The purpose of this study is the evaluate the net promotor score of arthroscopic subacromial decompression and rotator cuff repair. The Friends and Family Test, a variant of the Net Promoter Score, was adapted for the National Health Service to evaluate overall patient satisfaction and how likely patients are to recommend an intervention. It ranges from −100 to 100. Positive scores indicate good performance. This study quantifies the scores in 71 patients at 1 year following arthroscopic sub acromial decompression and rotator cuff repair. All of the procedures were performed by 1 consultant shoulder specialist. The patient filled out a shoulder questionnaire pre-operatively, at 6 months and 1 year. The score was 72 for subacromial decompression (n = 32) and 85 for rotator cuff repair +/− decompression (n = 39). Oxford shoulder score was also taken and had a rise of 4.3 and 6.9 respectively. Our study indicates that these procedures are highly valued and are recommended by patients according to the Friends and Family Test. The results of the Friends and Family Test correlated well with postoperative functional improvement and satisfaction. We conclude from this study that a compound score based on the Friends and Family Test is a useful addition to traditional measures of patient satisfaction

The treatment of massive rotator cuff tears remains controversial. There is lack of studies comparing patient-reported outcomes (PROM) of arthroscopic massive rotator cuff repairs (RCR) against large, medium and small RCRs. Our study aims to report the PROM for arthroscopic massive RCR versus non-massive RCR. Patients undergoing an arthroscopic RCR under a single surgeon over a 5-year period were included. Demographic data were recorded. Pre-operative Quick-DASH and Oxford Shoulder Score (OSS) were prospectively collected pre-operatively and at final review (mean of 18 months post-operatively). The scores were compared to a matched cohort of patients who had large, medium or small RCRs. A post-hoc power analysis confirmed 98% power was achieved. 82 patients were included in the study. 42 (51%) patients underwent massive RCR. The mean age of patients undergoing massive RCR was 59.7 and 55% (n=23) were female. 21% of massive RCRs had biceps augmentation. Quick-DASH improved significantly from a mean of 46.1 pre-operatively to 15.6 at final follow-up for massive RCRs (p<0.001). OSS improved significantly from a mean of 26.9 pre-operatively to 41.4 at final follow up for massive RCRs (p<0.001). There was no significant difference in the final Quick-DASH and OSS scores for massive and non-massive RCRs (p=0.35 and p=0.45 respectively). No revision surgery was required within the minimum one year follow up timescale. Arthroscopic massive rotator cuff repairs have no functional difference to non-massive rotator cuff repairs in the short term follow up period and should be considered in appropriate patient groups

Management of irreparable rotator cuff tears is challenging and controversial. Surgeons have been utilising biological tissue scaffolding to augment repairs, but there are concerns regarding viability and function. We wished to investigate this viability and clinical outcome in a small group of patients. All procedures were performed by a single surgeon over a three-year period. Inclusion criteria were patients with large cuff tears and failure of non-operative treatment. Exclusion criteria were patients with glenohumeral arthritis and where cuff repair could not be successfully performed. Open rotator cuff repair followed by augmentation with Graft Jacket® Regenerative Tissue Matrix (Wright Medical) was performed in all patients. A structured cuff repair physiotherapy protocol was then followed. Follow-up was at six months and at minimum twenty-four months post-operatively where Constant scores (CS) and Oxford Shoulder scores (OSS) were noted and a repeat ultrasound performed. Fourteen patients underwent the procedure. No patient was lost to follow-up. There were seven males and seven females with a mean age of 63 years (range 31–77). At minimum twenty-four month follow-up, thirteen patients had flexion and abduction above 90 degrees and symmetrical external rotation. Mean CS was 81 (range 70–91) and mean OSS was 46 (range 41–48). Shoulder ultrasound revealed an intact Graft Jacket® in all thirteen patients. The final patient had lower functional movement and lower CS (34) and OSS (25) and ultrasound identified a re-rupture. This study indicates that augmentation of large rotator cuff repairs with biological tissue scaffolding is a viable option and has good functional results

