Irreparable Posterosuperior Rotator Cuff Tears Research Articles

Superior Capsular Reconstruction Using an Acellular Dermal Xenograft or Allograft Improves Shoulder Function but Is Associated with a High Graft Failure Rate.

Objectives: The purpose of the present study was to evaluate clinical and functional outcomes, graft integrity rate and progression of osteoarthritis after superior capsular reconstruction (SCR) at short-term follow-up. Methods: Consecutive patients that underwent SCR using an acellular dermal xeno- or allograft between May 2018 and June 2020 for the treatment of irreparable posterosuperior rotator cuff tears were included. Shoulder function (American Shoulder and Elbow Surgeons [ASES] score), pain (Visual Analog Scale [VAS] for pain) and active shoulder range of motion (ROM) were evaluated preoperatively and after a minimum of 24 months postoperatively. Isometric strength was measured at follow-up and compared to the contralateral side. Magnetic resonance imaging was performed to evaluate graft integrity and osteoarthritis progression (shoulder osteoarthritis severity [SOAS] score). Results: Twenty-two patients that underwent SCR using a xeno- (n = 9) or allograft (n = 13) were evaluated 33.1 ± 7.2 months postoperatively. Four patients in the xenograft group underwent revision surgery due to pain and range of motion limitations and were excluded from further analysis (revision rate: 18.2%). Shoulder function (ASES score: 41.6 ± 18.8 to 72.9 ± 18.6, p < 0.001), pain levels (VAS for pain: 5.8 ± 2.5 to 1.8 ± 2.0, p < 0.001) and active flexion (p < 0.001) as well as abduction ROM (p < 0.001) improved significantly from pre- to postoperatively. Active external rotation ROM did not improve significantly (p = 0.924). Isometric flexion (p < 0.001), abduction (p < 0.001) and external rotation strength (p = 0.015) were significantly lower in the operated shoulder compared to the non-operated shoulder. Ten shoulders demonstrated a graft tear at the glenoid (n = 8, 44.4%) or humerus (n = 2, 11.1%). Graft lysis was observed in seven shoulders (38.9%). The graft was intact in one shoulder (5.6%), which was an allograft. A significant progression of shoulder osteoarthritis was observed at follow-up (SOAS score: 42.4 ± 10.1 to 54.6 ± 8.4, p < 0.001). Conclusions: At short-term follow-up, SCR using an acellular dermal xeno- or allograft resulted in improved shoulder function and pain with limitations in active external rotation ROM and isometric strength. Graft failure rates were high and osteoarthritis progressed significantly. Level of Evidence: Retrospective cohort study, Level III.

Arthroscopic-Assisted Lower Trapezius Tendon Transfer for Irreparable Posterosuperior Rotator Cuff Tears Using a Quadricipital Tendon Allograft and a Double-Row Construct

Lower trapezius transfer is a joint salvage treatment option for irreparable posterosuperior rotator cuff tears in relatively young patients. It requires the use of a tendinous graft to bridge the gap between the lower trapezius and the greater tuberosity. Inlay fixation of hamstring autografts and onlay single-row fixation of Achilles allografts have been described in the literature. This technical note describes an arthroscopic-assisted lower trapezius transfer using a quadricipital tendon allograft fixed with an onlay knotless double-row construct.

Latissimus dorsi transfer or lower trapezius transfer: a treatment algorithm for irreparable posterosuperior rotator cuff tears muscles transfers in posterosuperior rotator cuff tears

