Massive Cuff Tears Research Articles

Proximal humeral bone defect in reverse shoulder arthroplasty combined with latissimus-dorsi transfer is not related with a poor outcome

BackgroundReverse total shoulder arthroplasty (RSA) associated with modified L’Episcopo (isolated LD) or L’Episcopo (combined TM and LD) procedures had been confirmed to effectively overcome the expected external rotation deficit in patient with postero-superior massive cuff tear and teres minor deficiency. The objective of this study was to evaluate the radiological bony lesions of the lateral proximal humerus following RSA combined with tendon transfer, and to determine whether these bony lesions affect the clinical outcome. Material and methodsA retrospective review of 24 RSAs (mean age 68.71 years, range 52–83) associated with modified L’Episcopo procedure (9) and L’Episcopo procedure (15) was performed. X-rays were assessed for lateral cortex lesions and were categorized into either intact, irregular or complete lytic appearances. In addition, signs of stem loosening were assessed. Clinical outcome measures included range of motion, SSV, VAS, and Constant-Murley scores. ResultsWith a mean follow-up of 44.71 months (12–97; SD 27.42), eight (33.3%) patients demonstrated intact lateral cortex, eight (33.3%) irregular and eight (33.3%) lytic lesions. 40% of cemented stems demonstrated a deformed cortex compared to 74% of cementless stems. Radiolucent lines were detected in one cemented stem (p=0.046). GT resorption (p=0.147), condensations lines (p=0.449) and spot weld (p=0.342), appeared exclusively in non-cemented stem. Postoperatively all patients (24) demonstrated significant improvements in all clinical and functional parameters. A comparison between patient with (Group 2, 16 patients) and without bony lesions (Group 1, 8 patients) revealed no significant differences in functional scores and range of motion: Constant (p=0,61), VAS (p=0,61), SSV (p=0,66) and external rotation (p=0,34). ConclusionAt short-term follow-up, RSA combined with L’Episcopo or modified l’Episcopo procedure resulted in high incidence (67%) of lateral proximal humerus lesions. Radiolucent lines were noted in cemented stems whereas, signs of stress shielding and GT resorption appeared in non-cemented stems. Yet, no case of humeral loosening was detected and these lesions did not seem to affect the clinical outcome. The use of cemented straight standard-length humeral stems should be positively considered in RSA associated with LD\\TM tendon transfer. Level of evidenceIV; retrospective study.

Physiotherapy Rehabilitation in Arthroscopic Rotator Cuff Repair Patient- A Case Report

Rotator cuff pathology is usual, and the ailment's natural history suggests that tears enlarge with age. Rotator cuff tears are a familiar origin of pain and ailment in the shoulder. The research on treatment of rotator cuff tears is mixed. The aim of this review is to evaluate the evidence regarding the effectiveness of physiotherapy in lowering pain and enhance shoulder function in patients with symptomatic rotator cuff tears. Rotator cuff injuries are typically followed by a gradual onset of pain, but they can also be the result of an acute injury. Chronicity, underlying anatomic and physical factors, age, and the presence and severity of tendon tears all influence how rotator cuff conditions are managed. Conservative care, such as physical therapy, is typically used as the first line of defence, but surgical repair may be required later on. Rotator cuff (RC) tears can range from partial to full thickness tears of a single tendon to massive cuff tears. Rotator cuff tearing can be caused by glenohumeral trauma as well as pathological process. As a result, Treatment necessitates a diligent diagnosis as well as a distinguished approach that considers morphological and patient-specific effects. The therapeutic approach is determined by the patient's pathogenicity, tear morphology, clinical symptoms, and functional demands. The current case is about an 51 year old male who was admitted to the hospital with tear injury to right shoulder due to fall from truckmuscle strength and range of motion were main focus of physiotherapy intervention. The prime goal of this case study was to assess the patient’s response to physiotherapy for reinforcement and functional task.

