A historical review: Surgical management of massive irreparable rotator cuff tears.

» A massive rotator cuff tear is defined as a tear involving >2 tendons or >5 cm of retraction.» Superior capsular reconstruction is done with either a folded fascia lata autograft (6 to 8 mm in thickness) or acellular dermal allograft (3 to 4 mm in thickness). The graft is secured arthroscopically with anchors on the superior glenoid rim and multiple anchors on the humeral head with use of a transosseous-equivalent repair technique.» Superior capsular reconstruction is indicated for younger patients with massive and irreparable rotator cuff tears involving the supraspinatus and infraspinatus with minimal arthritis, intact subscapularis, and a functional deltoid. Contraindications include bone defects, stiffness, and moderate to severe arthropathy.» Arthroscopic superior capsular reconstruction with fascia lata autograft or humeral dermal allograft is a surgical option, with multiple studies showing statistically significant improvement in short-term outcomes for both pain and function among younger patients with massive irreparable rotator cuff tears. The long-term clinical effectiveness and value have yet to be determined.» Biomechanical data suggest improved restoration of superior glenohumeral stability with decreased subacromial contact pressures in association with the use of the 8-mm fascia lata graft as compared with the 4-mm acellular humeral dermal allograft. In addition, fascia lata graft has shown less elongation and thinning than humeral dermal graft.» Either fascia lata autograft or humeral dermal allograft may be used clinically for arthroscopic superior capsular reconstruction; however, a graft thickness of at least 3 mm is recommended to decrease the risk of radiographic and clinical failure.» No comprehensive quality-of-life or cost-comparison analyses are available to compare superior capsular reconstruction, reverse total shoulder arthroplasty (rTSA), tendon transfer, and partial rotator cuff repair for the treatment of massive irreparable rotator cuff tears. However, the potential higher cost of superior capsular reconstruction and the lack of long-term clinical outcomes or revision data suggest that either an attempt at repair or primary arthroplasty may be more cost-effective than superior capsular reconstruction.» Long-term outcome data are essential to determine the role of superior capsular reconstruction for young patients with massive irreparable rotator cuff tears.» Superior capsular reconstruction using fascia lata autograft may provide a different biomechanical and biological healing environment compared to acellular dermal allograft. Thus, the clinical outcome data between the 2 graft methods should not be generalized.

Despite advances in arthroscopic techniques and devices, symptomatic massive contracted rotator cuff tear is still a challenging to most shoulder surgeons. This rotator cuff tissue has all of the f...

This study aimed to compare the clinical and functional outcomes of reverse shoulder arthroplasty versus arthroscopic supe- rior capsular reconstruction in the treatment of patients with massive irreparable rotator cuff tears and Hamada grade 1-2 glenohumeral arthritis. It is a retrospective case-control study comparing the prospective results of 2 different treatment methods. This retrospective comparison of groups was conducted between May 2016 and May 2020. The study included 40 people with massive irreparable rotator cuff tear and Hamada grade 1-2 arthropathy who had arthroscopic superior capsular reconstruction with tensor fascia latae autograft or reverse shoulder arthroplasty surgery. Patients were divided into 2 groups according to treatment. Clinical outcome measures included shoulder range of motion, pain, and functional scores (Constant-Murley, American Shoulder and Elbow Surgeons). The mean age was 61.85 ± 7.56 and 71.10 ± 6.42 years, respectively, for group I [superior capsular reconstruction (n=20)] and group II [superior capsular reconstruction (n=20)]. The mean follow-up was 22.30 ± 8.4 and 32.50 ± 8.11 months, respectively. In the postoperative data, flexion degrees and Constant scores were significantly higher in the superior capsular reconstruction group (P=.007, P = .043). No significant difference was found between the 2 groups in all parameters (P > .05) except abduction. The increase in abduction value in the reverse shoulder arthroplasty group was significantly higher than in the superior capsular reconstruction group (P = .003). In addition, postoperative data in all parameters in both groups showed significant changes compared to preoperatively. This study has shown that superior capsular reconstruction with tensor fascia latae autograft can provide clinical and func- tional improvement similar to the reverse shoulder arthroplasty procedure in treating massive irreparable rotator cuff tears with Hamada grade 1-2 arthropathy. Level III, Therapeutic Study.

Superior Capsular Reconstruction—Technical Marvel or Fading Fashion?

Comparison of clinical outcomes of superior capsular reconstruction and reverse shoulder arthroplasty for irreparable rotator cuff tears in patients aged 65 and older: A propensity score-matched study

Treatment of massive irreparable rotator cuff tears without arthritis: a comparison of superior capsular reconstruction, partial rotator cuff repair, and reverse total shoulder arthroplasty

Consensus statement on the treatment of massive irreparable rotator cuff tears: a Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons.