IntroductionTendon transfers of the latissimus dorsi (LDT) or the lower trapezius (LTT) are treatment options for irreparable posterosuperior rotator cuff tears (PSIRCT). There is still no consensus on which type of tendon transfer is superior in the treatment of PSIRCT. Due to the differences in the anatomy and biomechanics, we hypothesize that there are different clinical situations in which either LDT or LTT should be preferred. The aim of this study was to evaluate the clinical and radiological outcomes of LDT and LTT in patients with PSIRCT to establish a clinical algorithm for the treatment decision. Materials and MethodsThis is a retrospective, single center observational study. Included were patients who underwent arthroscopically assisted LDT (aaLDT) or arthroscopically assisted LTT (aaLTT) for PSIRCT. In all patients, range of motion (ROM), external rotation strength, Visual Analogue Scale of Pain (VAS) and Subjective Shoulder Value (SSV) were determined pre- and postoperatively. Constant-Murley Score (CS) was evaluated at final follow-up. Complication rate, failure of the tendon transfer and revision rate were analyzed. ResultsIn total, 29 aaLDT (age 64 years, median follow-up time 45 months) and 8 aaLTT (age 54 years, median follow-up time 34 months) were included. Active ROM, VAS and SSV was significantly improved in both cohorts. At follow-up, the median CS was 73 (aaLDT) and 77 (aaLTT), respectively. Failure rate including revision surgery was 14% (aaLDT) and 13% (aaLTT), respectively. Low functional findings preoperatively were correlated to a lower functional outcome at follow-up in both groups. Painful loss of anterior elevation (PLEA) and loss of ER had no significant impact on functional outcomes in aaLDT. ConclusionFollowing the treatment algorithm based on the clinical examination, clinical outcome parameters, active ROM and pain could be significantly improved. Good preoperative function was associated with a good clinical outcome in both transfers. A low failure and revision rate supports the good decision-making of the algorithm presented.

Surgical Management of Massive Irreparable Cuff Tears/Management of Rotator Cuff Disease: Interpositional Graft for Irreparable Posterosuperior Rotator Cuff Tears.

Increasingly, massive irreparable rotator cuff tears present a treatment challenge due to their high re-tear rates. The reparability of such tears depends on factors like tear size, the number of involved tendons, tendon retraction extent, muscular atrophy, fatty infiltration, and the presence or absence of arthritis. There are non-surgical and several surgical treatment options described each with their specific indications, contraindications, pros, and cons. Bridging reconstruction restores the superior rotator cuff tissue and arrests humeral head superior migration. The purpose of his review is to explore the existing literature on interpositional graft mechanics, indications, surgical technique, and clinical outcomes. It aims to understand how these parameters can facilitate the incorporation of bridging reconstruction using interpositional grafts into a surgeon's practice for managing massive irreparable rotator cuff tears. Interpositional grafts for irreparable massive rotator cuff tears can either be auto-, allo-, xenografts, or synthetic material and are best suited for patients who are relatively younger, no glenohumeral arthritis, and minimal to no fatty infiltration and muscle atrophy. Short to medium term outcome studies available report good functional, clinical, and radiological improvements with bridging reconstruction utilizing acellular dermal matrix allograft. Interpositional grafts for management of irreparable posterosuperior cuff tears provides improved clinical and radiological outcomes with minimal complications and thus a viable and valuable surgical technique for a shoulder surgeon's armamentarium.

Subacromial Surgery for Irreparable Posterosuperior Rotator Cuff Tears

The irreparable posterosuperior rotator cuff tear describes a tear of the supraspinatus and/or infraspinatus tendon that is massive, contracted, and immobile in both the anterior–posterior and medial–lateral directions. Patients with an intact subscapularis and preserved forward elevation are challenging to treat because there is not a consensus treatment algorithm. For low-demand, elderly patients, several subacromial surgical options are available that can provide pain relief without the risks or burden of rehabilitation posed by reverse total shoulder arthroplasty or a complex soft-tissue reconstruction (e.g., superior capsular reconstruction, tendon transfer, bridging grafts). Debridement, more specifically the “smooth-and-move” procedure, offers a reliable outcome with documented improvements in pain and function at long-term follow-up. Similarly, the biodegradable subacromial balloon spacer (InSpace; Stryker, Kalamazoo, MI) has been shown to significantly improve pain and function in patients who are not responsive to nonoperative treatment. Disease progression with these options is possible, with a small percentage of patients progressing to rotator cuff arthropathy. Biologic tuberoplasty and bursal acromial reconstruction are conceptually similar to the balloon spacer but instead use biologic grafts to prevent bone-to-bone contact between the humeral head and the acromion. Although there is no single gold standard treatment, the variety of surgical techniques allows patients and surgeons to effectively manage these challenging situations.

