Massive Irreparable Rotator Cuff Tears Research Articles

What are the predictors of response to physiotherapy in patients with massive irreparable rotator cuff tears? Gaining expert consensus using an international e-Delphi study

BackgroundMassive irreparable rotator cuff tears can cause significant shoulder pain and disability. Treatment options include physiotherapy or surgery, with a lack of research comparing treatment options. For physiotherapy there is uncertainty about which patients will have a successful or unsuccessful response to treatment and a lack of consensus on what constitutes the best physiotherapy programme. With these significant gaps in the research, it is challenging for clinicians seeing patients with massive irreparable rotator cuff tears to advise on what is their best treatment pathway.MethodsA three round Delphi study was conducted with expert shoulder physiotherapists and orthopaedic surgeons to gain consensus on the important factors associated with response to physiotherapy in this patient population. Round 1 was an information-gathering round to identify predictors of response to physiotherapy in patients with massive irreparable rotator cuff tears. Rounds 2 and 3 were consensus-seeking rounds on the importance and modifiability of the predictors. Consensus criteria were determined a priori using median, interquartile range, percentage agreement and Kendall’s Coefficient of Concordance.ResultsParticipants were recruited April–October, 2023. 88 experts participated in Round 1 and of these, 70 completed Round 3 (79.54%). In Round 1, content analysis of 344 statements identified 45 predictors. In Round 2, 29 predictors reached consensus as important and 2 additional predictors were identified. In Round 3, of the 31 predictors from Round 2, 22 reached consensus as important and 12 of these reached consensus as modifiable by physiotherapists. Both patient factors and clinician factors from a broad range of domains reached consensus: biomechanical, psychological, social, co-morbidities, communication / healthcare interactions and pain.ConclusionsThe results of this Delphi study suggest that clinicians assessing patients with massive irreparable rotator cuff tears should assess across all these domains and target the modifiable factors with interventions. Particular emphasis should be placed on optimising modifiable clinician factors including therapeutic alliance, comprehensive explanation of the condition and collaborative and realistic goal-setting. These in turn may influence modifiable patient factors including patient expectations, engagement with the physiotherapy programme, motivation and self-efficacy thus creating the ideal environment to intervene on a biomechanical level with exercises.

Which muscle is the external rotation compensator after superior capsular reconstruction?

BackgroundSuperior capsular reconstruction (SCR) is a surgical option for massive irreparable rotator cuff tears, particularly involving the supraspinatus and infraspinatus. In this procedure, the torn infraspinatus is not repaired or reconstructed. However, an improvement in postoperative external rotation (ER) angle and strength is observed. There is a lack of studies explaining how ER is restored after SCR. The aim of this study is to identify the ER compensator by assessing the muscle volume of the posterior deltoid and teres minor. MethodsSixty-eight patients with massive rotator cuff tears underwent SCR during 2016-2021. Of these patients, 28 who met the following inclusion criteria were retrospectively reviewed: (1) massive rotator cuff tears including the supraspinatus and infraspinatus; (2) severe muscle atrophy and fatty change; (3) intact or reparable subscapularis tendon; (4) Hamada of grade 3 or lower. Posterior deltoid and teres minor volume were measured by using an open-source medical image processing software preoperatively and 1-year postoperatively. The percentage of the posterior deltoid and teres minor muscle volume change was compared between patients with 1-year postoperative ER manual motor testing (MMT) of grade 5 and of grade < 5. The relationship between grade of fatty change, percentage of the muscle volume change, and ER angle and strength were evaluated. ResultsThere was a significant increase in the 1-year postoperative teres minor volume compared with the preoperative volume (24.6±10.3 cm³ versus 20.9±8.3 cm³, p<0.000), while the posterior deltoid volume remained unchanged (178.1±48.3 cm³ versus 178.8±47 cm³). Patients with ER MMT of grade 5 had a greater teres minor volume compared to those with an ER MMT grade of less than 5 (22.3% versus 9.4%), although this difference was not significant (p=0.074, 95% CI=-1.3–27.0). The posterior deltoid volume showed no significant change. The percentage of teres minor volume change had a weak positive correlation with ER strength (r=0.308, p=0.055, 95% CI=-0.02–1.0). There was a significant negative correlation between ER strength and the severity of both preoperative and postoperative fatty changes in the teres minor (r=-0.258, p=0.065, 95% CI=-1.0–-0.042 and r=-0.323, p=0.028, 95% CI=-1.0–-0.113, respectively). The pre- and postoperative fatty changes in the teres minor were negatively correlated with the percentage of teres minor volume change (r=-0.298, p=0.062, 95% CI=-1.0–0.031 and r=-0.413, p=0.015, 95% CI=-1.0–-0.1, respectively). ConclusionThe teres minor may serve as a potential compensator for ER in patients with massive rotator cuff tears following SCR.

