Subscapularis Tears Research Articles

MRI IN THE EVALUATION OF ROTATOR CUFF TENDONS IN CHRONIC SHOULDER PAIN

Background: Shoulder pain is the third most common cause of non- traumatic musculoskeletal pain with rotator cuff pathology being the most common cause. Magnetic Resonance Imaging (MRI) is the imaging modality of choice which helps in accurate diagnosis for making a treatment plan as wrong treatment strategy may lead to poor prognosis. Methods: A descriptive prospective study conducted in 100 individuals with non-traumatic chronic shoulder pain referred to referred to Department of Radiodiagnosis and Imaging, Dhulikhel Hospital, Kavre between 27th August 2020 to 29th August 2021. MRI images were acquired and analyzed by using IBM SPSS 21.0 version Pearson correlation coefficient, Spearman correlation and chi square tests were used for statistical analysis. Results: Rotator cuff pathology was most commonly encountered with supraspinatus being the most frequently involved tendon seen in 28(63.6%), followed by subscapularis 10(22.7%), infraspinatus 4(9%) and teres minor 2(4.5%).Similarly, MRI detected partial tear of supraspinatus in 23(52.2%),partial tear of subscapularis in 8(18.1%),partial tear of infraspinatus in 3(6.8%) and partial tear of teres minor in 2(4.5%) patients. Likewise, complete tear of supraspinatus was observed in 5(11.3%), complete tear of subscapularis in 2(4.5%) and complete tear of infraspinatus in 1(2.2%). Conclusions: Rotator cuff pathologies were the most common causes of chronic shoulder pain, predominantly partial tear of supraspinatus, followed by subscapularis, infraspinatus and teres minor. Magnetic resonance imaging has become the gold standard for diagnostic imaging of the shoulder related to soft tissue injury.

Arthroscopic diagnosis of long head of biceps tendon instability in refractory anterior shoulder pain: A comparison study between pulley tear and non-tear lesions

BackgroundLong head of the biceps tendon (LHBT) instability and biceps reflection pulley (BRP) lesions are common cause of refractory anterior shoulder pain. We described a technique using dynamic arthroscopy to determine associated intraarticular pathologies. MethodsPatients with refractory anterior shoulder pain and arthroscopically-diagnosed LHBT instability were enrolled. LHBT instability and the integrity of BRP and concomitant intra-articular lesions were investigated by ramp test. Demographics and arthroscopic findings were compared between patients with and without BRP tear. ResultsForty patients were enrolled. BRP tear was noted in 25 patients (group A) and superior glenohumeral ligament (SGHL) insufficiency through ramp test in 15 patients (group B). Concomitant intraarticular pathologies were noted in 27 patients, including 19 in group A (76%) and eight in group B (53%), without significant group-wise difference (p = 0.138). The incidence of articular-side subscapularis tear was significantly higher in group A (p = 0.021), and those of the other intraarticular pathologies were similar between groups A and B. Fraying at the articular side of the subscapularis and supraspinatus tendons was frequent in group B, without difference of incidence as compared to group A (p = 0.5 and p = 0.084, respectively). ConclusionsLHBT instability was a common disorder in patients with refractory shoulder pain. In those patients, dynamic assessment of BRP lesions and SGHL insufficiency and meticulous survey of associated intra-articular pathologies, including subscapularis tear are necessary for making accurate diagnosis and treatment decision.

Subscapularis Failure after Anatomic Total Shoulder Arthroplasty: A Review of Diagnosis and Management

Background: The volume of anatomic total shoulder arthroplasty has been increasing in recent years. The deltopectoral approach necessitates detaching and subsequent repairing of the subscapularis tendon. Failure of the tendon to heal can lead to pain, compromised function, and patient dissatisfaction. Our aim is to present a review article regarding current thinking on the problem of a diagnostic algorithm and therapeutic guidelines for subscapularis failure following anatomic TSA. Materials and Methods: Searches were completed in July 2018 using a series of NOT phrases to match certain exclusion criteria in PubMed. Results: A total of 23 relevant studies were included in the analysis. Only three of the seven studies linked physical examination results to evidence of post-operative subscapularis rupture. Eleven of the eighteen patients with subscapularis tears obtained ultrasonography confirmation, whereas the remaining patients had revision surgery confirmation. The decrease in internal rotation strength and the lift-off test were the most regularly performed tests. The former was shown to be positive in all fourteen patients from two trials, whereas the latter was found to be positive in eight of fourteen. Five studies on therapy in different situations were proposed, but there was no head-to-head comparison of treatment outcomes. Conclusion: The most common cause of anterior instability in prosthetic shoulder is subscapularis insufficiency. Physical examination and radiological studies may not provide a conclusive diagnosis. Patients who present with pain, weakness, or instability require surgical treatment, which varies based on their age, tendon reparability, and component position. Keywords: Subscapularis tear; Subscapularis dysfunction; Subscapularis tenotomy; Lesser tuberosity osteotomy; Total shoulder replacement

