Massive Irreparable Cuff Tears Research Articles

Arthroscopic Superior Capsular Reconstruction in Males Provides Superior Outcomes to Reverse Total Shoulder or Debridement for Irreparable Rotator Cuff Tears

Objectives:Early results following arthroscopic superior capsular reconstruction(SCR) in patients with massive, irreparable rotator cuff tears are promising. However, no studies have compared patient reported outcomes between SCR or reverse total shoulder(rTSA) and rotator cuff debridement for these patients. Therefore, the purpose of this study was to compare 1-year outcomes between patients with massive irreparable rotator cuff tears who underwent a SCR, rTSA, or rotator cuff debridement with a concurrent biceps tenotomy or tenodesis.Methods:Patients(n=63) who underwent either SCR(n=21), rTSA(21), or cuff debridement(n=21) and biceps tenotomy or tenodesis for a massive, irreparable rotator cuff tear treated with a minimum 1-year follow up were retrospectively reviewed. Age, sex, BMI, smoking status, Charlson Index, Hamada classification, and ASES scores were recorded and compared using a multivariate ANOVA were used to compare between surgical approaches. A Chi Square analyses were used to compare sex distribution and the Charlson Deyo Index between groups (α=0.05).Results:Overall, patients across the 3 groups were not statistically different in age or follow up ASES score at minimum 14 month follow up (P> 0.05). There was a significant interaction effect between surgery group and sex (P=0.02) on ASES score but not age (P=0.08). Univariate F tests revealed that male patients who received an SCR displayed a 10-14% better outcome at follow up compared to other groups (Table 1) which exceeds the reported ASES score MCID.Conclusion:Our results show comparable results across surgical options for massive irreparable cuff tears with good patient reported outcomes. Male patients displayed clinically important greater ASES scores at 1 year follow up. Future studies should evaluate these preliminary results to assess if these preliminary results hold up at longer follow up times.

A clinical and radiological study of biodegradable subacromial spacer in the treatment of massive irreparable rotator cuff tears.

The aim of this retrospective study was to report the clinical and radiographic results of the biodegradable subacromial spacer (InSpace Balloon®) implantation in patients with massive irreparable rotator cuff tears. From February 2014 to October 2015, 30 patients affected by massive irreparable rotator cuff tears were treated with the implantation of InSpace Balloon®. Clinical evaluation (Constant Score and VAS), X-rays and MR imaging were performed preoperatively in all patients and 3, 6, 12 and 24 months after surgery, dividing patients in different groups according to the time elapsed from surgery. Constant Score increased from 39.89 to 62.33 points (p 0.0002) in the 6 months group and from 41.66 to 65.38 points (p< 0.0001) in the 12 months group. ROM (Range of Movement) and ADL (Activity of Daily Living) significantly improved with the contemporary reduction of VAS and pain at 12 months and, furthermore, an increase of functional performance with reduction of pain was registered at 24 months. Our results supported the surgical procedure of the arthroscopic implantation of biodegradable subacromial InSpace Balloon® for irreparable massive cuff tears in worker patients and with recreational activities' demands in order to recover the shoulder function with a reduction of the pain.

Three-dimensional analysis of the shoulder motion in patients with massive irreparable cuff tears after latissimus dorsi tendon transfer (ltd)

Three-dimensional analysis of the shoulder motion in patients with massive irreparable cuff tears after latissimus dorsi tendon transfer (ltd)

Arthroscopic suprascapular neurotomy for the painful irreparable rotator cuff tear.

Massive irreparable rotator cuff tears are becoming increasingly difficult to manage. Patients were considered for treatment if they had a painful shoulder in the presence of a compensated cuff tear. All patients had radiological evidence of a massive irreparable cuff tear and underwent suprascapular neurotomy, arthroscopically. There were 15 males and 25 females with a mean age of 74 years (range 59 years to 88 years). The mean pre-operative Oxford Shoulder Score (OSS) in all patients was 17.7, with a mean pre-operative visual analogue score (VAS) of 8.0. The mean post-operative OSS was 30.8 [27.42-34.18 = confidence interval (CI) 95%] with a mean VAS of 3.6 (2.64-4.56 CI 95%) at the 3-month (short-term) period (n = 32). The medium-term (1-year) OSS and VAS had improved to 33.6 (32.27-34.93 = CI 95%) and 3.7 (0-8.39 CI 95%) respectively (n = 26). The difference pre- and postoperatively at 12 months was statistically significant (p < 0.001). Patients who underwent biceps tenotomy at the time of surgery had a less significant improvement in their VAS and OSS. Suprascapular neurotomy can afford medium-term benefit in over two-thirds of the patients who would otherwise have undergone reverse polarity shoulder replacements. We consider that this is a reproducible technique.