The InSpace Balloon: Useful Augmentation or First-Line Therapy?: Commentary on an article by Nikhil Verma, MD, et al.: "InSpace Implant Compared with Partial Repair for the Treatment of Full-Thickness Massive Rotator Cuff Tears. A Multicenter, Single-Blinded, Randomized Controlled Trial".

Background. Massive rotator cuff tears are up to 40% and can progress to the stage of irreparable ones. Nowadays, there are many treatment options available for irreparable rotator cuff injuries, from conservative treatment and arthroscopic reconstructions to reverse shoulder arthroplasty. Currently, the comparative effectiveness of various treatment methods remains uncertain, and therefore there is no clear algorithm for choosing treatment tactics of such orthopedic shoulder pathologies. The aim of the study is to compare short-term treatment outcomes of patients with irreparable rotator cuff tears using arthroscopic partial rotator cuff repair, latissimus dorsi tendon transfer, pectoralis major tendon transfer and reverse shoulder arthroplasty. Methods. The study enrolled 75 patients who underwent the following types of surgical interventions: partial arthroscopic repair, posterior and anterior arthroscopically assisted latissimus dorsi tendon transfer, pectoralis major tendon transfer and reverse shoulder arthroplasty. Treatment results were assessed using measurements of the range of active movements in the shoulder joint, the ASES and Constant-Murley Score (CMS) questionnaires, the Visual Analog Scale (VAS), assessment of radiographs and MRI. The assessments were performed preoperatively and at 6 and 12 months after surgery. Results. In all groups, there was a statistically significant improvement by all indicators (p0.05). Clinical and functional results at the short-term follow-up after partial rotator cuff repair and various options of latissimus dorsi tendon transfer are largely comparable, while at the same time superior to the results of reverse shoulder arthroplasty and pectoralis major tendon transfer. Conclusions. The use of partial rotator cuff repair and musculotendinous transfers at the short-term follow-up gives comparable and better results in comparison with the use of reverse shoulder arthroplasty, which allows to consider “joint-preserving” interventions as an option in patients with massive irreparable rotator cuff tears.

Objectives:Treatment options for massive irreparable rotator cuff tears, in middle aged adults, consists of tendon transfer or superior capsular reconstruction (SCR). The purpose of this study was to evaluate if transfer of the latissimus dorsi tendon transfer is enhanced with combination of superior capsular reconstruction for treatment of massive irreparable rotator cuff tears.Methods:At a single institution, all consecutive patients undergoing transfer of the latissimus dorsi tendon with or without superior capsular reconstruction, between 2013 and 2016, for treatment of irreparable rotator cuff tears were evaluated. SCR, was indicated, in addition to latissimus transfer, for patients with impaired preoperative active abduction. All clinical notes, diagnostic imaging, and operative reports were reviewed in detail. Demographics, operative techniques, and radiographic parameters were collected and measured. Functional outcome scores were prospectively collected from patients. The primary outcome of the study was the Disability of Arm, Shoulder, Hand (DASH) score. The secondary outcomes of the study were the Visual Analog Scale (VAS) pain score, Single Assessment Numeric Evaluation (SANE) score, and the American Shoulder and Elbow Society (ASES) score.Results:At 3 years, there were a total of 26 latissimus dorsi tendon transfers performed in patients with irreparable rotator cuff tears. Of these, 8 patients underwent only latissimus dorsi tendon transfer and 18 patients underwent latissimus dorsi tendon transfer combined with a superior capsular reconstruction. Average age was 53 years old with the majority of patients being male (88%). The dominant extremity was involved in 22 (85%) of latissimus transfers and 14 (53%) of patients had previous surgery to address a rotator cuff tear. Follow-up, for the entire cohort, was on average 29 months. At final follow-up, there was no significant difference in physical examination or radiographic measurements between patients with latissimus transfer alone and those with latissimus transfer with SCR. All patients, undergoing either technique, showed significant improvement in both the DASH score (preoperative DASH=59.6, postoperative DASH=39.9, P=0.049) and VAS score (preoperative VAS=6.6, postoperative VAS=3.3, P=0.0006). However, those patients undergoing revision surgery, regardless of technique, showed significantly less improvement in the DASH score (P=0.005), VAS score (P=0.002), SANE score (P=0.005), and the ASES score (P=0.001). Transfer of the Latissimus tendon with SCR, in comparison to only tendon transfer, did not show any significant difference in the final DASH score (p-value=0.72). At the same time, there was no significant difference between latissimus transfer, with or without SCR, in the secondary outcomes of the VAS score(P=0.97), the SANE score(P=0.63), or the ASES score (P=0.74).Conclusion:This is the first study to report the outcomes of latissimus dorsi tendon transfer with superior capsular reconstruction in comparison to only latissimus dorsi tendon transfer for treatment of irreparable rotator cuff tears. The study suggests that transfer of the latissimus dorsi tendon in combination with superior capsular reconstruction, at short term follow-up of 2 years, may not significantly influence functional outcome. Rather, patients undergoing revision surgery, regardless of technique, may demonstrate smaller improvements in functional outcomes.Table 2.Range of Motion & Physical Examination in Latissimus Dorsi Tendon Transfer with/without SCR Lat Only (n=8)Lat + SCR (n=18) PreoperativePostoperativeP-ValuePreoperativePostoperativeP-ValueRange of Motion (Active)Abduction135 ± 21.276.4 ± 180.0475.4 ± 26.071.5 ± 220.80Forward Flexion106.9 ± 36.7135.7 ± 32.20.15103.5 ± 32.2110.6 ± 45.40.35External Rotation36 ± 11.442.9 ± 150.8025.3 ± 18.638.5 ± 16.30.04Internal Rotation65 ± 22.959.3 ± 12.40.5554.4 ± 13.363.1 ± 13.00.08Hornblower Sign2 (25%)2 (25%)0.9814 (78%)2 (11%)0.07External Rotation Lag6 (75%)2 (25%)0.3417 (94%)3 (17%)0.01Continuous data are reported as mean ± standard deviation. Categorical data reported as number (%).Table 4.Functional Outcomes at Final Follow-Up of Latissimus Dorsi Tendon Transfer with/without SCR Lat Only (n=8)Lat + SCR (n=18) Mean (Std Dev)Mean (Std Dev)P-ValuePrimary OutcomeDASH47.0 ± 39.842.5 ± 27.50.72Secondary OutcomeVas3.14 ± 3.53.4 ± 3.50.97SANE54.7 ± 38.560.9 ± 22.10.63ASES65.8 ± 36.360.6 ± 30.90.74Constance63.8 ± 31.050.3 ± 23.30.34

