Background:Higher retear rates after rotator cuff repair have been reported in older patients with large tears. Shear wave elastography (SWE) offers a noninvasive, objective way to assess tendon stiffness, yet the relationship between the preoperative and postoperative elastographic stiffness of the supraspinatus tendon has not been well studied. Purpose:To determine the association between preoperative and 6-week postoperative supraspinatus tendon elastographic stiffness and to assess the effect of age, symptom duration, tear thickness, and tear size on these measurements. Study Design:Case series; Level of evidence, 4. Methods:Included were 115 consecutive shoulders undergoing primary arthroscopic repair of isolated supraspinatus tears using the undersurface technique. SWE measurements were obtained of the torn supraspinatus tendon preoperatively and of the repaired tendon 6 weeks postoperatively using a standardized protocol. Results:The preoperative elastographic stiffness of the torn edge of the supraspinatus tendon was diminished in larger (R = -0.3; P < .0001), full-thickness (R = -0.4; P = .0001) tears and in older patients (R = -0.3; P = .002). The mean (± standard deviation) SWE velocity of the supraspinatus tendon decreased by 12% 6 weeks postoperatively (6 ± 1.8 m/s preoperatively vs 5 ± 0.85 m/s postoperatively). While a modest correlation existed between preoperative and 6-week postoperative SWE (R = 0.3; P = .01), a strong inverse relationship was found between preoperative SWE and the improvement in elastographic stiffness after repair (change in SWE [ΔSWE]) (R = -0.8; P < .0001). Multivariate analysis identified preoperative SWE as the strongest predictor of ΔSWE (F = 60; P < .0001). Conclusion:Preoperative elastographic stiffness of the supraspinatus tendon was only modestly associated with early postoperative elastographic stiffness, a finding largely explained by a regression-toward-the-mean effect. These data support the hypothesis that the elastographic stiffness of supraspinatus tendons decreases with advancing age and with larger full-thickness tears. While it was observed that these tendons were elastographically softer preoperatively, they demonstrated the capacity for significant improvement in elastographic stiffness after repair.

Background:Few studies have assessed the impact of trauma history and preoperative symptom duration on cuff integrity after arthroscopic rotator cuff repair (RCR). Purpose:To assess the hypothesis that acute, traumatic rotator cuff tears are less likely to retear after arthroscopic RCR compared with chronic, atraumatic tears. Study Design:Cohort study; Level of evidence, 3. Methods:We conducted a post hoc analysis of prospectively collected data for 2335 consecutive patients who underwent primary arthroscopic RCR and were evaluated for retear on ultrasound 6 months postoperatively. A single-row knotless repair technique was used for all patients. The cohort was divided into patients who recalled a specific event that instigated their symptoms ("traumatic" group) and those who did not ("atraumatic" group). Chi-square test was utilized to assess the difference in retear rate between the traumatic and atraumatic groups. Multivariate logistic regression analyses were performed to identify independent predictors of retear, and receiver operating characteristic curve analysis was used to evaluate the accuracy of the regression equations. Results:The traumatic and atraumatic groups consisted of 1489 and 846 patients, respectively. There was no significant difference in retear rate between the traumatic and atraumatic groups (13% and 11%, respectively; P = .14). In the entire cohort, trauma history and preoperative symptom duration were not predictive of retear. In the traumatic group, larger tear size area was the strongest independent predictor of retear (area under the curve [AUC], 0.76; 99% CI, 0.70-81), followed by longer operative time (AUC, 0.69; 99% CI, 0.64-0.74), older patient age (AUC, 0.68; 99% CI, 0.63-0.73) and full-thickness tear (AUC, 0.66; 99% CI, 0.61-0.71). In the atraumatic group, larger tear size area was the strongest independent predictor (AUC, 0.76; 99% CI, 0.68-0.83), followed by older patient age (AUC, 0.67; 99% CI, 0.59-0.75) and full-thickness tear (AUC, 0.66; 99% CI, 0.58-0.73). Conclusion:Trauma history and preoperative symptom duration did not affect cuff integrity 6 months after arthroscopic RCR. More important factors associated with enhanced repair integrity included smaller tear size and younger patient age.

