manipulated approach is used to fabricate UC scaffolds that retain a wealth of bioactive components and cytokines. The scaffold demonstrates the ability to modulate the TBI healing microenvironment by facilitating cell proliferation, migration, suppressing inflammation, and inducing chondrogenic differentiation. This foundation sets the stage for in vivo validation and clinical translation. Following implantation of UC scaffolds in the canine model, comprehensive assessments, including MRI and histological analysis confirm their efficacy in inducing TBI reconstruction. Encouraging short-term clinical results further suggest the ability of UC scaffolds to effectively enhance RC repair. This investigation explores the mechanisms underlying the promotion of TBI repair by UC scaffolds, providing key insights for clinical application and translational research.

The Subscapularis Healing Index: A New Scoring System for Predicting Subscapularis Healing After Arthroscopic Repair.

BACKGROUND: Previous research has emphasized the effect of prognostic factors on arthroscopic rotator cuff repair (ARCR) success, but a specific focus on subscapularis (SSC) tendon repair healing is lacking. PURPOSE: To identify prognostic factors for SSC healing after ARCR and develop the Subscapularis Healing Index (SSC-HI) by incorporating these factors. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This was a retrospective study using prospectively maintained data collected from patients with isolated or combined SSC tears who underwent ARCR between 2011 and 2021 at a single institution with a minimum 2-year follow-up. Functional outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), and visual analog scale (VAS) pain scale. SSC tendon healing was evaluated via ultrasound at the final follow-up. Multivariate logistic regression analysis was performed to determine the factors affecting SSC healing, and based on these factors, the SSC-HI, which ranges from 0 to 15 points, was developed using odds ratios (ORs). RESULTS: Among 1018 ARCR patients, 931 met the inclusion criteria; 279 returned voluntarily for postoperative SSC ultrasound assessment. The overall healing failure rate was 10.8% (30/279). Risk factors for healing failure included female sex (P = .008; OR, 3.119), body mass index (BMI) ≥30 (P = .053; OR, 2.323), supraspinatus fatty infiltration ≥3 (P = .033; OR, 3.211), lower SSC fatty infiltration ≥2 (P = .037; OR, 3.608), and Lafosse classification ≥3 (P = .007; OR, 3.224). A 15-point scoring system comprised the following: 3 points for female sex, 2 points for BMI ≥30, 3 points for supraspinatus fatty infiltration ≥3, 4 points for lower SSC fatty infiltration ≥2, and 3 points for Lafosse classification ≥3. Patients with ≤4 points had a 4% healing failure rate, while those with ≥9 points had a 55% rate of healing failure. Patients with a healed SSC reported significantly higher ASES (healed SSC: ΔASES, 44.7; unhealed SSC: ΔASES, 29; P < .01) and SSV (healed SSC: ΔSSV, 52.9; unhealed SSC: ΔSSV, 27.5; P < .01) and lower VAS (healed SSC: ΔVAS, -4.2; unhealed SSC: ΔVAS, -3; P < .01) scores compared with those with an unhealed SSC. CONCLUSION: The SSC-HI scoring system integrates clinical and radiological factors to predict SSC healing after surgical repair. Successful SSC healing was found to be associated with enhanced functional outcomes, underscoring the clinical relevance of SSC healing prediction in the management of these tears.

Balloon Spacer Implant is an "Intermediate Value" Innovation Relative to Partial Repair for Full-Thickness Massive Rotator Cuff Repairs: A Cost-Utility Analysis.

PURPOSE: The purpose of this study was to evaluate the cost-utility of a Balloon Spacer implant relative to partial repair (PR) for the surgical treatment of full-thickness massive rotator cuff tears (MRCT). METHODS: A decision-analytic model comparing Balloon Spacer versus PR was developed using data from a prospective, randomized, single-blinded, multi-center controlled trial of 184 randomized patients. Our model was constructed based on the various event pathways a patient could have after the procedure. The probability that each patient progressed to a given outcome and the quality-adjusted life years (QALY) associated with each outcome were derived from the clinical trial data. Incremental cost utility ratio (ICUR) and incremental net monetary benefit (INMB) were calculated based on a probabilistic sensitivity analysis using Monte Carlo simulations of 1,000 hypothetical patients progressing through the decision-analytic model. One-way sensitivity and threshold analyses were performed by varying cost, event probability, and QALY estimates. RESULTS: Balloon Spacer had an ICUR of $106,851 (95% CI, $96,317 to $119,143) relative to PR for surgical treatment of MRCT. Across all patients, Balloon Spacer was associated with greater 2-year QALY gain compared to PR (0.20 ± 0.02 for Balloon Spacer versus 0.18 ± 0.02 for PR), but with substantially higher total 2-year cost ($9,701 ± $939 for Balloon Spacer versus $6,315 ± $627 for PR). PR was associated with a positive INMB of $1,802 (95% CI, $1,653 to $1,951) over Balloon Spacer at the $50,000/QALY willingness-to-pay (WTP) threshold. CONCLUSIONS: Compared to PR, Balloon Spacer is an "intermediate value" innovation for treatment of MRCT over a 2-year postoperative period with an ICUR value that falls within the $50,000 to $150,000 WTP threshold.