Reduced retear rates yet similar clinical outcomes following arthroscopic partial repair of large and massive irreparable rotator cuff tears with biceps augmentation compared to repairs without biceps augmentation: A systematic review and meta-analysis.

To compare the clinical outcomes between arthroscopic partial rotator cuff repair with biceps augmentation(BA) and partial repair (PR) without BA. This systematic review included studies comparing outcomes of arthroscopic repair for large to massive irreparable rotator cuff tears with and without the BA. The focus was on postoperative clinical results and retear rates. Mean differences were used to express continuous outcomes, while odds ratios (ORs) were employed for dichotomous outcomes. Ten studies (733 shoulders, all level 3 evidence) were included. The BA group showed a significant reduction in retear rates (OR = 0.40, 95% confidence interval [CI]: 0.20-0.77, P = 0.007) and comparable postoperative outcomes across various measures: American Shoulder and Elbow Surgeons (ASES) score, visual analogue scale for pain, University of California-Los Angeles shoulder score, active forward flexion motionand active external rotation at the arm-at-side position compared to the PR group. Subgroup analysis of two BA techniques-rerouting and supplementation following supraglenoid tenotomy-showed no significant differences in ASES score for either technique versus PR. However, rerouting significantly lowered retear rates (OR = 0.21, 95% CI: 0.12-0.36, p < 0.001), while supplementation showed similar retear rates to PR (OR = 0.87, 95% CI: 0.37-2.02, n.s.). Arthroscopic partial rotator cuff repair with BA for large to massive irreparable rotator cuff tears is a reliable technique, resulting in improved postoperative outcomes. BA using supplementation following supraglenoid tenotomy showed similar clinical outcomes and range of motion but with lower retear rates compared to the PR group. Level III.

Shoulder balloon spacer for massive irreparable rotator cuff tears results in significant improvements.

The aim of the present study was to assess the effectiveness of balloon implantation in patients with irreparable supraspinatus tears alone or in combination withother rotator cuff (RC) tendon tearsand the effect of several covariables, such as age, gender, status of the long head biceps, with or without tendon repair and regardless the number of tendon involved. Patients enrolled from 'San Carlo' Hospital of Potenza (Italy, IT), from January 2012 to September 2014, underwent arthroscopic implantation of shoulder balloon by a single surgeon, and followed for 3 years. The American Shoulder and Elbow Surgeons (ASES) and Constant score (CS) were administered pre-, post-operatively at 12 months, and then annually. Patients were classified on the basis of the number of tendons involved in the tears and treatment performed, considering the reparability of the tendons themselves. Gleno-humeral joint osteoarthrosis (OA) was evaluated through shoulder radiographs and classified according to the Samilson-Prieto classification, at the first examination and at the final follow-up. Statistical improvements were evaluated using a variance model (least-squares means)and a T distribution test for the evaluation between different treatment groups. A total of 61 procedures were performed, and eight patients were lost during follow-up. The mean baseline CS was 30.2 ± 15.4 with statistically significant improvement, respectively, at 1-, 2- and 3-year follow-up to 69.3 ± 4.2, 74.6 ± 3.6 and 69.7 ± 5.1 respectively. ASES score at baseline was 22.5 ± 10.9, with a statistically significant improvement to 69.7 ± 9.2, 68 ± 17.8 and 71.2 ± 16.6 at 1-, 2- and 3-year follow-up, respectively. Tenotomy or absence of long head biceps at presentation did not influence results (n.s.), with no difference according to gender and age. At final follow-up, 24 patients (43.9%) showed progression of glenohumeral OA. One patient required secondary surgery for shoulder replacement after 18 months for persistent pain and one patient required implant removal following post-operative laser treatment. Arthroscopic rotator cuff tears repair with subacromial spacer balloon implantation showed statistically significant clinical and functional improvement at 3-year follow-up. Patients treated with combined partial repair and subacromial spacer balloon implantation experienced good results independent of gender, age, type of tear and long-head biceps tendon status. The risks related to this procedure appear to be minimal. Level IV.

