Massive Tears Research Articles

Application of Platelet-Rich Plasma in Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis.

Background:It is unclear how and which factors affect the clinical efficacy of platelet-rich plasma (PRP) applied during arthroscopic rotator cuff repair.Purpose:To evaluate the clinical efficacy of PRP for arthroscopic repair of full-thickness rotator cuff tear and investigate the factors that affect its clinical efficacy.Study Design:Systematic review; Level of evidence, 1.Methods:We searched Cochrane Library, EMBASE, MEDLINE, and OVID to identify randomized controlled trials (RCTs) of patients who received PRP treatment and arthroscopic rotator cuff repair (PRP group) versus controls (no-PRP group). The primary outcomes included retear rate, Constant-Murley score, University of California Los Angeles (UCLA) score, short-term American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) score for pain, and adverse events.Results:A total of 14 RCTs were included in this systematic review. Significant improvement in Constant-Murley, UCLA, and VAS pain scores were found in the PRP group during short-term, midterm, and long-term follow-up. The PRP group had a significantly decreased retear rate (risk ratio [RR], 0.57 [95% CI, 0.42 to 0.78]; P = .0003), especially for long-term follow-up (RR, 0.38 [95% CI, 0.17 to 0.83]; P = .02), large to massive tears (RR, 0.58 [95% CI, 0.42 to 0.80]; P = .0008), use of leukocyte-poor PRP (RR, 0.50 [95% CI, 0.33 to 0.76]; P = .001), and intraoperative application of PRP (RR, 0.57 [95% CI, 0.42 to 0.79]; P = .0007). No significant difference between the 2 groups was found in the incidence of adverse events (RR, 1.34 [95% CI, 0.83 to 2.15]; P = .23) or in ASES scores at short-term follow-up (weighted mean difference, 1.04 [95% CI, –3.10 to 5.19]; P = .62).Conclusion:The results of this review indicated that arthroscopic rotator cuff repair with PRP significantly reduced the long-term retear rate and shoulder pain and provided improved long-term shoulder function in patients. Intraoperative application of PRP, use of leukocyte-poor plasma, and large to massive tear size contributed to a significantly decreased retear rate for rotator cuff repair combined with PRP.

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.

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.

Increased acromiohumeral distance in a double-row arthroscopic rotator cuff surgery compared to a single-row surgery after 12 months

BackgroundArthroscopic rotator cuff surgery is an effective treatment for rotator cuff tears with the considered use of double-row repair techniques becoming popular in the last decade. We aim to compare the effects of double- and single-row arthroscopic rotator cuff repairs (ARCR) on repair integrity (RI) and acromiohumeral distance (AHD).MethodsIn this observational study, we retrospectively identified 98 patients with degenerative rotator cuff tear treated with arthroscopic rotator cuff repair between 2016 and 2019. We excluded 22 patients with partial-thickness tears, 15 with associated subscapularis or SLAP tears, 13 with massive tears, and 5 patients lost to follow-up; we included 43 patients who had ARCR for full-thickness cuff tear and clinical, radiologic follow-up. Of these 43 patients, 23 are grouped as double-row repair group (DRG) and 20 as single-row repair group (SRG). A minimum of 12 months after the surgery, bilateral shoulder MRIs were obtained. Contralateral shoulders without asymptomatic rotator cuff tears served as a control group (CG). The operating surgeon and two other surgeons experienced in arthroscopy blindly measured the AHD and determined the RI at the control MRIs in all groups. Functional assessments relied on UCLA and qDASH Scores.ResultsThe mean age was 57.89 (45–78) years, and the mean follow-up time was 28,65 (21–43) months. The mean AHD of the CG was 9.7 ± 0.96 mm, the preoperative AHD of DRG was 8.62 ± 1.45 mm, and SRG was 9.71 ± 0.95 mm. The postoperative mean AHD of DRG 9.61 ± 1.83 mm and SRG was 10.21 ± 1.97 mm. AHD differences between the preoperative and postoperative groups were significant (P=0.009). The increase of the AHD in the double-row group was significantly higher than the single-row group (P=0.004). There was a high correlation between the RI and DASH scores (P=0.005). RI did not correlate with the repair method (P=0.580).ConclusionAlthough double-row repairs can maintain greater AHD than single-row repairs in the clinical setting, this difference did not affect functional results. Regardless of the surgical intervention, functional results are favourable if RI is achieved.Level of evidenceLevel III, Retrospective Cohort Study