Biomechanical Comparison Between Superior Capsular Reconstruction and Lower Trapezius Tendon Transfer in Irreparable Posterosuperior Rotator Cuff Tears

Background: Superior capsular reconstruction (SCR) and lower trapezius tendon transfer (LTT) have recently been used to manage irreparable posterosuperior rotator cuff tears (PSRCTs). There has been a paucity of comparative biomechanical considerations between the 2 procedures. Purpose: To compare the glenohumeral stability and biomechanical properties between SCR and LTT in PSRCTs involving the entire infraspinatus tendon region. Study Design: Controlled laboratory study. Methods: Eight fresh-frozen cadaveric shoulders were tested at 0°, 20°, and 40° of shoulder abduction. Maximum internal, external, and total humeral range of motion (ROM), superior translation of the humeral head, and subacromial contact characteristics were compared among 4 conditions: (1) intact rotator cuff, (2) PSRCTs involving the entire infraspinatus tendon region, (3) LTT using Achilles allograft (12 N and 24 N of loading), and (4) SCR using fascia lata allograft. Results: Although a decrease in total ROM was noted in LTT with 12 N compared with the tear condition, LTT with both 12 N and 24 N as well as SCR did not restrict total rotational ROM compared with the intact condition. LTT had decreased total ROM compared with tear condition at 20° of abduction (P = .042), while no significant decrease was confirmed at all abduction angles after SCR. SCR and LTT with 24 N decreased superior translation compared with the PSRCT condition at 0° and 20° of abduction (P < .037) but not significantly at 40° of abduction, whereas LTT with a 24-N load decreased glenohumeral superior translation at all abduction angles (P < .039). Both SCR and LTT decreased subacromial contact pressure compared with the tear condition (P < .014) at all abduction angles. SCR decreased subacromial contact pressure at 0° and 40° of abduction (P = .019 and P = .048, respectively) compared with LTT with 12 N of loading, while there was no difference between SCR and LTT with 24 N of loading in all abduction angles. SCR increased the contact area compared with the PSRCT condition at all abduction angles (P < .023), whereas LTT did not increase the contact area. Conclusion: SCR and LTT decreased glenohumeral superior translation and contact pressure compared with PSRCT conditions. The LTT was superior to SCR in terms of superior translation of the humeral head at a higher shoulder abduction angle, whereas the SCR showed more advantageous subacromial contact characteristics compared with LTT. Clinical Relevance: These biomechanical findings provide insights into these 2 fundamentally different procedures for the treatment of young and active patients with PSRCTs involving the entire infraspinatus tendon region.

Lower Trapezius Transfer for Irreparable Posterosuperior Rotator Cuff Tears.

Functionally irreparable posterosuperior rotator cuff tears (FIRCT) represent a substantial source of morbidity for many patients. Several surgical options can be considered for the salvage of FICRTs. Transfer of the tendon of the lower trapezius to the greater tuberosity, originally described for surgical management of the paralytic shoulder, has emerged as an attractive option, particularly for patients with external rotation lag and those looking for strength restoration. The purpose of this publication is to review the indications, surgical technique, and reported outcomes of this procedure. Lower trapezius transfer (LTT) to the greater tuberosity in patients with irreparable posterosuperior rotator cuff tears has been reported to be associated with satisfactory outcomes and low reoperation rates. It seems to be particularly effective in improving external rotation motion and strength, even when the teres minor is involved. In patients with a reparable infraspinatus, minimal fatty infiltration, and an intact teres minor, the outcome of LTT may be similar to that of superior capsule reconstruction (SCR), but LTT is more beneficial otherwise. The hospital cost of LTT has been reported to be less than the cost of SCR and equivalent to the cost of reverse arthroplasty. When reverse arthroplasty has been performed after a failed LTT, the outcome and complication rates do not seem to increase. LTT provides satisfactory outcomes for many patients with a posterosuperior FIRCT, particularly when they present preoperatively with an external rotation lag sign, involvement of the teres minor, or a desire to improve strength.

Subacromial Balloon Spacer: When to Use This?

