Massive Irreparable Cuff Tears Research Articles

The Trillat procedure: the man and the technique revisited through the lens of arthroscopy.

The Trillat procedure, initially described by Albert Trillat, is historically one of the first techniques for addressing recurrent anterior shoulder instability, incorporating fascinating biomechanical mechanisms. After lowering, medializing, and fixing the coracoid process to the glenoid neck, the subcoracoid space is reduced, the subscapularis lowered, and its line of pull changed, accentuating the function of the subscapularis as a humeral head depressor centering the glenohumeral joint. Furthermore, the conjoint tendon creates a 'seatbelt' effect, preventing anteroinferior humeral head dislocation. Even though contemporary preferences lean towards arthroscopic Bankart repair with optional remplissage, bone augmentation, and the Latarjet procedure, enduring surgical indications remain valid for the Trillat procedure, which offers joint preservation and superior outcomes in two distinct scenarios: (i) older patients with massive irreparable cuff tears and anterior recurrent instability with an intact subscapularis tendon regardless of the extent of glenoid bone loss; (ii) younger patients with instability associated shoulder joint capsule hyperlaxity without concomitant injuries (glenoid bone loss, large Hill-Sachs lesion). Complications associated with the Trillat procedure include recurrent anterior instability, potential overtightening of the coracoid, leading to pain and a significant reduction in range of motion, risk of subcoracoid impingement, and restriction of external rotation by up to 10°, a limitation that is generally well-tolerated. The Trillat procedure may be an effective alternative technique for specific indications and should remain part of the surgical armamentarium for addressing anterior shoulder instability.

Short-Term Results after Reversed Total Shoulder Arthroplasty

Abstract Purpose Massive rotator cuff tear, with or without arthritis and proximal humerus fracture non-union or malunion, lead to the loss of center of rotation of shoulder, while anatomical total shoulder arthroplasty does not provide a stable center of rotation, Therefor reversed total shoulder arthroplasty (RTSA) is the suitable method for these indications, as well as in elderly patients with primary glenohumeralosteoarthritis because anatomical total shoulder arthroplasty has the risk of failure either due to loosening of glenoid component or cuff tear. This study aimed to determine the short-term results after RTSA in patients a with massive cuff tear, acute proximal humerus fracture, proximal humerus fracture malunion or non- union, and primary glenohumeralosteoarthritis. Methods This one arm clinical trial (interventional study) conducted in Ain Shams University Hospitals included 16 patients who underwent RTSA. Short-term outcomes included constant score, American Shoulder and Elbow Surgeon (ASES) score, and range of motion (ROM). Patients with rotator cuff arthropathy, massive irreparable cuff tear with or without glenohumeralarthritis, elderly patients with acute complex proximal humerus fracture, malunited or nonunited proximal humerus fracture, and patients with glenohumeralosteoarthritis were included. Patients who were aged <50 years were excluded, as well as patients with axillary nerve injury or deltoid muscle dysfunction. Results This study included 16 patients, including 8 males and 8 females. The mean age was 64.19 years and the duration of follow up-was 1 year postoperatively. Seven Patients with massive irreparable cuff tear were included, of them, 1 had associated anterior shoulder instability and recurrent anterior dislocation, 3 had a four-part proximal humerus fracture, 2 had fracture dislocation, 2 had proximal humerus fracture non –union, 1had neglected dislocation, and 2 had glenohumeralosteoarthritis. Outcomes were followed using constant and ASES scoring systems, and ROM. The global postoperative gain was statistically significant (p < 0.001). Complication in the form of dislocation occurred in one case that had RTSA after fracture non-union. Conclusion Good clinical and functional outcomes were achieved after RTSA, not only for classic massive cuff tear indication, but for other disorders, such as acute proximal humerus fracture, fracture non-union, and primary glenohumeralosteoarthritis. However, the outcomes after irreparable cuff tear were the best among all indications, while fracture non-union had the least improvement in clinical outcomes. Improvements in prosthesis design, surgeon’s experience, and clinical results are necessary to optimize this treatment for many shoulder conditions.

