Editorial Commentary: Concomitant Surgical Management for Rotator Cuff Tears With Adhesive Capsulitis is an Effective Treatment for Managing a Vexing Problem

Rotator cuff tears (RCT) with concomitant frozen shoulder is a challenging clinical scenario that I, along with many other shoulder surgeons, commonly encounter. Some controversy exists regarding the optimal treatment. Does one address the shoulder stiffness first and regain range of motion (ROM) via nonoperative or operative means, then treat the rotator cuff tear later, or should it all be done at the same time surgically via a concomitant arthroscopic capsular release with or without manipulation under anesthesia (MUA) followed by a rotator cuff repair (RCR) in the same setting? I believe there is overwhelming evidence in the literature to support the latter. Address both pathologies concomitantly through a single stage surgery! In the setting of the RCT with adhesive capsulitis, I routinely recommend early concomitant arthroscopic capsular release with gentle MUA and then perform an arthroscopic RCR in one stage. This is then followed by an accelerated postoperative protocol which is balanced with some protection for healing. We have reported excellent outcomes with this approach. Similarly, I have found this approach to be highly effective, reproducible, and efficient, with high patient satisfaction and outcomes comparable to my patients who undergo arthroscopic RCR without stiff shoulders.     

Editorial Commentary: Current Indications for Lateral Acromioplasty Include Patients With Elevated Critical Shoulder Angle Plus Subacromial Impingement With Rotator Cuff Pathology or Previous Rotator Cuff Repair

The critical shoulder angle (CSA) reflects the lateral extent of the acromion and the inclination of the glenoid. In 2013, CSA was first introduced and its association with rotator cuff (RC) tears and glenohumeral osteoarthritis (GHOA) was shown. It was speculated that with a high CSA, there was an increased superior force vector from the deltoid and that this superior force led to RC tears. Conversely, when the CSA was low, there was a greater compressive force from the deltoid and that this compressive force led to GHOA. CSA serves as a further development of 2 previously reported measurements (glenoid inclination and acromial index). A key potential therapeutic aspect of the CSA is the ability to modify it surgically, which theoretically could protect RC repairs or prevent progression. In our current clinical practice, we perform lateral acromioplasty (LA) in patients undergoing treatment of subacromial impingement with an “at-risk” rotator cuff (partial rotator cuff tear and severe tendinopathy on magnetic resonance imaging) with a CSA > 38° or all patients with a CSA >35° after an RC repair to protect the RC repair construct. The relationships of high and low CSA, the anatomic safe zone, and thus clinical applicability of LA are well established and performed in our daily surgical practice. However, we do not yet have widespread clear clinical evidence on potential benefits regarding the clinical outcome after LA. Finally, at this time, the downsides seem minimal, so we continue to use LA as an adjunct in patients with RC tears and RC tendons that are at risk.     

Mid-Term Outcomes of Arthroscopic Rotator Cuff Repair in Patients with Rheumatoid Arthritis

Objective

The effectiveness of arthroscopic rotator cuff repair (ARCR) on rheumatoid arthritis (RA) patients remains a controversial topic. This study investigates the mid-term outcomes of ARCR in RA patients and identifies the factors influencing clinical efficacy.

Methods

This retrospective study enrolled RA patients with small or medium rotator cuff tears (RCTs) between February 2014 and February 2019. Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons (ASES), and Constant–Murley scores were collected at each follow-up time. Ultimately, magnetic resonance imaging (MRI) and X-ray were employed to assess rotator cuff integrity and progression of shoulder bone destruction, respectively. Statistical methods used two-way repeated-measures ANOVA or generalized estimation equations.

Results

A total of 157 patients were identified and divided into ARCR (n = 75) and conservative treatment (n = 82) groups. ARCR group continued to be divided into small tear (n = 35) and medium tear (n = 40) groups. At the final, all scores were better in ARCR group than in the conservative treatment group (p < 0.05). A radiographic evaluation of the final follow-up demonstrated that the progression rate in ARCR group (18.67%) was significantly lower than that of the conservative treatment group (39.02%, p < 0.05). In the comparison of the small tear and medium tear groups, all scores increased significantly after surgery (p < 0.05), and the final follow-up scores were better than preoperative scores (p < 0.05) but worse than those of the 6-month postoperative follow-up (p < 0.05). Comparison between the two groups revealed that all scores of the small tear group were significantly better than those of the medium tear group at 6-month postoperative follow-up (p < 0.05). Although the scores of small tear group remained better than those of the medium group at the final postoperative follow-up, the difference was not statistically significant (p > 0.05). Radiographic assessment of the final follow-up demonstrated that the progression rate in the small tear group (8.57%) was significantly lower than that in the medium group (27.50%, p < 0.05), and the retear rate of small tear group (14.29%) was significantly lower than that of the medium tear group (35.00%, p < 0.05).

Conclusion

ARCR could effectively improve the quality of life for RA patients with small or medium RCTs, at least in the medium term. Despite the progression of joint destruction in some patients, postoperative retear rates were comparable to those in the general population. ARCR is more likely to benefit RA patients than conservative treatment.     