The subacromial balloon spacer is a novel treatment option for the management of massive irreparable rotator cuff tears. This device is introduced into the glenohumeral joint and acts to alleviate the acromiohumeral impingement, caused by the massive irreparable rotator cuff tear. The device also redistributes the tension around the adjacent muscles in the joint, allowing them to compensate for the torn rotator cuff tendons. By doing so, the balloon can act as a "rehabilitation accelerator", ultimately resulting in improved shoulder pain and function. Adherence to balloon indications when selecting the appropriate patient is necessary, and these include an irreparable posterosuperior rotator cuff tear, with preserved subscapularis function, minimal to no osteoarthritis, and the ability to forward flex to 90 degrees. Clinical studies have demonstrated promising potential regarding the benefit of the balloon, with numerous studies demonstrating great outcomes after its implantation. Nevertheless, future research remains necessary to render the evidence behind its utility unequivocal.

Changes in in vivo three dimensional shoulder kinematics following latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears: A systematic review with meta-analysis

BackgroundLatissimus dorsi transfer is a surgical procedure that can be used for treating posterosuperior rotator cuff tears. The procedure leads to improved shoulder function via alterations in the force vector couple around the shoulder. However, there is still no consensus on the biomechanical changes resulting from latissimus dorsi transfer. MethodsWe performed a systematic review of the literature on 3D motion analysis studies evaluating the effects of latissimus dorsi transfer on shoulder kinematics. The available data on segment and joint range of motion was extracted and subject to meta-analysis when consistent across the studies. FindingsOur meta-analysis of pre- and post-operative studies revealed a significant improvement in forward flexion and abduction following latissimus dorsi transfer. When comparing the latissimus transferred shoulder with an uninjured contralateral side the meta-analysis found no significant difference in flexion range of motion, while abduction and external rotation was significantly higher in the uninjured shoulders. The overall risk of bias was moderate to high. High heterogeneity was found in the reporting of data, which limited our ability to perform a meta-analysis across the studies for all interest outcomes. InterpretationsOur findings suggest that latissimus dorsi transfer for posterosuperior rotator cuff tears effectively improves shoulder flexion and abduction. External rotation is also expected to improve but at inferior levels as compared to the unaffected side. However, the heterogeneity of the reported data on 3D motion analysis studies highlights the need for better standardization in research and reporting as to conclude the impact of different joints.

Comparison of Outcomes After Arthroscopic Superior Capsule Reconstruction Versus Arthroscopic Partial Repair or Arthroscopic Debridement for Irreparable Rotator Cuff Tears.

Arthroscopic superior capsule reconstruction (SCR), arthroscopic partial repair (PR), and arthroscopic debridement (DB) are valid treatment options for irreparable rotator cuff (RC) tears. The purpose of this study was to compare clinical, functional, and radiological outcomes of arthroscopic SCR with arthroscopic PR and arthroscopic DB in patients with irreparable posterosuperior RC tears. It was hypothesized that SCR would lead to superior clinical and functional outcomes compared with PR or DB. Cohort study; Level of evidence, 3. Clinical and functional outcomes of this single-center retrospective study included range of motion, strength, and the age- and sex-adjusted Constant-Murley score. Patient-reported outcome measures (PROMs) involved the quick Disabilities of the Arm, Shoulder and Hand score, the Subjective Shoulder Value, and the visual analog scale for pain. Graft and repaired tendon integrity was evaluated by magnetic resonance imaging (MRI) at 12 months of follow-up. In total, 57 patients treated with SCR (n = 20), PR (n = 17), and DB (n = 20) were included. The mean clinical follow-up was 33.8 ± 17.9 months. Preoperative clinical and functional characteristics were comparable among the 3 groups. The range of motion and clinical and functional scores of all 3 groups significantly improved from pre- to postoperatively. Postoperative PROMs showed no differences among all 3 study groups. SCR revealed significantly higher postoperative strength compared with PR (P = .001) and DB (P = .004). Postoperative MRI revealed a rerupture in 4 patients with SCR (20%). Postoperative MRI showed a rerupture in 9 patients with PR ( 53%). Fatty muscle infiltration of the supraspinatus and infraspinatus significantly progressed within all 3 study groups in postoperative MRI scans. No clinical and functional differences were observed between intact and reruptured PR. Patients who underwent SCR had better postoperative strength recovery than patients who underwent PR or DB.