BACKGROUND:Retear following rotator cuff repair is relatively common. Onlay biological grafts offer a potential solution, as a source of additional healing. The purpose of this study was to determine whether the addition of an onlay bioinductive implant would improve repair integrity and examiner-measured and/or patient-rated shoulder function at ≥2 years after revision arthroscopic rotator cuff repair in workers' compensation patients. We hypothesized that the addition of the onlay bioinductive implant in arthroscopic revision rotator cuff repairs would improve repair integrity and functional outcomes at minimum 2-year follow-up compared with standard repair. METHODS:A post hoc matched-cohort study was conducted on prospectively recruited workers' compensation patients who had revision rotator cuff repair with an onlay bioinductive implant (REGENETEN [Smith & Nephew]) (n = 16). The control group was workers' compensation patients who had revision rotator cuff repair without the bioinductive implant and was matched for age and tear size (n = 24). Kaplan-Meier curves were used to compare the primary outcome of repair integrity. RESULTS:No adverse effects with the bioinductive implant were identified. The retear rate in the bioinductive implant group was 50% (8/16) compared with 38% (9/24) in the control group at minimum 2-year follow-up (P = .522). There were no significant differences in patient-rated or examiner-measured outcomes between the groups at a median of 2.3-year follow-up. CONCLUSION:The addition of a biological patch to revision rotator cuff repair offered no advantage at 6-month follow-up. This study amplifies those findings and shows that revision rotator cuff repairs continue to fail from 6 months to ≥2 years, with the onlay bioinductive implant having no additional benefit to the longer-term health of the repair in this difficult population.

INTRODUCTION:From the surgeon's perspective, a successful rotator cuff is one that remains intact. However, it is undetermined which factors contribute to an improved shoulder from the patient's perspective. The aim of this study was to determine the variables that predicted greater patient-rated benefit from presurgery to 6 months postarthroscopic rotator cuff repair. METHODS:Multiple linear regression analysis was conducted on prospectively collected data of 2010 consecutive patients who underwent arthroscopic rotator cuff repair by a single surgeon to determine the predictors of greater patient-rated benefit. Patient-rated shoulder ranking was graded on a five-point Likert scale in response to "How is your shoulder overall?" preoperatively and at 6 months postoperatively. The patient-rated benefit was the difference in rankings between these time points. RESULTS:Six months following rotator cuff repair, a self-reported benefit was observed in 84% of patients. Patients who rated their shoulder as poor preoperatively reported the greatest benefit (t = 22, P < 0.001). Other preoperative determinants of greater patient-rated benefit were lower patient-rated shoulder stiffness (t = 5, P < 0.001), an injury that was not related to work (t = 4, P < 0.001), stronger internal rotation strength (t = 4, P < 0.002), a more strenuous line of work preinjury (t = 3, P = 0.007), female sex (t = 2, P = 0.019), having a larger tear area (t = 2, P = 0.020), and weaker abduction strength (t = 2, P = 0.046). CONCLUSIONS:Patients who were most likely to perceive a benefit from rotator cuff repair at 6 months postoperation were those who preoperatively rated their shoulder poorly, had a less stiff shoulder, an injury that was not related to work, stronger internal rotation, more strenuous line of work preinjury, were female, had larger tear area, and weaker abduction strength.

