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Objective: Rotator cuff calcific tendinitis (RCCT) is a common cause of shoulder pain in adults and typically presents as activity-related shoulder pain. Between non-surgical and surgical treatment options, today a few minimal invasive techniques are available to remove the calcific deposit, and they represent a cornerstone in the management of this painful clinical condition. The aim of the work was a retrospective evaluation of double-needle ultrasound-guided percutaneous fragmentation and lavage (DNL), focused on understanding the factors which are of major importance in determining a quick and good response at 1 month., Methods: A series of 147 patients affected by RCCT and suitable for DNL were evaluated. A systematic review of anamnestic, clinical and imaging data was performed in 144 shoulders treated in a single-centre setting. Clinical reports and imaging examinations were revisited. The inclusion criteria were submission to DNL, therefore fitness for the percutaneous procedure, and following 1-month follow-up. There was no exclusion owing to risk of bias. The treatment was defined as successful for constant shoulder modified score (CSS) improvement of >50% at 1 month., Results: In 70% of shoulders, the treatment resulted in a quick and significant reduction of symptoms (successful). On the whole, CSS increase at 1 month was estimated at 91.5 ± 69.1%. CSS variations were significantly related to age of patients (better results between 30 and 40 years old), calcification size (more relevant improvement for middle-sized calcifications, 12-17 mm), sonographic and radiographic features of calcific deposits (softer calcifications) and thickening of subacromial/subdeltoid bursa walls. In the final model of stepwise regression for CSS variation, ultrasound score pre-treatment and post-treatment, the distance between bursa and calcification before treatment and the size of post-treatment calcification area were shown to be independently correlated to success. Numeric rating scale score for pain showed similar results. Pain at admission was also related to age, calcification size, ultrasound and Gärtner score, power Doppler positivity, bursal wall thickening and biceps tenosynovitis., Conclusion: The success of the procedure with quick improvement in function and symptoms is warranted in soft and middle-sized calcifications, in young adults., Advances in Knowledge: Ultrasound-guided percutaneous procedures for RCCT must be safe, effective and with prompt pain relief and function restoration. This study shows which clinical picture is more favourable to this purpose and actual prognostic factors for DNL (soft and middle-sized calcifications, in young adults, are more favourable).

The high incidence of recurrent tendon tears after repair of massive cuff lesions is prompting the research of materials aimed at mechanically or biologically reinforcing the tendon. Among the materials studied upto now, the extracellular matrix (ECM) scaffolds of human origin have proved to be the safest and most efficient, but the current laws about grafts and transplants preclude their use in Europe. In order to overcome this condition in 2006, we started a project regarding the production of an ECM scaffold of human origin which could be implanted in Europe too. In 2009, the clinical study began with the implantation of dermal matrix scaffolds in 7 middle-aged patients affected with large/massive cuff lesions and tendon degeneration. Out of 5 cases, followed for at least 1 year in which the scaffold was employed as an augmentation device, there were 3 patients with complete healing, 1 partial re-tear, and 1 total recurrence. The absence of adverse inflammatory or septic complications allows to continue this line of research with a prospective controlled study in order to define the real advantages and correct indications offered by scaffold application.

Tissue engineering may play a major role in the treatment of rotator cuff tendon lesions through replacement of an injured tendon segment. Tendons have very poor spontaneous regenerative capabilities, and despite intensive remodelling, complete regeneration is never achieved and the strength of tendon and ligaments remains as much as 30% lower than normal even months or years following an acute injury. Tendons seem to be the least complex of the connective tissues with respect to their composition and architecture and this leads to the expectation that they would be more amenable to tissue engineered approaches than other tissues. An accurate literature revision was done in order to know the state of the art of tissue engineering therapies in the field of rotator cuff regeneration. The following techniques of tissue engineering were considered: local injection of stem cells or growth factors, gene transfer, in situ tissue engineering and in vitro production of bioengineered tendons to be further transplanted in the lesion site. So far, few experimental or clinical studies have been done on tendon tissue engineering compared to the extensive work on other tissues of orthopaedic interest, such as bone and cartilage. The existing studies are related to the following tissue engineering methodologies: gene transfer, in situ tissue engineering and in vitro production of bioengineered tendons. In our opinion the previously described literature revision showed the necessity for future studies in this area also because of recent advances in biological and bioactive scaffolds.

Background: One cause of early failure of rotator cuff repairs is the pull out of the suture through the tendon. The aims of this study were to investigate the initial strength and failure mode of different tendon grasping techniques and to evaluate an alternative stitch proposed for arthroscopic repair of rotator cuff tendons., Methods: Four different stitches were investigated: simple stitch, Mattress, modified Mason-Allen and simple stitch closed over a horizontal loop. The last stitch was proposed as an alternative to the modified Mason-Allen stitch since the former is simpler to sew arthroscopically than the latter. The experimental procedure was designed to assess the mechanical behaviour of the stitches. Tests were performed using sheep infraspinatus tendons. Two different non-absorbable sutures were used. Each specimen was preloaded with about 30 N and then loaded to failure., Results: No significant difference was found in compliance among the four investigated stitches. Conversely, the tensile strength of the simple stitch and Mattress was lower than the tensile strength of the other two stitches, while no significant difference was observed between the modified Mason-Allen and the simple stitch closed over a horizontal loop. The maximum grasping power of these two 'reinforced' stitches was achieved only with the high-strength suture., Interpretation: The simple stitch closed over a horizontal loop seems to be an attractive alternative to the modified Mason-Allen for arthroscopic repair of the rotator cuff and it seems recommendable instead of simple or Mattress stitches. The use of a high-strength suture would increase the tensile strength of the grasping in the case of good quality tendon tissue.