Physiological Tensioning During Lower Trapezius Transfer for Irreparable Posterosuperior Rotator Cuff Tears May Be Important for Improvement in Shoulder Kinematics

Background: Lower trapezius transfer (LTT) has been proposed for restoring the anteroposterior muscular force couple in the setting of an irreparable posterosuperior rotator cuff tear (PSRCT). Adequate graft tensioning during surgery may be a factor critical for sufficient restoration of shoulder kinematics and functional improvement. Purpose/Hypothesis: The purpose was to evaluate the effect of tensioning during LTT on glenohumeral kinematics using a dynamic shoulder model. It was hypothesized that LTT, while maintaining physiological tension on the lower trapezius muscle, would improve glenohumeral kinematics more effectively than undertensioned or overtensioned LTT. Study Design: Controlled laboratory study. Methods: A total of 10 fresh-frozen cadaveric shoulders were tested using a validated shoulder simulator. Glenohumeral abduction angle, superior migration of the humeral head, and cumulative deltoid force were compared across 5 conditions: (1) native, (2) irreparable PSRCT, (3) LTT with a 12-N load (undertensioned), (4) LTT with a 24-N load (physiologically tensioned according to the cross-sectional area ratio of the lower trapezius muscle), and (5) LTT with a 36-N load (overtensioned). Glenohumeral abduction angle and superior migration of the humeral head were measured using 3-dimensional motion tracking. Cumulative deltoid force was recorded in real time throughout dynamic abduction motion by load cells connected to actuators. Results: Physiologically tensioned (Δ13.1°), undertensioned (Δ7.3°), and overtensioned (Δ9.9°) LTT each significantly increased the glenohumeral abduction angle compared with the irreparable PSRCT (P < .001 for all). Physiologically tensioned LTT achieved a significantly greater glenohumeral abduction angle than undertensioned LTT (Δ5.9°; P < .001) or overtensioned LTT (Δ3.2°; P = .038). Superior migration of the humeral head was significantly decreased with LTT compared with the PSRCT, regardless of tensioning. Physiologically tensioned LTT resulted in significantly less superior migration of the humeral head compared with undertensioned LTT (Δ5.3 mm; P = .004). A significant decrease in cumulative deltoid force was only observed with physiologically tensioned LTT compared with the PSRCT (Δ–19.2 N; P = .044). However, compared with the native state, LTT did not completely restore glenohumeral kinematics, regardless of tensioning. Conclusion: LTT was most effective in improving glenohumeral kinematics after an irreparable PSRCT when maintaining physiological tension on the lower trapezius muscle at time zero. However, LTT did not completely restore native glenohumeral kinematics, regardless of tensioning. Clinical Relevance: Tensioning during LTT for an irreparable PSRCT may be important to sufficiently improve glenohumeral kinematics and may be an intraoperatively modifiable key variable to ensure postoperative functional success.

Superior Capsular Reconstruction Using An Acellular Dermal Xeno- Or Allograft for the Treatment of Irreparable Posterosuperior Rotator Cuff Tears: Clinical and Radiographic Outcome at Minimum 2-Year Follow-Up

Superior Capsular Reconstruction Using An Acellular Dermal Xeno- Or Allograft for the Treatment of Irreparable Posterosuperior Rotator Cuff Tears: Clinical and Radiographic Outcome at Minimum 2-Year Follow-Up

Superior Capsular Reconstruction Versus Latissimus Dorsi Tendon Transfer for Irreparable Rotator Cuff Tears: Minimum 5-year Outcomes.