Background: Treating massive and irreparable rotator cuff tears are problematic. Several studies have reported that polytetrafluoroethy-lene (PTFE) patches demonstrated excellent construct integrity and positive clinical and patient outcomes. However, these studies either had small sample sizes or short follow-up periods.Purpose: To determine the survivorship, efficacy, and medium-term (2-19 years) outcomes of PTFE patch repairs.Methods: This retrospective study used prospectively collected data to establish the medium-term outcomes of PTFE interposition patch repairs for massive rotator cuff tears that could not be repaired by the standard technique. Patients included those who met the >2-year follow-up criteria post repair. Standardized assessments of patient-ranked shoulder pain and function and shoulder strength and passive range of motion (ROM) were performed preoperatively and at follow-up visits. Radiographs and ultrasonography were used to evaluate repair integrity, measure proximal humeral head migration, and determine glenohumeral arthritis scores. Results: Forty-one shoulders formed the study cohort at a mean follow-up period of 5 years (range: 2-19 years). The mean age of this group was 72 (standard deviation: 10; range: 50-88) and had 14 cm2 tears at surgery. Twenty-five of 41 (61%) PTFE interposition patch repairs remained intact at an average of 5 years postrepair. Thirteen patches failed at the patch-tendon junction, 1 was removed, and 2 patients underwent reverse total shoulder replacement. Patient-ranked shoulder stiffness (P < .05), frequency of pain during activity and sleep (P < .001), pain levels during overhead activity and rest (P < .001), and overall shoulder function significantly improved from bad preoperatively to fair at the mean 5-year postoperative visit (P < .001). No significant improvements were demonstrated in dynamometer-measured shoulder strength maneuvers and passive ROM. All patients demonstrated proximal humeral head migration on shoulder radiographs regardless of repair integrity (mean Upper Migration Index = 1.2). Failed repairs were associated with higher mean preoperative glenohumeral arthritis grades compared with intact repairs (grade 2 in failed repairs compared with grade 1 in intact repairs) (P < .01). Conclusion: PTFE interposition patch repairs for massive and irreparable tears had good construct integrity and clinical outcomes at 2 years. These outcomes were not maintained. PTFE patch repairs often failed at the patch-tendon junction at 4 years and beyond and were ineffective in (1) preventing proximal humeral head migration, (2) stopping progression of glenohumeral arthritis, and (3) improving shoulder strength and ROM.

Arthroscopic rotator cuff repairs have been reported to take between 72 and 113 min to complete. This team has adopted its practice to reduce rotator cuff repair times. We aimed to determine (1) what factors reduced operative time, and (2) whether arthroscopic rotator cuff repairs could be performed in under 5 min. Consecutive rotator cuff repairs were filmed with the intent of capturing a <5-min repair. A retrospective analysis of prospectively collected data of 2232 patients who underwent primary arthroscopic rotator cuff repair by a single surgeon was performed using Spearman’s correlations and multiple linear regression. Cohen’s f2 values were calculated to quantify effect size. Video footage of a 4-min arthroscopic repair was captured on the 4th case. Backwards stepwise multivariate linear regression found that an undersurface repair technique (f2 = 0.08, p < 0.001), fewer surgical anchors (f2 = 0.06, p < 0.001), more recent case number (f2 = 0.01, p < 0.001), smaller tear size (f2 = 0.01, p < 0.001), increased assistant case number (f2 = 0.01, p < 0.001), female sex (f2 = 0.004, p < 0.001), higher repair quality ranking (f2 = 0.006, p < 0.001) and private hospital (f2 = 0.005, p < 0.001) were independently associated with a faster operative time. Use of the undersurface repair technique, reduced anchor number, smaller tear size, increased surgeon and assistant surgeon case number, performing repairs in a private hospital and female sex independently lowered operative time. A <5-min repair was captured.

BACKGROUND:Postoperative stiffness affects up to 20% of patients following arthroscopic rotator cuff repair. Recent evidence indicates that early postoperative stiffness may associated with lower retear rates. This study aimed to identify the independent predictors of early postoperative stiffness. METHODS:A retrospective cohort study of 1526 rotator cuff repairs was performed. Range of motion at 6-week postop was used to identify stiff patients. Stiffness was defined as external rotation <27.5o or forward flexion <145o . Multiple logistic regression analysis was used to identify the independent predictors of 6-week stiffness. RESULTS:The independent predictors for external rotation stiffness at 6-week postop were more recent cases (Wald = 60), restricted preoperative external rotation (Wald = 36), younger age (Wald = 21) and poorer surgeon-ranked tissue quality (Wald = 15). The independent predictors for forward flexion stiffness were more recent cases (Wald = 101), restricted preoperative forward flexion (Wald = 16) and external rotation (Wald = 13) and female patients (Wald = 12). All patients that developed early postoperative stiffness had recovered range of motion by 6 months to preoperative levels (P < 0.0001). A significantly greater proportion of younger patients (40-49) developed postoperative stiffness when compared to older patients aged 50-59 (P < 0.0062), 70-79 (P < 0.0126) and 80-89 (P < 0.004). Patients that retore had significantly greater average 6-week postoperative range of motion. CONCLUSIONS:Patients earlier in the study were found to have greater postoperative range of motion, which coincided with a more aggressive rehabilitation program with less immobilization. Thus, the data supports the hypothesis that a temporary period of shoulder stiffness facilitates tendon repair and ultimately a better outcome post rotator cuff repair.

