Progressive early passive and active exercise therapy after surgical rotator cuff repair - study protocol for a randomized controlled trial (the CUT-N-MOVE trial).
ABSTRACT: BACKGROUND:Rotator cuff tear is a common cause of shoulder disability and results in patients predominantly complaining of pain and loss of motion and strength. Traumatic rotator cuff tears are typically managed surgically followed by ~?20 weeks of rehabilitation. However, the timing and intensity of the postoperative rehabilitation strategy required to reach an optimal clinical outcome is unknown. Early controlled and gradually increased tendon loading has been suggested to positively influence tendon healing and recovery. The aim of this trial is therefore to examine the effect of a progressive rehabilitation strategy on pain, physical function and quality of life compared to usual care (that limits tendon loading in the early postoperative phase) in patients who have a rotator cuff repair of a traumatic tear. METHODS:The current study is a randomized, controlled, outcome-assessor blinded, multicenter, superiority trial with a two-group paralleled design. A total of 100 patients with surgically repaired traumatic rotator cuff tears will be recruited from up to three orthopedic departments in Denmark, and randomized to either a progressive early passive and active movement program or a limited early passive movement program (usual care). The primary outcome measure will be the change from pre-surgery to 12 weeks post-surgery in the Western Ontario Rotator Cuff Index questionnaire. Secondary outcomes include the Disabilities Arm, Shoulder and Hand questionnaire (DASH), range of motion, strength and tendon healing characteristics from ultrasound measurements at 12 months follow up. DISCUSSION:We hypothesized that patients who receive the progressive rehabilitation strategy will benefit more with respect to pain reduction, physical function and quality of life than those who receive care as usual. If this is confirmed our study can be used clinically to enhance the recovery of patients with traumatic rotator cuff tear. TRIAL REGISTRATION:ClinicalTrials.gov, NCT02969135 . Registered on 15 November 2016.
Project description:Background:The association between concomitant pathologic characteristics and preoperative symptoms in patients identified as eligible for surgical rotator cuff repair has been sparsely evaluated. The purpose was to explore the associations between preoperative shoulder symptoms and additional structural pathology or injuries identified during surgery in patients with traumatic supraspinatus tears. Methods:This was a cross-sectional study including patients with traumatic supraspinatus tears. Preoperatively, patients reported pain and disability using a numeric pain rating scale from 0 to 10 and the Western Ontario Rotator Cuff Index. During surgery, the presence of prespecified structural injuries and pathologies including a full-thickness or partial supraspinatus tear, infraspinatus tear, subscapularis tear, hooked acromion, acromioclavicular joint osteoarthritis, biceps tendon pathology, labral tear, and cartilage lesion was recorded. Linear regression and analysis of covariance were used to assess associations. Results:A total of 87 patients (52 male patients, 60%) were included (mean age, 60 years; standard deviation, 9.2 years). Of these patients, 69 (79%) had a full-thickness supraspinatus tear and 18 (21%) had a partial-thickness tear. Concomitant structural pathology was found in 79 patients (91%). No association was found between the number of structural shoulder pathologies and preoperative numeric pain rating scale or Western Ontario Rotator Cuff Index score, and no particular concomitant pathology was associated with worse patient-reported symptoms. Conclusion:Pathology of the infraspinatus and subscapularis and other structural joint pathologies concomitant with supraspinatus tears were not correlated with preoperative self-reported pain and disability in patients scheduled to undergo rotator cuff surgery, suggesting that concomitant pathology adds little to the symptoms in patients with a traumatic supraspinatus tear.