Summary. Strong mechanical fixation is critical to the success of rotator cuff repairs. In this comparative study in cadaveric shoulders, single-tendon full-thickness supraspinatus tears were repaired using two different types of PEEK knotless suture anchors-ReelX STT (Stryker) and Opus Magnum PI (Arthrocare)-using a single-row technique in both instances. Cyclic testing was performed followed by loading until mechanical failure. No significant difference was observed in gap formation, measured as the distance between the supraspinatus tendon and bone at the repair site, during cyclic loading. However, the maximum load was statistically higher for repairs with the ReelX anchor. Purpose. The objective of this study was to compare the gap formation during cyclic loading and maximum repair strength of single-row full thickness supraspinatus repairs performed using two different types of PEEK knotless suture anchors in a cadaveric model. Methods. Nine matched pairs of cadaveric shoulders were used in this study. All soft tissue was removed except for the supraspinatus, and a full thickness tear was formed. Single-row repairs were performed with two anchors per repair using either the Opus Magnum PI (Arthrocare) or the ReelX STT (Stryker). The specimens were mounted to an Instron at 45° to simulate an anatomic direction of load, and fiducial markers were placed on the repair in anterior and posterior positions. A 10 N preload was applied and held for 60 seconds, and then the tendon was cycled from 10 N to 90 N at 0.25 Hz for 500 cycles, followed by load to failure at 1 mm/s. A video digitizing system was used to track the markers and measure gap formation during loading. Gap formation was calculated by subtracting the distance between the markers at 10 N preload from the maximum displacement at 5 and 500 cycles. Paired t-tests were used to compare the cyclic displacement and max load. Results. One specimen from each of two matched pairs (one from each anchor group) failed during cyclic loading, leaving seven matched pairs for analysis. No significant difference was found in cyclic displacement between the two groups in either anterior or posterior positions at 5 and 500 cycles. However, maximum load to failure was significantly greater for repairs performed with the ReelX STT anchors (289N ± 57N) as compared to the OPUS anchors (178N ± 36N), with a p=0.009. Conclusions. These results suggest that the anchor type chosen for cuff repairs may affect the overall stability of the repair. Achieving stable fixation is critical for promoting healing of the tendon back to bone and to the long-term success of the repair, and using anchors that provide stronger fixation may decrease the occurrence of post-surgical tears and instability. The ReelX STT anchor outperformed the Opus Magnum PI anchor in terms of supporting significantly higher loads before failure, potentially leading to stronger repairs clinically

INTRODUCTION. In order to address high failure rates following rotator cuff repairs, a greater understanding is required of the underlying structural changes so that treatments can be appropriately targeted and biomarkers of failure can be identified. As collagen is the primary constituent of tendon and determines force transmission, collagen structural changes may affect responses to loading. For example changes in collagen 1 and 5 are associated with the hyperelastic Ehlers-Danlos syndrome, which is diagnosed by looking for pathopneumonic altered collagen fibres or ‘collagen flowers’ in skin using transmission electron microscopy (TEM). To date no study has been performed on the microstructure of torn human rotator cuff tendons using TEM. It was hypothesized that normal, small and massive human rotator cuff tendons tears will have altered microscopic structures. The unique study aimed to use TEM to compare the ultrastructure of small and massive rotator cuff tears, to normal rotator cuff tendons. METHODS. Samples from 7 human rotator cuff tendons repairs were obtained, including 4 massive (>5 cm) and 3 small (< 1 cm) tears, and 3 matched normal controls with no history of connective tissue disorders. Specimens were fixed in 4% glutaraldehyde in 0.1M phosphate buffer, processed and examined blind using routine TEM examination. To assess whether changes in the relative expression of collagen 1 and 5 (COL1A1, COL5A1 and COL5A2) occurred in all tears, qPCR was performed on another 6 phenotypically matched patients. RESULTS. The basic structure of the normal tendon consisted of tightly packed clumps of dense packed parallel running collagen fibers with few fibroblasts and small amounts of fine filamentous material between clumps. In contrast, torn samples were more variable with areas of less dense packing of collagen fibers and larger areas of filamentous material plus variable numbers of lipid droplets both within the fibroblast and between the collagen bundles. There was also evidence of twisting and random orientation of individual collagen fibers. All torn tendons showed evidence of a proportion of the fibers within the collagen bundles being enlarged with a serrated outline, similar in appearance to ‘collagen flowers’. Clear differences between the small and massive tears were not identified. qRT-PCR of torn rotator cuff tendon specimens demonstrated no altered collagen expression compared to normal tendons. DISCUSSION. This novel study has identified the previously unreported presence of atypical collagen fibers with focal swelling resulting in the appearance of ‘collagen flowers’ in torn rotator cuff tendons only. This appearance is considered pathognomonic of Ehlers-Danlos syndrome, classical type 1 and 2. Torn tendons also showed an increase in filamentous material, and infiltration with fat droplets. These novel findings may offer insight into the mechanisms of structural damage that contribute to rotator cuff failure. Further examination is required, to evaluate the significance of these observations