Subacromial balloon spacer improves isokinetic performance in patients with massive irreparable rotator cuff tear.

The aim of this study was to analyse clinical, functional and shoulder kinematics results using subacromial balloon spacer in nonreparable massive rotator cuff tears. Subacromial balloon spacer was hypothesised to improve shoulder kinematics and increases clinical and functional outcomes scores in nonreparable massive rotator cuff tears. This is a prospective study in massive rotator cuff tears. From October 2021 to October 2022, a total of 127 shoulders suffering massive rotator cuff tears were initially evaluated. All patients were evaluated preoperatively, at 6 and 12 months. Patients' patient-reported outcome measures (PROM) subjective values using visual analogue scale (VAS) and the Spanish Western Ontario Rotator Cuff Index (WORC) version were analysed. We also evaluated objective outcomes: constant score, range of movement and kinematic shoulder analysis (isokinetic test to evaluate internal and external rotation forces). Statistical analysis was conducted using SPSS software; continuous variables were presented as means and standard deviations (SDs). Seventeen nonrepairable massive rotator cuff tears were finally included. Three patients required reverse shoulder arthroplasty before 6 months postoperative. After 1-year follow-up, objective and subjective (PROM) outcome scores and isokinetic measurements improved in 13 patients. Preoperative VAS improved from 6.5 ± 2.1 to 2 ± 1.9 points on average at 1-year follow-up and WORC index from 1603 ± 217.3 to 699 ± 361.6. Constant score from 42.1 ± 13.1 on average and at 1-year follow-up increased to 60.8 ± 14.7. Range of movement also improved in elevation 122.2 ± 39.3 to 166.9 ± 25.8, abduction 120.3 ± 38.6 to 134.6 ± 21.1, external rotation 30.3 ± 19.7 to 86.1 ± 13.8 and internal rotation L4-T12 on average at 1-year follow-up. Isokinetic evaluation showed functional improvement 1 year after implantation. Both internal and external rotation improved compared with their healthy shoulder. External rotation improved from 30.3° ± 19.7° preoperatively to 86.1° ± 13.8° (43.7% in the isokinetic study) and internal rotation from L4 preoperatively to L1 (49.8% in isokinetic study) on average. Among the different alternatives for irreparable rotator cuff injuries surgical treatment, subacromial balloon spacer is an effective alternative in selected patients, both in terms of clinical-functional improvement and short-term isokinetic results. Level II.

Restoring the Anteroposterior Shoulder Force Couple: Arthroscopic-Assisted Lower Trapezius Tendon Transfer With Partially Augmented Rotator Cuff Repair for Irreparable Massive Rotator Cuff Tears

Lower trapezius transfer presents a highly encouraging therapeutic approach for addressing posterosuperior irreparable massive rotator cuff tears. Based on studies on the balance of force couples of the rotator cuff, more scholars believe that attention should be paid to the reconstruction of the force couples of the rotator cuff. This study proposes a modified surgical approach that integrates an arthroscopic-assisted lower trapezius transfer with autologous hamstring tendon and partially augmented rotator cuff repair for irreparable massive rotator cuff tears, with a focus on restoring the anterior-posterior shoulder force couple.

