Background: Smoking increases retear rates after rotator cuff repair. However, the cessation duration required to achieve outcomes comparable to those of nonsmokers remains unclear.
Purpose: To determine the cessation duration required for former smokers to achieve retear rates comparable to those of nonsmokers after arthroscopic rotator cuff repair.
Study design: Cohort study; Level of evidence, 3.
Methods: The study included 1902 patients who underwent arthroscopic rotator cuff repair for full-thickness tears between March 2012 and October 2023. Patients were categorized as nonsmokers (1172 patients); former smokers stratified by cessation duration of <1 year, 1 to <3 years, 3 to <5 years, and ≥5 years (454 patients); or current smokers (276 patients). After 1:1:1 propensity score matching based on age, employment status, tear size, and fatty infiltration, the records of 276 patients per group were analyzed. The visual analog scale, Subjective Shoulder Value, American Shoulder and Elbow Surgeons score, University of California at Los Angeles score, and range of motion were used to compare functional outcomes. Six-month postoperative magnetic resonance imaging assessed structural integrity using the Sugaya classification.
Results: At the 2-year (range, 23-27 months; mean, 24.5 ± 1.0 months) follow-up evaluation, clinical scores and range of motion had significantly improved (P < .001 for all) in all groups without significant intergroup differences. However, retear rates differed significantly: 17.8% in nonsmokers, 25.4% in former smokers, and 29.3% in current smokers (P = .005). Former smokers demonstrated progressively decreasing retear rates with longer cessation: 28.6% at <1 year, 27.0% at 1 to <3 years, 20.1% at 3 to <5 years, and 19.4% at ≥5 years. Patients with ≥3 years' cessation achieved rates comparable to those of nonsmokers. Multivariable analysis identified smoking status, pack-years (cutoff, 14), and cessation duration (cutoff, 44 months) as independent predictors. The combined cessation duration/pack-year model demonstrated superior predictive performance (AUC, 0.716).
Conclusion: Sustained smoking cessation significantly lowers retear rates after rotator cuff repair, with at least 3 years of abstinence required to achieve rates comparable to those of nonsmokers. Pack-years and duration of cessation serve as independent predictors of tendon healing.
Background: Tendinopathy remains a major clinical challenge due to the limited regenerative capacity of tendon tissue. Mesenchymal stem cell (MSC)-derived extracellular vesicles (EVs) show therapeutic promise; however, strategies to enhance their local retention and therapeutic efficacy remain necessary.
Purpose: To evaluate the regenerative efficacy of an injectable collagen-EV system delivering human umbilical cord-derived MSC-EVs in a collagenase-induced supraspinatus tendinopathy rat model.
Study design: Controlled laboratory study.
Methods: EVs were isolated from MSCs and characterized using nanoparticle tracking analysis. EVs were incorporated into an injectable collagen scaffold. In vivo fluorescence tracking of PKH26-labeled EVs was performed in a separate cohort (4 shoulders per group) to evaluate EV retention over 14 days. A collagenase-induced tendinopathy model was established in the supraspinatus tendons of 16 rats. Rats were randomly assigned to 4 treatment groups (control, collagen, EV, and collagen + EV) and received local injections (8 shoulders per group). Magnetic resonance imaging (MRI) was performed at weeks 3 and 4 to evaluate tendon signal intensity and thickness after treatment. At week 4, all rats were sacrificed for histological and immunofluorescence analysis.
Results: Fluorescence tracking revealed sustained retention of EVs within the tendon for 14 days via collagen scaffold delivery. MRI analysis at weeks 3 and 4 showed significantly reduced tendon signal intensity and thickness in the collagen + EV group compared with all other groups (P < .001). Histological evaluation demonstrated superior collagen continuity, arrangement, and density, and significantly higher histological scores in the collagen + EV group (P < .001). Immunofluorescence revealed reduced iNOS and increased CD206, Arg-1, and FOXP3 expression, indicating anti-inflammatory and regulatory immune modulation.
Conclusion: Local delivery of MSC-EVs embedded within an injectable collagen scaffold enhanced tendon regeneration in a rat model of collagenase-induced tendinopathy. The collagen matrix provided sustained retention and bioactivity of the EVs, resulting in superior structural and histological recovery compared to either treatment alone. These findings support the therapeutic synergy between EVs and collagen and offer preclinical validation for a translatable, cell-free therapeutic strategy for tendinopathy.
Clinical relevance: Combining EVs with collagen carriers is a promising strategy for biological augmentation of tendinopathy.
