Large Cuff Tears Research Articles

Primary Cuff Repair Augmented With a Balloon Spacer in a Large and Massive Rotator Cuff Tear Series: A Technique and Short-term Outcome and Imaging Study.

Massive rotator cuff tears are a challenge for patients and surgeons. We explored the outcomes of patients with massive rotator cuff tears primarily treated with primary cuff repair augmented with a subacromial balloon spacer. The mean age of the patients was 64.3 years, with 24 (71%) having massive cuff tears and the remaining 29% having large cuff tears. Most patients (61%) exhibited significant fatty atrophy (at least grade 3 Goutallier). At 6 months, patients showed improved Constant score, UCLA score, and Oxford Shoulder Score. Pain scores also significantly decreased. A phase 1 study of postoperative imaging indicated balloon disintegration in 50% of cases at 6 weeks. Augmenting primary cuff repair with a subacromial balloon spacer demonstrates promising short-term outcomes. Our postoperative images suggest that balloon disintegration may occur as early as 6 weeks. We recommend caution in using a balloon spacer as a standalone therapy. [Orthopedics. 2025;48(1):e56-e61.].

Lower Trapezius Tendon Transfer With Achilles Tendon Allograft: A Technique Video

Background: While small to medium rotator cuff tears demonstrate good outcomes with primary repair, large, irreparable cuff tears pose a significant clinical challenge with high re-tear rates and lower patient satisfaction. Tendon transfers are procedures that can restore motion and strength in the shoulder in the case of irreparable rotator cuff tears. Trapezius tendon transfers are suitable for large posterosuperior cuff tears as the lower trapezius has a vector of pull similar to that of the infraspinatus. Indications: Lower trapezius tendon transfers are indicated for young and active patients with irreparable posterior and posterosuperior rotator cuff tears causing significant weakness and loss of external rotation. Contraindications to the procedure include advanced osteoarthritis of the glenohumeral joint, advanced age, and deficiency of the subscapularis, deltoid, or trapezius muscles. Technique Description: Using a scapular incision, the trapezius muscle body and tendon are dissected from the scapular spine and mobilized. The plane of the infraspinatus into the glenohumeral joint is tunneled using blunt dissection, and the prepared allograft is passed through under arthroscopic visualization. The allograft insertion is stabilized with 3 knotless anchors and reinforced using medial row sutures from a concomitant supraspinatus repair. The proximal graft origin is fixed to the trapezius tendon using a Pulvertaft weave morphology to reconstruct the muscle-tendon unit. Results: Outcomes data from the literature demonstrate improvement in symptoms and patient satisfaction following the procedure. In a retrospective analysis of 41 patients, Elhassan et al demonstrated that 90% of patients experienced significant improvement in visual analog scale (VAS), Subjective Shoulder Value (SSV), and Disabilities of the Arm, Shoulder, and Hand (DASH) score at mean follow-up time of 14 months. Discussion/Conclusion: In appropriately indicated patients, the lower trapezius tendon transfer offers restoration of external rotation strength and range of motion, pain relief, low risk of complications, and reduced risk of revision compared with alternative procedures. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Relationship between the preoperative grip strength and postoperative shoulder strength of patients treated via reverse shoulder arthroplasty.