OBJECTIVES:How the material properties of the human supraspinatus tendon change following arthroscopic rotator cuff repair is undetermined. Shear wave elastography ultrasound is a relatively new, noninvasive measure of tissue stiffness. We aimed to evaluate any temporal changes in stiffness and/or thickness of supraspinatus tendons in humans following primary arthroscopic rotator cuff repair.METHODS:Shear wave elastography was performed at three predetermined regions by a single sonographer at 1-, 6-, 12-, 24-, and 52 weeks postoperatively in 50 consecutive single-row inverted mattress primary arthroscopic rotator cuff repairs. One-way ANOVA with Tukey's correction and Spearman's correlation tests was performed.RESULTS:Of 50 patients, two retore by 1-week and were excluded. Two patients retore at 6 weeks, two at 12 weeks, and one at 24 weeks. The mean tendon stiffness in 48 patients at the tendon footprint increased by 21% (1.32 m/s) at 6 months (P < .001), with the lateral tendon stiffening before the medial tendon. Tendon thickness decreased by 11% (0.6 mm) at 6 weeks (P = .008), then stabilized to 24 weeks. Tendons that were less elastographically stiff at 1 week were more likely to be thinner at 6-weeks (r = .38, P = .010).CONCLUSIONS:The data supports the hypothesis that rotator cuff tendons repaired using the single-row inverted-mattress technique take 6 weeks to heal to bone. Unlike in other tendons, there was no hypertrophic healing response. Prior to 6 weeks, the tendon may stretch/thin-out, particularly if its material properties, as assessed by shear wave elastography, are inferior. The material properties of the tendon improved at the tendon insertion site first, then medially out to 12 months post-repair.

Background: Ultrasound is commonly used to assess rotator cuff repair (RCR), but no standardized criterion exists to characterize the tendon.Purpose: The aims of this study were to (1) develop content validity for ultrasound specific criteria to grade the postoperative appear-ance of a tendon after RCR, (2) assess the reliability of the criteria, and (3) assess the feasibility to use these assessments.Methodology: Following expert consultation and literature review for content validity, 2 scales were created: 1) the Fibrillar matrix, Echogenicity, Contour, Thickness, and Suture (FECTS) scale and 2) the Rotator Cuff Repair-Investigator Global Assessment (RCR-IGA). A prospective cohort study was undertaken on patients who had received a RCR and serial B-mode ultrasound images. Four raters assessed the 64-ultrasound images using the scales created in a blinded fashion using intraclass correlation coefficients.Results: The FECTS scale was a composite score with 5 key parameters and the RCR-IGA scale was a 5-point global score. The intra-rater reliability for the FECTS scale was excellent for the most experienced rater (0.92) and fair for the rater with no experience (0.72). The intrarater reliability for the RCR-IGA scale was excellent for 3 of the 4 raters (0.80-0.87) and fair when used by the least experi-enced rater (0.56). Inter-rater testing for all the FECTS scale parameters had excellent reliability (0.82-0.92) except for Fibrillar matrix (0.73). The average time to complete the FECTS scale per image was 23 seconds and 11 seconds for the RCR-IGA scale.Conclusion: The FECTS scale and the RCR-IGA scale are reliable tools to assess the ultrasonic appearance of the repaired rotator cuff tendon. The FECTS scale was more reliable for less experienced assessors. The RCR-IGA scale was easier, more time efficient and reliable for those with experience.Level of evidence: Basic Science Study; Development and Validation of Classification System (c) 2022 Journal of Shoulder and Elbow Board of Trustees. All reserved.