Comparison of Occurrence of Bone Tunnel Laceration, Clinical Results, and Cuff Repair Integrity of Transosseous Arthroscopic Rotator Cuff Repair With and Without Lateral Cortical Augmentation

PurposeTo compare the occurrence of bone tunnel laceration, the short-term clinical results, and cuff repair integrity of transosseous arthroscopic rotator cuff repair (ARCR) using a tunneling device, with and without lateral cortical augmentation.MethodsA retrospective review of patients who underwent transosseous ARCR from May 2012 to December 2017 was conducted. The inclusion criterion was repairable medium- to massive-sized full-thickness rotator cuff tear. This study included 2 consecutive series of patients undergoing transosseous ARCR with and without lateral cortical augmentation, called the ITO method and AT method, respectively. The incidence of bone tunnel laceration was evaluated intraoperatively. Patients were assessed through a range of motion and Constant scores preoperatively and at final follow-up. Further, magnetic resonance imaging was performed at 24 months postoperatively to examine the repaired rotator cuff integrity.ResultsA total of 121 subjects were included: 33 in the AT group and 88 in the ITO group. The intraoperative bone tunnel laceration occurrence rate was 67% and 4% for the AT and ITO methods, respectively; the difference was significant (P = .001). Anatomic failure rate (Sugaya Ⅲ, Ⅳ, and Ⅴ) rate for medium- to large-sized tears was significantly lower for the ITO than for the AT method (29% vs 65%, P = .004), but not for massive tears (61% vs 69%, P = .515). The mean forward elevation, abduction, external rotation, internal rotation, and Constant score were significantly improved at final follow-up from preoperative values. There were no significant differences between the 2 methods.ConclusionsTransosseous ARCR using a tunneling device with and without lateral cortical augmentation is a reliable method of improving clinical results at a minimum follow-up of 2 years. The intraoperative occurrence rate of bone tunnel laceration occurrence rate and the anatomic failure rate of medium- to large-sized cuff tear were lower with lateral cortical augmentation than without it.Level of EvidenceLevel Ⅳ, therapeutic cases series.

Classification Systems in Rotator Cuff Tears

Rotator cuff pathology is one of the most common conditions affecting the shoulder joint. Several classification systems have been used to describe rotator cuff tears in orthopedic literature. However, no comprehensive classification inclusive of all types and characteristics currently exists. Rotator cuff tears are classified based on various parameters. These include: 1. Tear depth 2. Tear Size/Extent 3. Tear Retraction 4. Tendon Quality 5. Tear Progression 6. Arthroscopic Classification. This review article aims to establish an algorithm based on the various existing classification systems so as to arrive at the best surgical or non-surgical solution as well as prognosticate the patient regarding the outcome. Special consideration needs to be made for massive tears which are irreparable. Keywords: Rotator cuff tears; Rotator cuff tear classification; Massive irreparable rotator cuff tears; Partial rotator cuff tears; Subscapularis tears; Geometric Classification; Arthroscopic Classification; Rotator cuff retraction; Rotator cuff tendon quality; Prognosis for Rotator Cuff tears.

Functional outcomes after physiotherapy program in patients with massive and irreparable rotator cuff tear

ObjectiveTo evaluate the short term and 1-year follow-up functional effects of a physiotherapy programme in patients over 60 years of age with massive and irreparable Rotator Cuff (RC) tear. MethodsA total of 96 patients with massive and irreparable RC tear were prospectively recruited. All patients were treated with a 12-week physiotherapy programme. Three evaluations were performed, at the beginning, at the end of the treatment and at one year of follow-up. The Constant–Murley questionnaire was used to assess shoulder function, the DASH questionnaire for upper limb function, and the Visual Analogue Scale (VAS) for pain intensity. ResultsAt the end of the treatment, all the variables showed a clinically and statistically significant difference (p<.05). At one year of follow-up, the Constant–Murley showed an increase of 26.5 points (Cohen's d=1.7; 95% CI: 23.5–29.5; p<.001), DASH showed a decrease of 31.4 points (Cohen's d=2.2; 95% CI: 28.5–34.3; p<.001), and the VAS showed a decrease of 3.9cm (Cohen's d=3.6; 95% CI: 3.6–4.1; p<.001). ConclusionIn the short term and 1-year follow-up, a physiotherapy programme showed clinically and statistically significant results in all functional variables in patients older than 60 years with massive and irreparable RC tear.