Systemic disorders including diabetes mellitus, obesity, and depression affect the outcomes of reverse shoulder arthroplasty (RSA). Sarcopenia (a general skeletal muscle disorder) is common in elderly people, but its effect on patients after RSA is not clear. We hypothesized that the preoperative sarcopenia indices of grip strength and general skeletal muscle mass would correlate with the clinical outcomes of RSA. Grip strength and general skeletal muscle mass were measured in patients scheduled (between 2016 and 2021) for primary RSA to treat cuff tear arthropathy, an unrepairable cuff tear, or osteoarthritis with a large cuff tear. Before surgery, grip strength was measured using a hydraulic dynamometer and general skeletal muscle mass was calculated from the appendicular relative skeletal muscle mass index (aRSMI) using dual-energy X-ray absorptiometry. In all, 58 patients were included; the minimal follow-up duration was 12months. The postoperative clinical results (pain, active range of motion, shoulder strength, and functional scores) were evaluated during scheduled outpatient visits. We calculated correlations between the preoperative sarcopenia indices, and the clinical results at the final follow-up. The mean preoperative grip strength and aRSMI were 21.6±4.0kg and 5.98±0.84kg/m2 in females and 30.6±7.5kg and 7.21±0.94kg/m2 in males, respectively; the grip strength and aRSMI were not associated with each other (P=.083). Ten females (25%) and 10 males (56%) met the criteria for sarcopenia. The postoperative abduction shoulder strength and Constant-Murley shoulder score increased significantly with higher preoperative grip strength (R=0.420 and P=.001; and R=0.497 and P<.001, respectively) and the American Shoulder and Elbow Surgeons score was related to the preoperative aRSMI (R=0.320, P=.039). The shoulder strength and functional score after RSA correlated positively with the preoperative grip strength. Measuring grip strength before RSA allows the surgeon to predict shoulder strength after RSA.

Rotator Cable Reconstruction: A Technique to Restore the Rotator Cable in the Setting of Large Cuff Tears

The rotator cable is an essential biomechanical structure in the shoulder that is commonly injured in the setting of large rotator cuff tears. Surgical techniques designed to reconstruct the cable have followed advancements in our understanding of the biomechanics and anatomic importance of this structure. Owing to its role in load sharing and stress shielding of the rotator cuff crescent, rotator cable reconstruction offers the potential to reduce retear rates and promote longevity of rotator cuff repairs. The purpose of this article is to describe a technique to augment rotator cuff repair with cable reconstruction.

Rotator cuff tears

Rotator cuff tears are most commonly the result of age-related degenerative pathology, although they can result from trauma at any age. Patients with rotator cuff tears (RCT) often present with pain, loss of strength and decreased range of motion, which significantly affects their function and quality of life. Some uncertainty persists about optimal treatment strategies and the timing of repairs for some RCTs. The incidence of rotator cuff repairs has rapidly increased in recent years, and studies show that the vast majority of patients go on to experience significant improvements in pain and function, although re-tear is a recognized complication. Novel strategies using grafts to augment repairs are being employed in the hope of reducing these re-tear rates. Augments are expensive and currently not fully supported by high-quality evidence demonstrating their efficacy. The management of larger, potentially irreparable cuff tears is challenging. It remains unclear whether surgery offers effective long-term results for most patients with large and massive cuff tears, as rotator cuff repairs for this cohort are associated with high failure rates.

Five Year Follow up of Retrospective Cohort Comparing Structural and Functional Outcome of Arthroscopic Single-row ersus Double-row Suture Bridge Repair of Large Posterosuperior Rotator Cuff Tear in Patients Less than or Equal to 70 Years.

High re-tear rates after repairing large-sized posterosuperior rotator cuff tears remain a significant concern which may affect the clinical outcome. The most optimal type of repair (single versus double-row suture bridge) suited for large size tear remains debatable. In a retrospective cohort study with a minimum of five years follow up, the structural and functional outcome of 103 patients with large size cuff tear repaired with single row (SR) or double row suture bridge (DRSB) were evaluated. The structural outcome was assessed with ultrasonography whereas functional outcome was evaluated with Constant Murley (CM) and American shoulder elbow score (ASES). There were 55 patients in the SR group and 48 patients in the DRSB group with a mean follow-up of 74.2 months (range, 60-96 months). While comparing the structural integrity in two groups, we found significantly lower re-tear rates in the DRSB group as compared to the SR group (10.4% vs. 32.7%; P=0.006). Also, there were more focal defects in the SR group (25.4%) than the DRSB group (8.3%). Overall, there was no significant difference in CM and ASES scores when the SR group was compared to DRSB. However, subgroup analysis between those with intact and retorn tendon revealed significant difference (P=0.0001) in the clinical scores. At a minimum of five years follow-up, the DRSB repair of large posterosuperior cuff tear resulted in superior structural healing over SR repair. Nevertheless, overall there was no significant functional difference between both the techniques. However, the functional outcome of the healed tendon subgroup was superior to retear tendon subgroup.