Supraspinatus Tendon Reconstruction Versus the Bridging Technique in a Rat Model: Histological, Biomechanical, and Functional Outcomes

Background: Massive irreparable rotator cuff tears (MIRCTs) are among the most challenging shoulder conditions to treat surgically. Supraspinatus tendon reconstruction (STR) is a recently introduced technique for MIRCTs based on fascia lata-muscle interface healing, which completely differs from the classic bridging technique with fascia lata-tendon interface healing. However, histological and biomechanical comparisons of the fascia-muscle and fascia-tendon interfaces have not been performed. Purpose: To investigate the histological and biomechanical healing of the fascia-bone interface and fascia-muscle interface after chronic MIRCTs in a rat model using different surgical methods. Study Design: Controlled laboratory study. Methods: The authors established a chronic MIRCT model in the right shoulder of rats and then repaired it using the STR or bridging repair technique. Evaluations were performed at 2, 4, 8, and 12 weeks, including histological, imaging, biomechanical, and functional analyses. Results: Both techniques resulted in good fascia-bone interface healing based on the histological results. The STR group had significantly more cartilage formation at 8 and 12 weeks and higher Modified Tendon Maturity Score after 12 weeks at the fascia-bone interface compared with the bridging repair group and formed the typical 4-layered structure. Collagen fibers in the fascia-muscle and fascia-tendon interfaces exhibited normal muscle-tendon interface characteristics at 12 weeks. However, the STR group had more improvement in fatty infiltration compared with the bridging repair group. The ultimate failure load and stiffness did not differ between the STR and bridging repair groups 4 weeks postoperatively in both the fascia-bone interface and supraspinatus muscle-fascia-bone integrity. Movement distance and grasp time were significantly longer in the STR group than in the bridging repair group at 12 weeks and attached the level in the normal control groups. Conclusion: These results suggest that the fascia-muscle interface from the STR technique is histologically and functionally better than the fascia-tendon interface. Moreover, this study provides a theoretical basis for the clinical use of the STR technique. Clinical Relevance: The fascia-muscle interface and fascia-tendon interface were the key points of the STR and bridging techniques, respectively. The fascia-muscle interface is histologically and functionally superior to the bridging technique, and the STR technique might be a better choice for the treatment of MIRCTs.

Rate of graft retear is higher in over-the-top superior capsular reconstruction for massive posterosuperior rotator cuff tears with subscapularis tear.

To compare side-to-side superior capsular reconstruction (SCR) with over-the-top SCR in terms of functional outcomes, pain relief and allograft survival rates. Patients who had undergone arthroscopic dermal allograft SCR for massive irreparable rotator cuff tears and clinical follow-up for ≥2 years were recruited. All patients underwent postoperative assessment with routine radiographic analysis for acromiohumeral distances, ultrasound imaging 1 and 3 months after SCR and magnetic resonance imaging (MRI) at least 12 months after SCR. The outcome measures were visual analogue scale (VAS), American Shoulder and Elbow Surgeons (ASES), Constant and Single Assessment Numeric Evaluation (SANE) scores. SCR was performed in 56 patients including side-to-side SCR in 32 and over-the-top SCR in 24. Postoperative MRI showed that the grafts were intact in 46 patients (82.1%; 26 who underwent side-to-side SCR and 20 who underwent over-the-top SCR). The proportion of nonhealing grafts in the over-the-top group was significantly higher with concomitant subscapularis tears (60% vs. 5.3%; p = 0.02). VAS scores and functional outcomes improved postoperatively in both groups and postoperative VAS (1.4 vs. 1.7; n.s.), Constant (74.8 vs. 76.0; n.s.), mean ASES (87.4 vs. 89.1; n.s.) and mean SANE (81.7 vs. 84.3; n.s.) scores did not differ significantly. For massive rotator cuff tears, over-the-top and side-to-side SCR achieve similar pain relief and functional improvement, and the rate of healing allografts is high. However, over-the-top SCR is not recommended for massive posterosuperior rotator cuff tears with repairable subscapularis tendon tears due to a higher nonhealing rate. Level III.

Treatment of massive irreparable rotator cuff tears by different surgical technigues: comparative analysis of early outcomes

