Understanding patient-specific factors that influence postoperative outcomes and failure rates following rotator cuff repair is crucial for surgeons to tailor individualized treatments. The purpose of this umbrella review was to identify preoperatively measurable factors that influence the risk of retear and functional outcomes following rotator cuff repair (RCR). Additionally, the study aimed to evaluate the quality of evidence from systematic reviews and meta-analyses to provide a comprehensive understanding of these predictive factors. A systematic search of the MEDLINE database via PubMed was conducted to identify systematic reviews and meta-analyses reporting preoperatively measurable factors affecting functional outcomes and failure rates following arthroscopic rotator cuff repair. The methodological quality of included reviews was assessed using the AMSTAR checklist. Data synthesis summarized key risk factors, quantified study overlap via Corrected Covered Area (CCA), and examined heterogeneity and publication bias when reported in the reviews. Twenty-three systematic reviews, including 11 meta-analyses, met the inclusion criteria, yielding a CCA of 0.403, which reflects moderate overlap. The average AMSTAR score was 7.57, indicating moderate methodological quality. However, only a few reviews included analyses of heterogeneity or publication bias, and the evidence presented was often contradictory. Meta-analyses revealed statistically significant associations between higher retear rates and factors such as advanced age, reduced bone mineral density, elevated body mass index, diabetes, shorter acromiohumeral interval, increased critical shoulder angle, involvement of multiple tendons, greater tendon retraction, longer symptom duration, larger tear size, poor tissue quality, and greater distance from the musculotendinous junction to the glenoid. Genetic analyses provided moderate to strong evidence linking healing failure to mutations in the matrix metallopeptidase 3 (MMP3) and Tenascin C (TNC) genes, as well as a single nucleotide polymorphism (SNP) in the Estrogen Related Receptor β (ESRRβ) gene. Improved tendon healing was associated with the upregulation of the growth factor Bone Morphogenetic Protein 5 (BMP5) and increased expression of collagen type III (COL3). High preoperative expectations consistently correlated with better functional outcomes, whereas other psychological factors, such as concerns and fear avoidance, were associated with poorer outcomes. Evidence synthesized in this review underscores the importance of patient age, expectations, and the extent of the rotator cuff tear in influencing outcomes following rotator cuff repair. These factors should be carefully considered in treatment planning for patients undergoing rotator cuff repair.

There is currently no consensus on which rehabilitation regimen is preferable for which patients after rotator cuff repair (RCR). The aim of this study was to evaluate which preoperatively measurable factors are considered relevant by experts of the German, Austrian and Swiss Shoulder and Elbow Society (DVSE) in choosing a rehabilitation plan after RCR. Members of the DVSE who had gained expert status in the society were queried via an online questionnaire. The survey consisted of 23 preoperatively measurable sociodemographic, patient-specific, and shoulder-specific factors that had been identified in a previous literature review. The experts were asked to assess each factor as either relevant in favor of choosing a progressive rehabilitation plan, relevant in favor of choosing a regressive rehabilitation plan, or irrelevant in their decision-making process. A total of 61 experts completed the entire survey. Active smoking status, older age, diabetes mellitus, pseudoparalysis, increased tendon retraction, greater tear size, high degree of fatty infiltration, tendon delamination, and involvement of more than one tendon were selected by the majority of the participants as relevant in favor of a regressive rehabilitation protocol. Shoulder stiffness was the only factor selected by the majority as relevant in favor of a progressive rehabilitation protocol. Active smoking status, older age, diabetes mellitus, pseudoparalysis, increased tendon retraction, greater tear size, high degree of fatty infiltration, tendon delamination, and involvement of more than one tendon were viewed as relevant factors in favor of a regressive rehabilitation protocol, while shoulder stiffness was viewed as the only relevant factor in favor of a progressive rehabilitation protocol. Shoulder surgeons should consider these factors when deciding on rehabilitation after RCR.

This article summarizes the current treatment approaches and concepts for the rehabilitation of the upper extremities. In recent years there have been new and innovative changes that more adequately address the complexity of mobility, strength, and stability. Rehabilitation is becoming increasingly more important in prevention and plays a significant role in the clinical results. In the same context, scientific interest and research in this area are also increasing. In addition to the classical pillars and content focus of follow-up treatment, criteria-based programs are particularly prominent. Hence, the fundamental principles and objectives of these approaches are discussed in detail. Furthermore, the article highlights the possibilities for testing strength and movement analysis for objective evaluation of the outcome, with the goal of individualized clearance for return to sport based on current scientific data.