Superior Capsule Reconstruction Is a Viable Option for Patients with Symptomatic, Isolated, and Irreparable Supraspinatus Tears

PurposeTo evaluate the outcome of superior capsular reconstruction for isolated subscapularis tears using a decellularized porcine allograft as a superior capsular reconstruction.MethodsPatients who had symptomatic tears of supraspinatus who had failed to improve a conservative rehabilitation program were included. Previous surgery to the shoulder was not a bar to inclusion. Patients were assessed preoperatively and postoperatively with the Oxford Shoulder Score (OSS), the single assessment numeric evaluation (SANE) score, as well as clinically assessed for their shoulder range of motion (ROM). Patients were followed up with in-person clinic appointments for the first year, followed by a postal questionnaire and telephone consultation at a minimum of 2 years following surgery.ResultsTwenty patients (11 males and 9 females) with a mean age of 67.5 years were included (range: 54-72 years). The average follow-up period was 31 months (24-50). The mean improvement in OSS was 14 points (P < .001), SANE score was 27 points (P < .01). Significant improvements in mean ROM were recorded (flexion 80.7°; P < .001; abduction: 81°; P < .001; external rotation: 31°; P < .001). Six patients suffered SCR failures diagnosed by magnetic resonance imaging, despite this they still recorded improvements in recorded OSS, SANE and ROM (excluding external rotation). Patient demographics for failed superior capsule reconstruction (SCR) highlighted smoking and revision surgery as risk factors.ConclusionsSCR appears to be a viable option for patients with symptomatic, isolated, and irreparable tears of the supraspinatus. Our results demonstrate that there are significant improvements in outcome scores and active range of motion, even in the subgroup in whom postoperative structural failure of the SCR was identified. We recommend caution in patients who have previously failed rotator cuff repair and in heavy smokers.Level of EvidenceLevel IV, therapeutic case series.

Risk Factors for Loss of Active Shoulder Range of Motion in Massive Rotator Cuff Tears.

Background:Patients with massive rotator cuff tears often exhibit loss of active range of shoulder motion, which can interfere with activities of daily living. The risk factors for loss of motion remain largely unknown.Purpose:To clarify the predictive factors that affect the range of motion in chronic massive rotator cuff tears using multivariate analyses.Study Design:Case-control study; Level of evidence, 3.Methods:The authors retrospectively reviewed 204 consecutive patients who were evaluated at their institution with chronic massive rotator cuff tears. In this study, the dependent variable was determined to be active anterior elevation limited to ≤90° or external rotation (ER) with the arm at the side limited to ≤0°. Explanatory variables included age; sex; affected side; duration of symptoms; smoking history; existence of diabetes, hypertension, or rheumatoid arthritis; involved tendons; presence of a 3-tendon tear; rupture of the long head of biceps tendon; superior migration of the humeral head; and cuff tear arthropathy. Baseline variables that were observed to be significant in the univariate analyses were included in multivariate models, which used logistic regression to identify independent predictors of loss of motion.Results:Overall, 73 patients (35.8%) exhibited limited anterior elevation, and 27 (13.2%) exhibited limited ER. Multivariate analyses showed that inferior subscapularis tear (odds ratio [OR], 14.66; 95% CI, 2.95-72.93; P = .001), smoking (OR, 4.13; 95% CI, 1.94-8.79; P < .001), superior migration of humeral head (OR, 3.92; 95% CI, 1.80-8.53; P = .001), and 3-tendon tear (OR, 3.29; 95% CI, 1.32-8.20; P = .011) were significantly associated with the loss of anterior elevation. Teres minor tear (OR, 73.37; 95% CI, 9.54-564.28; P < .001) and superior migration of the humeral head (OR, 3.55; 95% CI, 1.04-12.19; P = .044) were significantly associated with loss of ER.Conclusion:In the current study, a history of smoking, type of torn tendons, and superior migration of the humeral head were associated with loss of active shoulder motion. In particular, the status of inferior subscapularis or teres minor contributed to the onset of pseudoparalysis in massive rotator cuff tears.