Management of Massive Irreparable Posterosuperior Cuff Tears: A Systematic Review for Clinical & Functional & Radiological Outcomes

Abstract Background The management of massive irreparable cuff tears (MIRCT) remains a highly controversial subject with many possible surgical and non-surgical interventions and no clear evidence regarding the most effective and beneficial intervention. Different management options include: conservative management, partial repair, tendon transfer, superior capsular reconstruction, subacromial spacer insertion, reverse total shoulder arthroplasty (RTSA). Aim of the Work The aim of this systematic review is to compare the various methods of management of posterosuperior cuff tears without arthropathy to reach the most effective and sustainable mode of management. Patients and Methods A randomized controlled trial, non-randomized clinical trials, prospective and retrospective comparative cohort studies and case series. We will exclude cross-sectional studies, case reports and literature not in English. Results There is no high quality evidence on management of MIRCT. There was no Level I or II evidence. We included 69 papers that studied different modalities of management of MIRCT, 31 of level III and the remaining were of level IV evidence. Consequently, it’s still difficult to recommend one method of management over the other regarding the management of irreparable cuff tears. Patient age, demands, expectations, thorough clinical examination, surgeon experience and preference are still a major deciding factor when choosing and appropriate method. Conclusion Due to the unavailability of high-quality clinical studies available for guiding management of irreparable MRCT, it is consequently not possible to recommend for or against any specific treatment strategy. Rather, clinical experience, patient factors, patient expectations, and rotator cuff tear characteristics should guide clinical decision-making. Physical therapy compared to surgical treatments may have inferior outcomes. Standardized data collection, reporting and terminology are key to enhancing the quality of evidence-based medicine.

Up to date diagnosis and treatment of massive irreparable cuff tears: Results of the survey of the U45 ESSKA Committee.

Irreparable rotator cuff tears are disabling and can severely affect daily life activities, especially when young and active patients are involved. The definition is still debated, and they can have several clinical presentations. The treatment depends on the clinical presentation and the patient'sage. The survey was developed by the ESSKA U45 Committee and was uploaded on the ESSKA website. Fifty-seven questionnaires were returned. Several aspects of the diagnosis and treatment of massive irreparable cuff tears were investigated. Moreover, treatment options for specific clinical scenarios were given for posterior-superior and anterior-superior cuff tears in young and old patients. Fatty degeneration of the muscles was the most common criterion to define an irreparable tear (59.7%). In young patients with external rotation with the arm at side lag, partial repair of the cuff was the most common option (41.8%); in case of external rotation with the arm at side + external rotation at 90° of abduction lag without pseudoparalysis, the most common option was partial repair of the cuff + latissimus dorsi or lower trapezius transfer (39.3%), and in case of external rotation with the arm at side + external rotation at 90° of abduction lag with pseudoparalysis, partial repair of the cuff + latissimus dorsi or lower trapezius transfer was still the most common option (25.5%). The same scenarios in old patients yielded the following results: reverse prosthesis (49.1%), reverse prosthesis (44.6%) and reverse prosthesis ± latissimus dorsi or lower trapezius transfer (44.6%), respectively. The present survey clearly confirms that biological options (partial cuff repairs and tendon transfers) are the reference in the case of young patients with deficient cuffs (both posterior and anterior). Reverse shoulder prosthesis is the most common treatment option in old patients in all clinical scenarios. Level IV.

Surgical Management of Massive Irreparable Cuff Tears: Superior Capsule Reconstruction and Rotator Cable Reconstruction.

Massive irreparable rotator cuff tears (MIRCTs) present treatment challenges. Recently, superior capsule reconstruction (SCR) and anterior cable reconstruction have emerged as surgical options, but no single approach is superior. This review provides an overview of SCR and cable reconstruction techniques, including biomechanical studies, clinical outcomes, and surgical considerations. Biomechanical studies show SCR with autografts or allografts improves glenohumeral stability and mechanics. Clinical outcomes of SCR demonstrate improved range of motion, function scores, and pain relief in short-term studies. Anterior cable reconstruction reduces superior humeral head translation and subacromial pressures in biomechanical models. Early clinical studies report improved rotator cuff healing and outcomes for cable reconstruction in specific irreparable tear patterns. SCR and cable reconstruction are viable surgical options for MIRCTs based on early encouraging results. However, higher-level comparative studies with long-term follow-up are still needed. Careful consideration of tear pattern, patient factors, and surgical goals is required to optimize treatment of MIRCTs. Further research is necessary to determine the optimal role for these procedures.