Arthroscopic superior capsular reconstruction (SCR) has been introduced as a successful alternative to latissimus dorsi tendon transfer (LDTT) for irreparable posterosuperior rotator cuff tears. To compare minimum 5-year clinical outcomes of SCR and LDTT for the treatment of irreparable posterosuperior rotator cuff tears in patients with minimal evidence of arthritis and intact or reparable subscapularis tears. Cohort study; Level of evidence, 3. Patients who underwent SCR or LDTT and had undergone surgery ≥5 years earlier were included. The SCR technique used a dermal allograft customized to the defect. Surgical, demographic, and subjective data were collected prospectively and reviewed retrospectively. Patient-reported outcome (PRO) scores utilized were the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), the short version of the Disabilities of the Arm, Shoulder and Hand score (QuickDASH), 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS), and patient satisfaction. Further surgical procedures were documented, and treatment that progressed to reverse total shoulder arthroplasty (RTSA) or revision rotator cuff surgery was considered a failure. Kaplan-Meier survivorship analysis was performed. Thirty patients (n = 20 men; n = 10 women) with a mean follow-up of 6.3 years (range, 5-10.5 years) were included. A total of 13 patients underwent SCR and 17 patients underwent LDTT. The mean age of the SCR group was 56 years (range, 41.2-63.9 years), and the mean age of the LDTT group was 49 years (range, 34.7-57 years) (P = .006). One patient in the SCR group and 2 patients in the LDTT group progressed to RTSA. Two additional (11.8%) patients in the LDTT group had further surgery-1 had arthroscopic cuff repair and 1 had hardware removal with biopsies. The SCR group demonstrated significantly better ASES (94.1 ± 6.3 vs 72.3 ± 16.4; P = .001), SANE (85.6 ± 8 vs 48.7 ± 19.4; P = .001), QuickDASH (8.8 ± 8.7 vs 24.3 ± 16.5; P = .012), and SF-12 PCS (56.1 ± 2.3 vs 46.5 ± 6; P = .001) PROs at the final follow-up. There was no significant difference between groups in median satisfaction (SCR, 9; LDTT, 8 [P = .379]). At 5 years, survivorship rates were 91.7% and 81.3% for the SCR and LDTT groups, respectively (P = .421). At the final follow-up, SCR yielded superior PROs compared with LDTT for the treatment of massive, irreparable posterosuperior rotator cuff tears despite similar patient satisfaction and survivorship between procedures.

Allograft-enhanced latissimus dorsi transfer is better than the conventional technique for irreparable posterosuperior rotator cuff tears. A retrospective matched cohort.

Latissimus dorsi tendon (LDT) transfer (LDTT) to the greater tuberosity to treat irreparable posterosuperior rotator cuff tears (RCTs) in young active patients has been shown to have up to 36% of clinical failures, most of them happening because of either deltoid origin disruption or post-operative transfer rupture from the greater tuberosity. In an attempt to simultaneously prevent both complications, a modified technique includes the following adaptations to the original technique: reinforcement and augmentation of the LDT with a tendinous allograft, enabling the use of a single deltopectoral approach. The aim of this study is to compare mid-term outcomes of the traditional LDTT technique with this modified transfer. Retrospective cohort study comparing two groups who underwent either the traditional (group 1; n = 19) or the modified technique (group 2; n = 27). Group homogenization was assured by statistical comparison of 24 baseline independent variables. The outcome variables were the gains to active shoulder range of motions (ROM) and UCLA scores (and all its subscores, independently), at a minimum follow-up of two years. A p value < .05 was considered to be statistically significant. At a mean follow-up of 25months, both groups have shown improvements to most variables. However, group two (modified technique) achieved greater improvements to UCLA score (p = .009), active external rotation (p = .006) and internal rotation (p = .008). At mid-term follow-up, improvements to outcomes of the modified (single approach, allograft-enhanced) latissimus dorsi transfer were greater than those of the original technique.

Superior Capsular Reconstruction Partially Restores Native Glenohumeral Joint Loads in a Dynamic Biomechanical Shoulder Model