Purpose of this study is to create an experimental model of electrophysologic evaluation of the supraspinatus muscle on rats, after traumatic rupture of its tendon. The population of this study consisted of 10 male Sprague Dawley rats weighting 300–400g. Under general anaesthesia we proceeded with traumatic rupture of the supraspinatus tendon and exposure of the muscle. The scapula was immobilized, and the supraspinatus tendon was attached to a force transducer using a 3–0 silk thread. A dissection was performed in order to identify the suprascapular nerve, which was then stimulated with a silver electrode. Stimulations were produced by a stimulator (Digitimer Stimulator DS9A) and were controlled by a programmer (Digitimer D4030). Fiber length was adjusted until a single stimulus pulse elicited maximum force during a twitch under isometric conditions. Rectangular pulses of 0.5 ms duration were applied to elicit twitch contractions. During the recordings, muscles were rinsed with Krebs solution of approximately 37 8C (pH 7.2–7.4) and aerated with a mixture of 95% O2 and 5% CO2. The output from the transducer was amplified and recorded on a digital interface (CED). The following parameters were measured at room temperature (20–21 8C): single twitch tension; time to peak; half relaxation time; tetanic tensions at 10, 20, 40, 80 and 100 Hz; and fatigue index, which was evaluated using a protocol of low frequency (40 Hz) tetanic contraction, during 250 ms in a cycle of 1 s, for a total time of 180 s. The fatigue index value was then calculated by the formula [fatigue index=(initial tetanic tension − end tetanic tension) ∗ 100/(initial tetanic tension)]. In the end, the transducer was calibrated with standard weights and tensions were converted to grams. The mean single twitch was 8.2, the time to peak 0.034 msec and the half relaxation time 0.028 msec. The strength of titanic muscle contractures was 5.7 msec at 10Hz and 17.7 at 100Hz. Finally, the fatigue index was calculated at 48.4. We believe that electrophysiologic evaluation of the supraspinatus muscle in rats will help us understanding the pathology of muscle atrophy after rotator cuff tears and possibly the functional restoration after cuff repair

Introduction. Superior Labral Anterior Posterior Tears are being treated surgically in increasing numbers. Stiffness is the most common complication. We reviewed 115 cases of SLAP repairs to try and identify preoperative risk factors if any for stiffness. Methods. Retrospective cohort study of 115 patients who underwent SLAP repair. All patients failed attempts at conservative therapy including NSAIDS, Physical Therapy and cortisone injections. Results. Age ranged from 16–71 years, with an average age of 46. Male 84, Female 31. patient charts and operative notes were examined from 2004–2009. We used an average of 1.64 anchors per case; we performed arthroscopic Mumford on 15 patients, subscap repair (4), 19 cases with concomitant SLAP repair and Arthroscopic rotator cuff repair Other procedures included Biceps tenotomy and tenodesis, chondroplasty, Microfracture, removal of loose bodies, synovectomy and lysis of adhesions. Twelve patients underwent revision surgery(10%) We had 5 cases of stiffness which required lysis of adhesions and synovectomy, 4 cases had previous SLAP and concomitant rotator cuff repair done at the index surgery, 4 cases had arthrosis noted at index surgery and underwent chondroplasty and 2 of them underwent micro fracture. During the revision surgery 4 had also a concomitant cuff tear (new) which required repair Average time from index surgery to revision was 11 months, the patients who developed adhesive Capsulitis and stiffness the average age was 56 years. We had 2 titanium metal anchors pull out and present as loose bodies with one of the anchor causing chondral damage, we stopped using metal anchors and we have not had this problem recur since.5 cases had Mumford procedure done during the revision surgery.5 cases needed repeat SLAP repairs and by increasing use of biceps tenotomy this incidence should decrease. Conclusions. Our large retrospective case series shows an acceptable complication rate. Stiffness (5%) is still the most common complication especially in patients older than 50, withpreexisting Glenohumeral arthritis and concomitant rotator cuff tears. Hopefully our early aggressive mobilization will decrease this incidence

Introduction. Insufficient arthroscopic cuff tear reconstruction leading to massive osteoarthritis and irreparable rotator cuff tears might be salvaged by implantation of an inverted total shoulder prosthesis Delta in the elderly. However, despite the generally high success rate and satisfying clinical results of inverted total shoulder arthroplasty, this treatment option has potential complications. Therefore, the objective of this study was a prospective evaluation of the clinical and radiological outcome after a minimum of 2 years follow-up of patients undergoing inverted shoulder replacement with or without prior rotator cuff repair. Patients and Methods. Sixty-eight shoulders in 66 patients (36 women and 30 men) operated between February 2002 and June 2007 with a mean age of 66 years (ranging from 53 to 84 years) were first assessed preoperatively and then at minimum 2 years follow-up, using the Constant score for pain, Constant Shoulder Score, Oxford Shoulder Score, UCLA Shoulder rating scale, DASH Score, Rowe Score for Instability and Oxford Instability Score. 29 patients (Group A) had undergone previous shoulder arthroscopy for cuff tear reconstruction at a mean of 29 months (range 12 to 48 months) before surgery and 39 patients (Group B) underwent primary implantation of an inverted total shoulder prosthesis Delta. Any complications in both groups were assessed according to Goslings and Gouma. Results. We report statistically significant improvements of all obtained scores at a mean follow-up of 42 months (ranging from 24 to 96 months) in both groups. Significant outcome differences between 29 patients with previous shoulder arthroscopy for cuff tear reconstruction and 39 without previous shoulder arthroscopy were not observed. Eight complications occurred altogether, in terms of a nerve lesion once, loosening of the humeral stem three times, and loosening or fracture of the glenoid component four times. Conclusion. We did not detect any statistically significant impact of previous insufficient shoulder arthroscopy for cuff tear reconstruction on the outcome and survival rate after the implantation of the inverted total shoulder prosthesis Delta. We conclude that reverse total shoulder arthroplasty with the Delta prosthesis is significantly beneficial in terms of less shoulder pain, higher stability and gain of range of motion without this beneficial effect being significantly weakened by previous insufficient shoulder arthroscopy for cuff tear reconstruction. We believe that previous arthroscopic cuff tear reconstruction should therefore be included in the treatment algorithm

