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There is a phenomenon in which the tendon appears to increase the length after rotator cuff repair. However, it is unclear in which cases tendon lengthening occurs and how the degree of lengthening affects the surgical outcome. This study aimed to evaluate pre- and postoperative musculotendinous junction (MTJ) and tendon length on magnetic resonance imaging (MRI) and assess the postoperative tendon lengthening and its impact on postoperative outcomes.We reviewed 109 patients with good repair integrity after arthroscopic rotator cuff repair. Patients whose supraspinatus tendons were simply pulled out laterally without any additional procedures were included. They underwent serial MRI before surgery and at 3, 6, and 24 months after surgery. The location of the MTJ in relation to the line of the glenoid fossa and the supraspinatus tendon length were measured. Clinical evaluation was conducted 2 years after surgery, including the range of shoulder motion, shoulder strength index (affected/unaffected strength), Constant score, University of California, Los Angeles (UCLA) score, and pain numeric rating scale (NRS). The characteristics of the preoperative tendon, change in tendon length over time, amount of the lateral shift of MTJ location and tendon length, and impact of tendon lengthening on postoperative clinical outcomes were analyzed.The preoperative tendon retraction significantly correlated with the MTJ location (r = -0.75; p0.0001) and preoperative tendon length (r = -0.46; p0.0001). Tendon length at 3, 6, and 24 months after surgery was significantly longer than those before surgery (26.7 ± 5.8 mm, 27.9 ± 6.6 mm, 28.5 ± 5.6 mm, and 21.5 ± 5.1 mm, respectively). From before surgery to 24 months after surgery, the MTJ location moved 8.4 ± 8.6 mm laterally and the tendon length increased 7.0 ± 6.1 mm. A significant and weak negative correlation was found between tendon lengthening and the abduction strength index (r = -0.22; p = 0.03); however, no significant correlation with pain, range of shoulder motion, external rotation strength index, Constant score, and UCLA score was found. Multiple linear regression analysis also showed that tendon lengthening was only associated with the abduction strength index (standardized coefficient = -0.20, p = 0.03).Tendon lengthening and lateral shift of MTJ location were observed after arthroscopic rotator cuff repair, and they correlated with preoperative tendon retraction. Although the amount of tendon lengthening had negative weak correlation with abduction strength index, it did not affect other postoperative outcomes.

Background Arthroscopic Bankart repair (ABR) yields good results in young athletes with anterior shoulder instability. However, the treatment for overhead athletes is challenging because recovery of range of motion is necessary for return to play and repeated shoulder motion may lead to recurrent instability. The aim of this study was to investigate the clinical outcomes and return to sports after ABR on the dominant shoulder in overhead athletes. Methods This study included 24 competitive level overhead athletes who underwent ABR on their dominant shoulders. The mean age at surgery was 17.6 years, and the mean follow-up was 39.7 months. The range of bilateral shoulder motion, the Rowe score, the Japanese Shoulder Society Shoulder Instability Score (JSS-SIS), and the Japanese Shoulder Society Shoulder Sports Score (JSS-SSS) were evaluated before the surgery and at the final visit. Recurrent instability, the final level of return to sports, and the duration before returning to sports were confirmed, as well as the pre-, intra- and postoperative factors, which prohibited complete return to play. Results There were no cases of recurrent instability. The Rowe score, JSS-SIS, JSS-SSS, and the range of flexion, abduction, internal rotation significantly improved postoperatively. Fifteen athletes (62.5%) returned to the same or superior levels without any complaint in their shoulders. The mean duration needed for a complete return was 13.3 months. The postoperative external rotation deficit in abduction was larger in the athletes who returned incompletely than those who returned completely, 7.8° and 2.3°, respectively. Conclusions ABR is a reliable surgery for preventing recurrent instability in overhead athletes, however the rate of a complete return to preinjury level was low and a long duration was needed for complete return to play. The postoperative external rotation may be necessary for a complete return to overhead sports. Level of evidence Level IV: Retrospective Case Series.

