Introduction and Aims: To determine differences in rotator cuff tissue with duration of symptoms and tear size

Method: Rotator cuff tissue was obtained at debridement from 44 patients undergoing surgical repair. Pathological assessment was performed on H& E sections. Features evaluated included inflammation, micro-calcification, tendolipomatosis and fibroblast hypocellularity. Matrix quality and endothelial cell proliferation were examined. Patient details – age, tear size and duration of symptoms were extracted from notes.

Results: Matrix quality was significantly worse in small tears (p=0.028), particularly the extent of mucoid degeneration in the debrided tissue (p=0.017). Presence of a healthy cut margin was more likely in a large tear (10/14). Poor matrix was significantly associated with symptom duration > 15months (p=0.006) especially microcalicification (p=0.019) and mucoid degeneration (p=0.047). Endothelial cell proliferation was significantly more apparent in patients with longer duration of symptoms: previous vascular tufting (p=0.001) and ongoing vascular proliferation (p=0.019). Of 27 patients > 15months symptoms, vascular proliferation was strongly correlated with split collagen fibres (p< 0.018) and mucoid degeneration (p< 0.018) but not microcalcification. Tendolipomatosis was strongly correlated with ongoing vascular proliferation (p< 0.0006).

Conclusion: Successful surgical repair is only achieved in 30% patients with rotator cuff tears. Improvements in this success rate will be essential in order to maintain the independent lifestyle of an elderly population. Although the tissue examined here is debrided, and hence worst case tissue, several time-dependent processes are ongoing, degeneration, repair and remodelling. Matrix quality is deteriorating, however, this maybe supportive of the angiogenic component of repair. Remodelling may be seen in the increased probability of a healthy cut margin from patients with longer symptom duration.

Introduction and Aims: To determine whether non-steroidal anti-inflammatory drugs (NSAID) administration influences ongoing endothelial cell proliferation in tom rotator cuff?

Method: Rotator cuff tissue, obtained at debridement from 53 patients undergoing surgical repair, was fixed and embedded. Pathological assessment was performed on H& E sections. Ongoing vascular proliferation was identified by plump endothelial cells and budding of vessels. Patient cuff details and pre-operative drug prescription data was obtained from patients’ notes and by telephone from general practitioners. The drugs used were NSAIDs (including Aspirin, Ibuprofen and Diclofenac), COX 2 inhibitors and Opiates. The data was analysed using the SPSS program and the Pearson Chi-square test.

Results: Of the 35 patients taking analgesics, vascular proliferation was absent or reduced in 22 (63%). Twenty of these patients were taking NSAIDs. Four patients were taking only COX-2 inhibitor drugs; all these patients had increased vascularity. Twenty-three patients were taking codeine-based analgesics. Of 10 patients using codeine without NSAIDs, eight demonstrated active ongoing vascular proliferation (p=0.027).

Conclusion: Patients taking NSAIDs showed a significant reduction in ongoing vascular proliferation. If endothelial cell proliferation is an important component of repair in either the onset or post-operative stages of rotator cuff pathology, then attempts at repair could be compromised by inadequate local function of the vascular system. We have previously identified strong p27 positivity in rotator cuff endothelial 0 cells. NSAIDs can impair healing by inhibiting angiogenesis; the mechanism includes upregulation of p27 in endothelial cells. More work should be done to clarify this matter in the rotator cuff.

Purpose: To determine whether administration of non-steroidal anti-inflammatory drugs (NSAID) influences ongoing endothelial cell proliferation in torn rotator cuff?

Methods: Rotator cuff tissue, obtained at debridement from 53 patients undergoing surgical repair, was fixed and embedded. Pathological assessment was performed on H& E sections. Ongoing vascular proliferation was identified by plump endothelial cells and budding of vessels. Patient cuff details and preoperative drug prescription data was obtained from patient’s notes and general practitioners. The drugs considered were NSAIDs (including Aspirin, Ibuprofen and Diclofenac), COX 2 inhibitors & Opiates.

Results: Of the 35 patients taking analgesics, vascular proliferation was absent or reduced in 22 (63%). 20 of these patients were taking NSAIDs. Four patients were taking only COX-2 inhibitors, all these patients had increased vascularity. 23 patients were taking codeine based analgesics, of 10 patients using codeine without NSAIDs, 8 demonstrated active ongoing vascular proliferation (p=0.027).

Conclusion: Patients taking NSAIDs showed a significant reduction in ongoing vascular proliferation. If endothelial cell proliferation is an important component of repair processes in rotator cuff, this could be compromised. NSAIDs can impair healing by inhibiting angiogenesis, the mechanism includes upregulation of p27 in endothelial cells. We have peviously identified strong p27 positivity in rotator cuff endothelial cells.

Introduction: Distal humeral fractures represent a constant challenge to the most experienced surgeon. This is the first report of the use of an unlinked prosthesis for the treatment of distal humeral fractures in elderly persons.

Materials and Methods: From July 2000 to June 2001, 9 iBP elbow arthroplasties were performed in patients with acute fractures of the distal humerus. The average age of the group was 71 years. The mean interval between injury and TER was 11 days. The follow-up period averaged 12 months (range 5 to 16).

Results: Functional outcome was evaluated with patient-completed questionnaires. All patients had a flexion contracture of the elbow ranging from 15 to 30 degrees. All patients were able to perform daily activities, pain relief was satisfactory and patient satisfaction was high. All elbows met the criteria for functional motion and were stable at the latest follow-up examination. There were no major complications such as dislocation, ulnar nerve dysfunction or deep infection.

Conclusion: Unlinked non-congruous elbow arthroplasty when combined with a surgical exposure that allows proper soft tissue balance and instrumentation that enables correct positioning of the components can be a successful alternative in the management of acute distal humeral fractures in selected patients when conventional fixation is not a viable option.

Purpose: To investigate the relationships between vascular endothelial growth factor (VEGF), a proliferation marker (Ki-67) and the cell cycle inhibitor p27 (cyclin-dependent kinase inhibitor p27), in endothelial cells in chronic degeneration of the rotator cuff.

Background: The rotator cuff is subject to constant pressure from the head of the humerus. This tends to ‘wring out’ the blood supply resulting in a functionally avascular critical zone, although microvessels can be identified. This zone is the site of degeneration and tears. Attempts at repair under these circumstances could be compromised by inadequate local function of the vascular system particularly sprouting of the capillaries to support the repair process.

Methods: Rotator cuff tissue was obtained from ten patients (age 40–80y) undergoing surgical repair. The size of tear was 1–4.5cm, time from presentation to surgery was 1 month (acute) to between 0.5–4y (chronic). Immunohistochemical staining with commercial mono-clonal antibodies to VEGF, p27, Ki-67 was performed on formalin fixed paraffin embedded tissues. Endothelial cells were identified by CD31 and smooth muscle actin (SMA) positivity. Visualisation used a standard DAB chromagen technique.

Results: Microvessel distribution varied according to tissue location, being pronounced towards the muscle insertion and torn edges of tissue, but much reduced in areas of healthy tendon and absent from areas with clear signs of advanced matrix degeneration without tears. Widespread VEGF positivity was observed in fibroblast and endothelial cell populations and diffusely within the matrix. Strong P27 positivity was observed in many endothelial cells which consequently demonstrated little Ki-67 staining.

Conclusion: Thus the endothelial cells appear to be simultaneously under both a mitogenic, VEGF drive, and subject to an inhibition of proliferation i.e. p27 positivity.