Human Dermal Allograft Superior Capsule Reconstruction With Graft Length Determined at Glenohumeral Abduction Angles of 20° and 40° Decreases Joint Translation and Subacromial Pressure Without Compromising Range of Motion: A Cadaveric Biomechanical Study

To compare the biomechanical effects of superior capsule reconstruction (SCR) graft fixation length determined at 20° and 40° of glenohumeral (GH) abduction. Humeral translation, rotational range of motion (ROM), and subacromial contact pressure were quantified at 0°, 30°, and 60° of GH abduction in the scapular plane in 6 cadaveric shoulders for the following states: intact, massive rotator cuff tear, SCR with dermal allograft fixed at 20° of GH abduction (SCR 20), and SCR with dermal allograft fixed at 40° of GH abduction (SCR 40). Statistical analysis was conducted using a repeated-measures analysis of variance and a paired t test (P < .05). A massive cuff tear significantly increased total ROM compared with the intact state at 0° and 60° of abduction. SCR 20 or SCR 40 did not affect ROM. Compared with the intact state, the massive cuff tear model significantly increased superior translation by an average of 4.6 ± 0.5 mm in 9 of 12 positions (P ≤ .002). Both SCR 20 and SCR 40 reduced superior translation compared with the massive cuff tear model (P < .05); however, SCR 40 significantly decreased superior translation compared with SCR 20 at 0° of abduction (P≤ .046). Peak subacromial pressure for the massive cuff tear model increased by an average of 486.8 ± 233.9 kPa relative to the intact state in 5 of 12 positions (P ≤ .037). SCR 20 reduced peak subacromial pressure in 2 of 12 positions (P ≤ .012), whereas SCR 40 achieved this in 6 of 12 positions (P ≤ .024). SCR with dermal allograft fixed at 20° or 40° of GH abduction decreases GH translation and subacromial pressure without decreasing ROM. With an increasing abduction angle for graft fixation, the medial-to-lateral graft length is decreased and the graft tension is effectively increased. Surgeons may increase shoulder stability without restricting ROM by fixing the graft at higher abduction angles. However, surgeons should remain cognizant of potential graft failure due to increased tension.

The influence of preoperative teres minor muscle fatty degeneration on active external rotation following reverse total shoulder arthroplasty

BackgroundReverse total shoulder arthroplasty (rTSA) improves shoulder elevation in patients treated for cuff tear arthropathy (CTA) or irreparable massive cuff tears. Patient satisfaction can be limited by reduced active external rotation (AER). Rotator cuff muscles that externally rotate the shoulder are infraspinatus and teres minor (TM). AimThe purpose of this study was to assess the correlation between preoperative TM fatty degeneration and postoperative AER after rTSA performed for CTA or irreparable cuff tears. MethodsConstant scores and active range of motion were consecutively collected for 109 shoulders in 97 patients (mean: 75.73 ± 8.94 years; 31 male, 66 female) over a 10-year period. AER was evaluated with the humerus in adduction (AER1) and in abduction. TM muscle atrophy was scored according to Goutallier's classification, assessed on preoperative computed tomography scans. ResultsMultivariate analysis showed that TM fatty infiltration was a predictor of AER1. AER1 decreased by 4.9 degrees preoperatively and by 6.4 degrees at the final follow-up, for each increment in Goutallier grade (P = .02). Postoperatively, AER evaluated with humerus in abduction improved significantly (P < .001), but did not correlate with TM Goutallier grade. At a mean follow-up of 38 months (range: 24 to 96), mean Constant score improved from 20.5 ± 11.1 to 68.4 ± 14.9 (P < .001), as did shoulder active range of motion in all planes including AER1 (P < .001). ConclusionThis is the first study to quantify the inverse correlation between AER and TM Goutallier grade, both preoperatively and after rTSA; this information guides prognosis for patients with TM degeneration undergoing rTSA. Further studies are necessary to have a better understanding and find reliable solutions. Level of evidenceLevel III; Case Series

