Posterosuperior Rotator Cuff Tears Research Articles

Physiological Tensioning During Lower Trapezius Transfer for Irreparable Posterosuperior Rotator Cuff Tears May Be Important for Improvement in Shoulder Kinematics

Background: Lower trapezius transfer (LTT) has been proposed for restoring the anteroposterior muscular force couple in the setting of an irreparable posterosuperior rotator cuff tear (PSRCT). Adequate graft tensioning during surgery may be a factor critical for sufficient restoration of shoulder kinematics and functional improvement. Purpose/Hypothesis: The purpose was to evaluate the effect of tensioning during LTT on glenohumeral kinematics using a dynamic shoulder model. It was hypothesized that LTT, while maintaining physiological tension on the lower trapezius muscle, would improve glenohumeral kinematics more effectively than undertensioned or overtensioned LTT. Study Design: Controlled laboratory study. Methods: A total of 10 fresh-frozen cadaveric shoulders were tested using a validated shoulder simulator. Glenohumeral abduction angle, superior migration of the humeral head, and cumulative deltoid force were compared across 5 conditions: (1) native, (2) irreparable PSRCT, (3) LTT with a 12-N load (undertensioned), (4) LTT with a 24-N load (physiologically tensioned according to the cross-sectional area ratio of the lower trapezius muscle), and (5) LTT with a 36-N load (overtensioned). Glenohumeral abduction angle and superior migration of the humeral head were measured using 3-dimensional motion tracking. Cumulative deltoid force was recorded in real time throughout dynamic abduction motion by load cells connected to actuators. Results: Physiologically tensioned (Δ13.1°), undertensioned (Δ7.3°), and overtensioned (Δ9.9°) LTT each significantly increased the glenohumeral abduction angle compared with the irreparable PSRCT (P < .001 for all). Physiologically tensioned LTT achieved a significantly greater glenohumeral abduction angle than undertensioned LTT (Δ5.9°; P < .001) or overtensioned LTT (Δ3.2°; P = .038). Superior migration of the humeral head was significantly decreased with LTT compared with the PSRCT, regardless of tensioning. Physiologically tensioned LTT resulted in significantly less superior migration of the humeral head compared with undertensioned LTT (Δ5.3 mm; P = .004). A significant decrease in cumulative deltoid force was only observed with physiologically tensioned LTT compared with the PSRCT (Δ–19.2 N; P = .044). However, compared with the native state, LTT did not completely restore glenohumeral kinematics, regardless of tensioning. Conclusion: LTT was most effective in improving glenohumeral kinematics after an irreparable PSRCT when maintaining physiological tension on the lower trapezius muscle at time zero. However, LTT did not completely restore native glenohumeral kinematics, regardless of tensioning. Clinical Relevance: Tensioning during LTT for an irreparable PSRCT may be important to sufficiently improve glenohumeral kinematics and may be an intraoperatively modifiable key variable to ensure postoperative functional success.

The clinical impact of retears after repair of posterosuperior rotator cuff tears: a systematic review and meta-analysis.

Structural integrity after rotator cuff repair is frequently not achieved, but the clinical consequences of a retear remain disputed. The purpose of this meta-analysis was to analyze the relationships between postoperative cuff integrity and shoulder pain and function. We searched the literature for studies of surgical repair of full-thickness rotator cuff tears published after 1999 describing rates of retear and clinical outcomes and providing sufficient data to estimate effect sizes (standardized mean differences [SMDs]). Baseline and follow-up data of healed and failed repairs were extracted, including shoulder-specific scores, pain, muscle strength, and health-related quality of life. Pooled SMDs, mean differences, and overall change from baseline to follow-up according to structuralintegrity at follow-up were calculated. Subgroup analysis was performed to assess the influence of study quality on differences. This analysis included 43 study arms with 3350 participants. The average age of the participants was 62 years (range, 52-78 years). The median number of participants per study was 65 (interquartile range, 39-108). At a median of 18 months' follow-up (interquartile range, 12-36 months), 844 repairs (25%) were described as retorn on imaging. The pooled SMD between healed repairs and retears at follow-up was 0.49 (95% confidence interval [CI], 0.37 to 0.61) for the Constant-Murley score, 0.49 (95% CI, 0.22 to 0.75) for the American Shoulder and Elbow Surgeons score, 0.55 (95% CI, 0.31 to 0.78) for other shoulder-specific outcomes combined, 0.27 (95% CI, 0.07 to 0.48) for pain, 0.68 (95% CI, 0.26 to 1.11) for muscle strength, and -0.001 (95% CI, -0.26 to 0.26) for health-related quality of life. The pooled mean differences were 6.12 (95% CI, 4.65 to 7.59) for the Constant-Murley score, 7.13 (95% CI, 3.57 to 10.70) for the American Shoulder and Elbow Surgeons score, and 0.49 (95% CI, 0.12 to 0.87) for pain, all below the commonly suggested minimal clinically important differences. The differences were not significantly affected by study quality and were generally modest compared with overall improvements from baseline to follow-up for both healed and failed repairs. The negative impact of retears on pain and function was statistically significant but judged to be of minor clinical importance. The results indicate that most patients may expect satisfactory outcomes despite retears.