Bio-inductive implant for rotator cuff repair: our experience and technical notes.

The treatment of chonic large and partial rotator cuff tears represents a common challenge for orthopedic surgeons. Numerous treatments were suggested but the best is still controversial. Into this field the use of an augment for rotator cuff repair aims to protect the tension of the suture in the postoperative phase and to facilitate the biological healing process. In our institution we treated 4 patients (3 males and 1 female) with rotator cuff tear with bio-inductive implant. All patients presented with a postero-superior rotator cuff tear: 3 patients with a type C-III tear according to Snyder classification and 1 patient with partial articular tear with significant degeneration and poor tendon quality (type A-III tear according to Snyder classification). The final outcome is highly satisfying intraoperatively and the postoperative protocol reflects our normal postoperative protocol following to rotator cuff repair. No complications occurred at 6 months follow-up. The use of the bio-inductive implant in the arthroscopic rotator cuff repair resulted easy, rapid and reproducible. Although no current scientific evidences regarding such implants exist, in selected cases and with the correct indications, the use of bio-inductive implant could represent an effective aid and an option in case of complex rotator cuff tears. (www.actabiomedica.it)

Réparation des ruptures larges de la coiffe des rotateurs avec renfort au fascia lata

Background Excellent clinical results of arthroscopic surgical repair have been reported for rotator cuff tears, however treatment of large and massive rotator cuff tears remains challenging. We have performed single row repairs with graft augmentation of fascia lata for large and massive rotator cuff tears in order to reduce a tension at the tendon-bone repair site for prevention from retear of the repaired rotator cuff. The purpose of this study was to evaluate clinical outcomes and rotator cuff integrity after arthroscopic rotator cuff repair (ARCR) with graft augmentation of the fascia lata. Material and methods Nineteen patients who underwent ARCR but unable to perform footprint fixation were included. These patients (14 males and 5 females), with an average age of 66.2 years old (range; 52–79 year old), were diagnosed with a large and massive rotator cuff tear. Single row repairs with footprint medialization were performed in 7 cases (SR group) and graft augmentation of fascia lata in addition to single row repairs were done in 12 cases (GA group). MRI was assessed at 6 and 12 months postoperatively and a retear was defined as discontinuity of the repaired supraspinatus tendon. Japanese Orthopaedic Association (JOA) score, UCLA score, and Constant score were assessed as clinical outcomes. Results MRI examinations revealed 6 retears out of 7 SR cases (re-tear rate: 85%) and 2 cases out of 12 GA cases (re-tear rate: 17%) at 6 months postoperatively. There was no additional retear at 12 months. JOA score, UCLA score, and Constant score in both groups significantly improved at the final follow-up, but there was no statistical difference between both groups on each score. The abduction strength significantly improved only in the GA group. Discussion In the present study, ARCR with graft augmentation of fascia lata for large and massive rotator cuff tears showed good clinical scores with a low retear rate and improvement of abduction strength. The low retear rate might be due to reduction of tension at the cuff repair site. Therefore, graft augmentation of fascia lata would be a useful option for large and massive rotator cuff tears.

Clinical outcomes and ultrasonographic viability of GraftJacket® augmented rotator cuff repair: a prospective follow-up study with mean follow-up of forty-one months