Superior Capsular Reconstruction for Massive Irreparable Cuff Tears: A Systematic Review for Clinical & Functional & Radiological Outcomes

Background Massive rotator cuff tears (MRCT) are defined as a full-thickness tear of at least two tendons or measuring greater than five centimeters in diameter in the coronal plane. They represent about 20% of all rotator cuff tears and 80% of recurrent tears. Aim of the Work The treatment of massive irreparable cuff tears (MIRCT) is considered a consistent challenge for the orthopedic surgeons regarding the best management and the postoperative outcomes. Patients and Methods Search were conducted using the following databases: MEDLINE database, PubMed, Cochrane Bone and Muscle Trauma Group Specialized Register, Cochrane Register of Controlled Trails (The Cochrane Library). Data will be independently extracted by two reviewers and cross-checked. Results In radiological parameters, this review makes radiological assessment based on acromiohumeral distance and MRI graft integrity. AHD showed significant improvement in mean change postoperatively rather than preoperatively. As regarding MRI graft integrity, despite this high failure rate (20%) most patients still experienced improved functional outcome scores with two studies reporting no significant differences in functional scores between the intact and re-tear group. but on the other hand Denard et al. demonstrated that 100% of patients with healed grafts had a successful outcome compared to 45.5% when the graft did not heal (p = 0.009). Conclusion Not all patients with massive cuff tears are appropriate candidates for complex joint preservation surgery such as SCR because of age, comorbidities, and ability to participate in the lengthy postoperative rehabilitation, so rTSA is an optimal option for elderly, low-demand patients who can benefit from the speed of surgery and rehabilitation with rTSA for massive rotator cuff tears without arthritis.

Outcomes of Reverse Total Shoulder Arthroplasty with Latissimus Dorsi Tendon Transfer for External Rotation Deficit

Background: Latissimus dorsi transfer (LDT) has been purported to restore motion in patients undergoing reverse shoulder arthroplasty (RSA) who have preoperative combined loss of forward elevation (FE) and external rotation (ER). This systematic review summarizes the available evidence for the functional outcomes and complications after RSA with LDT. Furthermore, the effect of implant design and whether a concomitant teres major transfer (TMT) was performed were studied. Methods: A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting on LDT with RSA to restore ER. Our primary outcomes were ER, FE, Constant score, and complication incidence. Secondarily, we reported postoperative internal rotation (IR) and compared ER, FE, and Constant score based on lateralized versus medialized global implant design and whether concomitant TMT was performed. Results: Nineteen studies were evaluated; functional outcomes were assessed in 16 articles reporting on 258 RSAs (123 LDT, 135 LDT-TMT). Surgical indication was most commonly cuff tear arthropathy and massive irreparable cuff tear. Mean ER was −12° preoperatively and 25° postoperatively, FE was 72° preoperatively and 141° postoperatively. Mean postoperative Constant score was 65. Of 138 patients (8 studies) describing IR, only 25% reported a mean postoperative IR ≥L3. Subanalysis comparing lateralized versus medialized implants and whether TMT was concomitantly performed demonstrated no significant difference in postoperative ER, FE, and Constant score, nor preoperative to postoperative improvement in ER and FE. The complication rate was 14.1% (of 291 shoulders from 16 studies), including tear in the tendon transfer (n = 3), revision tendon repair (n = 1), nerve-related complication (n = 9), and dislocation (n = 9). Conclusions: RSA with LDT is a reliable option to restore motion, with a comparable complication rate with standard RSA. The use of medialized versus lateralized implants and whether the TM was concomitantly transferred may not influence clinical outcomes. Level of Evidence: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Modified Arthroscopic Latissimus Dorsi Transfer at the Infraspinatus Footprint With Anterior Extracortical Fixation

Massive irreparable cuff tears may represent as many as 20% to 40% of total cases of operated rotator cuff tears and can be a challenging clinical problem. Many treatment options have been proposed for their treatment. Among these options, latissimus dorsi tendon transfer can be considered a good alternative, especially in young patients before they develop glenohumeral arthritic changes. This technique aims at rebalancing the shoulder with a functioning subscapularis muscle and restoring both active external rotation and elevation with the aid of a properly functioning deltoid muscle. The modified arthroscopic latissimus dorsi transfer at the infraspinatus footprint with anterior extracortical fixation rebalances the pair of forces acting on the shoulder, stabilizing it in the transverse plane, minimizing the risk of latissimus dorsi transferred rupture and associated complications.