Superior Capsular Reconstruction Using An Acellular Dermal Xeno- Or Allograft for the Treatment of Irreparable Posterosuperior Rotator Cuff Tears: Clinical and Radiographic Outcome at Minimum 2-Year Follow-Up

Superior Capsular Reconstruction Using An Acellular Dermal Xeno- Or Allograft for the Treatment of Irreparable Posterosuperior Rotator Cuff Tears: Clinical and Radiographic Outcome at Minimum 2-Year Follow-Up

Aetiopathogenesis of Rotator Cuff Tear in Patients Younger than 50 Years: Medical Conditions Play a Relevant Role.

Background and Objectives: Studies on rotator cuff tears (RCT) in patients younger than 50 years have focused on the post-operative outcomes. Little is known about cuff tear etiopathogenesis, although it is a common belief that most tears are due to trauma. We have retrospectively verified the prevalence of medical conditions, whose role in tendon degeneration development have been widely demonstrated, in a group of patients younger than 50 years with postero-superior RCT. Materials and Methods: 64 patients [44M-20F; mean age (SD): 46.90 (2.80)] were enrolled. Personal data, BMI, smoking habit, diseases (diabetes, arterial hypertension, hypercholesterolaemia, thyroid diseases, and chronic obstructive pulmonary disease) were registered. The possible triggering cause and the affected side and tear dimensions were recorded, and statistical analysis was then performed. Results: 75% of patients had one or more diseases and/or a smoking habit for more than 10 years. In the remaining 25%, only four patients referred had had a traumatic event, while in the other eight patients, both medical condition and trauma were registered. The presence of two or more diseases did not affect RCT size. Conclusions: In our series, three quarters of patients with RCT had a smoking habit or medical conditions predisposing them to a tendon tear; therefore, the role of trauma in RCT onset in patients younger than 50 years is markedly resized. It is plausible that in the remaining 25%, RCT may be due to trauma or to genetic or acquired degeneration. Level of Evidence: IV.

Automated 3-dimensional MRI segmentation for the posterosuperior rotator cuff tear lesion using deep learning algorithm.

Rotator cuff tear (RCT) is a challenging and common musculoskeletal disease. Magnetic resonance imaging (MRI) is a commonly used diagnostic modality for RCT, but the interpretation of the results is tedious and has some reliability issues. In this study, we aimed to evaluate the accuracy and efficacy of the 3-dimensional (3D) MRI segmentation for RCT using a deep learning algorithm. A 3D U-Net convolutional neural network (CNN) was developed to detect, segment, and visualize RCT lesions in 3D, using MRI data from 303 patients with RCTs. The RCT lesions were labeled by two shoulder specialists in the entire MR image using in-house developed software. The MRI-based 3D U-Net CNN was trained after the augmentation of a training dataset and tested using randomly selected test data (training: validation: test data ratio was 6:2:2). The segmented RCT lesion was visualized in a three-dimensional reconstructed image, and the performance of the 3D U-Net CNN was evaluated using the Dice coefficient, sensitivity, specificity, precision, F1-score, and Youden index. A deep learning algorithm using a 3D U-Net CNN successfully detected, segmented, and visualized the area of RCT in 3D. The model's performance reached a 94.3% of Dice coefficient score, 97.1% of sensitivity, 95.0% of specificity, 84.9% of precision, 90.5% of F1-score, and Youden index of 91.8%. The proposed model for 3D segmentation of RCT lesions using MRI data showed overall high accuracy and successful 3D visualization. Further studies are necessary to determine the feasibility of its clinical application and whether its use could improve care and outcomes.