Use of biologics in rotator cuff disorders: Current concept review

Poor tendon to bone healing following rotator cuff repair has led to the continued interest and investigation into biological augmentation. The biology of tendinopathy is not fully understood and consequently the availability of disease modifying therapeutic targets is limited. A ceiling of benefit has been reached by mechanical optimisation of rotator cuff repair and thus, in order to improve healing rates, a biological solution is required. This review focuses on the strategies to biologically augment rotator cuff disorders with an emphasis on rotator cuff repair. Leucocyte rich platelet rich plasma has been shown to improve healing rates without clinically relevant improvements in outcome scores. Similarly, improved healing rates have also been reported with bone marrow stimulation and in long-term follow-up with bone marrow concentrate. Extracellular matrix (ECM) and synthetic scaffolds can increase healing through mechanical and or biological augmentation. A potential third category of scaffold is bio-inductive and has no mechanical support. Studies involving various scaffolds have shown promising results for augmentation of large to massive tears and is likely to be most beneficial when tendon quality is poor, however level I evidence is limited.

Repair Tension During Arthroscopic Rotator Cuff Repair is Correlated With Preoperative Tendon Retraction and Postoperative Rotator Cuff Integrity

This study aimed to examine the correlation of repair tension during arthroscopic rotator cuff repair (ARCR) with preoperative factors and to evaluate whether measuring tension during ARCR is effective for predicting rotator cuff integrity after ARCR. Patients who underwent ARCR from May 2014 to June 2017 were enrolled in this study. Inclusion criteria were patients with medium or larger-sized tears and with a minimum of 6 months' follow-up. Patients with a partial repair were excluded. Intraoperative repair tension was measured according to Davidson's method. Correlation of repair tension with preoperative factors was evaluated with Pearson and Spearman correlation coefficient tests. Logistic regression analysis was performed on intraoperative factors, including repair tension, to identify independent predictors of retear after ARCR. Receiver operating characteristic (ROC) curve was used to determine the cutoff value of repair tension for retear. One-hundred twenty patients met the inclusion criteria. Mean repair tension was 26.6±12.6 N, and retear was found in 29 shoulders (24.2%). Among the preoperative factors, tear size in the mediolateral (P < .001) and anteroposterior (P < .001) directions, DeOrio and Cofield's classification (P <0.001), geometric classification (P <.001), and fatty infiltration of supraspinatus (P= .006) and infraspinatus (P= .003) were significantly correlated with repair tension. However, multivariable logistic regression analysis identified only tear size in the mediolateral direction as an independent predictor of repair tension (P= .036). Logistic regression analysis showed that repair tension (P= .02) and geometric classification (P < .001) are significant factors affecting rotator cuff integrity after ARCR. ROC curve analysis showed the cutoff value of repair tension of large to massive tears for retear to be 35.6 N. This study demonstrated that intraoperative repair tension is strongly correlated with tear size in the mediolateral direction based on preoperative magnetic resonance imaging and that measuring tension during ARCR is effective for predicting rotator cuff integrity after ARCR. Level IV, prognostic study.

Long-Term Outcomes of Massive Rotator Cuff Tear Repair: A Systematic Review.

With an increase in the treatment options available for massive rotator cuff tears, understanding the long-term outcomes of the chosen modality is important. The purpose of this study was to systematically review the available literature on repair of massive rotator cuff repairs and learn the longevity of outcomes, the failure rate, outcomes after failure, and any contributing factors to poor outcomes or failure. We conducted a systematic review of the MEDLINE, Cochrane, and Embase databases to find studies that investigated the long-term results of repair of massive rotator cuff repairs. Studies were excluded if they did not stratify results of massive tears, provide a definition for a massive rotator cuff tear, or report isolate patients with long-term follow-up. Six studies met the inclusion criteria, for a total of 472 shoulders; average patient age was 57.6 years. Follow-up ranged from 119 to 240 months. Outcome scores improved significantly following repair and were maintained throughout follow-up. The repair failure rate across studies was 39.2%. Patients who suffered retear had significantly worse outcome scores than patients with intact tendons at long-term follow-up. The existing literature on long-term follow-up after massive rotator cuff repair is scarce and not of high level of evidence. This review found repair of massive rotator cuff tears leads to long-term maintained improvements in outcome measures. Failure of repair is quite common, but results following failure are superior to preoperative outcomes.