Background. Massive rotator cuff tears are up to 40% and can progress to the stage of irreparable ones. Nowadays, there are many treatment options available for irreparable rotator cuff injuries, from conservative treatment and arthroscopic reconstructions to reverse shoulder arthroplasty. Currently, the comparative effectiveness of various treatment methods remains uncertain, and therefore there is no clear algorithm for choosing treatment tactics of such orthopedic shoulder pathologies. The aim of the study is to compare short-term treatment outcomes of patients with irreparable rotator cuff tears using arthroscopic partial rotator cuff repair, latissimus dorsi tendon transfer, pectoralis major tendon transfer and reverse shoulder arthroplasty. Methods. The study enrolled 75 patients who underwent the following types of surgical interventions: partial arthroscopic repair, posterior and anterior arthroscopically assisted latissimus dorsi tendon transfer, pectoralis major tendon transfer and reverse shoulder arthroplasty. Treatment results were assessed using measurements of the range of active movements in the shoulder joint, the ASES and Constant-Murley Score (CMS) questionnaires, the Visual Analog Scale (VAS), assessment of radiographs and MRI. The assessments were performed preoperatively and at 6 and 12 months after surgery. Results. In all groups, there was a statistically significant improvement by all indicators (p0.05). Clinical and functional results at the short-term follow-up after partial rotator cuff repair and various options of latissimus dorsi tendon transfer are largely comparable, while at the same time superior to the results of reverse shoulder arthroplasty and pectoralis major tendon transfer. Conclusions. The use of partial rotator cuff repair and musculotendinous transfers at the short-term follow-up gives comparable and better results in comparison with the use of reverse shoulder arthroplasty, which allows to consider “joint-preserving” interventions as an option in patients with massive irreparable rotator cuff tears.

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

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

Improved Clinical Outcomes After Partial Repair and In Situ Biceps Tenodesis for the Treatment of Massive Irreparable Rotator Cuff Tears

To present the short-term outcomes of arthroscopic in situ biceps tenodesis combined with partial rotator cuff repair in patients with massive irreparable rotator cuff tears (MIRCTs) and minimal arthritis. A retrospective review was conducted using prospectively maintained institutional databases to identify patients who had undergone a partial rotator cuff repair with in situ biceps tenodesis between March 2017 and December 2022. Patients were included if they (1) were diagnosed pre- or intraoperatively with MIRCT and (2) had complete preoperative and minimum 1-year postoperative patient-reported outcome measures. Thirty-nine patients met the eligibility criteria and were included for analysis. The mean age of the study participants was 65 ± 7 years (range, 46-76) with 76.9% (n= 30) being male. The average follow-up was 21 ± 12 months (range, 12-58). Patients experienced significant improvement in visual analog scale for pain (VAS), American Shoulder and Elbow Surgeons (ASES) score, and subjective assessment numeric evaluation (SANE) score (P < .001 for all comparisons). The pre- to postoperative improvement was 3.1 ± 2.3 for VAS, 27.5 ± 20.6 for ASES, and 31.3 ± 24.8 for SANE. Postoperatively, the average scores for VAS, ASES, and SANE were 1.3 ± 1.5, 79.5 ± 17.0, and 69.6 ± 20.1, respectively. Twenty-six patients (66.7%) achieved the minimal clinically important difference (MCID) for VAS, 33 patients (84.6%) achieved the MCID for ASES, and 30 patients (76.9%) achieved the MCID for SANE. Partial rotator cuff repair with in situ biceps tenodesis is an effective treatment for MIRCT, leading to significant improvements in patient-reported outcome and range-of-motion measures compared to preoperative conditions. Level IV, retrospective case series.

Functional internal rotation is associated with subscapularis tendon healing and increased scapular tilt after Grammont style bony increased offset reverse shoulder arthroplasty with 155° humeral implant