BackgroundThe management of large rotator cuff tears in patients without evidence of glenohumeral arthritis is challenging and controversial. We wished to investigate the viability of Graft Jacket® augmentation and assess the clinical and radiological outcomes in a prospective study with a select cohort of patients. MethodsAll procedures were performed by a single shoulder surgeon over a three-year period. Inclusion criteria were patients with large cuff tears (size 3–5 cm) not amenable to end-to-end repair. Patients with radiographic evidence of glenohumeral arthritis or cuff tear arthropathy were excluded. Open rotator cuff repair followed by bridging with GraftJacket® Regenerative Tissue Matrix was performed. Outcome was assessed with Constant scores (CS), QuickDash (QD) and Oxford Shoulder scores (OSS) at minimum twenty-two months and ultrasound assessment at nine months post-operatively. ResultsThirteen patients were identified who fit inclusion criteria (one bilateral). No patients were lost to follow up. At final follow-up thirteen shoulders had achieved function range of movement. Mean CS was 83 (range 70–100), mean Quick DASH was 5.4 (range 0–18.2), and mean OSS was 46 (range 41–48). Shoulder ultrasound revealed an intact Graft Jacket® in these patients.One patient had lower functional movement and worse CS (34), QD (34.1) and OSS (25) and ultrasound assessment identified a re-rupture. DiscussionThis study indicates that augmentation of large rotator cuff repairs with a GraftJacket® scaffold is a viable option and has good functional results and sustained viability. Level of evidenceLevel 4.

Prevalence and Risk Factors of Neuropathic Pain in Patients with a Rotator Cuff Tear

Until now, few studies had investigated the neuropathic pain component in patients with a rotator cuff tear (RCT). The aim of the study was to identify the neuropathic pain component in patients with RCT and to determine the factors correlated with neuropathic pain in patients with RCT. Prospective, cohort, prognostic study. Study patients who required arthroscopic rotator cuff repair were analyzed in a hospital setting. We prospectively studied 101 patients who were less than 60 years old with full-thickness tears requiring arthroscopic rotator cuff repair and met the inclusion and exclusion criteria. Multiple regression analysis was performed to identify variables that independently affected neuropathic pain in patients with a RCT. We use Douleur neuropathique 4 questionnaire (DN4) to assess neuropathic pain, which was >/= 4 points of the DN4 questionaire. The visual analog scale (VAS) for the most severe pain within 4 weeks before admission and mean pain level during the last 4 weeks were checked. The atrophy grades of the rotator cuff muscles were classified on magnetic resonance images according to the Goutallier classification. The size and medial retraction of the RCT were measured during arthroscopic repair for RCT. Sixteen (15.8%) of the 101 patients had neuropathic pain according to the cut-off values on the DN4 questionnaire for diagnosing neuropathic pain. The neuropathic pain group had significantly higher prevalence of smoking (P = 0.042), more mean VAS during last 4 weeks (P = 0.008), larger cuff tear (P = 0.003), more medial retraction of cuff (P = 0.016), and severe fatty degeneration of rotator cuff muscles (supraspinatus, P < 0.001; subscapularis, P < 0.001; and infraspinatus, P = 0.003) than the nonneuropathic pain group. The multiple logistic regression analyses showed that more mean VAS during the last 4 weeks and tear size of a rotator cuff were independent of other factors for the neuropathic pain of the patients with a full-thickness RCT. Small sample size is the first limitation of this study. The prevalence of neuropathic pain in patients with a full-thickness RCT requiring arthroscopic rotator cuff repair was 15.8 % according to the DN4 questionnaire. The neuropathic pain component was more relevant to the severity of pain and tear size in the patients with a full-thickness RCT. It is important to be aware of the existence of neuropathic pain when treating a patient presenting with pain due to a RCT because accompanying neuropathy with a RCT could have a worse effect on repair of a RCT. IRB approval and clinical trial registration number: CR-15-045. Shoulder, rotator cuff tear, arthroscopic rotator cuff repair, neuropathic pain.