It is undetermined which factors predict return to work following arthroscopic rotator cuff repair. We aimed to identify which factors predicted return to work at any level, and return to pre-injury levels of work 6 months post-arthroscopic rotator cuff repair. Multiple logistic regression analysis of prospectively collected demographic, pre-injury, preoperative, and intraoperative data from 1502 consecutive primary arthroscopic rotator cuff repairs, performed by a single surgeon, was performed to identify independent predictors of return to work, and return to pre-injury levels of work respectively, 6 months post-surgery. Six months post-rotator cuff repair, 76% of patients returned to work (RTW), and 40% returned to pre-injury levels of work (Full-RTW). RTW at 6 months was likely if patients were still working after their injuries, but prior to surgery (Wald statistic [W]=55, p<0.0001), were stronger in internal rotation preoperatively (W=8, p=0.004), had full-thickness tears (W=9, p=0.002), and were female (W=5, p=0.030). Patients who achieved Full-RTW were likely to have worked less strenuously pre-injury (W=173, p<0.0001), worked more strenuously post-injury but pre-surgery (W=22, p<0.0001), had greater behind-the-back lift-off strength preoperatively (W=8, p=0.004), and had less passive external rotation range of motion preoperatively (W=5, p=0.034). Patients who were still working post-injury, but pre-surgery were 1.6-times more likely to RTW than patients who were not (p<0.0001). Patients who nominated their pre-injury level of work as “light” were 11-times more likely to achieve Full-RTW than those who nominated “strenuous” (p<0.0001). Six months post-rotator cuff repair, a higher patient-rated post-injury, but pre-surgery level of work was the strongest predictor of RTW. A lower patient-rated pre-injury level of work was the strongest predictor of Full-RTW. Greater preoperative subscapularis strength independently predicted both RTW, and Full-RTW.

Background:The most common complication of arthroscopic rotator cuff repair is retear, which is more common in larger tears and older patients. We hypothesized that the quality of the torn tendon is important in protecting against retear. Surgeons have traditionally assessed the quality of repaired tendons with a four-point Likert scale. Shear Wave Elastography Ultrasound (SWEUS) is a recent technological advancement that can quantify soft-tissue stiffness. This study aimed to determine how closely a surgeon's intraoperative ranking of tissue quality during rotator cuff repair correlated to postoperative supraspinatus tendon stiffness measured by SWEUS.Methods:This was a prospective case series on 50 patients undergoing arthroscopic rotator cuff repair, involving SWEUS measurements of each patient's supraspinatus tendon at 8 days, 6 weeks, 12 weeks, 6 months, and 12 months. The intraoperative surgeon score of tissue quality for each patient was ranked on a four-point Likert scale. Each patient's scores were compared to postoperative SWEUS velocity measurements of the supraspinatus tendon postrepair.Results:The SWEUS determined stiffness of supraspinatus tendons at their repaired insertion site postrepair increased by 22% from 6.3 ± 0.2 m/s to 7.7 ± 0.3 m/s over 12 months as the tendons healed (P = .0001). Supraspinatus tendon stiffness was greater in patients with smaller tears (r = -0.50, P = .001) and of younger age (r = -0.58, P = .00001). Surgeons also consistently rated younger patients (rs = -0.49, P = .0001) and smaller tears (rs = -0.56, P = .00001) as having superior intraoperative tendon quality. The correlations between SWEUS velocity and surgeon tissue quality rankings were modest at best and strongest at 12 weeks (rs = 0.27, P = .04). There were modest associations between SWEUS tendon stiffness and surgeon tendon mobility rankings at 6 weeks (rs = 0.26, P = .04) and repair quality rankings at 12 months (rs = 0.36, P = .02).Conclusions:These data support the finding that machines (SWEUS) are better at assessing torn rotator cuff tendon quality and whether that tendon will heal after repair than the 'person' performing the surgery. Supraspinatus tendons lose stiffness as they get older and when the tear is larger, likely explaining why retear post-cuff repair is more common with advanced age and larger tears.