Reliability of Magnetic Resonance Imaging Criteria for the Preoperative Assessment of Rotator Cuff Tears: A Systematic Review

Background: Magnetic resonance (MR) imaging is the most common modality for assessment of the rotator cuff before and after surgery. Several classifications have been described aiming to define main tear characteristics. However, there is still confusion when it comes to the reliability of those classifications. Purpose: (1) To identify all MR classifications available in the literature for preoperative assessment of rotator cuff tears, (2) to summarize available data on the reliability of identified classifications, and (3) to assess the methodological quality of reliability studies. Study Design: Systematic review; Level of evidence, 4. Methods: This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies reporting MR assessment in patients with a superior or posterosuperior rotator cuff tear were included. After identification of the available MR criteria, reliability studies were analyzed. Descriptive statistics were used to summarize findings. Methodological quality was assessed using the Quality Appraisal of Reliability Studies checklist. Results: A total of 75 studies were included in this review. Eight categories of outcomes could be identified. Of the total, 62 studies reported interobserver reliability whereas 32 reported intraobserver reliability of some of the identified criteria. Each category reflected a variety of reliability, ranging from poor to excellent agreement. MR proved to be a reliable imaging modality to detect the structural integrity of the posterosuperior cuff, especially in cases of full-thickness tear; it was also reliable in terms of tear width and length and muscle atrophy based on a tangent sign or Thomazeau classification. All other classifications did not prove acceptable reliability. Methodological quality was high for 23 articles and moderate for 14. Conclusion: Preoperative MR is a reliable imaging modality to identify full-thickness tears, measure tear size and morphology, and identify muscle atrophy with tangent sign or Thomazeau classification. All other outcomes and classifications did not show acceptable reliability; therefore, caution is needed when using them for preoperative evaluation of a rotator cuff tear.

Superior Capsular Reconstruction Versus Latissimus Dorsi Tendon Transfer for Irreparable Rotator Cuff Tears: Minimum 5-year Outcomes.

Arthroscopic superior capsular reconstruction (SCR) has been introduced as a successful alternative to latissimus dorsi tendon transfer (LDTT) for irreparable posterosuperior rotator cuff tears. To compare minimum 5-year clinical outcomes of SCR and LDTT for the treatment of irreparable posterosuperior rotator cuff tears in patients with minimal evidence of arthritis and intact or reparable subscapularis tears. Cohort study; Level of evidence, 3. Patients who underwent SCR or LDTT and had undergone surgery ≥5 years earlier were included. The SCR technique used a dermal allograft customized to the defect. Surgical, demographic, and subjective data were collected prospectively and reviewed retrospectively. Patient-reported outcome (PRO) scores utilized were the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), the short version of the Disabilities of the Arm, Shoulder and Hand score (QuickDASH), 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS), and patient satisfaction. Further surgical procedures were documented, and treatment that progressed to reverse total shoulder arthroplasty (RTSA) or revision rotator cuff surgery was considered a failure. Kaplan-Meier survivorship analysis was performed. Thirty patients (n = 20 men; n = 10 women) with a mean follow-up of 6.3 years (range, 5-10.5 years) were included. A total of 13 patients underwent SCR and 17 patients underwent LDTT. The mean age of the SCR group was 56 years (range, 41.2-63.9 years), and the mean age of the LDTT group was 49 years (range, 34.7-57 years) (P = .006). One patient in the SCR group and 2 patients in the LDTT group progressed to RTSA. Two additional (11.8%) patients in the LDTT group had further surgery-1 had arthroscopic cuff repair and 1 had hardware removal with biopsies. The SCR group demonstrated significantly better ASES (94.1 ± 6.3 vs 72.3 ± 16.4; P = .001), SANE (85.6 ± 8 vs 48.7 ± 19.4; P = .001), QuickDASH (8.8 ± 8.7 vs 24.3 ± 16.5; P = .012), and SF-12 PCS (56.1 ± 2.3 vs 46.5 ± 6; P = .001) PROs at the final follow-up. There was no significant difference between groups in median satisfaction (SCR, 9; LDTT, 8 [P = .379]). At 5 years, survivorship rates were 91.7% and 81.3% for the SCR and LDTT groups, respectively (P = .421). At the final follow-up, SCR yielded superior PROs compared with LDTT for the treatment of massive, irreparable posterosuperior rotator cuff tears despite similar patient satisfaction and survivorship between procedures.