Of 545 consecutive patients with anterior shoulder dislocations, 108 (20%) were aged 60 years or more at the time of injury. We reviewed and radiographed 95 of these elderly patients after a mean follow-up of 7.1 years. Axillary nerve injuries were seen in 9.3% of the 108 patients, but all recovered completely in 3 to 12 months. There were single or multiple recurrences of dislocation in 21 patients (22.1%), but within this group age had no influence on the tendency to redislocate. Tears of the rotator-cuff were diagnosed by imaging studies or clinically in 58 patients (61%), including all who had redislocations. Sixteen patients required surgery. Eight with a single dislocation and a cuff tear had only repair of the torn cuff. Of the eight patients with multiple dislocations requiring operation, five also had a torn cuff and needed either a stabilising procedure and a cuff repair or repair of the cuff only. All patients who were operated on had a satisfactory result, with the exception of those with multiple redislocations and a cuff tear who had repair of the cuff only. Anterior shoulder dislocation in elderly subjects is more common than is generally believed; 20% suffer redislocation and 60% have a cuff tear. Operation may be needed to repair a torn cuff or to stabilise the shoulder. Patients with multiple redislocations will probably require both procedures

Introduction. The pathophysiology of high failure rates following rotator cuff tendon repairs, particularly massive tears, is not fully understood. Collagen structural changes have been shown to alter tendon thermal and mechanical properties. Thermal changes in small biopsies, detected by differential scanning calorimetry (DSC) can help to quantify collagen structural differences in torn rotator cuff tendons. This study aimed to form a quantitative rather than qualitative assessment, of whether differences in collagen structure and integrity existed between small biopsies of normal, small and massive rotator cuff tears using DSC. Methods. Thermal properties were measured for 27 human biopsies taken intra-operatively from normal, small, and massive rotator cuff tendon tears. 3 samples were taken from each patient and subjected to a modulated temperature ramp between 20–80°C at a rate of 2°C per minute with 0.318°C amplitude. The melting temperature (TM) is proposed to represent amide-amide hydrogen bond breakage and resulting protein backbone mobility. Denaturing temperature (TD) reportedly corresponds to the temperature at which the proteins fall out of solution. Denaturation enthalpy (H) should correlate with the amount of triple helical structure. Based upon a pre-study power calculation, this study had 90% power to detect a 10% difference in melting and denaturation temperature between groups with alpha=0.05. 1 specimen per patients was also frozen and cryosectioned and polarised light microscopy was used for quantitative validation. The effect of tear size on heat related parameters were performed using a one-way ANOVA test. A student's unpaired t-test was used to search for differences between individual groups (small tears, massive tears and normal tendons). Results. Small and massive rotator cuff tears had significantly higher melting temperature (TM), and denaturation enthalpy (H) compared to controls. The denaturing temperature (TD) was higher in the massive tears only compared to normal tears. No difference was detected between small and massive tears. Histology of massive tendon tears confirmed greater collagen structural disruption compared to small tears and controls. Conclusion. These novel findings suggest greater quantifiable collagen structural disruption in rotator cuff tears, compared to controls. A decrease in important thermal properties of torn tendons suggests that the material is intrinsically less stable. It is likely that torn tendons cannot withstand changes in temperature or stress as well as a perfect material could, particularly for massive tears which are more amenable to denaturation. This study offers insight into possible mechanisms for, or adaptation to, failure in tears and reduced strength

Objectives

A rigorous approach to developing, delivering and documenting rehabilitation within randomised controlled trials of surgical interventions is required to underpin the generation of reliable and usable evidence. This article describes the key processes used to ensure provision of good quality and comparable rehabilitation to all participants of a multi-centre randomised controlled trial comparing surgery with conservative treatment of proximal humeral fractures in adults.