Project description:Rotator cuff tears are a common cause for pain and reduced function. Tears of the tendons of the cuff can be a result of a degenerative process or as a consequence of trauma. Management of cuff tears are surrounded by controversy from indications for surgical management to rehabilitation protocol post-surgical repair. The aim of post surgical rehabilitation is to improve functional outcome, reduce pain and promote tendon healing. In the case of rotator cuff repair, rehabilitation can be broadly divided into early passive range of motion (EPM) and delayed range of motion (DRM). The EPM regime is defined by minimal immobilisation of the shoulder and passive mobilisation of the joint within the first post-operative period. In contrast, DRM immobilises the shoulder joint up to six weeks post-operatively. Proponents of EPM state various advantages of their rehabilitation protocol including improved range of motion and earlier return to normal activities of daily living. However, there has also been concern that this rehabilitation regime may result in an increased rate of re-rupture. Since this is a highly controversial issue, various high quality literature have been published looking to clarify which regime is best following rotator cuff surgery. Reviewing these articles, it appears that there is an increase rate of re-tear of the repaired rotator cuff tendon when the EPM regime is employed. Statistical significance however was limited by small sample sizes. Range of motion post-repair also appears to be associated with post-operative rehabilitation regime. As expected, the EPM regime has been shown to improve range of motion post-repair. Despite this, literature reports patients managed with the DPM showed a statistically better patient reported outcome measure. We conclude that based on the evidence we currently have, early range of motion post rotator cuff repair is related with an increase risk of re-tear. The DPM regime reduces this risk with the possible complication of reduced range of shoulder movement. This problem is thought to be an easier clinical issue to deal with compared to re-rupture of the repaired rotator cuff tendon. There is however lack of data to achieve statistical significance in most of these analysis. There is a definite need for a large, multi-centre single blinded randomised controlled trial to further shed light on this controversial topic.
Project description:BACKGROUND: Long head biceps (LHB) degeneration in combination with rotator cuff tears can be a source of chronic shoulder pain. LHB tenotomy is an approved surgical procedure for pain reduction and improvement of joint function, however, the pathophysiology of LHB degeneration is not fully understood. In the literature, neoangiogenesis in tendon tissue has previously been shown to be associated with tendon degeneration. Vascular Endothelial Growth Factor (VEGF) is an important inducer of neoangiogenesis. The hypotheses are first that an elevated VEGF expression and vessel density can be found in degenerated LHB tissue and second that there is a relation between VEGF expression, vessel density and the different types of rotator cuff tears. METHODS: LHB samples of 116 patients with degenerative rotator cuff tears were harvested during arthroscopic tenotomy. The samples were dehydrated and paraffin embedded. VEGF expression was determined using immunohistochemistry. Vessel density and vessel size were determined on Masson-Goldner stained tissue sections. On the basis of intraoperative findings, patients were assigned to 4 different groups (control group, partial thickness rotator cuff tear, full thickness rotator cuff tear and cuff arthropathy). Partial thickness rotator cuff tears were classified according to Ellman grade I-III, full thickness rotator cuff tears according to Bateman's classification (grade I-IV). The control group consisted of eight healthy tendon samples. RESULTS: VEGF expression in the LHB was significantly higher in the presence of rotator cuff tears than in healthy tendons (p < 0.05) whereas vessel density and vessel size were significantly higher in the LHB of patients with cuff arthropathy (p < 0.05). Furthermore, there was significantly higher VEGF expression in LHB samples from patients with articular-sided compared to bursal-sided partial thickness rotator cuff tears (p < 0.05). No significant dependence was found between VEGF expression, vessel size and vessel density in LHB of patients with full thickness rotator cuff tears and the extent of the cuff tear following Bateman's classification. CONCLUSION: Elevated VEGF expression can be detected in degenerated LHB tissue. The quantity of VEGF expression and vessels are related to the extent of LHB degeneration.
Project description:It has been theorized that degenerative rotator cuff tears most commonly involve the supraspinatus tendon, initiating at the anterior portion of the supraspinatus insertion and propagating posteriorly. The purposes of this study were to determine the most common location of degenerative rotator cuff tears and to examine tear location patterns associated with various tear sizes.Ultrasonograms of 360 shoulders with either a full-thickness rotator cuff tear (272) or a partial-thickness rotator cuff tear (eighty-eight) were obtained to measure the width and length of the tear and the distance from the biceps tendon to the anterior margin of the tear. Tears were grouped on the basis of their size (anteroposterior width) and extent (partial or full-thickness). Each tear was represented numerically as a column of consecutive numbers representing the tear width and distance posterior to the biceps tendon. All tears were pooled to graphically represent the width and location of the tears within groups. Frequency histograms of the pooled data were generated, and the mode was determined for each histogram representing various tear groups.The mean age (and standard deviation) of the 233 subjects (360 shoulders) was 64.7 +/- 10.2 years. The mean width and length of the tears were 16.3 +/- 12.1 mm and 17.0 +/- 13.0 mm, respectively. The mean distance from the biceps tendon to the anterior tear margin was 7.8 +/- 5.7 mm (range, 0 to 26 mm). Histograms of the various tear groups invariably showed the location of 15 to 16 mm posterior to the biceps tendon to be the most commonly torn location within the posterior cuff tendons. The histograms of small tears (a width of <10 mm) and partial-thickness tears showed similar distributions of tear locations, indicating that the region approximately 15 mm posterior to the biceps tendon may be where rotator cuff tears most commonly initiate.Degenerative rotator cuff tears most commonly involve a posterior location, near the junction of the supraspinatus and infraspinatus. The patterns of tear location across multiple tear sizes suggest that degenerative cuff tears may initiate in a region 13 to 17 mm posterior to the biceps tendon.