The remaining teres minor and subscapularis may contribute to preventing superior migration of the humeral head and progression of osteoarthritic change in rotator cuff tears

Superior migration of the humeral head is common in large and massive rotator cuff tears (RCTs). Humeral heads migrate superiorly according to an increase in the RCT size; however, the relevance of the remaining cuff has not been elucidated. This study investigated the relation between superior migration of the humeral head and the remaining rotator cuff, especially the teres minor (TM) and subscapularis (SSC), in RCTs involving tears and atrophy of the infraspinatus (ISP). Plain anteroposterior radiographic and magnetic resonance imaging examinations were performed on 1345 patients between January 2013 and March 2018. A total of 188 shoulders with tears of the supraspinatus and ISP with atrophic ISP were evaluated. Gradings of superior migration of the humeral head and osteoarthritic change were evaluated using the acromiohumeral interval, Oizumi classification, and Hamada classification on plain anteroposterior radiographs. The cross-sectional area of the remaining rotator cuff muscles was evaluated using oblique sagittal magnetic resonance imaging. The TM was classified as hypertrophic (H) and normal and atrophic (NA). The SSC was classified as nonatrophic (N) and atrophic (A). All shoulders were classified as groups A (H-N), B (NA-N), C (H-A), and D (NA-A). Age- and sex-matched patients with no cuff tears were also enrolled (control). The acromiohumeral intervals of the control group and groups A-D were 11.4±2.4, 9.5±3.8, 7.8±4.1, 7.2±4.0, and 5.4±3.5 mm (84, 74, 64, 21, and 29 shoulders, respectively), with significant differences between groups A and D (P<.001) and groups B and D (P=.016). Grade 3 of the Oizumi classification and grades 3, 4, and 5 of the Hamada classification were significantly higher in group D than in others (P<.001). The group showing hypertrophic TM and nonatrophic SSC prevented significantly migration of the humeral head and cuff tear osteoarthritis compared to the group showing atrophic TM and SSC in posterosuperior RCTs. The findings indicate that the remaining TM and SSC may prevent superior migration of the humeral head and progression of osteoarthritic change in RCTs. In treating patients with large and massive posterosuperior RCTs, the status of the remaining TM and SSC muscles should be assessed.

Allograft-enhanced latissimus dorsi transfer is better than the conventional technique for irreparable posterosuperior rotator cuff tears. A retrospective matched cohort.

Latissimus dorsi tendon (LDT) transfer (LDTT) to the greater tuberosity to treat irreparable posterosuperior rotator cuff tears (RCTs) in young active patients has been shown to have up to 36% of clinical failures, most of them happening because of either deltoid origin disruption or post-operative transfer rupture from the greater tuberosity. In an attempt to simultaneously prevent both complications, a modified technique includes the following adaptations to the original technique: reinforcement and augmentation of the LDT with a tendinous allograft, enabling the use of a single deltopectoral approach. The aim of this study is to compare mid-term outcomes of the traditional LDTT technique with this modified transfer. Retrospective cohort study comparing two groups who underwent either the traditional (group 1; n = 19) or the modified technique (group 2; n = 27). Group homogenization was assured by statistical comparison of 24 baseline independent variables. The outcome variables were the gains to active shoulder range of motions (ROM) and UCLA scores (and all its subscores, independently), at a minimum follow-up of two years. A p value < .05 was considered to be statistically significant. At a mean follow-up of 25months, both groups have shown improvements to most variables. However, group two (modified technique) achieved greater improvements to UCLA score (p = .009), active external rotation (p = .006) and internal rotation (p = .008). At mid-term follow-up, improvements to outcomes of the modified (single approach, allograft-enhanced) latissimus dorsi transfer were greater than those of the original technique.

Superior Capsular Reconstruction Partially Restores Native Glenohumeral Joint Loads in a Dynamic Biomechanical Shoulder Model