To evaluate the effect of an irreparable posterosuperior rotator cuff tear (PSRCT) on glenohumeral joint loads and to quantify improvement after superior capsular reconstruction (SCR) using an acellular dermal allograft. Ten fresh-frozen cadaveric shoulders were tested using a validated dynamic shoulder simulator. A pressure mapping sensor was placed between the humeral head and glenoid surface. Each specimen underwent the following conditions: (1) native, (2) irreparable PSRCT, and (3) SCR using a 3-mm-thick acellular dermal allograft. Glenohumeral abduction angle (gAA) and superior humeral head migration (SM) were measured using 3-dimensional motion-tracking software. Cumulative deltoid force (cDF) and glenohumeral contact mechanics, including glenohumeral contact area and glenohumeral contact pressure (gCP), were assessed at rest, 15°, 30°, 45°, and maximum angle of glenohumeral abduction. The PSRCT resulted in a significant decrease of gAA along with an increase in SM, cDF, and gCP (P < .001, respectively). SCR did not restore native gAA (P < .001); however, SM was significantly reduced (P < .001). Further, SCR significantly reduced deltoid forces at 30° (P= .007) and 45° of abduction (P= .007) when compared with the PSRCT. SCR did not restore native cDF at 30° (P= .015), 45° (P < .001), and maximum angle (P < .001) of glenohumeral abduction. Compared with the PSRCT, SCR resulted in a significant decrease of gCP at 15° (P= .008), 30° (P= .002), and 45° (P= .006). However, SCR did not completely restore native gCP at 45° (P= .038) and maximum abduction angle (P= .014). In this dynamic shoulder model, SCR only partially restored native glenohumeral joint loads. However, SCR significantly decreased glenohumeral contact pressure, cumulative deltoid forces, and superior migration, while increasing abduction motion, when compared with the posterosuperior rotator cuff tear. These observations raise concerns regarding the true joint-preserving potential of SCR for an irreparable posterosuperior rotator cuff tear, along with its ability to delay progression of cuff tear arthropathy and eventual conversion to reverse shoulder arthroplasty.

Superior capsular reconstruction using hybrid graft for irreparable massive rotator cuff tear.

To evaluate the clinical and radiological outcomes of arthroscopic superior capsular reconstruction (SCR) using hybrid grafts composed of tensor fascia lata autografts and human dermal allografts. This study included 30 patients with chronic irreparable posterosuperior rotator cuff tears (RCTs) who underwent arthroscopic SCR using a hybrid graft composed of tensor fascia lata autograft and human dermal allograft. Clinical outcomes were evaluated using the pain visual analogue scale score, shoulder range of motion, American Shoulder and Elbow Surgeons score, constant score, University of California-Los Angeles score, and simple shoulder test score preoperatively and at least 2years after surgery. Radiographic analysis included the Hamada classification grade, acromiohumeral distance (AHD), and graft integrity at 2years after surgery. All patients exhibited significant clinical improvement in all functional outcome measurements, except external rotation (all P < 0.05). The number of patients who exhibited pseudoparalysis decreased from 7 (23.3%) to 2 (6.7%) postoperatively. Complications were not observed. Radiologically, the mean postoperative AHD increased significantly from 6.9 ± 1.6cm to 8.8 ± 2.1cm at 2years postoperatively (P < 0.001). Twenty five out of the 30 (83.3%) patients showed successful graft healing, and all healing failures occurred on the humeral side. The differences between the healed-graft and failed-graft groups were significantly lower graft thickness (P = 0.001) and smaller AHD (P < 0.001) in the failed-graft group. Every functional outcome scores were not statistically different between healed-graft and failed-graft groups. An arthroscopic SCR technique using a hybrid graft consisting of a tensor fascia lata autograft and human dermal allograft showed satisfactory clinical outcomes in patients with irreparable RCTs. IV.

Management of Irreparable Posterosuperior Rotator Cuff Tears-A Current Concepts Review and Proposed Treatment Algorithm by the AGA Shoulder Committee.

Posterosuperior rotator cuff tears range among the most common causes of shoulder complaints. While non-operative treatment is typically reserved for the elderly patient with low functional demands, surgical treatment is considered the gold standard for active patients. More precisely, an anatomic rotator cuff repair (RCR) is considered the most desirable treatment option and should be generally attempted during surgery. If an anatomic RCR is impossible, the adequate choice of treatment for irreparable rotator cuff tears remains a matter of debate among shoulder surgeons. Following a critical review of the contemporary literature, the authors suggest the following evidence- and experience-based treatment recommendation. In the non-functional, osteoarthritic shoulder, treatment strategies in the management of irreparable posterosuperior RCT include debridement-based procedures and reverse total shoulder arthroplasty as the treatment of choice. Joint-preserving procedures aimed at restoring glenohumeral biomechanics and function should be reserved for the non-osteoarthritic shoulder. Prior to these procedures, however, patients should be counseled about deteriorating results over time. Recent innovations such as the superior capsule reconstruction and the implantation of a subacromial spacer show promising short-term results, yet future studies with long-term follow-up are required to derive stronger recommendations.