全关节镜与小切口修复肩袖损伤疗效的Meta分析

目的对全关节镜及小切口两种方法修复肩袖损伤的疗效进行Meta分析。方法计算机检索Ovid Medline和PubMed Medline(1966～2008.5),Embase(1980～2008.5),Cochrane Central Register of Controlled trials(2008)和中国生物医学文献数据库(1990～2008.5),搜集到所有的已发表的用于论证这些问题的对照研究,且采用RevMan 4.2.10进行Meta分析。结果共纳入10例对照研究,Meta分析显示这两组肩关节功能评分(SMD=-0.04,95%CI=-0.24～0.16,P=0.68)、患者满意度(OR=0.7,95%CI=0.35～1.40,P=0.32)、肩袖翻修率(OR=0.75,95%CI=0.40～1.41,P=0.37)、关节僵硬发生率(OR=0.48,95%CI=0.22～1.06,P=0.07)没有统计学意义。结论肩袖损伤全关节镜术后2年随访肩关节功能、病人满意度、肩袖翻修率及关节僵硬发生率等方面没有明显优势,但是它有较少的软组织损伤、极低的三角肌劈开风险、较少的早期切口疼痛及更快的功能恢复等潜在优势,可明显改善术后肩关节外展、外旋功能。而有趋势表明关节僵硬发生率与小切口相关,由于目前缺乏随机化对照试验证据,进一步比较仍须要大样本的多中心的随机化对照试验研究。     

手术治疗肩袖损伤患者的护理

对153例肩袖损伤患者进行手术治疗，术后随访6个月至3．5年，肩关节功能优66例，良84例，差3例。提出术前消除患者的心理负担，采用中药熏洗治疗。以及手术后生命体征的观察、术后体位的护理、患肢的观察与护理及功能锻炼，对肩袖损伤患者功能康复具有重要作用。     

手术治疗肩袖损伤患者的护理

对153例肩袖损伤患者进行手术治疗,术后随访6个月至3.5年,肩关节功能优66例,良84例,差3例.提出术前消除患者的心理负担,采用中药熏洗治疗以及手术后生命体征的观察、术后体位的护理、患肢的观察与护理及功能锻炼,对肩袖损伤患者功能康复具有重要作用.     

Prevalence of and Risk Factors for Hypovitaminosis D in Patients with Rotator Cuff Tears

BackgroudIt has been reported that vitamin D may play an important role in rotator cuff tears. However, there has been limited information about the prevalence of and risk factors for hypovitaminosis D in patients with rotator cuff tears. Therefore, the purpose of current study was to investigate the prevalence of and risk factors for hypovitaminosis D in patients with rotator cuff tears.MethodsOne hundred seventy-six patients (age, 61.9 ± 8.90 years) who underwent arthroscopic rotator cuff repair for a full-thickness tear were enrolled in this retrospective study. Preoperative serum vitamin D levels (25-hydroxyvitamin D) were measured. Hypovitaminosis D was defined as a serum concentration of 25-hydroxyvitamin D < 20 ng/mL. We investigated whether age, sex, height, weight, body mass index, bone mineral density, alcohol consumption, smoking status, and outdoor occupation were associated with hypovitaminosis D.ResultsThe prevalence of hypovitaminosis D in patients with rotator cuff tears was 44.3% (78/176). The mean serum concentration of 25-hydroxyvitamin D of total patients was 24.7 ± 13.7 ng/mL. A higher serum level of vitamin D was significantly associated with older age (p < 0.001). Young age was an independent risk factor for hypovitaminosis D. The prevalence of hypovitaminosis D was also lower in patients with an outdoor occupation than in those with an indoor occupation (19.0% vs. 31.4%, p = 0.001).ConclusionsThe prevalence of hypovitaminosis D in patients with rotator cuff tears was 44.3%. Age had a significant positive correlation with the serum concentration of 25-hydroxyvitamin D. Young age and indoor working were independent risk factors for hypovitaminosis D in patients with rotator cuff tears. Therefore, the possibility of hypovitaminosis D should be considered for young and indoor working patients who have rotator cuff tears.     

Association of Superoxide-Induced Oxidative Stress With Rotator Cuff Tears in Human Patients

Rotator cuff degeneration is one of the factors contributing to rotator cuff tears. Oxidative stress is involved in tendon degeneration, and superoxide-induced oxidative stress plays a pathological role in regulating the balance between oxidation and reduction. The role of oxidative stress in rotator cuff tears, however, is unclear. This study, therefore, aimed to investigate the contribution of superoxide-induced oxidative stress to rotator cuff tears. Seventy patients were recruited and divided into two groups: patients with (Ruptured group) and those without (Unruptured group) a rotator cuff tear. Specimens from both groups were collected during surgery. Degeneration morphology was classified according to the degeneration score. Superoxide-induced oxidative stress was assessed according to dihydroethidium (DHE) relative fluorescence intensity, capacity for antioxidation according to superoxide dismutase (SOD) activity, and the balance between oxidation and reduction based on the redox ratio. Data were compared between groups. Correlations between the degeneration score and the oxidative stress factors were calculated. Degeneration score and DHE relative fluorescence intensity were significantly higher in the Ruptured than the Unruptured group. The SOD activity was not significantly different between groups. Degeneration score was positively correlated with both DHE relative fluorescence intensity and SOD activity. Thus, superoxide-induced oxidative stress and tendon degeneration were greater in rotator cuff tear tissues than in those with no tear, suggesting that oxidative imbalance may be involved in degenerative rotator cuff tears. Clinical Relevance: Understanding the mechanisms of superoxide-induced oxidative stress may lead to targeted tissue therapy for degenerative rotator cuff tears. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:212–218, 2020