Background The purpose of this study was to identify differences in the morphology of the scapula according to the presence or absence of a rotator cuff tear (RCT). Methods One hundred and three shoulders with and 87 shoulders without RCTs were included in this study. The critical shoulder angle (CSA) and lateral acromion angle in the frontal view and the acromial coverage angle (ACA) and coracoid and scapular spine angle (CSSA) in the lateral view were evaluated using three-dimensional computed tomography. The glenoid anterior tilt, anterior acromial projection angle (AAPA), coracoid process angle, scapular spine angle (SSA) and inferior angle angle (IAA) with respect to the scapular plane were measured in the lateral view. The morphological parameters of the scapula associated with RCT were statistically analysed using a multivariate logistic regression analysis. Results In univariate logistic regression analysis, CSA, ACA, CSSA, AAPA, SSA and IAA were significantly different between shoulders with and without RCTs. In multivariate logistic regression analysis, CSA and IAA were greater in shoulders with RCT and were significantly associated with this condition. Conclusion To the best of our knowledge, this is the first study to focus on the relationship between RCT and the scapular body. RCT cases were characterised by a greater curvature of the scapular body in addition to CSA.

Background We performed arthroscopic rotator cuff repair (ARCR) combined with miniopen supraspinatus and infraspinatus muscle advancement for massive rotator cuff tears (RCTs) to decrease tension at the repair site with the goal of reduction of the failure rate. We evaluated the clinical outcomes and failure rate after this procedure. Methods This study included 47 patients diagnosed with chronic massive RCTs between October 2010 and March 2015. Of these patients, 21 underwent transosseous equivalent (TOE) ARCR only (control group), and 26 underwent TOE ARCR with muscle advancement (study group). We evaluated shoulder clinical outcomes at preoperative and postoperative assessments and also measured muscle strength and the acromiohumeral interval (AHI) at the same time in both groups. Failure rates were calculated in both groups by evaluating the cuff integrity with postoperative magnetic resonance imaging. Results Although there was statistically significant improvement for the mean clinical scores in the both groups, there were no significant differences between the 2 groups. The postoperative abduction muscle strength and AHI were significantly higher in the study group (46.3 ± 20.6 N and 9.4 ± 2.9 mm; P = .04) than in the control group (34.6 ± 20.0 N and 7.7 ± 3.0 mm; P = .04). The failure rates were significantly lower in the study group than in the control group (23.1% and 52.4%; P = .03). Conclusion The TOE ARCR with muscle advancement can achieve significantly better abduction muscle strength, wider AHI, and lower failure rates for massive RCTs than the normal TOE ARCR.

Context: Tennis is a noncontact sport playable at an individual’s own pace. Thus, it is popular among the older adults. It is known that older adults often suffer from rotator cuff tears (RCTs), which may affect tennis activity. However, the prevalence and influence of RCTs on tennis play among older players are not well-known. This study aimed to evaluate the prevalence of RCTs in older tennis players and its impact on physical findings and shoulder function. Design: A cross-sectional study. Methods: Fifty-three tennis players (mean age: 70.7 y; range: 60–83 y) participating in a recreational-level tennis tournament were examined in this study. An ultrasonographic examination of both shoulders was performed to detect RCTs. Relationships between RCTs of the dominant shoulder and clinical findings, shoulder pain, and shoulder function including range of motion, shoulder strength, and Single Assessment Numeric Evaluation score, and Disability of the Arm, Shoulder and Hand—Sports Module score were assessed. Results: RCTs were detected in 19 (36%) dominant shoulders and 6 (11%) nondominant shoulders. Asymptomatic RCTs were detected in 11 (58%) dominant shoulders and 5 (83%) nondominant shoulders. Increased crepitus and more positive results in the empty can test, and infraspinatus test were observed in the dominant shoulders with RCTs than in those without; however, there was no difference in shoulder pain, range of motion; strength; Single Assessment Numeric Evaluation score; and Disability of the Arm, Shoulder and Hand—Sports Module score between the players with and without RCTs. Conclusions: One-third of the older tennis players in this study had RCTs in the dominant shoulder with some positive physical sign of an RCT. However, shoulder pain and shoulder function did not differ between the players with and without RCTs, suggesting that RCTs had a minor impact on the tennis performance in the participants of this study.