To evaluate the effect of an irreparable posterosuperior rotator cuff tear (PSRCT) on glenohumeral joint loads and to quantify improvement after superior capsular reconstruction (SCR) using an acellular dermal allograft. Ten fresh-frozen cadaveric shoulders were tested using a validated dynamic shoulder simulator. A pressure mapping sensor was placed between the humeral head and glenoid surface. Each specimen underwent the following conditions: (1) native, (2) irreparable PSRCT, and (3) SCR using a 3-mm-thick acellular dermal allograft. Glenohumeral abduction angle (gAA) and superior humeral head migration (SM) were measured using 3-dimensional motion-tracking software. Cumulative deltoid force (cDF) and glenohumeral contact mechanics, including glenohumeral contact area and glenohumeral contact pressure (gCP), were assessed at rest, 15°, 30°, 45°, and maximum angle of glenohumeral abduction. The PSRCT resulted in a significant decrease of gAA along with an increase in SM, cDF, and gCP (P < .001, respectively). SCR did not restore native gAA (P < .001); however, SM was significantly reduced (P < .001). Further, SCR significantly reduced deltoid forces at 30° (P= .007) and 45° of abduction (P= .007) when compared with the PSRCT. SCR did not restore native cDF at 30° (P= .015), 45° (P < .001), and maximum angle (P < .001) of glenohumeral abduction. Compared with the PSRCT, SCR resulted in a significant decrease of gCP at 15° (P= .008), 30° (P= .002), and 45° (P= .006). However, SCR did not completely restore native gCP at 45° (P= .038) and maximum abduction angle (P= .014). In this dynamic shoulder model, SCR only partially restored native glenohumeral joint loads. However, SCR significantly decreased glenohumeral contact pressure, cumulative deltoid forces, and superior migration, while increasing abduction motion, when compared with the posterosuperior rotator cuff tear. These observations raise concerns regarding the true joint-preserving potential of SCR for an irreparable posterosuperior rotator cuff tear, along with its ability to delay progression of cuff tear arthropathy and eventual conversion to reverse shoulder arthroplasty.

Peripheral microcirculation alteration as cause of postero-superior rotator cuff tear: the possible indirect contribution of nailfold capillaroscopy.

Most of the recent literature regarding rotator cuff tear etiology identifies in peripheral microcirculation disorders the probable main cause of tissue degeneration, and consequently of tendon rupture. Nailfold capillaroscopy is a practical and inexpensive diagnostic technique used to evaluate the health status of the peripheral microcirculation and, recently, its use has found other indications in addition to that of diagnosing connective tissue diseases and Raynaud's phenomenon. We verified the possible indirect contribution of nailfold capillaroscopy in the identification of peripheral microcirculation disturbances in a group of patients with rotator cuff tear and whether these possible alterations could be related to rotator cuff tear size. A case control study was performed. 100 patients [(56M-44F; mean age(SD): 60.46 (5.46)] with different sized postero-superior cuff tears and 100 healthy controls [(38M:62F mean age (SD):60.40(6.34)] were submitted to capillaroscopic exam. The following parameters were examined: capillary morphology and density; avascular areas; visibility of the sub-papillary venous plexus; enlarged and giant capillaries; ectasias and microaneurysms; neo-angiogenesis; hemosiderin deposits; pericapillary edema; capillary blood flow. Severe exclusion criteria were applied. Statistical analysis was performed. Visibility of SPVP (p<0.001), pericapillary edema (p<0.001), capillary blood flow (p<0.001), ectasias and microaneurysms (p<0.001) and neo-angiogenesis (p = 0.04) were significantly associated with presence of RCT. Our results contribute to support the hypothesis that microcirculation disorder has a relevant role on the genesis of cuff degeneration and, consequently, of tendon rupture. However, these alterations do not seem to be related to rotator cuff tear size.

Comparison of suture-bridge and independent double-row techniques for medium to massive posterosuperior cuff tears: a two-year retrospective study