BACKGROUND:The main complication of rotator cuff repair is retear, which is most common in older patients and patients with greater tear sizes. However, it is unknown why these factors are associated with increased rates of retear. The aim of this study was to determine whether the factors associated with rotator cuff retear (age, tear size, sex, history of trauma, and duration of symptoms) are also associated with decreased mechanical stiffness of the supraspinatus tendon after repair, as assessed by shear wave elastography. METHODS:This was a prospective study of 50 patients undergoing primary rotator cuff repair. A sonographer conducted shear wave elastography ultrasound in all patients at 1, 6, 12, 26, and 52 weeks after repair. The shear wave velocity of the supraspinatus tendon was measured at the tendon-bone interface, 3 mm medial to the interface, and 6 mm medial to the interface. A multiple linear regression analysis was performed with calculation of Cohen F2 values to determine the factors that independently affected supraspinatus tendon stiffness postoperatively. RESULTS:For every decade increase in age, the shear wave velocity of the supraspinatus tendon decreased by 0.5 m/s (P = .004). Greater tear size correlated with reduced supraspinatus shear wave velocity (P < .03 at 6 weeks). Male patients had greater supraspinatus tendon stiffness than female patients (8.2 m/s vs. 6.9 m/s, P = .04). Tendons in patients with a history of trauma were approximately 16% stiffer postoperatively than those in patients with no trauma history (P < .001). Duration of symptoms had no impact on the mechanical stiffness of the supraspinatus tendon. CONCLUSION:Older age, larger tear size, female sex, and nontraumatic tear causation were independently associated with reduced shear wave velocity of the supraspinatus tendon postoperatively. The findings of our study correlate with the results of cohort studies assessing the influence of these variables on rotator cuff retear rates, suggesting that the mechanical stiffness of the supraspinatus tendon, as assessed by shear wave elastography, may have an important association with a successful repair.

BACKGROUND:Pain is a common presentation after glenohumeral labral injuries. However, the source of that pain is undetermined.PURPOSE/HYPOTHESIS:We aimed to determine if there is a differential expression of nerve fibers around the glenoid labrum and if torn labra have increased neuronal expression compared with untorn labra (rotator cuff repair labra). We hypothesized that the superior labrum would have a higher concentration of neurofilament than would the rest of the labrum and that the concentration of neurofilament would increase at the site of a labral tear.STUDY DESIGN:Descriptive laboratory study.METHODS:Seven labra were sampled at the 3-, 5-, 9-, and 12-o'clock positions during total shoulder arthroplasty. Samples were also collected at the 3-, 5-, and 12-o'clock positions during rotator cuff repair (16 labra), anterior labral repair (6 labra), type II superior labral anterior to posterior (SLAP) repair (4 labra), and capsular release for idiopathic capsulitis (5 labra). Sections were immunostained with antibodies to neurofilament, a specific neuronal marker that is used to identify central and peripheral nerve fibers, and the concentration and intensity of immunostained-positive cells assessed.RESULTS:The concentration of neurofilament staining was similar in the superior, anterior, posterior, and inferior glenoid labrum in untorn labra (8 neurofilament expressing cells per square millimeter; P = .3). Torn labra exhibited a 3- to 4-fold increase in neuronal expression, which was isolated to the location of the tear in SLAP (P = .09) and anterior labral tears (P = .02). The concentration of neurofilament expressing cells in torn glenoid labrum samples was comparable that in with the glenoid labrum of adhesive capsulitis samples (P = .7).CONCLUSION:This study supports the hypothesis that after a tear of the anterior or superior labrum the labrum in that region becomes populated with new nerves fibers and that these fibers may be responsible for the pain noted by patients with superior (SLAP) and/or anterior labral (Bankart) tears.CLINICAL RELEVANCE:This study suggests that neural infiltration contributes to the pain experienced by patients with labral tears. It may help with patient education and direct future management of labral lesions.