Surgical Management of Massive Irreparable Cuff Tears/Management of Rotator Cuff Disease: Interpositional Graft for Irreparable Posterosuperior Rotator Cuff Tears.

PURPOSE OF REVIEW: Increasingly, massive irreparable rotator cuff tears present a treatment challenge due to their high re-tear rates. The reparability of such tears depends on factors like tear size, the number of involved tendons, tendon retraction extent, muscular atrophy, fatty infiltration, and the presence or absence of arthritis. There are non-surgical and several surgical treatment options described each with their specific indications, contraindications, pros, and cons. Bridging reconstruction restores the superior rotator cuff tissue and arrests humeral head superior migration. The purpose of his review is to explore the existing literature on interpositional graft mechanics, indications, surgical technique, and clinical outcomes. It aims to understand how these parameters can facilitate the incorporation of bridging reconstruction using interpositional grafts into a surgeon's practice for managing massive irreparable rotator cuff tears. RECENT FINDINGS: Interpositional grafts for irreparable massive rotator cuff tears can either be auto-, allo-, xenografts, or synthetic material and are best suited for patients who are relatively younger, no glenohumeral arthritis, and minimal to no fatty infiltration and muscle atrophy. Short to medium term outcome studies available report good functional, clinical, and radiological improvements with bridging reconstruction utilizing acellular dermal matrix allograft. Interpositional grafts for management of irreparable posterosuperior cuff tears provides improved clinical and radiological outcomes with minimal complications and thus a viable and valuable surgical technique for a shoulder surgeon's armamentarium.

A rare presentation of a large suprascapular fossa lipoma causing suprascapular nerve traction injury leading to massive rotator cuff tear, treated arthroscopically - case report.

Suprascapular fossa lipoma extending to the suprascapular notch causing traction injury to the suprascapular nerve is a rare presentation. We report a 47-year-old male with progressive weakness of the right shoulder joint of 8 months duration, with a palpable mass over the spine of the scapula was noticed 2 months earlier and developed a sudden drop in arm following a moderate strain. A magnetic resonance imaging (MRI) scan revealed a rotator cuff tear involving the supraspinatus and infraspinatus muscles with a tumor like lesion in the suprascapular fossa, displacing the suprascapular muscle mass and extending into the suprascapular notch. Electromyography and nerve conduction velocity studies revealed suprascapular neuropathy. After histopathologic confirmation, an arthroscopic excision of the mass with decompression of the suprascapular notch was performed along with repair of the rotator cuff. Six months after the procedure, the patient had improved considerably in terms of function and postoperative MRI revealed a complete excision of the mass, and further follow-up of 2 years showed no recurrence. Suprascapular nerve entrapment can be caused by a lipoma in the shoulder, leading to weakness, atrophy, and consequent tear of the rotator cuff tendons. Arthroscopic management, after histopathological confirmation, gives good results in this situation. LEVEL OF EVIDENCE: Level IV.

A Scapular Statistical Shape Model can Reliably Predict Premorbid Glenoid Morphology in Conditions of Severe Glenoid Bone Loss.