BackgroundTransosseous-equivalent suture-bridge (TOE-SB) and independent double-row (IDR) repair techniques were developed to treat rotator cuff tears. The study was designed to prove that both TOE-SB and IDR techniques provided comparable clinical results and retear rate for medium to massive posterosuperior rotator cuff tears, while the surgical time and number of suture anchor used were less in the IDR group.Study designLevel of evidence: level III, Retrospective comparative study.MethodsPatients with medium to massive posterosuperior rotator cuff tears receiving arthroscopic TOE-SB and IDR between November 2016 to October 2019 were retrospectively enrolled. All patients were confirmed to have grade ≤ 2 fatty infiltration in the muscles of the torn tendons. Revision, concomitant subscapularis tear, acromiohumeral distance < 7 mm, glenohumeral osteoarthritis, partial repair, incomplete repair, partial thickness, or irreparable posterosuperior cuff tear were excluded. Surgical time, number of suture anchor used for the surgery, pre-operative, and post-operative clinical scores such as Constant-Murley score, subjective shoulder value (SSV), and visual analog scale (VAS) were compared. The retear rates between groups were evaluated by ultrasound.ResultsThirty-five IDR and thirty-five TOE-SB repairs were enrolled. The IDR technique required much fewer anchors than TOE-SB did to complete the cuff repair. The mean operation time in IDR and TOE-SB group were 86(18.23), and 114(18.7) (min), respectively (P < 0.01). The mean number of anchors used to complete the cuff repair was 2(0.17) in IDR and 3(0.61) in TOE-SB (P < 0.01). The Constant-Murley score improved from 34.9 ± 6.6 to 80.6 ± 9.4 in the IDR group, and 37.4 ± 6 to 81.9 ± 4.6 in the TOE-SB group (both P < 0.001). SSV improved from 24.6 ± 9.6 to 79.3 ± 10.6 in the IDR, and 27.9 ± 9 to 82.9 ± 6.9 in the TOE-SB group (both P < 0.001). VAS improved from 7.9 ± 0.6 to 1.5 ± 0.7 in the IDR, and 8 ± 0.5 to 1.3 ± 0.6 in the TOE-SB group (both P < 0.001) at final follow-up. No significant difference was found between the retear rates (14.3% in the IDR vs. 17.1% in the TOE-SB, respectively) in the 2-year follow-up.ConclusionsBoth IDR and TOE-SB group provided comparable clinical results and retear rates for medium to massive posterosuperior rotator cuff tears. The surgical time and number of anchors used were less in the IDR group than in the TOE-SB group.

Early postoperative recovery comparisons of superior capsule reconstruction to tendon transfers.

The management of massive posterosuperior rotator cuff tears is controversial, with no gold standard. Two recently developed techniques that have shown promising initial results include arthroscopic superior capsular reconstruction (SCR) and tendon transfers (latissimus or lower trapezius). However, there remains a scarcity of studies examining each procedure's early postoperative clinical outcomes individually or in comparison to each other. The purpose of this study is to compare the early postoperative recovery outcomes of tendon transfers (TTs) to SCR. Using the surgical outcomes system global database (Arthrex Inc.), we assessed the postoperative recovery outcomes for all patients who had outcomes recorded at least 6 months after SCR or TT. The time points analyzed included preoperative and postoperative (2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years). The outcomes analyzed included pain visual analog scale (VAS) score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, VR-12 physical, and Single Assessment Numeric Evaluation (SANE). Overall, 163 patients underwent SCR and 24 arthroscopically assisted TT. The mean age for SCR and TT was 60 and 56 years, respectively. Postoperative recovery curves demonstrate that both procedures produced improved outcomes at each postoperative time point compared to preoperative. The pain and functional outcomes measures, including VAS, ASES, SANE, and VR-12 physical, were comparable for TT and SCRs, with similar recovery curves between the 2 techniques. Ultimately at 2 years postoperatively, there were no significant differences between the 2 techniques. Analysis of the early outcomes associated with arthroscopic treatment of massive posterosuperior rotator cuff tears demonstrated that the arthroscopically assisted tendon transfers and arthroscopic superior capsular reconstruction had similar pain and functional outcomes throughout the 2-year postoperative recovery period. Overall, the process of recovery appears equivalent between the 2 techniques. Future studies are needed to assess the outcomes of each technique and specific indications in an attempt to delineate an algorithm for the treatment of irreparable rotator cuff tears.

Superior capsular reconstruction using hybrid graft for irreparable massive rotator cuff tear.

To evaluate the clinical and radiological outcomes of arthroscopic superior capsular reconstruction (SCR) using hybrid grafts composed of tensor fascia lata autografts and human dermal allografts. This study included 30 patients with chronic irreparable posterosuperior rotator cuff tears (RCTs) who underwent arthroscopic SCR using a hybrid graft composed of tensor fascia lata autograft and human dermal allograft. Clinical outcomes were evaluated using the pain visual analogue scale score, shoulder range of motion, American Shoulder and Elbow Surgeons score, constant score, University of California-Los Angeles score, and simple shoulder test score preoperatively and at least 2years after surgery. Radiographic analysis included the Hamada classification grade, acromiohumeral distance (AHD), and graft integrity at 2years after surgery. All patients exhibited significant clinical improvement in all functional outcome measurements, except external rotation (all P < 0.05). The number of patients who exhibited pseudoparalysis decreased from 7 (23.3%) to 2 (6.7%) postoperatively. Complications were not observed. Radiologically, the mean postoperative AHD increased significantly from 6.9 ± 1.6cm to 8.8 ± 2.1cm at 2years postoperatively (P < 0.001). Twenty five out of the 30 (83.3%) patients showed successful graft healing, and all healing failures occurred on the humeral side. The differences between the healed-graft and failed-graft groups were significantly lower graft thickness (P = 0.001) and smaller AHD (P < 0.001) in the failed-graft group. Every functional outcome scores were not statistically different between healed-graft and failed-graft groups. An arthroscopic SCR technique using a hybrid graft consisting of a tensor fascia lata autograft and human dermal allograft showed satisfactory clinical outcomes in patients with irreparable RCTs. IV.