Background: It is undetermined which factors predict return to work after arthroscopic rotator cuff repair. Purpose: To identify which factors predicted return to work at any level and return to preinjury levels of work 6 months after arthroscopic rotator cuff repair. Study Design: Case-control study; Level of evidence, 3. Methods: Multiple logistic regression analysis of prospectively collected descriptive, preinjury, preoperative, and intraoperative data from 1502 consecutive primary arthroscopic rotator cuff repairs, performed by a single surgeon, was performed to identify independent predictors of return to work at 6 months postoperatively. Results: Six months after arthroscopic rotator cuff repair, 76% of patients had returned to work, and 40% had returned to preinjury levels of work. Return to work at 6 months was likely if patients were still working after their injuries but before surgery (Wald statistic [W] = 55, P < .0001), were stronger in internal rotation preoperatively (W = 8, P = .004), had full-thickness tears (W = 9, P = .002), and were female (W = 5, P = .030). Patients who continued working postinjury but presurgery were 1.6 times more likely to return to work at any level at 6 months compared to patients who were not working ( P < .0001). Patients who had a less strenuous preinjury level of work (W = 173, P < .0001), worked at a mild to moderate level post injury but presurgery, had greater preoperative behind-the-back lift-off strength (W = 8, P = .004), and had less preoperative passive external rotation range of motion (W = 5, P = .034) were more likely to return to preinjury levels of work at 6 months postoperatively. Specifically, patients who worked at a mild to moderate level postinjury but presurgery were 2.5 times more likely to return to work than patients who were not working, or who were working strenuously postinjury but presurgery ( p < 0.0001). Patients who nominated their preinjury level of work as “light” were 11 times more likely to return to preinjury levels of work at 6 months compared to those who nominated it as “strenuous” ( P < .0001). Conclusion: Six months after rotator cuff repair, patients who continued to work after injury but presurgery were the most likely to return to work at any level, and patients who had less strenuous preinjury levels of work were the most likely to return to their preinjury levels of work. Greater preoperative subscapularis strength independently predicted return to work at any level and to preinjury levels.

BACKGROUND:Superior capsular reconstruction (SCR) for massive, irreparable rotator cuff tears involves anchoring a graft between the superior glenoid and the greater tuberosity of the humerus. Optimizing the graft size is important. We aimed (1) to evaluate the reliability of plain film radiography in determining graft size for SCR and (2) to create a database to help predict future graft sizes.METHODS:An inter- and intra-rater reliability trial was conducted on 10 and 6 subjects with healthy shoulders, respectively, using plain film radiography to measure the distance between the superior glenoid and the supraspinatus footprint. The subjects were positioned upright with an abduction pillow modified to hold the shoulder at 30° abduction and 45° external rotation, afterwhich a true antero-posterior shoulder radiograph was captured. Thirty subjects were recruited for the database and grouped using the aforementioned protocol.RESULTS:The inter-rater and intra-rater trial agreement was excellent, with intraclass correlation coefficients of 0.94 (95% CI) and 0.76 (95% CI), respectively. Three medio-lateral patch sizes, of 33 mm, 38 mm, and 47 mm, were proposed based on the protocol in 30 subjects.CONCLUSIONS:Plain film radiography demonstrated excellent reliability in measuring the distance between the superior glenoid and the supraspinatus footprint. Three ordinal patch sizes are proposed.

Background:The addition of onlay biological grafts to augment difficult rotator cuff repairs has shown encouraging results in a case series. Purpose/Hypothesis:The purpose of this study was to determine whether the addition of an onlay bioinductive implant would improve repair integrity, shear wave elastographic appearance of the repaired tendon and patch, and patient-rated and/or surgeon-measured shoulder function when used in workers' compensation patients undergoing revision arthroscopic rotator cuff repair. We hypothesized that the addition of the bioinductive implant would enhance repair integrity and clinical outcomes compared with standard repair. Study Design:Cohort study; Level of evidence, 3. Methods:A post hoc matched-cohort study was conducted on prospectively recruited workers' compensation patients who received a bioinductive implant for revision rotator cuff repair (n = 19). The control group was selected from consecutive workers' compensation revision rotator cuff repair patients before the introduction of bioinductive implants. Then, they were matched for age and tear size (n = 32). Kaplan-Meier curves were generated to compare the primary outcome of repair integrity between groups. The secondary outcomes were to evaluate the elastographic appearance of the tendon and patch in the bioinductive implant group and to compare patient-rated and surgeon-measured shoulder function between groups preoperatively and at 1 week, 6 weeks, 3 months, and 6 months postoperatively. Results:No major complications associated with the bioinductive implants were identified. Six months after the revision rotator cuff repair, the retear rate in the bioinductive implant group was 16% (3/19), compared with 19% (6/32) in the age- and tear size-matched control group (P = .458). At the final follow-up, the retear rate in the bioinductive implant group was 47% (9/19) at a mean of 14 months compared with 38% (12/32) at a mean of 29 months in the control group (P = .489). The shear wave elastographic stiffness of repaired tendons augmented with the bioinductive implant remained unchanged at 6 m/s from 1 week to 6 months postoperatively, which is lower than the stiffness of 10 m/s in healthy tendons. There were no significant differences in patient-rated or surgeon-measured outcomes between groups 6 months postoperatively. Conclusion:There were no differences in repair integrity or clinical outcomes between workers' compensation patients who underwent revision arthroscopic rotator cuff repair with an onlay bioinductive implant compared to those who underwent standard revision rotator cuff repair.