Reliable interobserver and intraobserver agreement of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) classification system of rotator cuff tears

ObjectiveThe ISAKOS Shoulder Committee developed a new comprehensive classification system aimed to describe all rotator cuff tears. The five characteristics of the tears included are pattern (P), extension (E), fatty atrophy (A), retraction (R), and location (L), conforming to the acronym “PEARL.” The objective of this study is to assess if the ISAKOS Rotator Cuff Tear Classification System is reliable by measuring the intraobserver and interobserver multirater reliability. MethodsArthroscopic videos of 36 rotator cuff tears, including tears of varying sizes and configurations, were evaluated twice by four surgeons from different continents blinded to tear type. Intraobserver and interobserver reliability was measured using multirater and intraobserver Kappa coefficients. ResultsIntraobserver reliability: An almost perfect agreement for “location” (κ = 0.98), substantial agreement for “extension” (κ = 0.73) were obtained for mean intrarater kappa, lower κ agreement for “pattern” (κ = 0.58), and relatively high agreement of 0.79 for “retraction.” Every characteristic of “location” had an almost perfect agreement among the surgeons (κ = 0.91). Intrarrater reliability: In the partial-thickness posterosuperior tears “location,” there was good agreement in tears involving less than 50% of the tendon (κ = 0.74) and moderate in those deeper than 50% of the tendon thickness (κ = 0.58). “Extension” in full-thickness posterosuperior RCT achieved moderate agreement. Within the anterior subscapularis tears, we have a substantial agreement in Lafosse´s Type 1 (κ = 0.73), moderate in Types 2 and 3 (κ = 0.45 and κ = 0.46) and slight agreement in Type 4 (κ = 0.06). The overall kappa summarizing all categories indicated moderate agreement (κ = 0.52). The articular pattern in the partial-thickness posterosuperior RCT “location” had a perfect kappa of 1, while the bursal pattern showed an almost complete agreement (κ = 0.87). In the full-thickness posterosuperior RCTs, we observed fair agreement in C, U, and reverse L configurations and slight agreement in L pattern (κ = 0.18). The overall kappa is 0.44 with a confidence interval of 0.41–0.47. There was substantial agreement in every category and the overall kappa for “retraction” (k = 0.70). ConclusionISAKOS rotator cuff tear classification system provides sufficient interobserver reliability for communicating among surgeons and for pooling of data from clinical studies. Study designCohort study (diagnosis); Level of evidence, 2.

Mid-term clinical and radiological outcomes of arthroscopic repair of isolated and combined subscapularis tears: A single-center experience.

The aim of this study was to evaluate the mid-term clinical and radiological results of patients who underwent arthroscopic subscapularis (SSC) tendon repair and to address the possible effect of repair technique(single or double row), tear pattern, and concomitant procedures among supraspinatus tears and long head of biceps tendon (LHBT) pathologies on outcomes and failure parameters. 45 patients (24 female; mean age = 55.9 years, age range = 37 - 78) who underwent arthroscopic repair of an SSC tear between January 2009 and December 2016 were retrospectively identified and included inthe study. Pre- and postoperative internal rotation strength and shoulder joint range of motion angles were measured. Clinical outcomes were assessed by Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons (ASES), Constant-Murley, Rotator cuff-quality of life (RC-QoL), and University of California Los Angles (UCLA) scores preoperatively and at the final follow-up. The mean follow-up was 45.2 (range = 36-104) months. 14 patients had isolated SSC tears. The mean preoperative VAS, ASES, Constant-Murley, RC-QoL, and UCLA scores for all patients were respectively 8.6, 21.2, 24, 28.9, and 12. Significant improvement was observed in each clinical outcome at the final follow-up: 0.96, 88.4, 86.4, 90.2, and 32.2, respectively. Improvement in outcome scores was more prominent in patients with Lafosse grade I and II SSC tendon tears repaired by singlerow technique and in patients with concomitant supraspinatus tendon repairs. The mean preoperativeinternal rotation strength according to theOxford scalewas 3.4 (±0.6) / 5 and raised to 4.7 (±0.4) / 5 at the final follow-up (P <.001).Although concomitant biceps interventions significantly improved the outcome scores; this improvement was not clinically significant. Failure was only seen in 6 patients with high-grade (Lafosse III or IV) tears. Significant improvement in clinical outcomes and lower failure ratios were more prominent in patients with Lafosse grade I or II tears than grade III or IV. Concomitant biceps interventions made a positivecontribution to the clinical outcome. Early diagnosis and repair seem to be advantageous before low-grade SSC tendon tears turn into high-grade tears. Level IV, Therapeutic Study.