Project description:Latissimus dorsi transfer is a reasonable treatment option for massive posterosuperior rotator cuff tears that can substantially improve chronically painful and dysfunctional shoulders. This report and accompanying video describe the treatment of an active 43-year-old man with severe pain and weakness in the right shoulder after 3 failed rotator cuff repairs. Preoperative imaging showed a massive posterosuperior rotator cuff tear retracted to the glenoid as well as a hypermobile os acromiale likely causing dynamic impingement and recurrent rotator cuff tears. After diagnostic arthroscopy, the latissimus tendon is harvested and augmented with a 3-mm human acellular dermal patch (ArthroFlex; Arthrex, Naples, FL). The native rotator cuff tissue is repaired as much as possible, and the latissimus tendon is passed underneath the deltoid and posterior to the teres minor. The patch-augmented tendon is then integrated into a double-row SpeedBridge repair of eight 4.75-mm BioComposite SwiveLock anchors (Arthrex). The bony surface of the os acromiale is prepared and then fixed to the acromion with 2 cannulated partially threaded screws and additional tension-band wiring. Postoperative rehabilitation initially focuses on early passive range of motion, followed by active and active-assisted motion and a biofeedback program starting at 6 weeks postoperatively.
Project description:Long head biceps (LHB) degeneration, in combination with rotator cuff tears, can be a source of chronic shoulder pain. LHB tenotomy reduces pain and improves joint function although the pathophysiological context is not well understood. Tendon integrity depends on the extracellular matrix (ECM), which is regulated by matrix metalloproteinases (MMP). It is unclear which of these enzymes contribute to LHB but we chose to study MMP 1, 3, and 9 and hypothesized that one or more of them may be altered in LHB, whether diagnosed preoperatively or intraoperatively. We compared expression of these MMPs in both LHB and healthy tendon samples.LHB samples of 116 patients with degenerative rotator cuff tears were harvested during arthroscopic tenotomy. Patients were assigned to 4 groups (partial thickness tear, full thickness tear, cuff arthropathy, or control) based upon intraoperative findings. Partial and full thickness tears were graded according to Ellman and Bateman's classifications, respectively. MMP expression was determined by immunohistochemistry.MMP 1 and 9 expression was significantly higher in the presence of rotator cuff tears than in controls whereas MMP 3 expression was significantly decreased. MMP 1 and 9 expression was significantly higher in articular-sided than bursal-sided partial thickness tears. No significant association was found between MMP 1 and 9 expression and full thickness tears, and the extent of the cuff tear by Bateman's classification.Increased MMP 1 and 9 expression, and decreased MMP 3 expression are found in LHB degeneration. There is a significant association between the size and location of a rotator cuff tear and MMP expression.