Chapter 7 - Rotator Cuff Augmentation

Restoration of rotator cuff muscle forces in lower trapezius transfer and superior capsular reconstruction in massive rotator cuff tear

The management of massive irreparable rotator cuff tears is a challenging problem, especially in young and active patients. While various treatment options have been proposed, including arthroscopic debridement, partial rotator cuff tendon repairs, superior capsular reconstruction, subacromial balloons and ultimately reverse total shoulder arthroplasty, tendon transfers around the shoulder have been shown to be a successful treatment option in a selected group of patients. Historically, the latissimus dorsi tendon (LDT) transfer, which was first described by Gerber in 1988, has been the gold standard tendon transfer for the management of posterosuperior rotator cuff tears, with long-term results demonstrating durable and reliable improvements in shoulder function. More recently, the lower trapezius tendon (LTT) transfer, which has been described by Elhassan, has been proposed as an alternative to the LDT transfer, with theoretically a better line of pull and synergistic muscle activation. In this chapter, we describe our technique for arthroscopic-assisted lower trapezius tendon transfer using an achilles tendon-bone allograft.KeywordsLower trapezius tendon transferMassive irreparable rotator cuff tearShoulder arthroscopy

The Subacromial Balloon Spacer Versus Superior Capsular Reconstruction in the Treatment of Irreparable Rotator Cuff Tears: A Biomechanical Assessment

To report the outcomes and complications of reverse shoulder arthroplasty (RSA) in massive irreparable rotator cuff tears (MIRCT) and cuff tear arthropathy (CTA). A systematic review of the literature contained in Medline, Cochrane, EMBASE, Google Scholar and Ovid databases was conducted on May 1, 2016, according to PRISMA guidelines. The key words "reverse total shoulder arthroplasty" or "reverse total shoulder prostheses" with "rotator cuff tears"; "failed rotator cuff surgery"; "massive rotator cuff tears"; "irreparable rotator cuff tears"; "cuff tear arthropathy"; "outcomes"; "complications" were matched. All articles reporting outcomes and complications of RSA for the management of MIRCT or CTA were included. The comparison between preoperative and postoperative clinical scores, as well as range of motion (ROM), was performed using the Wilcoxon-Mann-Whitney test. P values lower than 0.05 were considered statistically significant. Seven articles were included in our qualitative synthesis. A statistically significant improvement in all clinical scores and ROM was found comparing the preoperative value with the postoperative value. The degrees of retroversion of the humeral stem of the RSA do not influence the functional outcomes in a statistically significant fashion. There were 17.4% of complications. The most frequent was heterotopic ossification, occurring in 6.6% of patients. Revision surgery was necessary in 7.3% of patients. RSA restores pain-free ROM and improves function of the shoulder in patients with MIRCT or CTA. However, complications occur in a high percentage of patients. The lack of level I studies limits the real understanding of the potentials and limitations of RSA for the management of MIRCT and CTA.