BackgroundWhile forward flexion consistently improves after reverse shoulder arthroplasty (RSA), restoration of internal rotation behind the back (IR1) is much less predictable. This study aims to evaluate the role of the subscapularis tendon in restoration of IR and identify other factors that may influence IR such as anterior scapular tilt and postoperative passive internal rotation at 90° of abduction (IR2). The hypothesis was that IR1 is positively associated with both subscapularis healing, postoperative passive IR2, and anterior scapular tilt. MethodsA retrospective review was performed on a consecutive series of Grammont style BIO (bony increased offset) RSAs performed by a single surgeon between January 2014 and December 2015. Inclusion criteria were: (1) primary RSA for rotator cuff arthropathy, massive irreparable rotator cuff tear, or primary osteoarthritis with B2 glenoid morphology, (2) minimum of two years clinical follow-up, and (3) complete intraoperative repair of a repairable subscapularis tendon. The primary outcomes were postoperative return of IR1 compared to postoperative IR2, healing rate of subscapularis tendon, and scapular tilt. ResultsThe cohort included 77 patients, aged 72.6±7.0 years at index surgery and comprising 32 men (42%) and 45 women (58%). At a mean follow-up of 3.3±1.0 years, ultrasound evaluation revealed a successful repair of the subscapularis in 41 patients (53%). Healed subscapularis repair was significantly associated with greater IR1 (85% vs. 53%, p=0.031). A multivariate logistic regression revealed functional postoperative IR1 was independently associated with subscapularis healing (OR, 4.3; 95%CI [1.1-20.2]; p=0.046) as well as greater anterior tilt (OR, 1.2; 95%CI [1.1-1.5]; p=0.008) and postoperative IR2 (OR, 1.09; 95%CI [1.05-1.14]; p<0.001) but lower postoperative passive abduction (OR, 0.96; 95%CI [0.92-1.00], p=0.045). The area under receiver operating characteristic curve obtained with the Youden index was 0.88 with a sensitivity of 81.8% and specificity of 90.6%. ConclusionsThis study revealed that in a Grammont-type RSA, postoperative IR1 recovery is first associated with subscapularis tendon healing, followed by IR2 and finally the ability to tilt the scapula anteriorly. Better understanding of these factors preoperatively may provide greater insight on expected return of functional internal after RSA.

Distalization and lateralization shoulder angles: do they have a role in predicting postoperative clinical outcomes?

BackgroundLateralization Shoulder Angle (LSA) and Distalization Shoulder Angle (DSA) have been proposed to estimate the appropriateness of reverse shoulder arthroplasty (RSA) positioning. The purpose of this study was to evaluate the predictive value of DSA and LSA over clinical outcomes in a group of patients treated by the same surgeon with the same clinical and radiographic follow-up. MethodsA retrospective analysis of a consecutive series of RSAs performed between 2017 and 2021 was carried out. Inclusion criteria were primary RSA as a treatment for Cuff Tear Arthropathy, Massive Irreparable rotator cuff tear, Osteoarthritis or Rheumatoid arthritis, a true anteroposterior radiograph of the affected shoulder in neutral rotation at final follow-up, a minimum follow-up of 12 months, radiograph used to measure the angles, and clinical evaluation with the same follow-up. Outcome measures were shoulder range of motion (ROM), visual analog scale (VAS) for pain and Constant-Murley score (CS). ResultsA total of 83 patients were included in the study. Patients achieved on average, 130 ± 14.14° of flexion, 97.5 ± 17.67° of abduction, 62.5 ± 3.53° and 72.5 ± 10.60° of external rotation, respectively, at 0° and 90° of abduction, and 5.13° of internal rotation. The mean VAS and CS were, respectively, 2.5 ± 3.5 mm and 69 ± 2.82 points at last follow-up. The mean DSA and LSA were 45 ± 2.72 and 92.99 ± 9.17, respectively. Neither the linear nor the quadratic regression fit for DSA or LSA revealed relevant associations with any of individual ROM measures, except for the quadratic fit correlating LSA and forward flexion (beta = 0.029, P = .027). Linear fit showed a low reverse, but significant, association between DSA and VAS (beta = −0.56, P = .036) and an association of LSA with both CS (beta = −0.344, P = .009) and VAS (beta = 0.091, P = .01). Quadratic models showed higher R squared for all associations, but correlation was significant only between VAS and LSA (beta = 0.006, P = .011) ConclusionWe present the first evaluation of the predictive value of both DSA and LSA in a group of patients treated by the same surgeon with the same clinical and radiographic follow-up. DSA and LSA play only a marginal to no role in the prediction of RSA postoperative ROM and might have a role in predicting VAS and CS.

Indications, outcomes, and complications of tendon transfer for massive irreparable rotator cuff tears

Indications, outcomes, and complications of tendon transfer for massive irreparable rotator cuff tears

Arthroscopic Medialization Partial Repair with Biologic Interposition Tuberoplasty for Large to Massive Irreparable Rotator Cuff Tear.