Arthroscopic repair of wide rotator cuff ruptures is burdened by a percentage of recurrences that is greater than the repair carried out when an open technique is used. One of the main reasons for this difference can be searched for in the minor hold of stitching on the tendinous aspect obtained with arthroscopic repair. In fact, when an open technique is used, good hold can be guaranteed by using reinforced stitches such as the modified Mason-Allen. Thus, arthroscopic repair technique on the tendinous aspect, particularly in wide and massive injuries, must be improved. It was the purpose of this study to compare a new reinforced stitch that can easily be obtained in arthroscopy (simple stitch that orthogonally crosses a horizontal stitch previously knotted on the tendon: SS-HL), with traditional stitches (simple stitch, mattress-stitch and modified Mason-Allen stitch). Tests were carried out on sheep infraspinatus tendons in order to evaluate the resistance of pull-out. The SS-HL stitch showed resistance to loading that was similar to that when the modified Mason-Allen was used, but it was greater than that shown by the simple stitch (+48%) and the mattress stitch (+35%).

Calcific tendinitis of the rotator cuff is a relatively frequent pathology and at times, in some phases, it is a disabling one: for this reason, numerous therapeutic options have been proposed. The authors propose an algorithm for the classification and treatment of calcific tendinitis and report their experience with arthroscopic treatment over a three-year period from 2001 to 2004. Based on the algorithm proposed, out of a total of 126 shoulders affected with calcific tendinitis of the rotator cuff for which debridement was indicated, 106 us-guided percutaneous surgeries (EPT), and only 20 arthroscopies were performed. Arthroscopy is indicated, on the basis of the algorithm that we followed, in patients affected by chronic and persistent calcific tendinitis who did not benefit from the execution of previous types of non-surgical treatment for a period of at least 6 to 12 months. Shoulder instability was found to be present in 8 patients out of 20 treated arthroscopically. After arthroscopy, short- and medium-term results were always positive with the exception of one case that evolved into adhesive capsulitis. Based on an analysis of this series, we were able to confirm the usefulness and clinical applicability of an algorithm to classify and treat calcific tendinitis of the rotator cuff; we also confirmed the role of arthroscopic treatment that in cases which did not respond to conservative procedures proved to be effective in resolving symptoms.

Objective: This study investigated the initial strength and failure mode of different rotator cuff repair techniques., Background: Full or partial re-rupture of the repair is one of the main post-operative complications for rotator cuff repair. The rate of failure is strongly affected by the extension of the tear, increasing in case of large or massive tears up to 62%., Design: The study was planned to assess the three individual components of the tendon-to-bone repair (tendon grasping, suture knotting, suture-to-bone fixation) and to identify the best combinations in terms of mechanical strength to failure. The best combinations were tested to compare the mechanical behaviour of the entire repair and suggest potential improvements in the repair technique., Methods: Experimental tests were performed using sheep shoulders. Three tendon-grasping techniques, two suture knotting techniques, and the effect of bone augmentation with metallic plate and bone quality on suture-to-bone fixation were investigated., Results: This study assessed the mechanical behaviour of different repair components. The best combinations of the investigated techniques showed that the weakest link was the tendon-suture interface. More importantly, the compliance of the investigated repairs was large., Conclusions: The initial strength of the rotator cuff repair can be improved by changing the repair technique. Nevertheless, even a low physiological load stressing the repaired tendon may cause a gap formation at the tendon-bone interface without necessarily producing failure of the repair., Relevance: Post-operative protection of the repaired rotator cuff from tension load is necessary to reduce the risk of delaying or preventing of the healing process.

It was the purpose of the experimental study to use laboratory experience to verify the effectiveness of different methods used to repair the rotator cuff. The sheep was used as an animal model because its infraspinous tendon is the most similar to that in the human. Three static trials were conducted using Instron machines, comparing the repair systems used most by the same authors in their clinical work, the hold of the suturing wires with two different threading procedures in the bone tunnels and two types of knotting, and the breakage loading of the suturing wires in the two different miniplate systems. The authors conclude that tendinous anchoring must be entrusted to reinforced suturing systems (modified SCOI and Mason Allen), the threading of wires in pairs in a single bone tunnel makes surgery easier and shortens the amount of time required, with threading of wires similar to or better than threading with a single wire. There are no differences in breakage loading of the wire at the level of the holes in the two miniplates considered in this study.