Effect of reverse total shoulder arthroplasty humeral inclination on glenohumeral range of motion, deltoid force, and glenoid strain: a biomechanical study

BackgroundReverse total shoulder arthroplasty (RSA) primarily varies between 2 implant design options: a 135 humeral stem inclination that closely resembles anatomic orientation, versus the Grammont-style 155 humeral stem inclination that further medializes and distalizes the center of rotation (COR). The purpose of this study was to compare deltoid force, glenoid strain, and simulated glenohumeral range of motion (ROM) between RSA 135 and RSA 155 designs, with a series of standardized permutations of glenosphere offset and rotator cuff pathology. MethodsTwelve fresh-frozen cadaveric shoulder specimens were studied using a shoulder simulator. Native shoulder motion profiles for reproducible abduction range of motion were established using a customized testing device. Optical 3-dimensional tracking and pressure sensors were used to accurately record glenohumeral range of motion (ROM), deltoid force, and glenoid strain for RSA 135 and RSA 155 designs. For each cohort, all combinations of glenosphere offsets and rotator cuff tendon involvement were evaluated. ResultsThere was no significant difference in the overall abduction ROM between the 155 and the 135 humeral stem implants (P = .75). Resting abduction angle and maximum abduction angle were significantly greater with a 155 + STD (standard offset) construct than with a 135 + STD construct (P < .001 and P = .01, respectively). Both stem inclinations decreased combined deltoid force requirements as compared the native shoulder with a massive cuff tear. Effective glenoid strain did not vary significantly between 135 + STD and 155 + STD constructs (P = .66). ConclusionOverall, range of motion between the 135 and the 155 humeral stem inclinations was not significantly different. The cumulative deltoid force was lower in RSA shoulders when compared to native shoulders with massive rotator cuff tears, highlighting the utility of both implant designs. The Grammont-style 155 stem coupled with a 2.5 mm inferior offset glenosphere required less deltoid force to reach maximum abduction than did the more anatomic, lateralized 135 stem coupled with a 4 mm lateral offset glenosphere. Level of EvidenceBasic Science, Biomechanics Controlled Laboratory Study

WITHDRAWN: Shoulder pseudoparalysis in a child after massive cuff tear interposed within the glenohumeral joint: a case report

<h2>Abstract</h2> We report an unusual case of a complete rotator cuff tendon avulsion with glenohumeral joint incarceration in skeletally-immature patient after significant trauma to the shoulder. Generally, it occurs in high-energy trauma, frequently in association with glenohumeral joint dislocation. Surgical treatment was performed confirming the injury and the rotator cuff interposition. It is important that orthopedic surgeons and radiologists become familiar with this entity which, because of its rarity, might be neglected in cases of shoulder trauma. Furthermore, this case documents the youngest patient ever to sustain such an injury in the orthopedic literature.

Infraspinatus shift for massive, posterosuperior tears yields good clinical outcome.

To evaluate the functional outcome of partial reconstruction margin convergence in the treatment of massive, irreparable posterosuperior rotator cuff tear (RCT). This retrospective, single-center study included all patients that were operated by means of a partial repair and infraspinatus shift for a massive, posterosuperior cuff tear between 2009 and 2016, either in arthroscopic or mini-open technique. Outcome measures included sex- and age-adapted Constant Score (saCS), Western Ontario Rotator Cuff (WORC) Index, Disabilities of Arm, Shoulder and Hand Scores (DASH), and relative effect per patient (REPP). Fifty-six shoulders in 54 patients (mean age: 66 ± 7years) were evaluated at a mean follow-up of 40 ± 9months. The mean tear size was Bateman 3.1 ± 0.7 and Patte 2.3 ± 0.4. All clinical scores showed improvement. The saCS improved from 64.1 ± 13.4 to 90.4 ± 13.7 (p < 0.0001), the DASH score from 51.8 ± 9.4 to 10.2 ± 13.4 (p < 0.0001) and the WORC index from 47.1% ± 8.6 to 87.9% ± 13.7 (p < 0.0001). The abduction strength of the affected side (1.7 ± 1.6kg) was not restored to the same level as the contralateral side (5.4 ± 2.7kg, p < 0.0001). Partial cuff repair for posterosuperior, massive cuff tears yields good clinical outcome with a low rate of complications and high proportion of good and excellent responders. Level IV, therapeutic case series.