An irreparable rotator cuff tear is a challenging condition to treat, and various treatment modalities are being introduced. Medialization in the partial repair method has the limitation of exposing the tuberosity, while tension-free biologic interposition tuberoplasty using acellular dermal matrix has the limitation of exposing the humeral head. The authors believe that by combining these two techniques, it is possible to complement each other's limitations. Therefore, they propose a surgical method that combines medialization and biologic interposition tuberoplasty for addressing these constraints.

Fascia Lata Autografts Achieve Interface Healing With the Supraspinatus Muscle Histologically and Mechanically in a Rat Supraspinatus Tendon Reconstruction Model for Massive Irreparable Rotator Cuff Tears

PurposeTo evaluate the histologic healing process and mechanical characteristics of the interface between a fascia lata autograft and supraspinatus muscle by establishing a supraspinatus tendon reconstruction model for chronic massive, irreparable rotator cuff tears (MIRCTs). MethodsA total of 40 rats were studied. Eight rats were sacrificed to establish an intact control group, and the other rats were first established as the chronic MIRCTs model and then developed as the supraspinatus tendon reconstruction model. Histology, fatty infiltration, mechanics and the open field test for the interface between the fascia lata autograft and muscle were assessed at 2, 4, 8 and 16 weeks postoperatively. ResultsHistologically, the interface between the fascia lata autograft and muscle gradually regenerated structural similarities to the normal muscle-tendon interface by 16 weeks postoperatively. The amounts of collagen I and III were both increased significantly during the healing time and stabilized at 8 weeks postoperatively. Fatty infiltration was obvious in the supraspinatus muscle 4 weeks after the MIRCTs model. However, the degree of fatty infiltration in the supraspinatus muscle gradually decreased after supraspinatus tendon reconstruction and stabilized at 8 weeks postoperatively. The ultimate failure force and the ultimate stress gradually increased from 2 to 16 weeks and reached the level of the intact control tendon at 16 weeks postoperatively (P=0.086). The movability of the forepaw returned to normal in the open field test (P=0.907). ConclusionsIn this rat supraspinatus tendon reconstruction model, fascia lata autografts showed good interface healing with the supraspinatus muscle, and fatty infiltration in the supraspinatus muscle was histologically decreased. The interface between the fascia lata autograft and muscle can sustain mechanical strength similar to the anatomical muscle–tendon interface. Clinical RelevanceThe supraspinatus tendon reconstruction technique using fascia lata autografts might be a good histological and biomechanical option for treating MIRCTs.

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.

The Insertion of a Subacromial Balloon Spacer Can Provide Symptom Relief and Functional Improvement at a Minimum 5-Year Follow-Up in Patients With Massive Irreparable Rotator Cuff Tears

To examine long-term patient-reported outcomes and range of motion in patients with massive irreparable rotator cuff tears (MIRCTs) who underwent subacromial balloon spacer implantation. A retrospective review of all patients who underwent subacromial balloon placement procedure for MIRCTs at our institution was conducted. Patients with adequate preoperative and postoperative data, with at least 5 years of follow-up, were included in our study. Outcome measures were range of motion (forward elevation), American Shoulder and Elbow Surgeon (ASES) score, and visual analog scale (VAS) score. Independent t test was conducted to check for statistically significant differences between preoperative and postoperative outcome scores, with P < .05 deemed significant. Ten patients were identified: 4were lost to follow-up beyond 2 years and were excluded. One was converted to an arthroplasty at the 1-year mark and was then lost to follow-up (conversion rate: 16.6%). Five patients had at least 5 years of follow-up after the balloon procedure and were involved in our case series analysis. Mean age was 63.1 years, and mean follow-up was 5.8 years (range, 5-7 years). Preoperatively, mean forward elevation was 110 degrees, mean ASES score was 40.68, and mean VAS score was 6.2. On follow-up, mean forward elevation was 163 degrees (P= .007), mean ASES score was 90.97 (P= .001), and mean VAS score was 0.9 (P= .004). All patients showed significant improvements in all outcome measures, and none had any significant complications. In this study, we found that the use of a subacromial balloon spacer can lead to good outcomes at a minimum 5-year follow-up in patients with MIRCTs. Level IV, therapeutic case series.