Arthroscopic Suture-Bridge Repair of the Subscapularis Tendon—“Inside and Outside the Box” With Preservation of the Comma Sign

The subscapularis muscle and its tendon are of major importance in the kinematics of the glenohumeral joint. Therefore, a diligent repair of subscapularis tears is essential. We describe our reliable standardized arthroscopic suture bridge technique to repair subscapularis tears under intra- and extraarticular visualization and with preservation of the “comma sign.” This technique provides excellent exposure of the subscapularis tendon, allows its complete release in the subcoracoid space and ensures a safe and stable repair.

Owen, Sugaya, and Hayashida Classifications Give Poor Intra- and Inter-Rater Agreement on a Magnetic Resonance Imaging Evaluation of Subscapularis Tendon Retears

To investigate the intra- and inter-rater agreements for magnetic resonance imaging (MRI) evaluations of subscapularis tendon integrity at 6 months after arthroscopic rotator cuff repairs. Patients who had isolated or combined subscapularis tears and had undergone arthroscopic rotator cuff repairs were retrospectively included. The exclusion criteria included revision of arthroscopic surgery, minor subscapularis tears without repair, and inadequate postoperative images. MRI scans 6 months after surgery were used for the purpose of accessing the integrity of the subscapularis tendons. Three orthopaedic surgeons blindly evaluated the images twice at 2-week intervals. Three currently available classifications were used: the Owen classification, the Sugaya classification, and the Hayashida classification. Dichotomization and trichotomization methods were used for the Sugaya classification and Hayashida classifications. The aforementioned classification scores were combined for the agreement evaluation. Intra- and inter-rater agreement was assessed by calculating the Fleiss' kappa coefficients. A total of 35 patients were included. Both the Owen and Hayashida classifications had poor inter-rater agreements (κ= 0.10 and 0.04, respectively) and poor-to-weak intra-rater agreements (κ= 0.27-0.44 and 0.16-0.45, respectively). The Sugaya classification had poor inter-rater agreement (κ= 0.10) and poor intra-rater agreements (κ= 0.16-0.32). Dichotomization and trichotomization of Sugaya and Hayashida classifications did not lead to superior agreements. The classification combination resulted in poor inter- and intra-rater agreements (κ= 0.01-0.12 and 0.08-0.39, respectively). The Owen classification, Sugaya classification, and Hayashida classification had poor intra- and inter-rater agreement in terms of evaluating subscapularis tendon re-tears on 6 months' postoperative MRI. The dichotomized and trichotomized classifications as well as the combined classifications from currently available classifications did not lead to superior agreements. Level IV, diagnostic: case series.

Defining Clinically Significant Outcomes Following Superior Capsular Reconstruction With Acellular Dermal Allograft

To define clinically significant outcomes (CSO) thresholds for minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptomatic state (PASS) in patients undergoing superior capsular reconstruction (SCR) with an acellular dermal allograft. We also evaluated patient-specific variables predictive of achieving CSO thresholds. The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), and subjective Constant-Murley (Constant) scores were collected preoperatively and at the most recent follow up for patients undergoing SCR from 2010 to 2019. A distribution-based approach was used to calculate MCID, and an anchor-based approach was used to calculate SCB and PASS. Logistic regression was used to determine factors associated with CSO achievement. Fifty-eight patients were identified (n= 39 males; n= 19 females) with a mean age of 53.4 ± 14.1 years at surgery and an average follow-up of 23 months. The MCID, SCB, and PASS were 11.2, 18.02, and 68.82 for ASES, 14.5, 23.13, and 69.9 for SANE, and 3.6, 10, and 18 for Constant, respectively. Subscapularis tear, female sex, and workers compensation (WC) status reduced odds of achieving MCID. Reduced odds of achieving Constant SCB were associated with older age, female sex, and WC status, while concomitant distal clavicle excision during SCR and lower preoperative ASES increased odds of achieving ASES SCB. Reduced odds for achieving ASES PASS were associated with female sex and WC status, while reduced odds for achieving SANE PASS were associated with subscapularis tearing preoperatively. On the basis of calculated values for MCID, SCB, and PASS, subscapularis tearing, WC status, age, and sex are associated with failure to achieve clinically significant outcomes following SCR. Concomitant distal clavicle excision during SCR and lower preoperative ASES was predictive for achievement of MCID and SCB. By defining the thresholds and variables predictive of achieving CSOs following SCR, surgeons may better counsel patients prior to SCR. Level IV, case series.