Background The extent of fatty infiltration and rotator cuff (RC) atrophy is crucial for the clinical results after rotator cuff repair (RCR). The purpose of this study was to evaluate changes in fatty infiltration and RC atrophy after revision RCR and to correlate them with functional outcome parameters. Methods Patients who underwent arthroscopic revision RCR for symptomatic recurrent full-thickness tear of the supraspinatus tendon between 2008 and 2014 and were retrospectively reviewed with a minimum follow up of 2 years. Magnetic resonance imaging (MRI) was performed pre- and postoperatively to assess 1) tendon integrity after revision RCR according to Sugaya classification, (2) RC atrophy according to Thomazeau classification, and (3) fatty infiltration according to Fuchs MRI classification. Constant score (CS) and the American Shoulder and Elbow Surgeon (ASES) score were used to correlate functional outcome, tendon integrity, and muscle degeneration. Results 19 patients (17 males and 2 females) with a mean age of 57.5 years (range, 34 to 72) were included into the study at a mean follow-up of 50.3 months (range, 24 – 101). At final evaluation, 9 patients (47%) presented with intact RCR and 10 patients (53%) suffered a re-tear after revision repair. No progress of fatty infiltration was observed postoperatively in the group with intact RC, atrophy progressed in only 1 out of 9 patient (11%). Fatty infiltration progressed in 5/10 patients (50%) and RC atrophy increased in 2/10 patients (20%) within the re-tear group. CS (42.7 ± 17.7 preop, 65.2 ± 20.1 postop) and ASES (47.7 ± 17.2 preop, 75.4 ± 23.7 postop) improved significantly from pre- to postoperatively ( p < 0.001). A positive correlation between fatty infiltration and RC integrity was detected (r = 0.77, p < 0.01). No correlation between clinical outcome and tendon integrity or RC atrophy was observed. Conclusion Arthroscopic revision RCR leads to reliable functional outcomes even in case of a recurrent RC retear. An intact RCR maintains the preoperative state of fatty infiltration and muscle atrophy but does not lead to muscle regeneration. Level of evidence Level IV; Therapeutic study.

Im folgenden Beitrag werden die aktuellen Therapieansätze und Konzepte der Rehabilitation der oberen Extremität zusammengefasst. Hier gab es in den letzten Jahren neue und innovative Änderungen, die der Komplexität aus Beweglichkeit, Kraft und Stabilität gerecht werden. Die Rehabilitation bekommt einen zunehmend höheren Stellenwert in der Prävention und ist maßgeblich am klinischen Ergebnis beteiligt. Im selben Zusammenhang steigen auch das wissenschaftliche Interesse und die Aufarbeitung. Neben den klassischen Säulen und inhaltlichen Schwerpunkten der Nachbehandlung stehen v. a. kriterienbasierte Programme im Vordergrund. Diese werden detailliert dargestellt und die jeweiligen Grundlagen und Ziele besprochen. Weiter werden die Möglichkeiten der Überprüfung durch spezifische Testabläufe für Kraft und Bewegungsanalysen zur Objektivierbarkeit des Ergebnisses aufgezeigt, mit dem Ziel der individuelle Return-to-Sport-Freigabe anhand der aktuellen wissenschaftlichen Datenlage.

To determine specific return to sports (RTS) and return to work (RTW) rates of patients with septic arthritis following anterior cruciate ligament reconstruction (ACLR), and to assess for factors associated with a diminished postoperative return to physical activity after successful eradication of the infection. In this study, patients who were treated for postoperative septic arthritis of the knee following anterior cruciate ligament reconstruction between 2006 and 2018 were evaluated at a minimum follow-up (FU) of 2 years. Patients’ outcomes were retrospectively analyzed using standardized patient-reported outcome scores including the Lysholm score and the subjective IKDC score, as well as return to sports and return to work questionnaires to assess for the types, number, and frequency of sports performed pre- and postoperatively and to evaluate for potential occupational changes due to septic arthritis following ACLR. To assess for the signifiance of the graft at follow-up, outcomes were compared between patients with a functioning graft at FU and those without, as well as between patients with initial graft retention and those with graft removal and consecutive revision ACLR. Out of 44 patients eligible for inclusion, 38 (86%) patients at a mean age of 36.2 ± 10.3 years were enrolled in this study. At a mean follow-up of 60.3 ± 39.9 months, the Lysholm score and the subjective IKDC score reached 80.0 ± 15.1 and 78.2 ± 16.6 points, respectively. The presence of a graft at FU yielded statistically superior results only on the IKDC score (p = 0.014). There were no statistically significant differences on the Lysholm score (n.s.) or on the IKDC score (n.s.) between patients with initial graft retention and those with initial removal who had undergone revision ACLR. All of the included 38 patients were able to return to sports at a median time of 8 (6–16) months after their last surgical intervention. Among patients who performed pivoting sports prior to their injury, 23 (62.2%) returned to at least one pivoting sport postoperatively. Overall, ten patients (26.3%) returned to all their previous sports at their previous frequency. The presence of a graft at FU resulted in a significantly higher RTS rate (p = 0.010). Comparing patients with initial graft retention and those with graft removal and consecutive revision ACLR, there was no statistically significant difference concerning the RTS rate (n.s.). Thirty-one patients (83.8%) were able to return to their previous work. Successful eradication of septic arthritis following anterior cruciate ligament reconstruction allows for a postoperative return to sports and a return to work particularly among patients with ACL-sufficient knees. However, the patients’ expectations should be managed carefully, as overall return rates at the pre-injury frequency are relatively low. IV.