Endoscopic transfer of gluteus maximus and tensor fasciae latae for massive gluteus medius tear: Preliminary results

We report preliminary results for a novel technique of endoscopic Whiteside transfer for massive gluteus medius tear: i.e., tendon reinsertion not or only partly feasible and/or severe fatty atrophy of the muscle. Endoscopic transfer of gluteus maximus and/or tensor fasciae latae is associated to gluteus medius tendon reinsertion if at least partial tendon repair is feasible. In a continuous series of 6 patients at a minimum 2 years’ follow-up, there was 1 early failure; 2 patients showed no improvement in pain and limping; 3 had satisfactory results, including 2 with complete resolution of limping and pain. Endoscopic Whiteside transfer associated to gluteus medius tendon repair provided only moderate results in terms of recovery of abduction power and resolution of Trendelenburg gait.

Revision Rotator Cuff Repair Versus Primary Repair for Large to Massive Tears Involving the Posterosuperior Cuff: Comparison of Clinical and Radiological Outcomes.

Background:The retear rate after revision rotator cuff repair (rRCR) ranges from 50% to 90%. Patients who undergo primary RCR (pRCR) for large to massive rotator cuff tear (mRCT) also have unpredictable outcomes.Purpose:To compare the clinical outcomes after rRCR for a posterosuperior rotator cuff tear of any size with those after pRCR for mRCT and to identify the risk factors for poor outcomes and retear after rRCR.Study Design:Cohort study; Level of evidence, 3.Methods:Among patients with posterosuperior cuff tear treated between 2010 and 2017, the clinical outcomes of 46 patients who underwent rRCR were compared with 106 patients who underwent pRCR for mRCT. Between-group differences in patient-reported outcomes (visual analog scale [VAS] for pain, VAS for satisfaction and American Shoulder and Elbow Surgeons [ASES] and Constant scores) at final follow-up were evaluated and compared with previously published minimal clinically important difference (MCID) values. Radiological outcomes were evaluated using magnetic resonance imaging or ultrasonography at a minimum 1-year follow-up. Multivariate linear regression analysis was performed to identify the risk factors for poor ASES score, and multivariate logistic regression analysis was used to assess the risk factors for retear after rRCR.Results:The mean follow-up was 26.4 months (range, 24-81 months). Although final VAS for pain, VAS for satisfaction, and ASES scores in the rRCR group were significantly worse than those in the pRCR group, the Constant score was similar between the groups. These differences in outcomes did not exceed the MCID threshold. The retear rate in the rRCR group was 50% compared with 39% for the pRCR group (P = .194). In the rRCR group, risk factors for worse ASES score were retear (P = .043; r = –11.3), lower body mass index (P = .032; r = 1.9), and lower preoperative VAS for pain (P = .038; r = 2.3), and risk factors for retear were preoperative high-grade fatty degeneration (Goutallier grades 3 and 4) of the supraspinatus muscle (P = .026; odds ratio, 5.2) and serum hyperlipidemia (P = .035; odds ratio, 11.8).Conclusion:Both study groups had similar clinical and radiological outcomes. Patients with symptomatic failed rotator cuff repairs having high-grade fatty degeneration of the supraspinatus muscle and/or serum hyperlipidemia had a greater likelihood of retear after rRCR.

Incomplete footprint coverage under tension in repair of isolated supraspinatus full-thickness tear

Although it is well known that repairing large or massive tears under tension may have an adverse effect on healing of the repaired tendons, only few studies have addressed this issue in medium-sized isolated supraspinatus full-thickness tear. The purpose of this study was to compare the clinical outcomes and structural integrity of arthroscopic rotator cuff repair with tension versus without it. This study retrospectively investigated 90 patients who underwent arthroscopic repair in a single-row for medium-sized isolated supraspinatus full-thickness tear. The patients were assigned to either repaired under tension (Group A, n = 38) or repaired without tension (Group B, n = 52) groups. Functional outcomes were assessed using the patient reported subjective values and the active range of motion (ROM). Postoperative radiographic evaluation was performed 6 months after the surgery to assess the structural integrity of the repaired tendons. Changes in the subjective shoulder scores from initial to 2 years after surgery showed no statistical significance between the two groups. The ROMs measured at initial and 2 years after surgery also showed no statistical difference between the two groups. Postoperative radiological evaluations found a significantly higher re-tear rate in Group A (28.9%, 11/38) than in Group B (9.6%, 5/52). The torn cuff tendons that were repaired under tension as retraction with limited mobility had significantly higher re-tear rate despite having immobilized for 6 weeks after surgery, but their clinical outcomes showed no significant difference from the outcomes of repaired tendons without tension.

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.