Factors affecting rotator cuff integrity after arthroscopic repair for medium-sized or larger cuff tears: a retrospective cohort study

We wished to identify the preoperative prognostic factors associated with structural integrity after repair of medium-sized and larger rotator cuff tears and to determine the cutoff values using receiver operating characteristic curve analysis. The study included 180 patients with medium-sized and larger rotator cuff tears. Each had a minimum 2-year postoperative follow-up by magnetic resonance imaging. We assessed several patient-related and disease-related preoperative factors using univariate and multivariate logistic regression analysis. To determine the cutoff value for the significant variables, receiver operating characteristic curve analysis was performed. Retears occurred in 28 of the 180 patients (15.6%). Univariate analysis found that retear was significantly affected by the type of work and pattern of tear. The rate of retear was significantly increased in diabetes and with increasing tear size, extent of retraction, delamination, and fatty infiltration. Furthermore, reduced remnant tendon length, distance from the musculotendinous junction to the face of the glenoid, occupation ratio, and acromiohumeral interval were also significant risk factors. In the multivariate analysis, body mass index, diabetes, dyslipidemia, extent of retraction, delamination, distance from musculotendinous junction to face of glenoid, occupation ratio, fatty infiltration of infraspinatus, and acromiohumeral interval remained significant risk factors. The extent of retraction (22.2 mm) and the occupation ratio (53.5%) showed highly accurate cutoff values for predicting retear. Multiple factors influenced the healing process after rotator cuff repair. The best predictors were the extent of retraction and occupation ratio, which could help assist in determining the prognosis after rotator cuff repairs.

Are We Doing Too Many Margin Convergence? A Prospective MRI Study on Re-Tear Rate after Arthroscopic Rotator Cuff Repair

The use of margin convergence, despite helpful to achieve a successful intra-operative complete repair for arthroscopic assisted rotator cuff repair, did not protect the repair from re-tear. Re-tear after successful arthroscopic rotator cuff repair is common. It is notorious that large and massive cuff tear is associated with a lower successful intra-operative complete repair and a higher postoperative re-tear rate. Margin convergence is commonly used to achieve intra-operative complete repair. Despite a very popular technique, the relationship between margin convergence and re-tear after rotator cuff repair is not known. It was hypothesized that there was no difference in the re-tear rate between the repair performed with margin convergence and those without. A prospective study on primary arthroscopic assisted complete repair of full thickness supraspinatus tendon tear using double-row suture-bridge technique was carried out in the author’s institution from 2010 to 2013. 60 repairs were recruited after applying inclusion and exclusion criteria. The follow-up rate at one-year post-operation was 98% and that of two-year was 95%. 50 patients (83%) received reassessment MRI. The repair status was classified according to Sugaya classification. Full thickness re-tear was defined as Sugaya Type IV or V repair. Association of use of margin convergence technique with retear after rotator cuff repair was examined using univariate analysis with Chi square test. The potential association of retear rate and other known patient-related and cuff-related risk factors (including age, DM, active smoking, heavy manual worker, tear size, tear retraction, tear topography in sagittal plane, tear morphology, number of full thickness tendon tear) were examined. Multivariate analysis was then conducted to determine the most significant factor predicting the rate of re-tear. 50 arthroscopic complete repair of full thickness supraspinatus tendon tear using double-row suture-bridge technique with reassessment MRI was studied. The average age was 59 years. 19 were male and 31 were female. Right shoulder was involved in 36 patients. The average follow-up was 37 +/- 13 months. There was 19 full thickness re-tear found on reassessment MRI (11 Sugaya IV and 8 Sugaya V). The incidence was 38%. 10 patients received margin convergence during the repair. The incidence of re-tear after repair with margin convergence was 80% and that without was 28% (p=0.002). The other risk factors identified by univariate analysis to be significantly associated with incidence of re-tear was (1) large and massive tear (p=0.018); (2) increased number of full thickness tendon tear (p=0.03); (3) medial retraction of tear (p=0.001) and (4) Geometric classification of tear morphology (p=0.004). After running mulivariate analysis, the most significant factor predicting re-tear after arthroscopic rotator cuff repair was medial retraction of tendon (p=0.048). The re-tear rate of Patte I, II and III were 24%, 50% and 100% respectively. The incidence of rate of re-tear was significantly higher when margin convergence was used (80% vs 28%, p=0.002). The most important factor predicting rate of re-tear was degree of tear retraction (p=0.048). Despite helping to achieve a successful intraoperative complete repair, the use of margin convergence did not protect the repair in Patte II and III retraction from going into re-tear.