To determine the sensorimotor and clinical function of patients with confirmed successful outcome after either undergoing acromioclavicular joint (ACJ) stabilization, Bankart repair (BR), or rotator cuff repair (RC), and to compare these measures to the contralateral, healthy side without history of previous injuries or surgeries of the upper extremity. It was hypothesized that patients of each interventional group would have inferior sensorimotor function of the shoulder joint compared to the contralateral, healthy side, while presenting with successful clinical and functional outcomes. Three intervention groups including ten patients who had confirmed successful clinical and functional outcomes after either undergoing ACJ stabilization, BR, or RC were evaluated postoperatively at an average follow-up of 31.7 ± 11.6 months. Additionally, a healthy control group (CG) of ten patients was included. Clinical outcomes were assessed using the Constant–Murley (CM) and American Shoulder and Elbow Surgeons (ASES) Score. Pain was evaluated using the visual analogue scale (VAS). Sensorimotor function was assessed by determining the center of pressure (COP) of the shoulder joint in a one-handed support task in supine position on a validated pressure plate. Each interventional group demonstrated excellent clinical outcome scores including the CM Score (ACJ 83.3 ± 11.8; BR 89.0 ± 10.3; RC 81.4 ± 8.8), ASES Score (ACJ 95.5 ± 7.0; BR 92.5 ± 9.6; RC 96.5 ± 5.2), and VAS (ACJ 0.5 ± 0.9; BR 0.5 ± 0.8; RC 0.5 ± 0.8). Overall, the CG showed no significant side-to-side difference in COP, whereas the ACJ-group and the BR-group demonstrated significantly increased COP compared to the healthy side (ACJ 103 cm vs. 98 cm, p = 0.049; BR: 116 cm vs. 102 cm, p = 0.006). The RC-group revealed no significant side-to-side difference (120 cm vs. 108 cm, n.s.). Centre of pressure measurement detected sensorimotor functional deficits following surgical treatment of the shoulder joint in patients with confirmed successful clinical and functional outcomes. This may indicate that specific postoperative training and rehabilitation protocols should be established for patients who underwent surgery of the upper extremity. These results underline that sensorimotor training should be an important component of postoperative rehabilitation and physiotherapeutic activities to improve postoperative function and joint control. IV.

To show descriptive clinical and magnetic resonance (MR) imaging results after an additional periosteal flap augmentation in mini-open rotator cuff reconstruction and to evaluate potential healing improvement at long-term follow-up. Twenty-three patients with degenerative rotator cuff tears were followed after receiving a mini-open single-row repair with a subtendinous periosteal flap augmentation. Data were collected preoperatively, after 12 months and after 11 years. Clinical examination, simple shoulder test (SST), Constant–Murley Score (CS), ultrasonography examination and 3T MR imaging were performed. Out of 23 patients, 20 were available for short-term and 19 for final follow-up at a median of 11.5 years (range 10.4–13.0). Questions answered with “yes” in SST improved from baseline 5.0 (range 1.0–8.0) to short 10.5 (range 8.0–12.0) and final follow-up 12.0 (range 7.0–12.0). CS improved from 53.5 (range 25.0–66.0) to 80.8 (range 75.9–89.3) and finally to 79.8 points (range 42.3–95.4). Improvement was highly significant (p < 0.05). Severe retears were found in 9/19 patients. Ossifications along the refixed tendon were noticed in 8/19 cases. Ossifications did not correlate with clinical outcome. At final follow-up, patients with retears seemed likely to have lower strength values in CS (mean ± SD) than patients without retears (7.3 ± 4.1 vs. 12.8 ± 5.3; p < 0.05). No positive effect on improving healing response in rotator cuff refixation with a periosteal flap augmentation could be found. Retear rate is comparable to that of conventional rotator cuff refixation in the published literature. Ossifications along the tendon, without negatively affecting the clinical outcome, were seen. This invasive technique cannot be advised and should not be used anymore. IV.