BACKGROUND: Knowledge of premorbid glenoid parameters at the time of shoulder arthroplasty, such as inclination, version, joint line position, height, and width, can assist with implant selection, implant positioning, metal augment sizing and/or bone graft dimensions. The objective of this study was to validate a scapular statistical shape model (SSM) in predicting patient-specific glenoid morphology in scapulae with clinically relevant glenoid erosion patterns. METHODS: Computer tomography scans of 30 healthy scapulae were obtained and used as the control group. Each scapula was then virtually eroded to create seven erosion patterns (Walch A1, A2, B2, B3, D, Favard E2, and E3). This resulted in 210 uniquely eroded glenoid models, forming the eroded glenoid group. A scapular SSM, created from a different database of 85 healthy scapulae, was then applied to each eroded scapula to predict the premorbid glenoid morphology. The premorbid glenoid inclination, version, height, width, radius of best fit sphere, and glenoid joint line position were automatically calculated for each of the 210 eroded glenoids. The mean values for all outcome variables were compared across all erosion types between the healthy, eroded, and SSM predicted groups using a two-way repeated-measures analysis of variance. RESULTS: The SSM was able to predict the mean premorbid glenoid parameters of the eroded glenoids with a mean absolute difference of 3±2° for inclination, 3±2° for version, 2±1mm for glenoid height, 2±1mm for glenoid width, 5±4mm for radius of best fit sphere, and 1±1mm for glenoid joint line. The mean SSM predicted values for inclination, version, height, width, and radius were not significantly different than the control group (P>0.05). DISCUSSION: A statistical shape model has been developed that can reliably predict premorbid glenoid morphology and glenoid indices in patients with common glenoid erosion patterns. This technology can serve as a useful template to visually represent the premorbid healthy glenoid in patients with severe glenoid bony erosions. Knowledge of the premorbid glenoid preoperatively can assist with implant selection, positioning, and sizing.

Distal Clavicular Resection Worsens Outcomes in Rotator Cuff Repair: A National Database Study.

Introduction: Distal clavicular resection (DCR) is a procedure used to alleviate acromioclavicular joint (ACJ) pain, often done alongside rotator cuff repair (RCR). This investigation explored the relationships between DCR and RCR, outcomes of DCR during RCR, and complication rates of DCR. Methods: This retrospective study used electronic medical record data from the TriNetX database. Cohorts were subdivided based on the timeline of DCR in comparison to RCR, as well as comparing RCR with DCR against RCR without DCR. Results: In total 46 534 patients underwent RCR with 14.8% (6898) of these patients also undergoing DCR. And 72.8% (5021) had DCR during RCR, and 10.7% (740) had DCR after RCR. Less than 5% (<10) of patients with preexisting ACJ pain required DCR 3 years postoperatively, and 0.002% (78) patients without ACJ pain developed ACJ pain within 3 years. Less that 20 patients underwent DCR within 3 years of being diagnosed with ACJ pain. Patients who had RCR with DCR were more likely to have chronic pain postoperatively (P < .0001). Conclusion: Patients undergoing RCR do not require subsequent DCR. Performing DCR does not offer significant benefit when compared to performing isolated RCR without DCR in patients with preexisting ACJ pain, but increases risk for ACJ instability and chronic pain.

Subacromial bursa in patients with rotator cuff tear with or without adhesive capsulitis exhibits a differential transcriptome with potential molecular biomarkers.

Background: Although adhesive capsulitis (AC) is a common condition, the pathological mechanisms remain understudied. The purpose of our research was to evaluate variations in gene expression across the entire genome in the subacromial bursa tissue of individuals with rotator cuff tears (RCT), with or without AC, and to explore the factors that may influence the occurrence and progression of AC. Methods: Transcription profiles of subacromial bursa samples from 12 RCT patients, of whom 6 had also AC, were evaluated. Data were generated using RNA-seq. DESeq2 was utilized to identify the differentially expressed genes (DEGs) in both groups. In order to conduct a more in-depth examination of the DEGs, we performed Gene Ontology (GO) functional enrichment and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis. A network of interactions between proteins was built, and the central genes were determined using Cytoscape. The hub genes were confirmed through qRT-PCR and immunohistochemistry. Results: 324 of the 16,251 detected genes were identified as DEGs. Analysis of GO functional enrichment showed that the DEGs were enriched in domains of biological process, molecule function and cellular component. Analysis of KEGG pathways revealed enrichment of DEGs in pathways like IL-17 signaling and ECM-receptor interaction. We verified that the association between AC and the increase in expression of the PPI network hub genes. Conclusion: This study investigated the transcriptome differences of subacromial bursa in RCT patients with or without AC. Using bioinformatics technology, we identified the DEGs and screened out the hub genes. The research enhanced the data on gene expression profiles of DEGs in the subacromial bursa tissue of patients with RCT, offering fresh perspectives on the regulation of gene transcription.