PSEUDOPARALYSIS

The definition of pseudoparalysis in shoulder is controversial. Gwschend initially described pseudoparalysis as an appearance of paralysis with severe rotator cuff tear. Later, Werner described pseudoparesis as active elevation under 90° caused by an irreparable massive cuff tear. Since these descriptions, many articles across the literature make the confusion between pseudoparesis and pseudoparalysis who differ in term of lesion and treatment options. Subsequently, this adds confusion to confusion when evaluating the results to determine the optimal therapeutic strategy. Conservative and arthroplasty options are discussed but the reverse arthroplasty appears to be the treatment of choice in a true pseudoparalyzed shoulder.

Minimal Clinically Important Differences for Oxford, Constant, and University of California Los Angeles Shoulder Scores After Reverse Shoulder Arthroplasty to Allow Interpretation of Patient-Reported Outcome Measures and Future Statistical Power Analyses

To determine Minimal clinically important difference (MCID) for Constant-Murley Score (CMS), University of California Los Angeles (UCLA) Shoulder Score and Oxford Shoulder Score (OSS) after reverse shoulder arthroplasty. Patients were prospectively followed up between January 2011 and February 2020. Inclusion criteria was that of patients who underwent reverse shoulder arthroplasty for massive irreparable cuff tear, cuff tear arthropathy, and fractures, with and without prior cuff repair by a fellowship trained surgeon. Patients were assessed preoperatively and at 3, 6 and 12 months postoperatively. Functional outcome was assessed by the CMS, UCLA score, and OSS and the respectively MCIDs were determined using simple linear regression in consonance with patient satisfaction and expectation fulfilment. A total of one hundred and thirty-one patients were followed up for 12 months. The MCIDs at 3 months for CMS, UCLA and OSS were 7.2, 3.3 and 6.9 respectively. At 6 months, the MCIDs for CMS, UCLA and OSS were 6.6, 2.4 and 4.7 respectively. At 12 months, the MCIDs for CMS, UCLA and OSS are 9.3, 2.9 and 6.6 respectively. CMS, UCLA and OSS are valid scores to calculate MCID after Reverse Shoulder Arthroplasty and the MCID established in this study can be used for the interpretation of these scores to help in statistical power analysis for future studies.

The Arthroscopic Trillat Procedure Is a Valuable and Durable Treatment Option for Recurrent Anterior Instability Associated With Massive Irreparable Cuff Tears

The purpose of the present study is to report the mid- and long-term clinical and radiologic outcomes of the arthroscopic Trillat for the treatment of recurrent anterior instability in patients with chronic massive irreparable rotator cuff tears (MIRCTs) and maintained active shoulder motion where reverse shoulder arthroplasty (RSA) is not indicated. Twenty-one consecutive patients (mean age 61 years) were identified and retrospectively reviewed. All patients had recurrent anterior dislocations and conserved active forward elevation and active external rotation. The MIRCTs included a retracted (stage 3) supraspinatus tear in 14%, a supra- and infraspinatus tear in 76.5%, and a 3-tendon tear in 14%. A closed-wedge osteotomy of the coracoid was performed, and the coracoid was fixed above the subscapularis with a cannulated screw (10 cases) or suture buttons (11 cases). We followed patients with x-rays and computed tomography scan at 6 months, along with Subjective Shoulder Value, visual analog scale, Walch, Constant, and Rowe scores. The mean clinical and radiographic follow-up was 58 months (24-145 months). Overall, 96% (20/21) of the patients had a stable and functional shoulder and were satisfied with the procedure; no patient lost active shoulder motion. The Subjective Shoulder Value increased from 44% (10%-75%) to 94% (80%-100%), P < .001. The Constant and Rowe scores improved from 60 (25-81) to 81 (66-96) and from 54 (35 to 65) to 92 (70-100), respectively (P < .001). Among the 13 patients practicing sports before surgery, 10 (77%) went back to sports. At last follow-up, only 1 patient was revised to RSA. The arthroscopic Trillat procedure is a valuable and durable option for the treatment of recurrent anterior dislocations in older patients with chronic MIRCTs and conserved active shoulder motion. Level IV, therapeutic case series.