In Reparable Rotator Cuff Tears with Lesions of the Long Head of the Biceps Brachii Tendon, Tenotomy Did Not Differ from Tenodesis in Terms of Function or Pain.

Lee HJ, Jeong JY, Kim CK, Kim YS. Surgical treatment of lesions of the long head of the biceps brachii tendon with rotator cuff tear: a prospective randomized clinical trial comparing the clinical results of tenotomy and tenodesis. J Shoulder Elbow Surg. 2016 Jul;25(7):1107-14. ### Question: In patients with reparable rotator cuff tears and symptomatic lesions of the long head of the biceps brachii tendon (LHBT), what is the comparative efficacy of tenotomy and tenodesis? ### Design: Randomized (allocation not concealed)*, blinded (patients and outcome assessors), controlled trial with follow-up at a mean of 20 or 25 months. ### Setting: The Catholic University of Korea, Seoul, Republic of Korea. ### Patients: 137 patients (mean age, 63 years; 77% women) who needed surgical repair for small to medium-sized rotator cuff tears and had concomitant symptomatic partial tears of the LHBT (confirmed with magnetic resonance imaging) that had shown no improvement after ≥1 month of conservative treatment with medication or corticosteroid injections. The exclusion criteria were large or massive rotator cuff tears, previous shoulder surgery or trauma, glenohumeral arthritis, …

A randomized clinical trial to compare the effectiveness of rotator cuff repair with or without augmentation using porcine small intestine submucosa for patients with moderate to large rotator cuff tears: a pilot study

The rate of rotator cuff repair failure is between 13% and 67%. Porcine small intestine submucosa (SIS) may be suitable to augment the repair. There were 62 patients with moderate and large cuff tears randomized to repair alone (control) or augmentation with SIS (Restore Orthobiologic Implant; DePuy, Warsaw, IN, USA). Primary outcome was repair failure using magnetic resonance arthrography. Randomization occurred on completion of the repair. Patients and assessors were blind to group. Assessments occurred preoperatively and postoperatively at 2 and 6 weeks and 3, 6, 12, and 24 months. There were 62 patients randomized (34 SIS, 28 control). Patient demographics, rotator cuff tear characteristics, and repair details were similar between groups. At 1 year, risk of failure was 52.9% (18/34) in the SIS group and 65.4% (17/26) in the control group for a risk difference of 12% (80% confidence interval, -7% to 32%) or relative risk of 0.81 (95% confidence interval, 0.53-1.24, P = .33) in favor of SIS. At 1 and 2 years, the mean difference between groups for patient-reported outcomes was small and consistent with chance but did not exclude the possibility of a clinically important difference. There was no statistically significant difference (P = .50) between the SIS group (59.6 ± 38.9; range, 3-112) and the control group (52.7 ± 38.6; range, 5-112) in number of days to being narcotic and pain free (<20 mm on a 100-mm visual analog scale). We found no evidence that SIS-augmented rotator cuff repair provides superior outcomes in patients with moderate rotator cuff tears.

Does application of moderately concentrated platelet-rich plasma improve clinical and structural outcome after arthroscopic repair of medium-sized to large rotator cuff tear? A randomized controlled trial

Platelet-rich plasma (PRP) has the potential to improve tendon-bone healing. The evidence is still controversial as to whether PRP application after repair of medium-sized to large cuff tears leads to superior structural and clinical outcome, especially after single-row repair. In a randomized study, 102 patients (PRP group, 52 patients; control group, 50 patients) with medium-sized and large degenerative posterosuperior tears were included for arthroscopic repair with a minimum follow-up of 2 years. Patients were evaluated with clinical scores (visual analog scale score, Constant-Murley score, University of California-Los Angeles score, and American Shoulder and Elbow Surgeons score) and ultrasound to assess retear and vascularity pattern of the cuff. Visual analog scale scores were significantly lower in the PRP group than in controls at 1 month, 3 months, and 6 months but not later. Constant-Murley scores were significantly better in the PRP group compared with controls at 12 and 24 months, whereas University of California-Los Angeles scores were significantly higher in the PRP group at 6 and 12 months (P < .05). The American Shoulder and Elbow Surgeons score in both groups was comparable at all the times. At 24 months, retear in the PRP group (n = 2; 3.8%) was significantly lower than in the control group (n = 10; 20%; P = .01). The retear difference was significant only for large tears (PRP:control group, 1:6; P = .03). Doppler ultrasound examination showed significant vascularity in the PRP group repair site at 3 months postoperatively (P < .05) and in peribursal tissue until 12 months. Application of moderately concentrated PRP improves clinical and structural outcome in large cuff tears. PRP also enhances vascularity around the repair site in the early phase.