Background The purpose of this study was to evaluate the relationship of fatty infiltration in rotator cuff muscles and shoulder strength in rotator cuff tears and these changes during nonsurgical treatment. Methods Fifty-three shoulders from 47 patients (mean age: 69.9 years) diagnosed with rotator cuff tears by magnetic resonance imaging (MRI) were treated nonsurgically. The degrees of fatty infiltration in supraspinatus (SSP) and infraspinatus (ISP) muscles were graded by the modified Goutallier classification (grade 0–1, grade 2–3, or grade 4). The isometric strength of the abductors (Abd) and external rotators (ER) were examined with a hand dynamometer. We analyzed the correlation of the modified Goutallier classification in SSP and ISP muscles with the strength of Abd and ER at initial visit. In addition, MRI and strength tests were repeated after 24 ± 6 months, and changes in fatty infiltration and strength were examined. Results Fatty infiltration of SSP and ISP muscles had a negative correlation with the strengths of Abd and ER at initial visit, respectively. Six of 45 shoulders (SSP grade: 0–3) and 7 of 43 shoulders (ISP grade: 0–3) had progression of fatty infiltration. Predictive factor of a progression of fatty infiltration during follow-up was decreased initial strength of Abd. There was no significant change in the strength of Abd, and the strength of ER showed significant improvement between the initial and post-treatment measurements. Even in the subgroup that had progression of fatty infiltration at follow-up, the strength of Abd and ER did not decrease significantly. Conclusions Although fatty infiltration of the rotator cuff muscles exhibited a negative correlation with muscle strength, fatty infiltration and muscle weakness did not progress at the same rate.

Background The quality of tendons has considerable limitations regarding torn rotator cuff tendons. Tissue-engineering techniques using a biodegradable scaffold offer potential alternatives for recreating a valid tendon-to-bone interface. Hypothesis A polyglycolic acid (PGA) sheet could facilitate the regeneration of the rotator cuff tendon insertion in vivo. Study Design Controlled laboratory study. Methods An implant consisting of a PGA sheet, a rapidly absorbable material, was used to replace a completely resected infraspinatus tendon insertion in 33 adult Japanese white rabbits. The contralateral infraspinatus tendon was replaced by poly-L-lactate-epsilon-caprolactone (PLC), a slowly absorbable material, by the same methods based on the results of the pilot study. Histological comparisons were made at 4, 8, and 16 weeks, and mechanical evaluations were performed at 4 and 16 weeks in both groups. Unrepaired defects were created in a control group. Results: In the control group, the rotator cuff defects were covered with thin fibrous membranes with many fibroblasts arranged in an irregular pattern. In the PLC group, some chondrocytes were seen in the tendon insertion; however, these were not arranged along the long axis for a 16-week period. In the PGA group, a well-arranged fibrocartilage layer could be found in the regenerated tendon insertions; however, these tendon insertions were mainly regenerated by type III collagen. In mechanical examinations, the PGA group had significantly higher values in the maximum failure load, tensile strength, and Young's modulus for the 4-week and 16-week periods. These 3 categories statistically improved from 4 to 16 weeks postoperatively in both groups except for the Young's modulus in the PGA group (E = 5.66 at 4 weeks to 5.53 at 16 weeks). Conclusion The PGA sheet scaffold material allows for tendon insertion regeneration with a fibrocartilage layer but displays mechanical properties inferior to those of the normal tendon in an animal model. Clinical Relevance The PGA sheet represent a possible alternative scaffold material for tendon regeneration in rotator cuff repair.

The purpose of this study was to evaluate histologically and biomechanically the interface between porous hydroxyapatite ceramics and a tendon grafted into ceramics, and to compare the interface in two ceramics with different porous structures: interconnected porous calcium hydroxyapatite ceramics (IP-CHA) with an effective porosity index (interpore diameter > 20 μm) of 63.6%, and porous calcium hydroxyapatite ceramics with less interconnection (HA-L) with an effective porosity index of 5.5%. The tendon-IP-CHA complex and the tendon-HA-L complex were implanted into the bone defects made in both knees of rabbits. With IP-CHA, abundant fibrous tissue, including vessels and collagen fiber continuity, was observed inside interface-region pores. The amount of osseous tissue in interface-region pores increased over time, and at 24 weeks after operation, the tendon was in direct contact with the osseous tissue in IP-CHA. With HA-L, the amount of fibrous tissue in interface-region pores was low and did not increase. The results of biomechanical analysis revealed that the maximum tendon pull-out load from IP-CHA was significantly higher than that from HA-L. With the porous hydroxyapatite ceramics having highly interconnecting porous structure, a bioactive interface was achieved between ceramics and grafted tendon. On the basis of these results, we conclude that bone defects, including tendon insertion, can be reconstructed using IP-CHA. © 2006 Wiley Periodicals, Inc. J Biomed Mater Res, 2006