Long-term impact of scapular notching after reverse shoulder arthroplasty.

Because it medializes the centreof rotation, one of the drawbacks of reverse shoulder arthroplasty (RSA) is the risk of impingement between the humerus and lateral border of the scapula resulting in scapular notching. The long-term impact of this notching is not well known, either on function or the risk of glenoid loosening. The aim of this longitudinal study was to analyze the drawbacks of this notching. Between 1993 and 2006, 81 patients (91 shoulders) underwent RSA for primary glenohumeral osteoarthritis or massive cuff tear with or without osteoarthritis. This cohort was followed longitudinally with post-operative assessments done at one to two years (T1), three to eight years (T2), and nine+ years (T3). Before T3, 25 patients had died, nine were lost to follow-up, five had the implants changed, and seven had incomplete records. Thus, 45 shoulders were available for follow-up beyond nine years (mean follow-up of 12 years) and were used to determine the long-term impact of notching. Survival curves were generated using the occurrence of Sirveaux grade 3 or 4 notching and the presence of aseptic glenoid loosening as endpoints. The survivorship before grade 3 or 4 notching developed was 83% at five years, 60% at 10 years, and 43% at 15 years. In the end, aseptic glenoid loosening occurred in four shoulders, all of which had developed grade 4 notching. No glenoid loosening occurred in the population with grade 0, 1, 2, or 3 notching (p = 0.02). The Constant score significantly decreased between T2 and T3, although it was not different between shoulders with and without advanced notching. Beyond the second year post-RSA, the number of shoulders with grade 3 or 4 notching increases steadily up to the longest follow-up. Grade 4 notching always preceded the occurrence of late glenoid loosening. The functional outcomes become significantly worse after the 9th year post-RSA, although they were not correlated to the presence of high-grade scapular notching.

An update on reverse total shoulder arthroplasty: current indications, new designs, same old problems.

Reverse total shoulder arthroplasty (RTSA) was originally developed because of unsatisfactory results with anatomic shoulder arthroplasty options for the majority of degenerative shoulder conditions and fractures.After initial concerns about RTSA longevity, indications were extended to primary osteoarthritis with glenoid deficiency, massive cuff tears in younger patients, fracture, tumour and failed anatomic total shoulder replacement.Traditional RTSA by Grammont has undergone a number of iterations such as glenoid lateralization, reduced neck-shaft angle, modular, stemless components and onlay systems.The incidence of complications such as dislocation, notching and acromial fractures has also evolved.Computer navigation, 3D planning and patient-specific implantation have been in use for several years and mixed-reality guided implantation is currently being trialled.Controversies in RTSA include lateralization, stemless humeral components, subscapularis repair and treatment of acromial fractures.Cite this article: EFORT Open Rev 2021;6:189-201. DOI: 10.1302/2058-5241.6.200085

Reverse total shoulder arthroplasty.