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

Biologic Tuberoplasty With an Acellular Dermal Allograft for Massive Rotator Cuff Tears

We present the technique of biologic tuberoplasty, where an acellular dermal allograft is used to cover the tuberosity in patients with massive irreparable cuff tears to prevent bone-to-bone contact between the tuberosity and acromion when active elevation is attempted. This technique can be performed in patients with massive rotator cuff tears who are low-demand and have significant medical comorbidities, poor bone quality, or who are not candidates for a reverse shoulder arthroplasty or who cannot tolerate a lengthy rehabilitation protocol. It is less time-consuming than a superior capsule reconstruction and more bone-sparing than traditional tuberoplasty. Patients with massive rotator cuff tears involving the supraspinatus and a portion of the infraspinatus lose their force couple, leading to superior humeral head migration with abutment of the tuberosity against the acromion upon deltoid activation. The center of rotation moves superiorly with deltoid contraction, developing an acromiohumeral articulation. This results in bone-to-bone contact between the acromion and humerus, leading to pain and acetabularization of the acromion over time. Coverage of the tuberosity with the acellular dermal allograft acts as an interpositional tissue and prevents bone-to-bone contact between the tuberosity and acromion.

Surgical Management of Massive Irreparable Cuff Tears: Superior Capsular Reconstruction.

Superior capsular reconstruction (SCR) is a surgical procedure that has been developed to provide an alternative for joint preservation in patients with massive irreparable rotator cuff tears. The purpose of this review is to assess the improvements in biomechanical properties and functional outcomes of this novel procedure. Biomechanically, SCR decreases superior translation and subacromial contact pressure. Glenoid fixation is maximized with three anchors, while margin convergence to any remaining rotator cuff improves stability, and findings vary based on graft type. Clinically, SCR has been associated with improvement in functional outcome in the setting of an isolated procedure, or in conjunction with rotator cuff repair. Outcomes appear to be dependent upon indications. However, in select cases, SCR may even be successful in reversing pseudoparalysis. SCR seems to lead to improved biomechanics for the cuff-deficient shoulder resulting in satisfactory functional outcomes. While surgical techniques have evolved, further research is needed to optimize graft healing and longer follow-up studies are needed to continue to refine indications for SCR as a joint preservation effort in the setting of irreparable massive rotator cuff tears without arthritis.

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.].

Primary reverse shoulder arthroplasty did not result in increased blood metal ion levels regardless of glenosphere size: A randomized controlled trial

BackgroundThe utilization of reverse shoulder arthroplasty (RSA) has increased over time. Toxic increases of metal ion levels have been reported selectively after hip arthroplasty. However, studies evaluating the effect of RSA on in vivo metal ion levels have not been evaluated. Therefore, the purposes of this study were (1) to determine in vivo levels of cobalt, chromium, and nickel in a randomized controlled trial of patients undergoing reverse total shoulder arthroplasty (RSA) with one of four glenosphere sizes, and (2) to identify possible factors affecting changes in metal ion levels. MethodsBetween May 2016 and September 2018, 72 shoulders with cuff tear arthropathy, massive irreparable cuff tears, or glenohumeral osteoarthritis with posterior subluxation were randomized to undergo RSA using a single implant system and four possible glenosphere options based on size (36 or 40 mm) and offset (+2 mm, +6 mm). In vivo metal ion levels (cobalt, chromium, nickel) and complete blood count (CBC) were assessed preoperatively, 3-months, and 1-year after surgery. Clinical evaluation included pain, motion, Subjective Shoulder Value, ASES scores, and Oxford Shoulder Scores. ResultsReverse shoulder arthroplasty led to statistically significant improvements in all outcome measures considered (p < 0.001). Changes in nickel, cobalt or chromium blood levels did not reach statistical significance at 3 months (p = 0.87, 0.86, 0.85, respectively) or 1 year (p = 0.88, 0.38, 0.98, respectively). There was no difference in any of these metal ion levels when assessed by (1) glenosphere size, or (2) offset at 3 months or 1 year. This was also true when each of the four groups were assessed individually at 3 months and 1 year. ConclusionIn this randomized controlled trial of patients undergoing reverse total shoulder arthroplasty with a single design, in vivo levels of cobalt, chromium, and nickel remained reassuringly low. In addition, increase in glenosphere size, offset, or both, did not appear to affect in vivo metal ion levels over the short-term. Longer term studies are needed to further assess the effects of implant modularity on metal ion levels and their potential adverse effects in patients undergoing reverse shoulder arthroplasty. Level of evidenceLevel I; Randomized Controlled Trial

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...