Tendon attachment to interconnected porous calcium hydroxyapatite ceramics (IP-CHA) with cultured bone marrow stromal cells (BMSC) was analysed. The purpose of this study was to evaluate whether BMSC in IP-CHA could augment the tendon attachment to IP-CHA histologically and biomechanically. Eighteen Japanese white rabbits were used. Cultured BMSCs were subcultured in IP-CHA. The grafted tendon and IP-CHA with BMSC complex were implanted in a bone defect of the knee [BMSC(+) group]. In the contralateral knee, a tendon and IP-CHA without BMSC complex were implanted [BMSC(-) group]. Histological findings of the interface between the tendon and IP-CHA were similar in the two groups 3 weeks after the operation. However, 6 weeks after the operation, more abundant bone formation around the tendon was observed in the BMSC(+) group. The direct apposition of the tendon to bone in pores and collagen fibre continuity between the tendon and fibrous tissue in pores were observed. In biomechanical evaluation, the maximum pull-out load of the tendon from the IP-CHA in the BMSC(+) group was significantly higher than that in the BMSC(-) group 6 weeks after the operation. BMSCs cultured in IP-CHA could augment tendon attachment to IP-CHA.

Nonsurgically treated rotator cuff tears sometimes become irreparable in the lead up to surgical repair. The purposes of our study were to identify predictive factors in the progression of tear size, and determine the changes in tear location.Eighty shoulders from 71 patients (mean age 69.4 years) diagnosed with rotator cuff tears by MRI were treated nonsurgically. MRI was repeated after more than 1 year of initial diagnosis. Tear size was measured from the edge of the tear to the lateral aspect of the greater tuberosity. Tears were classified into 5 groups based on tear size and 4 groups based on tear location. Changes in tear size and location were examined.The mean follow-up period was 22.3 months. The average progression of tear size was 5 mm during follow-up, averaging 3 mm per year. Tears that were initially1 or ≥4 cm were unlikely to progress in tear size. On the other hand, 1- to 2-cm tears on the initial MRI exhibited the greatest progression in tear size, followed by 2- to 3-cm tears. Furthermore, 62.5 % of localized tears in the posterior of the superior facet spread anteriorly, whereas 88.9 % of localized tears in the anterior of the superior facet did not change.Medium-sized tears are at high risk of tear progression. In contrast, there is little risk of early development of irreparable damage in partial tear or small full-thickness tears. In addition, typical tears may start in the posterior of the superior facet, and subsequently spread anteriorly. Our present findings may serve as a useful reference in determining the treatment course for rotator cuff tears.Level IV, Case Series, Prognosis Study.