Combined latissimus dorsi transfer and deltoid flap for irreparable rotator cuff tear: A retrospective analysis.

This study will evaluate the outcomes of the combined latissimus dorsi tendon transfer and deltoid flap for the management of irreparable posterosuperior rotator cuff tears. This is a retrospective study of 15 patients who have undergone double transfer surgery for their irreparable posterosuperior rotator cuff tears. These patients were followed up in three periods. Functional outcomes such as the constant score (CS), subjective shoulder value (SSV), and range of motion were assessed as well as radiographic outcomes such as the acromio-humeral distance. Fifteen patients were included in the early and intermediate follow-up while only 8 remained at the latest follow-up. At the early follow-up the SSV (p=0.001), CS (p=0.021), and A-H distance (p=0.008) showed a statistically significant improvement from their pre-operative values. At the latest follow-up, only the external rotation decreased from its value at the intermediate follow-up (p=0.027). The double transfer technique showed sustainable improvement of the functional outcomes except for the external rotation. However, the loss of external rotation did not affect the remaining outcomes. Trials comparing this technique to other surgical managements or MIRCTs are needed to confirm these results.

Long-term outcomes of teres major transfer for irreparable posterosuperior rotator cuff tears in patients aged

Massive rotator cuff tears are defined as irreparable when tendon-to-bone or tendon-to-tendon continuity with the adducted arm cannot be restored and severe muscle fatty infiltration is present. Tendon transfer is a palliative procedure that improves shoulder function and relieves pain. We reviewed the records of patients aged <65 years, whose irreparable posterosuperior rotator cuff tears had been managed with teres major tendon transfer at our institution. Their 5- and 10-year clinical and radiographic follow-up records were examined to assess long-term outcomes. Patients' Constant Score, Disabilities of the Arm, Shoulder, and Hand score, and the visual analog scale for pain were calculated before the procedure and at 5 and 10 years. There were 24 consecutive patients aged <65 years (mean, 59; 12 men and 12 women) who had received no prior treatment except rehabilitation. All patients underwent teres major tendon transfer due to the failure of conservative treatment. The mean Constant Score was 26 preoperatively and 68 and 66 at 5 and 10 years, respectively (P=.0001 and P=.25). The mean Disabilities of the Arm, Shoulder, and Hand scores were 62.2 preoperatively and 7.8 and 9.3 at 5 and 10 years, respectively (P=.0009 and P=.1). The mean visual analog scale scores at rest were 6.1 preoperatively, and 0.3 and 0.5 at 5 and 10 years, respectively (P=.0003 and P=.1). Based on Hamada's classification, at 5 years, 3 patients showed grade 2 changes, and another had grade 3 changes; at 10 years, 7 patients showed grade 2 changes, and one showed grade 3 changes. Complications (8%) developed after the 10-year evaluation and included pain in 1 patient and secondary rupture of the transfer in another. Improving shoulder function and reducing pain in relatively young patients with irreparable posterosuperior cuff tears involves replacing the lost muscle with a muscle-tendon transfer. The chief aims of the procedure are to restore the balance with the subscapularis muscle, achieve joint stability, keep the humeral head in the glenoid cavity, and improve shoulder abduction and external rotation. Teres major tendon transfer can achieve these goals. Altogether, 22 of our 24 patients experienced improved daily activity function and pain relief that became stable after 5 years. Teres major transfers are useful surgical procedures, particularly in younger patients and in those with high functional demands, providing good and stable long-term results.

Association of Arthroscopically-Assisted Latissimus Dorsi Tendon Transfer with Implantation of a Subacromial Balloon Spacer for Patients with Irreparable Posterosuperior Rotator Cuff Tears

Association of Arthroscopically-Assisted Latissimus Dorsi Tendon Transfer with Implantation of a Subacromial Balloon Spacer for Patients with Irreparable Posterosuperior Rotator Cuff Tears