Arthroscopic Superior Capsular Reconstruction With Biceps Autograft: Snake Technique

Many options have been developed to treat irreparable massive cuff tears. Superior capsular reconstruction has been reported as one of the treatment options for relatively young patients with irreparable massive cuff tear. However, this original technique has a disadvantage of requiring a tensor facia lata autograft. It requires another incision at the lateral thigh and can be a cause of thigh pain. This article describes our modified technique for arthroscopic superior capsule reconstruction using the biceps autograft to preserve the long head of the biceps tendon anchors to the glenoid labrum (the snake technique).

Aseptic Glenoid Baseplate Loosening After Reverse Total Shoulder Arthroplasty: A Systematic Review and Meta-Analysis.

Aseptic glenoid baseplate loosening can lead to the failure of reverse total shoulder arthroplasty (RTSA). Estimates of the prevalence of aseptic glenoid baseplate loosening after RTSA are required to guide clinical decisions, but published results are variable and lack precision. The goal of this meta-analysis was to determine a precise estimate of the prevalence of aseptic glenoid baseplate loosening after RTSA and to explore variation in the prevalence according to different variables, such as the type of procedure (primary or revision), preoperative diagnosis, the center of rotation of the glenoid component (medialized or lateralized), study size, the definition of aseptic glenoid baseplate loosening, and the duration of follow-up. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. We searched the MEDLINE and Embase databases for English-language articles describing the outcomes after RTSA with a minimum 12-month follow-up in which radiographic findings of aseptic glenoid baseplate loosening were reported. Random-effects meta-analysis was performed, and meta-regression was used to explore the influence of variables on heterogeneity. Subgroup analyses and sensitivity analyses were performed. One hundred and three studies (covering 6,583 RTSAs) performed from 1991 to 2015 met our inclusion criteria. The pooled prevalence of radiographic aseptic glenoid baseplate loosening for all RTSAs was 1.16% (95% confidence interval [CI], 0.80% to 1.69%). The prevalence of aseptic glenoid baseplate loosening was lower among primary RTSAs (0.90%; 95% CI, 0.54% to 1.49%) than among revision RTSAs (3.64%; 95% CI, 1.91% to 6.84%). The pooled prevalence of aseptic glenoid baseplate loosening by diagnosis was 2.69% for osteoarthritis with bone loss, 1.71% for cuff tear arthropathy, 1.20% for rheumatoid arthritis, 1.08% for sequelae of fracture, 0.94% for irreparable massive cuff tear, and 0.25% for acute proximal humeral fracture. The prevalence of aseptic glenoid baseplate loosening was not significantly different for prostheses with a medialized center of rotation (1.15%) versus a lateralized center of rotation (1.84%). To our knowledge, the present study represents the first meta-analysis investigating only aseptic glenoid baseplate loosening after RTSA. Multiple variables were found to be associated with the prevalence of aseptic glenoid baseplate loosening. The rates reported here are lower than those reported previously because of the inclusion of more recent evidence and more studies that evaluated aseptic glenoid baseplate loosening. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Massive irreparable rotator cuff tears

Management of massive irreparable posterosuperior rotator cuff tears is a surgical challenge, particularly in young active patients without any signs of osteoarthritis. Different surgical techniques have been described. To the three main deficits of active range of motion previously reported for a massive irreparable cuff tear, i.e., isolated loss of active elevation (ILEA), isolated loss of active external rotation (ILER), and combined loss of elevation and external rotation (CLEER), we add two new entities: isolated loss of active internal rotation (ILIR) and combined loss of active elevation and active internal rotation (CLEIR). We suggest that a combined deficit (CLEER or CLEIR) could lead to a new definition of a pseudoparalytic shoulder and propose a novel algorithm to redefine the role of latissimus dorsi transfer in each of these situations. We also describe a fully arthroscopic latissimus dorsi transfer technique that prevents any deltoid muscle insult, offers better visualization of the neighboring neurovascular structures at risk, and allows simultaneous management of biceps pathology and partial rotator cuff repair.