Management of Irreparable Posterosuperior Rotator Cuff Tears-A Current Concepts Review and Proposed Treatment Algorithm by the AGA Shoulder Committee.

Posterosuperior rotator cuff tears range among the most common causes of shoulder complaints. While non-operative treatment is typically reserved for the elderly patient with low functional demands, surgical treatment is considered the gold standard for active patients. More precisely, an anatomic rotator cuff repair (RCR) is considered the most desirable treatment option and should be generally attempted during surgery. If an anatomic RCR is impossible, the adequate choice of treatment for irreparable rotator cuff tears remains a matter of debate among shoulder surgeons. Following a critical review of the contemporary literature, the authors suggest the following evidence- and experience-based treatment recommendation. In the non-functional, osteoarthritic shoulder, treatment strategies in the management of irreparable posterosuperior RCT include debridement-based procedures and reverse total shoulder arthroplasty as the treatment of choice. Joint-preserving procedures aimed at restoring glenohumeral biomechanics and function should be reserved for the non-osteoarthritic shoulder. Prior to these procedures, however, patients should be counseled about deteriorating results over time. Recent innovations such as the superior capsule reconstruction and the implantation of a subacromial spacer show promising short-term results, yet future studies with long-term follow-up are required to derive stronger recommendations.

Combined latissimus dorsi transfer and deltoid flap for irreparable rotator cuff tear: A retrospective analysis.

This study will evaluate the outcomes of the combined latissimus dorsi tendon transfer and deltoid flap for the management of irreparable posterosuperior rotator cuff tears. This is a retrospective study of 15 patients who have undergone double transfer surgery for their irreparable posterosuperior rotator cuff tears. These patients were followed up in three periods. Functional outcomes such as the constant score (CS), subjective shoulder value (SSV), and range of motion were assessed as well as radiographic outcomes such as the acromio-humeral distance. Fifteen patients were included in the early and intermediate follow-up while only 8 remained at the latest follow-up. At the early follow-up the SSV (p=0.001), CS (p=0.021), and A-H distance (p=0.008) showed a statistically significant improvement from their pre-operative values. At the latest follow-up, only the external rotation decreased from its value at the intermediate follow-up (p=0.027). The double transfer technique showed sustainable improvement of the functional outcomes except for the external rotation. However, the loss of external rotation did not affect the remaining outcomes. Trials comparing this technique to other surgical managements or MIRCTs are needed to confirm these results.

Long-term outcomes of teres major transfer for irreparable posterosuperior rotator cuff tears in patients aged

Massive rotator cuff tears are defined as irreparable when tendon-to-bone or tendon-to-tendon continuity with the adducted arm cannot be restored and severe muscle fatty infiltration is present. Tendon transfer is a palliative procedure that improves shoulder function and relieves pain. We reviewed the records of patients aged <65 years, whose irreparable posterosuperior rotator cuff tears had been managed with teres major tendon transfer at our institution. Their 5- and 10-year clinical and radiographic follow-up records were examined to assess long-term outcomes. Patients' Constant Score, Disabilities of the Arm, Shoulder, and Hand score, and the visual analog scale for pain were calculated before the procedure and at 5 and 10 years. There were 24 consecutive patients aged <65 years (mean, 59; 12 men and 12 women) who had received no prior treatment except rehabilitation. All patients underwent teres major tendon transfer due to the failure of conservative treatment. The mean Constant Score was 26 preoperatively and 68 and 66 at 5 and 10 years, respectively (P=.0001 and P=.25). The mean Disabilities of the Arm, Shoulder, and Hand scores were 62.2 preoperatively and 7.8 and 9.3 at 5 and 10 years, respectively (P=.0009 and P=.1). The mean visual analog scale scores at rest were 6.1 preoperatively, and 0.3 and 0.5 at 5 and 10 years, respectively (P=.0003 and P=.1). Based on Hamada's classification, at 5 years, 3 patients showed grade 2 changes, and another had grade 3 changes; at 10 years, 7 patients showed grade 2 changes, and one showed grade 3 changes. Complications (8%) developed after the 10-year evaluation and included pain in 1 patient and secondary rupture of the transfer in another. Improving shoulder function and reducing pain in relatively young patients with irreparable posterosuperior cuff tears involves replacing the lost muscle with a muscle-tendon transfer. The chief aims of the procedure are to restore the balance with the subscapularis muscle, achieve joint stability, keep the humeral head in the glenoid cavity, and improve shoulder abduction and external rotation. Teres major tendon transfer can achieve these goals. Altogether, 22 of our 24 patients experienced improved daily activity function and pain relief that became stable after 5 years. Teres major transfers are useful surgical procedures, particularly in younger patients and in those with high functional demands, providing good and stable long-term results.