Predominance of the critical shoulder angle in the pathogenesis of degenerative diseases of the shoulder

The critical shoulder angle (CSA) could be responsible for cuff tears and concentric osteoarthritis. We aimed to assess this association when potential confounding factors were excluded and to test the hypothesis that more extreme CSAs are associated with larger tears and more severe osteoarthritis. The study cohort was composed of 200 patients with primary concentric osteoarthritis (40 patients), isolated supraspinatus tears (40 patients), cuff tears involving at least the supraspinatus and infraspinatus (40 patients), and no history of shoulder problems (control group, 80 patients). Data pertaining to CSA, age, gender, dominant arm, smoking, hypertension, body mass index, and type of work were collected. The average CSA angle was 34° ± 3° in the control group, 36° ± 3° with supraspinatus tears, 40° ± 3.5° with supraspinatus and infraspinatus tears, and 28° ± 2° with concentric osteoarthritis. Patients with large cuff tears had a significantly greater CSA compared with those with isolated supraspinatus tears (P = .03). The CSA (odds, 1.7; confidence interval [CI], 1.4-2.0) was the most relevant risk factor for cuff tears. The Spearman coefficient between CSA and grade of eccentric osteoarthritis was 0.4 (P = .01). The 2 significant risk factors for concentric osteoarthritis were the CSA (odds, 0.5; CI 0.4-0.6) and age (odds, 1.1; CI, 1.0-1.2). Larger CSAs are associated with increased risk of symptomatic cuff tears, larger cuff tears, and the severity of eccentric osteoarthritis. Smaller angles increased the risk and severity of concentric symptomatic osteoarthritis. These associations remained significant even after removal of some of the potentially confounding variables.

Factors Affecting Clinical Outcome in Patients With Structural Failure After Arthroscopic Rotator Cuff Repair

(1) To compare clinical outcomes between patients with large or massive rotator cuff tears who have healed cuffs and patients with postoperative structural failure (retear after complete or partial repair) and (2) to identify factors associated with clinical outcomes in patients with postoperative structural failure. We conducted a retrospective study of consecutive patients with large or massive cuff tears who underwent arthroscopic repair at our institution between 2005 and 2012. On the basis of intraoperative findings and magnetic resonance imaging at final follow-up, the patients were divided into 3 groups: healed group, retear group (after complete repair), and partial-repair group. The outcome measures comprised the Japanese Orthopaedic Association (JOA) and University of California, Los Angeles (UCLA) scores; muscle strength; and range of motion. The tear length, tear width, muscle atrophy, and fatty degeneration were evaluated by preoperative and postoperative magnetic resonance imaging. The extent of tendon reattachment to the superior, middle, and inferior facets and the lesser tuberosity was examined on magnetic resonance images at final follow-up. In total, 74 patients (healed, 41; retear, 19; and partial repair, 14) were included in this study. The mean age was 63.8 ± 8.5 years, with a mean follow-up period of 3.6 ± 1.4 years. The postoperative JOA and UCLA scores significantly improved in all 3 groups, but the differences were not significant. In the retear and partial-repair groups, postoperative tendon preservation at the middle facet significantly affected the JOA and UCLA scores (P= .003 and P=.014, respectively). The JOA and UCLA scores were significantly improved in patients with structural failure. Under these conditions, the only clinical factor that affected patient outcome was tendon healing at the middlefacet. Thus tendon preservation at the middle facet was a predictor of good clinical outcomes in patients who underwent arthroscopic rotator cuff repair of large or massive tears and had postoperative structural failure. Level III, case-control study.