Background: Rotator cuff regeneration using tissue engineering techniques is a challenging treatment in elderly patients with irreparable rotator cuff tears. Hypothesis: A polyglycolic acid sheet scaffold with seeded mesenchymal stem cells (MSCs) may enhance the expression of type I collagen products and increase the mechanical strength of the regenerated tendon in vivo. Study Design: Controlled laboratory study. Methods: A surgically created defect of infraspinatus tendons of rabbits was reconstructed with 2 different materials, a polyglycolic acid (PGA) sheet alone (PGA group) (n = 34) and a PGA sheet seeded with autologously cultured MSCs (MSC group) (n = 34). The authors created a tendon defect model without embedding any graft as the control model (control group) (n = 34). The rabbits were sacrificed at 4, 8, and 16 weeks after the operation and then were histologically evaluated. The rabbits were also biomechanically evaluated by measuring the ultimate failure loads and Young’s modulus at 4 and 16 weeks following implantation. Results: In the MSC group, the fibrocartilage layers and Sharpey fibers were found regularly in the insertion site at 8 weeks compared with the PGA group. In control group, thin membranes with many fibroblasts arranged in an irregular pattern linked the end of the torn cuff to the bone without any Sharpey fibers and type I collagen. A large volume of type I collagen was found in comparison with type III collagen at 16 weeks in the MSC group, whereas type III collagen was more prevalent than type I in the PGA group. The tendon maturing score in the MSC group had higher values than the PGA and control groups at 8 and 16 weeks (mean values were 21.0 ± 0.89, 24.0 ± 2.53 in the MSC group; 16.7 ± 2.25, 21.3 ± 2.42 in the PGA group; and 10.2 ± 0.98, 12.2 ± 1.72 in the control group, respectively) ( P < .05). The results of the mechanical analysis revealed that the regenerated tendons in the MSC group had better tensile strength than in the PGA and control groups at 16 weeks (mean values were 3.04 ± 0.54 in the MSC group, 2.38 ± 0.63 in the PGA group, and 1.58 ± 0.13 in the control group) ( P < .05). Conclusion: Bone marrow–derived MSCs were able to regenerate tendon-bone insertions and the tendon belly, including the production of type I collagen, and increased the mechanical strength of the regenerated rotator cuff tendon. Clinical Relevance: Rotator cuff regeneration using MSCs is a promising treatment for massive rotator cuff defects.

10 LONGITUDINAL STUDY FOR ROTATOR CUFF TEARS IN THE GENERAL POPULATION Atsushi Yamamoto, Kenji Takagishi, Hitoshi Shitara, Tsuyoshi Ichinose, Tsuyoshi Sasaki, Noritaka Hamano, Tsutomu Kobayashi, Daisuke Shimoyama, Toshihisa Osawa, Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Department of Physical Therapy, Takasaki University of Health and Welfare, Department of Orthopaedic Surgery, Takasaki General Medical Center The purpose of this study was to elucidate the natural history of rotator cuff tears (RCTs) in the general population. We have performed annual medical check-ups since 2006. The subjects of this study consisted of 568 people, with 1,136 shoulders, who were investigated longitudinally more than two times between 2009 and 2015, which comprised 400 men and 736 women, with a mean age of 67.2 years (range; 30-85), and a mean follow-up period of 3.5 years (range; 1-6). We performed ultrasonography to diagnose RCTs. At the beginning of the survey, 957 shoulders were diagnosed as non-tear. As time passed, 45 and 29 of these shoulders progressed to partial-thickness tear (PTT) and full-thickness tear (FTT), respectively. At the same time, 32 shoulders were diagnosed as PTT, and 53.1% of them progressed to FTTas time passed. Additionally, 147 shoulders were diagnosed as FTTat the beginning of the survey, and 33.3% of them enlarged the size of tears by more than 5 mm during the survey. In 147 of FTTs, 43 shoulders were symptomatic tears and 104 shoulders were asymptomatic tears. The development of symptoms in both symptomatic and asymptomatic tears was associated with the enlargement of the size of tear. In conclusion, RCTs might become asymptomatic if the size of tear the remains the same, while they seem to be symptomatic when a new tear or enlargement of the size of the existing tear occurs.

Many clinicians believe that a large bony defect of the glenoid must be treated with bone grafting when a Bankart procedure is performed. Various types of bone graft, such as open bone graft, Eden-Hybinnette, J-bone graft, coracoid transfer, and Latarjet, have been used. These require open procedures that are difficult to perform arthroscopically. We performed an arthroscopic autologous bone graft and an arthroscopic Bankart repair at the same time to treat a patient with recurrent dislocation of the shoulder joint and a large bony Bankart lesion. We harvested from the lateral site of the acromion 2 bones that were 2.7 mm in cylindrical diameter. We transplanted these bones to the large bony defect of the anteroinferior area of the glenoid and placed anchors between the 2 plugs. During the 30 months since the surgery was performed, the patient has not experienced dislocation or apprehension about the shoulder. A 3-dimensional computed tomography scan showed enlargement of the glenoid surface. Our surgical procedure offers promise for treatment of patients with recurrent dislocation of the shoulder joint and a large bony Bankart lesion because it allows the surgeon to alter the size and the grafted site of the cylindrical bone according to the size of the defect.