Background: Posterior shoulder instability has been associated with abnormal acromial and glenoid morphology. However, the role of coracoid morphology in posterior instability remains unclear.
Hypothesis: Patients undergoing surgery for posterior shoulder instability will have more inferiorly oriented and lateralized coracoids compared to patients with anterior instability or a noninstability comparison group.
Study design: Cohort study; Level of evidence, 3.
Methods: Magnetic resonance imaging measurements were collected for 3 surgical cohorts: posterior instability (n = 41), anterior instability (n = 39), and a comparison group undergoing arthroscopy for snapping scapula (n = 38). Coracoid morphology metrics included: lateral coracoid offset, sagittal coracoid angle, coronal coracoid angle (CCA), transverse coracoid length, coracoacromial length (CAL), coracohumeral distance, and inferior coracoid coverage (ICC). Glenoid version and bone loss were also measured. One-way analysis of variance with Tukey post hoc testing or Kruskal-Wallis with Dunn testing was used as appropriate to compare groups. The P value was set a priori at <.05 to represent statistical significance. Analyses were performed using SPSS Version 30.0 and R Version 4.5.0.
Results: The posterior instability group demonstrated a significantly higher CCA (69.4° ± 23.5°) than the anterior (52.8° ± 23.8°; P = .002) and comparison (56.9° ± 17.7°; P = .015) groups. The CAL and ICC were also significantly different in the posterior group (both P < .001). No significant differences in coracoid morphology were found between the anterior and comparison groups. Patients with posterior instability had significantly increased glenoid retroversion (-8.1° ± 3.7°) versus the anterior (-3.1° ± 5.3°) and comparison (-4.2° ± 4.3°) groups (both P < .001).
Conclusion: Coracoid morphology differs significantly in patients undergoing posterior shoulder stabilization when compared to patients undergoing surgery for anterior instability or a comparison cohort. Increased CCA, increased CAL, and greater ICC are associated with patients undergoing posterior stabilization surgery. These findings suggest that a lower coracoid with increased inferior coverage of the humeral head may contribute to the pathogenesis of posterior instability.
Background: Patient Acceptable Symptom State (PASS) values for commonly used patient-reported outcome measures are known for operatively treated patients with femoroacetabular impingement syndrome (FAIS) but have not been established for those undergoing nonoperative treatment.
Purpose: First, to determine the PASS for International Hip Outcome Tool-33 (iHOT-33), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and pain visual analog scale (VAS) in patients with FAIS treated nonoperatively; second, to assess the baseline factors that were associated with achieving PASS.
Study design: Cohort study (diagnosis); Level of evidence, 2.
Methods: Patients with FAIS who were treated nonoperatively with an expert-validated physical therapy protocol at 2 academic centers were prospectively enrolled. Patients completed the iHOT-33, HOS-ADL, and pain VAS at baseline and 6 months after beginning treatment. Receiver operating characteristic curve analyses were conducted to determine PASS cutoff points. Multivariable regression analyses were performed to determine the association of patient factors, radiographic markers, and disease severity on the likelihood of achieving PASS.
Results: Of the 214 patients enrolled, 121 (57%) were female, and the mean age was 34 years. The median symptom duration before beginning the prescribed physical therapy regimen was 24 months. The mean (SD) iHOT-33 score was 42.9 (16.7) at baseline and 54.2 (22.0) at 6 months. The iHOT-33 score for PASS is 50 (specificity, 91%; sensitivity, 82%; area under the curve [AUC], 0.95). The mean (SD) HOS-ADL was 72.9 (16.0) at baseline and 77.1 (17.1) at 6 months. The HOS-ADL score for PASS is 66 (specificity, 81%; sensitivity, 86%; AUC, 0.90). The mean (SD) pain VAS score was 53.7 (23.1) at baseline and 41.9 (SD25.4) at 6 months. The pain VAS score for PASS is 36 (specificity, 67%; sensitivity, 85%; AUC, 0.87). Patient age was significantly predictive of achieving PASS for iHOT-33 (odds ratio, 1.04; 95% CI, 1.01-1.08). Patients with higher baseline iHOT-33 scores were more likely to achieve PASS for all patient-reported outcome measures (P < .005). Otherwise, patient factors, radiographic markers, and symptom duration were not associated with achieving PASS.