Pigmented villonodular synovitis of the shoulder associated with massive rotator cuff tear treated by arthroscopic synovectomy and debridement

Pigmented villonodular synovitis (PVNS) is a rare condition. Our purpose is to describe the largest series of patients with shoulder PVNS, massive irreparable rotator cuff tear, and glenohumeral osteoarthritis treated with arthroscopic debridement and synovectomy. We treated 9 patients with PVNS of the shoulder, irreparable rotator cuff tear, and slight glenohumeral arthropathy (group I). Patients underwent arthroscopic synovectomy and debridement. Results [constant score (CS) and subjective shoulder value (SSV)] were compared to those obtained from a control group (group II) of 20 consecutive patients undergoing arthroscopic debridement for irreparable cuff tear associated with hemorrhagic synovitis with no or slight glenohumeral arthropathy. Histologic examination was obtained in all cases to obtain the correct diagnosis. The preoperative shoulder function in group I was reduced with respect to group II. Upon follow-up, CS and SSV were lower in group I. Preoperatively, the differences relating to the CS value and to each item of the score were always statistically significant; instead, at follow-up, significant differences emerged in the CS, ADL, and ROM. At follow-up, significant differences emerged between CS of group I and of group II without glenohumeral arthropathy. Differences using the SSV were always statistically significant. The poor functional outcome of patients affected by PVNS can be attributed to the coexistence of the irreparable cuff tear and to the glenohumeral arthropathy. All patients with PVNS had shoulder osteoarthritis; it cannot be simply attributed to natural history of massive irreparable cuff tears, but to the pigmented villonodular synovitis.

Biomechanical effect of latissimus dorsi tendon transfer for irreparable massive cuff tear

The purpose of this study was to determine the biomechanical effects of latissimus dorsi transfer in a cadaveric model of massive posterosuperior rotator cuff tear. Eight cadaveric shoulders were tested at 0°, 30°, and 60° of abduction in the scapular plane with anatomically based muscle loading. Humeral rotational range of motion and the amount of humeral rotation due to muscle loading were measured. Glenohumeral kinematics and contact characteristics were measured throughout the range of motion. After testing in the intact condition, the supraspinatus and infraspinatus were resected. The cuff tear was then repaired by latissimus dorsi transfer. Two muscle loading conditions were applied after latissimus transfer to simulate increased tension that may occur due to limited muscle excursion. A repeated-measures analysis of variance was used for statistical analysis. The amount of internal rotation due to muscle loading and maximum internal rotation increased with massive cuff tear and was restored with latissimus transfer (P < .05). At maximum internal rotation, the humeral head apex shifted anteriorly, superiorly, and laterally at 0° of abduction after massive cuff tear (P < .05); this abnormal shift was corrected with latissimus transfer (P < .05). However, at 30° and 60° of abduction, latissimus transfer significantly altered kinematics (P < .05) and latissimus transfer with increased muscle loading increased contact pressure, especially at 60° of abduction. Latissimus dorsi transfer is beneficial in restoring humeral internal/external rotational range of motion, the internal/external rotational balance of the humerus, and glenohumeral kinematics at 0° of abduction. However, latissimus dorsi transfer with simulated limited excursion may lead to an overcompensation that can further deteriorate normal biomechanics, especially at higher abduction angles.

(i) Shoulder arthroplasty for osteoarthritis and rheumatoid arthritis

Replacement arthroplasty represents the treatment of choice for most patients with end-stage glenohumeral osteoarthritis or rheumatoid arthritis. Multiple studies have documented reliable improvements in pain, range of motion, function and quality of life after this procedure. Total shoulder arthroplasty seems to be associated with more reliable pain relief and improvements in elevation when compared to hemiarthroplasty. The main surgical principles of shoulder arthroplasty apply equally to patients with osteoarthritis and rheumatoid arthritis; however, the different underlying pathology associated with these two conditions needs to be understood in order to modify the surgical technique accordingly. Most patients with osteoarthritis have an intact rotator cuff and enough glenoid bone stock to allow implantation of a glenoid component. Asymmetric posterior glenoid erosion often needs to be corrected and capsular releases are needed to restore elevation and external rotation. In rheumatoid arthritis, implantation of a glenoid component may not be possible in the presence of severe glenoid bone loss or a massive irreparable cuff tear; in addition, rheumatoid involvement of other joints needs to be taken into consideration. Infection, instability, periprosthetic fractures, and glenoid loosening or erosion are the main failure mechanisms of shoulder arthroplasty. Careful surgical technique and a well-executed physical therapy program translate into successful outcomes in most patients with osteoarthritis and rheumatoid arthritis. Replacement arthroplasty represents the treatment of choice for most patients with end-stage glenohumeral osteoarthritis or rheumatoid arthritis. Multiple studies have documented reliable improvements in pain, range of motion, function and quality of life after this procedure. Total shoulder arthroplasty seems to be associated with more reliable pain relief and improvements in elevation when compared to hemiarthroplasty. The main surgical principles of shoulder arthroplasty apply equally to patients with osteoarthritis and rheumatoid arthritis; however, the different underlying pathology associated with these two conditions needs to be understood in order to modify the surgical technique accordingly. Most patients with osteoarthritis have an intact rotator cuff and enough glenoid bone stock to allow implantation of a glenoid component. Asymmetric posterior glenoid erosion often needs to be corrected and capsular releases are needed to restore elevation and external rotation. In rheumatoid arthritis, implantation of a glenoid component may not be possible in the presence of severe glenoid bone loss or a massive irreparable cuff tear; in addition, rheumatoid involvement of other joints needs to be taken into consideration. Infection, instability, periprosthetic fractures, and glenoid loosening or erosion are the main failure mechanisms of shoulder arthroplasty. Careful surgical technique and a well-executed physical therapy program translate into successful outcomes in most patients with osteoarthritis and rheumatoid arthritis.