Reverse shoulder arthroplasty (RSA) shows a growing number of implantations and is a valuable option to improve shoulder function and decrease pain. However, there is no consensus concerning the rehabilitation protocol following surgery. To review and evaluate current rehabilitation contents and protocols after RSA by reviewing the existing scientific literature and providing an overview of the clinical practice of selected German Society of Shoulder and Elbow Surgery (Deutsche Vereinigung für Schulter- und Ellenbogenchirurgie e. V., DVSE) shoulder experts. A literature search for the years 1989–2016 was conducted in relevant databases and bibliographies including the Guidelines International Network, National Guidelines, PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and the Physiotherapy Evidence Database. In addition, 63 DVSE experts were contacted via an online questionnaire. Since no level I/II studies on postoperative protocols after RSA were found, the 856 hits were searched by the committee members and sorted according to the topics “rehabilitation”, “complications”, “clinical outcome studies”, “basic science”, “reviews” and “miscellaneous”. Additionally, survey results were analyzed and compared to the literature. The comparison between literature recommendation and expert survey showed agreement according principal aspects (e.g. brace/sling, immobilization, passive exercises). Based on the literature and the expert opinions obtained, a four-phase rehabilitation protocol could be developed.

Background: The retear rate after primary rotator cuff (RC) reconstruction is high and commonly leads to poorer clinical outcomes and shoulder function. In the case of primary failure, revision RC reconstruction (RCR) has become increasingly important to re-create RC integrity and improve outcomes. To date, clinical and structural outcomes after RCR have not been sufficiently investigated and described at midterm follow-up. Hypothesis/Purpose: The purpose was to evaluate the clinical and radiological outcomes after revision RCR. It was hypothesized that revision RCR significantly improves clinical outcomes and that the outcomes positively correlate with tendon integrity on magnetic resonance imaging (MRI). Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent revision RCR between 2008 and 2014 were retrospectively evaluated with a minimum follow-up of 2 years. Outcomes were assessed by a clinical examination, a visual analog scale for pain (VAS), the Constant Score (CS), the American Shoulder and Elbow Surgeons (ASES) score, and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Tendon integrity was determined using 3-T MRI and graded according to the Sugaya classification. Results: Thirty-one of 40 patients (77.5%) were available for the final assessment at a mean follow-up of 50.3 ± 20.4 months. Clinical outcome scores significantly improved from preoperatively to postoperatively for the CS (39.7 ± 16.7 to 65.1 ± 19.7; P < .001), ASES (44.2 ± 17.7 to 75.2 ± 24.8; P < .001), and DASH (68.6 ± 15.1 to 21.5 ± 19.1; P < .001). The VAS score decreased from 6.1 ± 1.8 preoperatively to 1.3 ± 1.8 at final follow-up (P < .001). MRI demonstrated a retear rate of 55.5%. No differences in CS, ASES, and DASH scores were detected between patients with an intact repair and failure. Abduction strength was not significantly different in patients with an intact repair and retears (55.5 N vs 44.0 N, respectively, P = .52). Conclusion: Revision RCR improves clinical outcomes and shoulder function at midterm follow-up. The clinical outcome scores were comparable in patients with an intact repair and those with failed RC healing. Therefore, tendon integrity was not correlated with better clinical outcomes after revision RCR at final follow-up.

Introduction: Currently, no therapeutic intervention is universally accepted, and the most effective management for restoring motion and diminishing pain in patients with shoulder stiffness has yet to be defined. This systematic review analyses outcomes of conservative and surgical interventions to treat shoulder stiffness. Source of data: A systematic review of literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, Ovid and Google Scholar databases using various combinations of the keywords 'shoulder', 'shoulder stiffness', 'stiff shoulder', 'conservative', since inception of databases to June 2018 was performed. Areas of agreement: Shoulder stiffness could be treated with conservative means including nonsteroidal anti-inflammatory medications, corticosteroid injections, or transcutaneous electrical nerve stimulation, manipulation under anaesthesia, and arthroscopic capsular release. Areas of controversy: No therapeutic intervention is universally accepted, and the most effective management to restore motion and diminish pain in patients with shoulder stiffness has yet to be defined. Growing points: The rate of failure after treatment for stiff shoulder is higher in the surgical group than in the conservative group. Areas timely for developing research: There is insufficient evidence to establish whether surgical or conservative management is the best choice to manage shoulder stiffness. Prospective, randomized studies are needed to establish whether surgical or conservative management produce a clinically relevant difference in functional outcome.