This systematic review asked which patterns of complications are associated with the three reverse total shoulder arthroplasty (RTSA) prosthetic designs, as classified by Routman et al, in patients undergoing RTSA for the management of cuff tear arthropathy, massive cuff tear, osteoarthritis, and rheumatoid arthritis. The three implant design philosophies investigated were medial glenoid/medial humerus (MGMH), medial glenoid/lateral humerus (MGLH), and lateral glenoid/medial humerus (LGMH). A systematic review of the literature was performed via a search of MEDLINE and Embase. Two reviewers extracted data on complication occurrence and patient-reported outcome measures (PROMs). Meta-analysis was conducted on the reported proportion of complications, weighted by sample size, and PROMs were pooled using the reported standardized mean difference (SMD). Quality of methodology was assessed using Wylde's non-summative four-point system. The study was registered with PROSPERO (CRD42020193041). A total of 42 studies met the inclusion and exclusion criteria. Rates of scapular notching were found to be significantly higher in MGMH implants (52% (95% confidence interval (CI) 40 to 63)) compared with MGLH ((18% (95% CI 6 to 34)) and LGMH (12% (95% CI 3 to 26)). Higher rates of glenoid loosening were seen in MGMH implants (6% (95% CI 3 to 10)) than in MGLH implants (0% (95% CI 0 to 2)). However, strength of evidence for this finding was low. No significant differences were identified in any other complication, and there were no significant differences observed in PROMs between implant philosophies. This systematic review has found significant improvement in PROMS and low complication rates across the implant philosophies studied. Scapular notching was the only complication found definitely to have significantly higher prevalence with the MGMH implant design. Cite this article: Bone Joint J2021;103-B(5):813-821.

Influence of preoperative factors on timing for bilateral shoulder arthroplasty.

In bilateral shoulder arthroplasty patients, it is unclear what features are responsible for the timing of their contralateral shoulder arthroplasty. This study hypothesized that patient factors (age, gender, and hand dominance), disease factors (diagnosis and radiographic severity of contralateral shoulder), and surgical factors (type of arthroplasty) impact the timing to contralateral surgery. A retrospective review of 332 patients treated with bilateral anatomic (TSA) or reverse (RSA) shoulder arthroplasty (172 TSA/TSA, 107 RSA/RSA, or 53 TSA/RSA) were divided into groups depending on the interval timing between arthroplasty surgeries: group 1, n = 142 (≤1 year); group 2, n = 62 (1-2 years); and group 3, n = 128 (≥2 years). Preoperative factors were analyzed to determine associations between different time groups, including age, gender, hand dominance, diagnosis, radiographic severity of contralateral shoulder, and type of surgery. Bilateral diagnoses included 211 osteoarthritis (OA), 36 cuff tear arthropathy (CTA), 13 inflammatory arthritis, 12 massive cuff tears without OA, and 4 avascular necrosis. OA patients had their contralateral shoulder arthroplasty sooner than CTA patients (P = .035). OA patients with arthritic changes on contralateral radiographs before the first arthroplasty had their contralateral arthroplasty sooner than those without contralateral radiographs (P < .0001). Patients who had TSA first had their contralateral arthroplasty sooner than patients who had RSA first (P = .037). This study confirmed our hypothesis identifying preoperative variables associated with different time intervals between arthroplasties. The preoperative factors associated with the highest likelihood of having contralateral shoulder arthroplasty within 1 year included OA, radiographic bilateral shoulder disease, and TSA for the first surgery.

Complete and partial repair of massive rotator cuff tears provide sustainable long term improvement in clinical scores

Objectives:The aim was to report results of arthroscopic repair of 86 massive cuff tears and decided to assess whether or not clinical scores were maintained 5 years later.Methods:Of the initial series of 86 shoulders, 2 patients died, 16 were lost to follow-up and 4 had a repeat surgery. Therefore, it was possible to reevaluate 64 patients. Repairs were complete in 44 cases and partial in 20 cases. Seventeen shoulders were pseudoparalytic. Tears with fatty degeneration at stage 4 or higher according to the Goutallier classification were not eligible for repair. Preoperatively, the Constant Score (CS), shoulder strength, location of the tear, tendon retraction and degree of fatty infiltration were assessed. Patients were assessed at 8.1±0.6 years [7.1-9.3] using absolute and age- and sex-adjusted CS, the subjective shoulder value (SSV) and the simple shoulder test (SST).Results:The absolute CS was 80.0±11.7 at the first follow-up (at 2-5 years) and decreased to 76.7±10.2 at the last follow-up (at 7-10 years) (p<0.001). The adjusted CS was 99.7±15.9 at the first follow-up and remained at 98.8±15.9 at the last follow-up (ns.). In terms of the other criteria, strength decreased over time (p<0.001) but pain, SSV and SST remained the same. Partial repairs had less strength at the first and last follow-up (p<0.05). Pseudoparalytic shoulders had a lower absolute and adjusted CS at the last follow-up (p<0.05) but the improvement in CS was greater (p=0.014).Conclusion:Partial and complete arthroscopic repair provide good long-term results in patients with massive rotator cuff tears, regardless of the location of the tear, the degree of fat infiltration (I to III according to the Goutallier classification) and even in case of a pseudoparalytic shoulder.