Does presence of anterior greater tuberosity cysts change the function in patients with chronic rotator cuff tear?

This study aims to compare rotator cuff muscle atrophy with fatty degeneration, tear size, range of motion, shoulder muscle strength, pain and upper extremity function in patients with chronic rotator cuff tear, and with or without anterior greater tuberosity cyst. A total of 101 patients (32 males, 69 females; mean age 51 ± 12.9 years; range 17 to 76 years) were evaluated in this study. Fifty-eight patients were excluded due to traumatic or acute rotator cuff tears and neck pain. Forty-three patients of chronic rotator cuff tear were divided into two groups as patients with (n=15) and without (n=28) an anterior greater tuberosity cyst. Patients were evaluated for range of motion, shoulder muscle strength, pain and upper extremity function, and radiologically. Statistical differences were investigated between two groups. The number of patients with tears larger than 1 cm and the number of patients who had muscle atrophy were higher in the group of patients with a cyst. Also, upper extremity function was reduced in the group of patients with a cyst (Western Ontario Rotator Cuff Index, p=0.03, Nine-Hole Peg Test, p=0.02). Our findings demonstrated that decreased function, larger cuff tears and muscle atrophy can be observed patients with anterior greater tuberosity cysts. Anterior greater tuberosity cysts can be detected by plain X-rays. The presence of these cysts should warn the physician regarding the possibility of decreased shoulder function, muscle atrophy and larger cuff tear before ordering a magnetic resonance imaging.

Returning to overuse activity following a supraspinatus and infraspinatus tear leads to joint damage in a rat model

Large rotator cuff tears (supraspinatus and infraspinatus) are common in patients who perform overhead activities (laborers, athletes). In addition, following large cuff tears, these patients commonly attempt to return to pre-injury activity levels. However, there is a limited understanding of the damaging effects on the uninjured joint tissues when doing so. Therefore, the objective of this study was to investigate the effect of returning to overuse activity following a supraspinatus and infraspinatus tear on shoulder function and the structural and biological properties of the intact tendons and glenoid cartilage. Forty rats underwent 4 weeks of overuse followed by detachment of the supraspinatus and infraspinatus tendons and were then randomized into two groups: return to overuse or cage activity. Ambulatory measurements were performed over time and structural and biological properties of the adjacent tendons and cartilage were evaluated. Results demonstrated that animals returning to overuse activity did not have altered shoulder function but despite this, did have altered cartilage and tendon properties. These mechanical changes corresponded to altered transcriptional regulation of chondrogenic genes within cartilage and tendon. This study helps define the mechanical and biological mechanisms leading to joint damage and provides a framework for treating active cuff tear patients.

Late prosthetic shoulder hemiarthroplasty after failed management of complex proximal humeral fractures.

Background. The purpose of this study was to report our experience with shoulder hemiarthroplasty in the context of old trauma. Methods. 33 patients with failed treatment for a complex proximal humeral fracture underwent prosthetic hemiarthroplasty. There were 15 men and 18 women with a mean age of 58.1 years. The average period from initial treatment was 14.9 months. Sequelae included 11 malunions, 4 nonunions, 15 cases with avascular necrosis (AVN) and 3 neglected posterior locked dislocations. Follow up investigation included radiological assessment and clinical evaluation using the Constant score and a visual analogue pain scale. Results. After a mean follow up of 82.5 months the median Constant score was 75.7 points, improved by 60% in comparison to preoperative values. Greater tuberosity displacement, large cuff tears and severe malunion were the factors most affected outcome. No cases of stem loosening or severe migration were noted. 60% of the patients were able to do activities up to shoulder level compared with 24% before reconstruction. Conclusions. Late shoulder hemiarthroplasty is technically difficult and the results are inferior to those reported for acute humeral head replacement, nonetheless remains a satisfactory reconstructive option when primary treatment fails.