BACKGROUND:Interposition graft rotator cuff repair is one option for the treatment of massive, otherwise irreparable rotator cuff tears. It is undetermined how different suturing techniques influence morphology at the patch-tendon interface in interposition rotator cuff repairs, particularly with respect to increased cross-sectional area at the repair site post-exposure to cyclic loading, which may influence healing. We aimed to analyze how the morphology of the grafts used in polytetrafluoroethylene (PTFE) interposition rotator cuff repairs differed according to whether the graft was secured using the multiple mattress technique or the weave technique respectively.METHODS:Twelve PTFE interposition rotator cuff repairs (two groups, n = 6) were cyclically loaded. The thickness, width, cross-sectional area at the individual patches and at the repair site, and patch elongation were compared between repairs using the 'multiple mattress' technique and repairs that used the 'weave' technique.RESULTS:At all loads, repair site cross-sectional area and thickness was greater in the weave group than in the multiple mattress group (P<0.05), despite repair site width being greater in the multiple mattress group (P<0.05). No significant differences in elongation were found between the multiple mattress and weave groups.CONCLUSION:Greater repair site cross-sectional area under cyclic loading was observed in polytetrafluoroethylene interposition rotator repairs that used the weave technique than in those that used the multiple mattress technique. Increased repair site cross-sectional area in the weave group occurred due to increased thickness and decreased width relative to the multiple mattress group. No differences in cross-sectional area were found between groups at the individual patches.

Objectives: Pain is a common presentation following glenohumeral labral injuries. However, the source of that pain is undetermined. We aimed to determine if there is a differential expression of nerve fibres around the glenoid labrum and if torn labra have increased neuronal expression compared to untorn labra. Methods: Labral tissue was collected at 3, 5, 9 and 12 o clock during total shoulder arthroplasty (n = 7). Samples were also collected at 3, 5 and 12 o clock during rotator cuff repair (n = 16), anterior labral repair (n = 6), type II superior labral anterior to posterior (SLAP) repair (n = 4) and capsular release for idiopathic capsulitis (n = 5). Sections were immunostained with antibodies to neurofilament, a specific neuronal marker which is used to identify central and peripheral nerve fibres, and the concentration and intensity of immunostained-positive cells assessed. Results: The concentration of neurofilament staining was similar in the superior, anterior, posterior and inferior glenoid labrum in untorn labra (8 neurofilament expressing cells/mm2, p > 0.05). Torn labra exhibited a 3-4-fold increase in neuronal expression which was isolated to the location of the tear in SLAP (p = 0.09) and anterior labral tears (p = 0.02). The concentration of neurofilament expressing cells in torn glenoid labrum samples were comparable to the glenoid labrum of adhesive capsulitis samples (p > 0.05). Figure 3. Mean (SD) neurofilament expressing cells per mm2 at 12 o’clock (A), 3 o’clock (B) and 5 o’clock (C) using labral tissue from patients with either a; RCT (n = 16), anterior labral tear (n = 6), SLAP tear (n = 4) or a frozen shoulder (n = 5). *p <0.05 compared using a one-way ANOVA with post-hoc analysis. Conclusions: This study supports the hypothesis that following a traumatic tear of the anterior or superior labrum, the labrum in that region becomes populated with new nerves fibres and that these fibres are likely to be responsible for many of the symptoms noted by patients with superior (SLAP) and/or anterior labral (Bankart) tears.