Suprascapular Nerve Release: Technique Based on Anatomic Landmarks

Dysfunction of the suprascapular nerve (SSN) is closely related to rotator cuff pathology; nerve dysfunction can lead to cuff disease and vice versa. Owing to repetitive microtrauma during overhead sports or massive cuff tears with significant tendon retraction, the SSN may suffer compression or traction neuropathy at the suprascapular notch. The SSN release technique has already been described. However, on the basis of the many hands-on cadaveric laboratories in which we have participated in the past 20 years, only a few instructors and almost none of the attendants have shown the experience and skill set needed to release the SSN at the suprascapular notch. Therefore, a review of the surgical technique following the anatomic descriptions of an expert anatomist (P.G.) of the shoulder girdle is quite valuable.

Partial Rotator Cuff Repair for Massive Tears Rarely Require Revision Surgery

Arthroscopic management of massive rotator cuff tears is a challenging and technically demanding problem. Despite advances in surgical devices and techniques, a complete repair is not always possible. The goal of this study was to determine the significance of initial and residual rotator cuff tear defect size on the need for revision surgery in a consecutive group of patients undergoing partial repair of massive rotator cuff tears. A retrospective chart review was carried out for all arthroscopic rotator cuff repairs performed by a single surgeon between January of 2013 and December of 2016 (n=1954). All of the patients with massive rotator cuff tears (>30cm2) that underwent partial repair were included in the study (38 of 1954 shoulders). The cross-sectional area of the initial and residual tear defect was measured arthroscopically, and patients were followed postoperatively for a minimum of 2 years (mean 4.5 years). Outcomes for the surgical procedure were measured based on the necessity for revision surgery or adjunct therapy including steroid injections or additional physical therapy after initial release from care. The mean initial rotator cuff defect size, 38.7 cm2 (30 - 48 cm2), was reduced intraoperatively to a mean defect size of 7.5 cm2 (1 - 20 cm2) following partial repair. Those patients undergoing revision surgery represented 5.2% (2/38) of the series and had an average initial / residual tear defect area of 45.0 / 7.0 cm2. Patients requiring adjunct therapy represented 7.9% (3/38) of the series and possessed an average initial / residual tear defect size of 40.0 / 16.0 cm2. The remaining 33 (86.9%) patients did not require revision surgery or adjunct therapy at a minimum follow up of 2 years. These patients requiring no additional treatment following surgical intervention had an average initial / residual tear defect size of 38.2 / 6.8 cm2. There was no correlation between initial and/or residual rotator cuff tear defect size and the need for revision surgery. However, there was a significant difference in the mean residual defect size in the patients requiring additional nonoperative treatment after initial release from care (p=0.012). This consecutive series demonstrates that partial repair of massive rotator cuff tears proved to be a durable intervention with only 5.2% of patients requiring subsequent surgical intervention at an average follow up of 4.5 years after index surgery. Larger residual rotator cuff defects did correlate with the necessity for subsequent nonoperative interventions. However, there was no correlation between residual cuff defect size and need for revision surgery. Partial repair of massive cuff tears is a viable option when managing these complex patients and preserves the option for more invasive salvage operations if needed.