Conclusion: This study determined the PASS values for iHOT-33 (PASS = 50), HOS-ADL (PASS = 66), and pain VAS (PASS = 36) for patients with FAIS treated nonoperatively with an exercise-based, core-focused physical therapy program. These values can be utilized by clinicians in counseling individual patients to anticipated outcomes and by investigators for future nonoperative-focused outcomes research.
Background: Previous studies have shown good mid-term outcomes of hip labral tear treatment with arthroscopy. However, long-term results are limited within the young adult population.
Purpose: To report survivorship and patient-reported outcome measures (PROMs) at a minimum 10-year follow-up in young adult patients after primary hip arthroscopy with labral repair or debridement.
Study design: Case Series; Level of evidence, 4.
Methods: Data were prospectively collected and retrospectively reviewed on all patients who underwent primary hip arthroscopy between June 2008 and August 2012. Young adult patients, aged >19 and <40 years, who underwent labral debridement repair or reconstruction and concomitant procedures were included. Preoperative and minimum 10-year follow-up data for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), iHOT-12 (International Hip Outcome Tool), and visual analog scale for pain (VAS-Pain) were collected. The exclusion criteria were previous ipsilateral hip surgery/conditions, Tönnis grade >1, hip dysplasia, workers' compensation status, or femoral head and acetabular Outerbridge scores of 4. Rates of achieving the minimal clinically important difference (MCID) and the patient acceptable symptomatic state (PASS), as well as hip joint survival from conversion to total hip arthroplasty and progression to subsequent ipsilateral revision hip arthroscopy, were reported.
Results: Of the 241 hips eligible for analysis, 194 hips (80.5%) had a minimum 10-year follow-up. A total of 122 women (62.9%) and 72 men (37.1%) were included in the present analysis, with a mean age of 28.9 years and a mean body mass index of 24.8 kg/m2. The 10-year survivorship for young adult patients was 91.8%, and 12.9% of patients underwent subsequent ipsilateral arthroscopy at a mean of 36.8 months after the initial procedure. Significant improvements were observed in all PROMs from baseline to a minimum 10-year follow-up-including the mHHS, NAHS, HOS-SSS, VAS-Pain, iHOT-12, and patient satisfaction (P < .05). Patients aged 19 to 40 years achieved high rates of MCID, for mHHS, NAHS, and VAS-Pain, as well as high rates of PASS for the mHHS.
Conclusion: Young adults who underwent primary hip arthroscopy with labral treatment demonstrated an overall 10-year survivorship of 91.8%, significant improvements in PROMs, and high achievement rates of PASS for the mHHS and MCID for the mHHS, NAHS, and VAS-Pain.
Background: Bone grafting is a common and effective treatment for anterior shoulder instability. Graft healing is critical for the success of this procedure; however, few studies have investigated methods to enhance the healing process. Furthermore, suitable animal models are scarce for this type of surgery.
Purpose: To (1) establish an animal model of anterior shoulder instability, and (2) evaluate whether a surgical modification based on an inlay structure (creating a groove on the glenoid and shaping the graft to match it) along with postoperative administration of the bone anabolic agent parathyroid hormone 1-34 (PTH1-34) could accelerate graft healing.
Study design: Controlled laboratory study.
Methods: A rabbit model of anterior shoulder instability was established, and autologous iliac bone grafting was performed. Gross morphological observation, micro-computed tomography imaging and analysis, and histological staining and evaluation were employed to assess whether the inlay-based surgical modification and postoperative intermittent subcutaneous injection of PTH1-34 could enhance graft healing.
Results: The modified inlay technique increased the expression of Runx2 and type I collagen within the graft, accelerated graft integration with the glenoid, promoted more rapid callus remodeling and maturation, and reduced graft resorption. Additionally, for both the modified inlay and classic onlay bone grafting procedures, postoperative intermittent subcutaneous injection of PTH1-34 enhanced osteogenic capacity of the autograft and glenoid, increased new bone volume, and shortened the graft healing time.
Conclusion: We successfully developed an animal model of autologous bone grafting for anterior shoulder instability. Using this model, we demonstrated that the modified inlay bone grafting procedure improves osteogenic ability, shortens healing time, and promotes callus maturation. Intermittent subcutaneous administration of PTH1-34 after surgery further enhanced graft-glenoid healing.
Clinical relevance: The modified inlay technique and postoperative intermittent PTH1-34 administration may improve graft healing rates after bone grafting procedures for anterior shoulder instability.
Background: Hip arthroscopy has demonstrated favorable short- and mid-term outcomes for femoroacetabular impingement syndrome (FAIS) in patients with borderline hip dysplasia (BHD). However, long-term outcomes in patients with FAIS and BHD treated with hip arthroscopy remain understudied.