Project description:INTRODUCTION:For patients who are diagnosed with lesions of the rotator cuff that present advanced levels of fatty degeneration, arthroscopic repair of the rotator cuff remains controversial. This controversy can be attributed to the frequently reported high failure rate of the tendon fixation and the fact that it remains unclear why repair for these tears results in significant clinical improvement independent of the occurrence of such a re-tear. Recent publications have reported comparable clinical improvements when merely a tenotomy of the long head of the biceps tendon was performed and the rotator cuff tear was left untreated. These observations raise questions on the value of performing the more extensive cuff repairs in degenerative cuff tears. Even more, rehabilitation after an isolated tenotomy is much less cumbersome as compared with rehabilitation after rotator cuff repair and, therefore, might result in improved patient satisfaction. The goal of this trial is to study function and quality-of-life of patients undergoing arthroscopic biceps tenotomy with or without an additional cuff repair and to include an economic evaluation. METHODS AND ANALYSIS:This multicentre randomised controlled non-inferiority trial, including an economic evaluation, is designed to compare the short-term and long-term outcome of patients who underwent an arthroscopic tenotomy of the long head of the biceps tendon with or without a cuff repair. We will include 172 patients with stage 2-3 Goutallier fatty infiltration cuff tears and with clinical symptoms of biceps pathology. Primary outcome is the rotator cuff specific quality-of-life (Western Ontario Rotator Cuff index) on the short term (6 months postoperatively). Secondary outcomes are quality-of-life 1, 2 and 5?year postoperatively and function (Constant-Murley score, glenohumeral range of motion), recovery status, pain (visual analogue scale), economic evaluation, satisfaction of treatment on the short-term and long-term and re-tear rate at 6 months determined with an ultrasound. ETHICS AND DISSEMINATION:This trial has been approved by the Medical Research Ethics Committees United (MEC-U), Nieuwegein, the Netherlands (NL54313.100.15) and will be performed in accordance with the Declaration of Helsinki with the Medical Research Involving Human Subjects Act (WMO). The results of this study will be reported in peer-reviewed journals and at (inter)national conferences. Furthermore, we will share our findings with the appropriate guideline committees. TRIAL REGISTRATION NUMBER:The Dutch Trial Registry (NL4010).
Project description:Massive rotator cuff tears are particularly challenging to treat and severely limit the function of the shoulder. Compared with a small rotator cuff tear, massive tears are more unpredictable and usually present with low tendon quality. When performing an anatomical repair of the rotator cuff, the surgical treatment is often associated with failure of the construct. An alternative procedure that can be performed in the setting of a massive tear is superior capsular reconstruction (SCR), using an autograft or allograft. This procedure has been shown to be effective and is associated with positive treatment outcomes. Moreover, the combination of an SCR with an anatomic repair of the rotator cuff tendon may provide a stronger fixation for the rotator cuff and ultimately lead to a lower likelihood of retear and failure. The purpose of this Technical Note is to describe our preferred procedure for the treatment of a massive rotator cuff tear through SCR with superimposition of the repair of the native rotator cuff tendons.
Project description:Massive rotator cuff tears pose significant clinical and surgical challenges for orthopaedic surgeons and increased morbidity to the patient. Left untreated, this pathology can lead to inability to perform daily activities, weakness, pain, and eventual cuff tear arthropathy. Several treatment options exist for irreparable cuff tears, such as reverse shoulder arthroplasty and tendon transfers. However, there exists significant concern for high complication rates and unpredictable clinical outcomes following such treatments. Superior capsular reconstruction (SCR) represents a viable alternative in treating irreparable cuff tears, providing biomechanical stability and improving pain related to this pathology by reducing superior humeral instability and subacromial impingement. Over-the-top repair of the native rotator cuff tendons with incorporation of the SCR allograft may provide surgeons the opportunity to perform a robust repair in situations where arthroplasty or other more invasive procedures were once the only options. The authors present a surgical technique with associated pearls and pitfalls for their preferred procedure of SCR with incorporation of the native rotator cuff in transosseous equivalent double-row repair for the treatment of massive, irreparable rotator cuff tears.
Project description:Articular surface partial rotator cuff tendon tears are a common source of shoulder pain and dysfunction, and there is no consensus regarding the optimal arthroscopic treatment. Commonly accepted techniques, such as transtendinous repair or tear takedown with primary repair, may violate healthy tendon tissue and increase the suture anchor density. In this note, we describe an outside-in double row-equivalent technique for repair of partial articular-sided rotator cuff tears. A medial row of inverted horizontal mattress stitches is placed percutaneously using spinal needles to shuttle partially absorbable braided sutures into the joint. The technique may incorporate a soft tissue biceps tenodesis into the rotator cuff with a second, oblique medial row mattress stitch. Suture limbs are retrieved and tied in the subacromial space and then secured to a lateral anchor. The result is a side-to-side double row-equivalent rotator cuff repair, anatomically reproducing the footprint of the rotator cuff without removing healthy tissue. We believe this is an efficient and reproducible technique that preserves intact bursal tissue, limits implant costs, and produces reliable healing in partial articular-sided tears of the rotator cuff.