Arthroscopic Superior Capsular Reconstruction of the Shoulder Using Dermal Allograft

Irreparable massive cuff tears in young patients pose a difficult problem for shoulder surgeons. Arthroscopic superior capsular reconstruction has shown promise in recent years in the treatment of this challenging patient population. The majority of the literature is limited to surgical techniques. The authors present the 2-year clinical outcomes of 25 patients undergoing arthroscopic superior capsular reconstruction with dermal allograft from a single center. The Oxford Shoulder Score and range of motion were assessed preoperatively and then at 3 to 6 months, 1 year, and 2 years following surgery. Patient satisfaction was recorded at final follow-up. Magnetic resonance imaging was performed at 3 months postoperatively to assess graft integrity. All patients were available at 1-year follow-up, and 23 were available at 2 years. The mean Oxford Shoulder Score improved by a minimum of 10 points at all time points compared with preoperatively. The mean forward flexion and abduction improved by 20° and external rotation by 7°. Revision to reverse shoulder arthroplasty was seen in 3 patients (12%). Graft failure was seen in 4 patients (16%). Overall, 20 patients had successful outcomes at 1 year (80%) and 18 patients had successful outcomes at 2 years (72%). Superior capsular reconstruction offers a safe and effective short-term bridging option for young patients with irreparable supraspinatus tears in the absence of glenohumeral arthritis. However, long-term outcome studies are required to evaluate the true clinical effectiveness and failure rates. [Orthopedics. 2020;43(4):215-220.].

Three-dimensional in vivo comparative analysis of the kinematics of normal shoulders and shoulders with massive rotator cuff tears with successful conservative treatment

BackgroundThis study used in vivo three-dimensional to two-dimensional image registration techniques to compare the glenohumeral kinematics of shoulders with massive rotator cuff tears that were successfully treated conservatively and those of normal shoulders. MethodsTen patients (age, 67.4 ± 3.63 years) with massive rotator cuff tears on one side and without contralateral tears were enrolled. We performed computed tomography and fluoroscopy on both shoulder joints and created three-dimensional bone models of the humerus and scapula using image registration techniques. We measured the humeral superoinferior translation, angle of humeral external rotation, scapular upward rotation, scapular anteroposterior tilt, and scapular external rotation of the torn shoulders with good range of motion after effective conservative treatment and compared these measurements to those of the contralateral normal shoulders. FindingsThere was a significant difference in the initial position of the humeral head relative to the glenoid in the tear group; it was 2.0 mm higher than that in the normal group (p < .05). This difference disappeared in the range from 40° to full elevation. The scapular motion of the tear group was significantly more upwardly rotated than that of the normal group: by 9.9° at rest (p < .05) and by 11.6° at terminal elevation (p < .05). No significant differences were detected for humeral head external rotation, scapular anteroposterior tilt, and scapular external rotation between the two groups. InterpretationKinematics of shoulders with massive cuff tears could not be recovered completely even though the patients had no significant symptoms after successful conservative treatment.

Defining the younger patient: age as a predictive factor for outcomes in shoulder arthroplasty