Association of Arthroscopically-Assisted Latissimus Dorsi Tendon Transfer with Implantation of a Subacromial Balloon Spacer for Patients with Irreparable Posterosuperior Rotator Cuff Tears

Association of Arthroscopically-Assisted Latissimus Dorsi Tendon Transfer with Implantation of a Subacromial Balloon Spacer for Patients with Irreparable Posterosuperior Rotator Cuff Tears

Arthroscopic Double-Row Repair of Posterosuperior Rotator Cuff Tears: Suture Bridge Technique Reinforced With Modified Mason–Allen and Simple Sutures

Rotator cuff (RC) tears represent one of the most common causes of pain and dysfunction of the shoulder. Numerous RC repair techniques have been reported. In this Technical Note, we introduce an arthroscopic double-row repair technique that combines a suture bridge construct with modified Mason–Allen and simple suture fixation to optimize load-sharing and compression of the RC to the footprint. The described technique is ideal for crescent-shaped and large reparable U-shaped posterosuperior RC tears.

Effect of Fatty Infiltration of the Infraspinatus Muscle on Outcomes and Graft Failure After Arthroscopic Superior Capsule Reconstruction for Irreparable Posterosuperior Rotator Cuff Tears

Background: Superior capsule reconstruction (SCR) was developed as an alternative treatment for irreparable rotator cuff tears to restore superior stability of the glenohumeral joint. Although fatty infiltration (FI) of the rotator cuff muscles, especially the infraspinatus, has been implicated as a predictor of outcomes and graft integrity after rotator cuff repair, it has not been fully investigated in cases of SCR. Purpose: To evaluate the effect of FI of the infraspinatus muscle on clinical and radiological outcomes after SCR. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 55 consecutive patients with irreparable posterosuperior rotator cuff tears who underwent SCR between January 2013 and August 2020 were included retrospectively. Preoperative and postoperative clinical and radiological findings (median follow-up of >2 years), including magnetic resonance imaging results, were thoroughly reviewed. The patients were divided into 2 groups: group 1 with mild FI of the infraspinatus (Goutallier grades 0-2) and group 2 with severe FI of the infraspinatus (Goutallier grades 3-4). The American Shoulder and Elbow Surgeons score, Constant score, visual analog scale score for pain, and range of motion were evaluated. Acromiohumeral distance and rotator cuff tear arthropathy using the Hamada classification were assessed on plain radiography. Postoperative graft integrity was evaluated by magnetic resonance imaging. Graft failure was defined as complete discontinuity. Univariate and multivariable logistic regression analyses were performed to evaluate clinical and radiological findings that might be associated with successful SCR. Results: Clinical and radiological outcomes significantly improved after SCR. Graft failure was noted in 15 (27.3%) patients and was more frequent in group 2 than in group 1 (50.0% vs 14.3%, respectively; P = .004). Univariate analysis indicated a significant association between severe FI in the infraspinatus (group 2) and graft failure after SCR (odds ratio, 6.00 [95% CI, 1.65-21.80]; P = .006). Multivariable analysis indicated that FI of the infraspinatus was the only factor associated with graft failure (odds ratio, 6.37 [95% CI, 1.63-24.90]; P = .008). Conclusion: Severe FI of the infraspinatus muscle was a factor indicating a poor prognosis for graft integrity after SCR. Preoperative evaluation of FI in the rotator cuff muscles can help predict postoperative outcomes and may help guide therapeutic options.