Background: Septic arthritis (SA) of the knee after anterior cruciate ligament reconstruction (ACLR) is a rare but potentially devastating condition. In certain cases, graft removal becomes necessary. Purpose: To evaluate clinical, subjective, and radiologic outcomes of patients with SA after ACLR and assess whether graft retention has superior clinical results as compared with graft removal. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who were at least 12 months out from arthroscopic treatment of SA after isolated ACLR at our institution were eligible for inclusion. Patients were categorized into 2 groups: group 1, patients with initial graft retention; group 2, patients with initial graft removal. Group 2 was subdivided into 2 groups: group 2a, patients with graft reimplantation; group 2b, patients without graft reimplantation. Objective and subjective assessments were obtained at follow-up, including the International Knee Documentation Committee (IKDC) knee examination form, KT-1000 arthrometer measurements, WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score, Lysholm score, and IKDC subjective evaluation. Radiologic assessment was performed with pre- and postoperative magnetic resonance imaging. Results: Of the 41 patients included, 33 (81%) were available for follow-up at a mean ± SD 54.7 ± 24.4 months at an age of 28.4 ± 9.3 years. When compared with patients from group 2 (n = 12), patients from group 1 (n = 21) obtained significantly better results on the objective IKDC score (normal or nearly normal: group 1, 66.6%; group 2, 36.4%; P = .047) and KT-1000 measurements (group 1, 1.3 ± 1.0 mm; group 2, 2.9 ± 1.5 mm; P = .005). Group 1 also scored better than group 2 on the Lysholm (P = .007), IKDC subjective (P = .011), and WOMAC (P = .069) measures. Between groups 2a (n = 4) and 2b (n = 8), no significant differences in outcomes could be detected (P values, .307-.705), although patients with anterior cruciate ligament graft reimplantation showed a clear tendency toward better results in objective and not subjective parameters. Magnetic resonance imaging evaluation showed higher rates of cartilage damage and meniscal tears among patients with graft resection versus graft retention. Conclusion: Patients with graft retention showed superior postoperative results when compared with patients who underwent initial graft resection, although subanalysis showed comparable outcomes between graft retention and reimplantation. Thus, while graft-retaining protocols should have the highest priority in the treatment of SA after ACLR, graft reimplantation should be performed in cases where graft resection becomes necessary, to avoid future cartilage and meniscal lesions. Finally, further studies with larger numbers of patients are needed to gain a better understanding of the outcomes of patients with SA after ACLR.

BACKGROUND:Tears and lesions of the rotator cuff are a frequent cause of shoulder pain and disability. Surgical repair of the rotator cuff is a valuable procedure to improve shoulder function and decrease pain. However, there is no consensus concerning the rehabilitation protocol following surgery.OBJECTIVES:To review and evaluate current rehabilitation contents and protocols after rotator cuff repair by reviewing the existing scientific literature and providing an overview of the clinical practice of selected German Society of Shoulder and Elbow Surgery e. V. (DVSE) shoulder experts.MATERIALS AND METHODS:A literature search for the years 2004-2014 was conducted in relevant databases and bibliographies including the Guidelines International Network, National Guidelines, PubMed, Cochrane CentralRegister of Controlled Trials, Cochrane Database of Systematic Reviews, and the Physiotherapy Evidence Database. In addition, 63 DVSE experts were contacted via online questionnaire.RESULTS:A total of 17 studies, four reviews and one guideline fulfilled the inclusion criteria. Based on these results and the obtained expert opinions, a four-phase rehabilitation protocol could be developed.

Tears and lesions of the rotator cuff are a frequent cause of shoulder pain and disability. Surgical repair of the rotator cuff is a valuable procedure to improve shoulder function and decrease pain. However, there is no consensus concerning the rehabilitation protocol following surgery.

Fractures of the humeral greater tuberosity (GT) are a frequent injury progressively treated with arthroscopic suture anchor repair. Yet, no biomechanical study has been performed comparing fixation strength of arthroscopic single- (SR) vs. double row (DR) fixation.