Purpose: To evaluate hip survivorship and patient-reported outcomes (PROs) in patients with FAIS and BHD compared with those without BHD at a minimum 10-year follow-up.
Study design: Cohort Study; Level of evidence, 4.
Methods: A retrospective matched-cohort study was conducted on patients undergoing primary hip arthroscopy for FAIS by a single surgeon (2012-2024). BHD was defined as a lateral center-edge angle (LCEA) of 20° to 25°. Patients with BHD were matched 1 to 2 to controls without BHD based on age, sex, body mass index, and preoperative modified Harris Hip Score (mHHS). Radiographic parameters (eg, alpha angle, LCEA) were assessed pre- and postoperatively. PROs-including mHHS, Non-Arthritic Hip Score (NAHS), and hip survivorship (revision arthroscopy, conversion to total hip arthroplasty [THA])-were compared.
Results: The study included 23 patients with BHD (mean age, 33.6 years; 69.6% women) and 46 controls (mean age, 32.7 years; 65.2% women). Both groups showed significant improvements in mHHS and NAHS at 10 years (all P < .001), with no differences in postoperative scores or minimal clinically important difference achievement (BHD group, 91.3% vs control group, 97.5%; P = .55). There were no conversions to THA in the BHD group and 2 in the control group (4.3%; P = .189). Revision arthroscopy rates were 0% in the BHD group and 8.7% in the control group (P = .549). Patients with BHD exhibited significantly greater reductions in alpha angles on 45° Dunn views (-13° vs -1.9°; P = .01).
Conclusion: At a minimum 10-year follow-up, patients with BHD who underwent hip arthroscopy for FAIS achieved comparable PROs and hip survivorship to those without BHD. These findings support the use of hip arthroscopy as a durable and effective treatment for FAIS in this population.
Background: Optimal graft selection for anterior cruciate ligament (ACL) reconstruction (ACLR) remains controversial, particularly regarding tendon-to-bone incorporation and biomechanical performance among autografts, allografts, and hybrid grafts.
Hypothesis: Autografts demonstrate superior tendon-to-bone healing, biomechanical strength, and functional recovery compared with allografts and hybrid grafts.
Study design: Controlled laboratory study.
Methods: A total of 84 rats underwent ACLR using autograft, allograft, or hybrid grafts (a construct combining autograft and allograft tissues) (n = 21 per group), with an intact group serving as the control group. Grafts were harvested from the peroneus longus tendon. Assessments at 1, 2, 4, and 8 weeks included histology (hematoxylin and eosin; the Masson trichrome staining; immunohistochemistry), gait analysis, micro-computed tomography, and biomechanical testing.
Results: Histologically, compared with allografts and hybrid grafts, autografts exhibited significantly improved synovial coverage, lower cartilage degeneration (score, autograft vs allograft vs hybrid graft: 10.80 ± 0.84 vs 3.20 ± 0.84 vs 4 ± 0.71; P < .001), improved collagen alignment, reduced inflammation, and enhanced vascularization and tenogenesis, whereas allografts and hybrid grafts exhibited distinct necrosis. Autografts exhibited superior value of bone volume per total volume (femur, autograft vs allograft vs hybrid graft: 5.40 ± 0.55 vs 2.60 ± 0.86 vs 2.69 ± 0.25; P < .001). Gait parameters, including stride length and step height, were restored to near-control levels only in the autograft group (intact control vs autograft: stride length, 3.09 ± 0.40 vs 2.96 ± 0.35; P = .899; step height, 2.67 ± 0.31 vs 2.26 ± 0.35; P = .199). Biomechanically, autografts demonstrated superior stress (autograft vs allograft: 14.86 ± 4.26 vs 2.64 ± 1.35; P < .001), stiffness (autograft vs allograft: 11.21 ± 5.55 vs 3.15 ± 1.55; P = .027), and tensile modulus (autograft vs allograft vs hybrid graft: 31.71 ± 10.35 vs 3.71 ± 1.83 vs 15.07 ± 4.51; P < .001).
Conclusion: Autografts provided superior tendon-to-bone integration, biomechanical performance, and functional outcomes compared with allograft and hybrid grafts in a rat ACLR model.
Clinical relevance: This preclinical study, conducted in a rat model, provides mechanistic evidence that autografts exhibit superior biological incorporation and mechanical integrity, supporting the existing clinical preference for autograft in ACLR and helping inform graft selection.
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