The purpose of this study was to define an age cutoff at which clinical outcomes and revision rates differ for patients undergoing primary anatomic total shoulder arthroplasty (TSA) and patients undergoing primary reverse shoulder arthroplasty (RSA). This retrospective cohort study included 1250 primary shoulder arthroplasties (1131 patients) with minimum 2-year clinical follow-up (mean, 50 months [range, 24-146 months]). TSA (n = 518; mean age, 68.1 years [range, 28-90 years]) was performed for osteoarthritis in most cases (99%), whereas the primary diagnoses for RSA (n = 732; mean age, 70.8 years [range, 22-91 years]) included rotator cuff arthropathy (35%), massive cuff tear without osteoarthritis (29.8%), and osteoarthritis (20.5%). Outcomes included range of motion, the American Shoulder and Elbow Surgeons (ASES) score, and the revision rate. The relationship between age at the time of surgery in 5-year increments (46-50 years, 51-55 years, and so on) and the revision rate was examined to identify the age cutoff; this was then used to assess clinical outcomes. In patients younger than 65 years, TSA was associated with a 3.4-fold increased risk of revision (P = .01). RSA performed in patients younger than 60 years was associated with a 4.8-fold increased risk of revision (P < .001). TSA patients aged 65 years or older and RSA patients aged 60 years or older had better total ASES scores (82 vs. 77 [P = .03] and 72 vs. 62 [P = .002], respectively) and better internal rotation (interquartile range, TSA 5-6 vs. 4-5 [P = .002] and RSA 4-5 vs 3-4 [P = .04])-where 6 represents T4 to T6 and 4 represents T11 to L1-than their younger counterparts. Age at index arthroplasty affects outcomes and the risk of revision. Primary TSA patients younger than 65 years and RSA patients younger than 60 years have a significantly increased revision risk. These age cutoffs are also correlated with differences in ASES scores and internal rotation.

Rotator Cuff Reconstruction Using Fascia Lata Patch Autograft for the Nonrepairable Rotator Cuff Tear

A large to massive rotator cuff tear is a common issue that lacks reliable options to return a patient's range of motion and function when conservative treatment has failed. With up to 96% of massive rotator cuff repairs failing within the first 6 months of repair, surgeons have been searching for a reliable treatment option for this difficult subset of patients. Surgical options for massive, retracted rotator cuff tears include re-establishing the counterforce coupling of the rotator cuff with techniques such as a partial repair or superior capsular reconstruction, preventing superior humeral migration as seen with balloon spacer implantation, and eliminating pain generators with techniques such as biceps tenotomy; however, these do not reconstitute dynamic cuff control. More recently, an acellular dermal allograft, as seen in superior capsular reconstruction, has been used to reconstruct the remaining rotator cuff. We describe a technique using a fascia lata autograft to reconstruct the rotator cuff in the setting of a massive cuff tear. This is of particular importance in centers that lack the funding or institutional approval to use acellular dermal allografts that have been popularized to date.

Irreparable Massive Rotator Cuff Tear: How do I address

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...

Clinical and structural outcome 20 years after repair of massive rotator cuff tears

Short- and mid-term outcomes after massive cuff tear repair are well reported, but there is no documentation of the clinical and structural outcomes at 20 years of follow-up. The hypothesis of the present study was thatat 20 years, deterioration of the shoulder would have occurred and led to a substantial number of reoperations. The authors retrospectively recalled all 127 patientsoperated for massive rotator cuff tears in 1994 at 6 different centers. At the 20-yearfollow-up, 26 patients died and 35 were lost to follow-up. Thirteen (10.2%) had been reoperated. This left 53 patientsfor personal clinical assessment. Forty-nine consented to standardized radiographic evaluation for assessment of osteoarthritis, 36 patients underwent magnetic resonance imaging, allowing assessment of tendon healing, atrophy, and fatty infiltration (FI) of the cuff muscles. The final Constant-Murley score (CS) was 68 ± 17.7 (range, 8-91) vs. 44 ± 15.3 (range, 13-74) preoperatively (P < .05). The final Subjective Shoulder Value (SSV) was 73% ± 23% (range, 0-100). Retears (Sugaya IV and V) were found in 17 cases (47%). Nine patients (17%) had cuff tear arthropathy (Hamada stage 4). The CS and SSV for the shoulders with FI stages III or IV were significantly inferior (53 ± 19 points and 65% ± 14% respectively) than for those with FI stages 0-II (respectively, 71.6 ± 6 points and 73% ± 4%) (P < .05). Twenty years after surgical repair of massive rotator cuff tears, the functional scores remain satisfactory, and the rate of revision is low.