Mixed-reality improves execution of templated glenoid component positioning in shoulder arthroplasty: a CT imaging analysis

Glenoid placement is critical for successful outcomes in total shoulder arthroplasty (TSA). Preoperative templating with three-dimensional imaging has improved implant positioning, but deviations from the planned inclination and version still occur. Mixed-Reality (MR) is a novel technology that allows surgeons intra-operative access to three-dimensional imaging and templates, capable of overlaying the surgical field to help guide component positioning. The purpose of this study was to compare the execution of preoperative templates using MR vs.standard instruments (SIs). Retrospective review of 97 total shoulder arthroplasties (18 anatomic, 79 reverse) from a single high-volume shoulder surgeon between January 2021 and February 2023, including only primary diagnoses of osteoarthritis, rotator cuff arthropathy, or a massive irreparable rotator cuff tear. To be included, patients needed a templated preoperative plan and then a postoperative computed tomography scan. Allocation to MR vs. SI was based on availability of the MR headset, industry technical personnel, and the templated preoperative plan loaded into the software, but preoperative or intraoperative patient factors did not contribute to the allocation decision. Postoperative inclination and version were measured by two independent, blinded physicians and compared to the preoperative template. From these measurements, we calculated the mean difference, standard deviation (SD), and variance to compare MR and SI. Comparing 25MR to 72 SI cases, MR significantly improved both inclination (P<.001) and version (P<.001). Specifically, MR improved the mean difference from preoperative templates (by 1.9° inclination, 2.4° version), narrowed the SD (by 1.7° inclination, 1.8° version), and decreased the variance (11.7-3.0 inclination, 14.9-4.3 version). A scatterplot of the data demonstrates a concentration of MR cases within 5° of plan relative to SI cases typically within 10° of plan. There was no difference in operative time. MR improved the accuracy and precision of glenoid positioning. Although it is unlikely that 2° makes a detectable clinical difference, our results demonstrate the potential ability for technology like MR to narrow the bell curve and decrease the outliers in glenoid placement. This will be particularly relevant as MR and other similar technologies continue to evolve into more effective methods in guiding surgical execution.

Margin convergence vs. superior capsular reconstruction for massive irreparable rotator cuff tears: outcomes are equivalent unless there is preoperative pseudoparesis

Margin convergence (MC) and superior capsular reconstruction (SCR) are common treatment options for irreparable rotator cuff tears in younger patients, although they differ in associated costs and operative times. The purpose of this study was to compare range of motion, patient-reported outcomes (PROs), and reoperation rates following MC and SCR. We hypothesized superior outcomes after SCR relative to MC regarding functional outcomes, subjective measures, and reoperation rates. This was a multicenter retrospective review of 59 patients from 3 surgeons treating irreparable rotator cuff tears with either MC (n=28) or SCR (n=31) and minimum 1-year follow-up from 2014-2019. Visual analog scale (VAS) for pain, Subjective Shoulder Value (SSV), active forward flexion (FF), external rotation (ER), retear rate, and conversion rate to reverse shoulder arthroplasty were evaluated. t tests and χ2 tests were used for continuous and categorical variables, respectively (P<.05). Baseline demographics, range of motion, and magnetic resonance imaging findings were similar between groups. Average follow-up was 31.5 months and 17.8 months for the MC and SCR groups, respectively (P<.001). The MC and SCR groups had similar postoperative FF (151°±26° vs. 142°±38°; P=.325) and ER (48°±12° vs. 46°±11°; P=.284), with both groups not improving significantly from their preoperative baselines. However, both cohorts demonstrated significant improvements in VAS score (MC: 7.3 to 2.5; SCR: 6.4 to 1.0) and SSV (MC: 54% to 82%; SCR: 38% to 87%). There were no significant differences in postoperative VAS scores, SSV, and rates of retear or rates of conversion to arthroplasty between the MC and SCR groups. In patients with preoperative pseudoparesis (FF<90°), SCR (n=9) resulted in greater postoperative FF than MC (n=5) (141°±38° vs. 67°±24°; P=.002). Both MC and SCR demonstrated excellent postoperative outcomes in the setting of massive irreparable rotator cuff tear, with significant improvements in PROs and no significant differences in range of motion. Specifically for patients with preoperative pseudoparesis, SCR was more effective in restoring forward elevation. Further long-term studies are needed to compare outcomes and establish appropriate indications.