Factors aff5cting outcomes of conservative management for pseudoparalysis of the shoulder

This study aimed to analyze factors aff5cting the outcome of conservative management of pseudoparalysis of the shoulder. This study included 27 patients with pseudoparalysis of the shoulder, including 18 women and 9 men, with a mean age of 80.1 years. The type of cuff tear was massive tear in all the patients. All patients were treated conservatively for a mean duration of 3.9 months. Satisfactory results were achieved in 19 patients. Eight patients with unsatisfactory results eventually required surgery. The factors that caused nonresponse to treatment in 8 patients were compared with the contributing factors to treatment response in 19 patients. The factors were as follows: patient characteristics, degree of osteoarthritis change, and associated tear of the subscapularis tendon. All data were statistically analyzed. The identified factors that had a significant difference between the 2 groups were as follows: degree of osteoarthritis change and associated tear of the subscapularis tendon. Tear of the subscapularis tendon and changes in osteoarthritis were suggested to be factors that aff5cted the outcomes of conservative management. In the patients with osteoarthritis, satisfactory pain relief was difficult to attain. In patients with tears of the subscapularis tendon, decreased centripetal force due to collapse of the force couple was considered the cause of the poor outcomes. Surgical treatment should be considered positively for patients with factors that cause poor outcomes of conservative management of pseudoparalysis of the shoulder.

Superior Capsular Reconstruction of the Shoulder Using the Long Head of the Biceps Tendon: A Systematic Review of Surgical Techniques and Clinical Outcomes.

Background and Objectives: Superior capsular reconstruction (SCR) with the use of a fascia lata autograft or a dermal allograft is an established treatment in treating irreparable rotator cuff (RC) tears. The long head of the biceps tendon (LHBT) has been recently proposed as an alternative graft for SCR. The purpose of this study was to present the surgical techniques and clinical studies utilizing the LHBT for SCR. Material and Methods: Medline, Scopus, and the Cochrane library were searched for relevant studies up to December 2020. The primary outcomes were pain intensity improvement and the incidence of RC and LHBT graft retears. Secondary outcomes were functional scores and acromiohumeral distance (AHD) improvements. Results: Nine studies described surgical techniques of SCR using the LHBT, and four clinical studies reported the outcomes of the technique. The mean pain intensity improved from 4.9 ± 2.3 to 1.6 ± 1.5 in terms of the visual analog scale, exceeding the minimum clinically important difference for adequate pain relief. Significant improvements were also noted in functional scores and AHD. When compared with other repair techniques for massive RC tears, i.e., the double-row repair, the transosseous-equivalent technique with absorbable patch reinforcement, and the traditional SCR with a fascia lata autograft, there were no significant differences in pain and function improvements. Conclusion: SCR using the LHBT is a useful treatment option for massive RC tears; it is equally effective with the traditional SCR and other established techniques. It presents numerous advantages being a safe, easy, time-saving, and cost-effective method. The only precondition for the technique is the presence of an intact LHBT. Additional clinical trials are necessary to determine which treatment is superior for treating massive RC tears, as well as to evaluate the long-term results of the technique.

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

Resultados funcionales de un programa de fisioterapia en pacientes con rotura masiva e irreparable del manguito rotador

ObjectiveTo evaluate the short term and 1-year follow-up functional effects of a physiotherapy program in patients over 60 years of age with massive and irreparable Rotator Cuff (RC) tear. MethodsA total of 96 patients with massive and irreparable RC tear were prospectively recruited. All patients were treated with a 12-week physiotherapy program. Three evaluations were performed, at the beginning, at the end of the treatment and at one year of follow-up. The Constant-Murley questionnaire was used to assess shoulder function, the DASH questionnaire for upper limb function, and the Visual Analogue Scale (VAS) for pain intensity. ResultsAt the end of the treatment, all the variables showed a clinically and statistically significant difference (p < 0.05). At one year of follow-up, the Constant-Murley showed an increase of 26.5 points (Cohen's d = 1.7; 95% CI 23.5 to 29.5; p < 0.001), DASH showed a decrease of 31.4 points (Cohen's d = 2.2; 95% CI 28.5 to 34.3; p < 0.001), and the VAS showed a decrease of 3.9 cm (Cohen's d = 3.6; 95% CI 3.6 to 4.1; p < 0.001). ConclusionIn the short term and 1-year follow-up, a physiotherapy program showed clinically and statistically significant results in all functional variables in patients older than 60 years with massive and irreparable RC tear.

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.