Computational analysis of subscapularis tears and pectoralis major transfers on muscular activity

BackgroundPectoralis major is the most common muscle transfer procedure to restore joint function after subscapularis tears. Limited information is available on how the neuromuscular system adjusts to the new configuration, which could explain the mixed outcomes of the procedure. The purpose of this study is to assess how muscles activation patterns change after pectoralis major transfers and report their biomechanical implications. MethodsWe compare how muscle activation change with subscapularis tears and after its treatment by pectoralis major transfers of the clavicular, sternal, or both these segments, during three activities of daily living and a computational musculoskeletal model of the shoulder. FindingsOur results indicate that subscapularis tears require a compensatory activation of the supraspinatus and is accompanied by a reduced co-contraction of the infraspinatus, both of which can be partially recovered after transfer. Furthermore, although the pectoralis major acts asynchronously to the subscapularis before the transfer, its activation pattern changes significantly after the transfer. InterpretationThe capability of a transferred muscle segment to activate similarly to the intact subscapularis is found to be dependent on the given motion. Differences in the activation patterns between intact subscapularis and the segments of pectoralis major may explain the difficulty in adapting psycho-motor patterns during the rehabilitation period. Thereby, rehabilitation programs could benefit from targeted training on specific motion and biofeedback programs. Finally, the condition of the anterior deltoid should be considered to improve joint function.

Diagnostic performance of conventional magnetic resonance imaging for detection and grading of subscapularis tendon tear according to Yoo and Rhee classification system in patients underwent arthroscopic rotator cuff surgery.

To assess the diagnostic accuracy of conventional MRI for detecting and grading subscapularis (SSC) tears by applying the Yoo and Rhee classification. A total of 179 patients who underwent MRI followed by arthroscopic rotator cuff surgery were enrolled. Two musculoskeletal radiologists evaluated the SSC using axial, oblique sagittal, and oblique coronal MRI according to the Yoo and Rhee classification. Using arthroscopic findings as the reference standard, the sensitivity, specificity, accuracy, and interobserver agreement of SSC tears were analyzed. Arthroscopy confirmed that the numbers of type I, IIA, IIB, III, IV, and V tears were 35, 70, 35, 9, 9, and 0, respectively. The sensitivity, specificity, and accuracy of readers 1 and 2 for the detection of tears (type IIA or higher) were 85%, 75%, and 82%, and 89%, 70%, and 83%, respectively, while those for the detection of surgical candidates (type IIB or higher) were 77%, 75%, and 75%, and 77%, 83%, and 82%, respectively. The interobserver agreement for detecting SSC tear presence was substantial (κ = 0.70) for reader 1 vs. reader 2, and those for detecting the surgical candidate group was substantial (κ = 0.68) for reader 1 vs. reader 2. The interobserver agreement for grading SSC tears was excellent (κ = 0.86) for reader 1 vs. reader 2. Conventional MRI showed 82.5% and 78.5% average accuracy in detecting IIA and IIB or higher tears by applying the Yoo and Rhee classification for the diagnosis of SSC tears with an excellent interobserver agreement in tear grading.

Arthroscopic single anchor repair techniques for upper third subscapularis tears provide sufficient biomechanical stability.

Upper third tears of the subscapularis tendon can be repaired successfully with a single anchor according to previous literature. The aim of the present study was to compare three single anchor repair techniques regarding fixation strength, footprint coverage and contact pressure in a biomechanical test set-up on human cadaveric shoulders. Eighteen human cadaveric shoulders were randomized in three groups with respect to the repair technique; group 1: knotted lasso-loop mattress, group 2: knotted mattress and group 3: knotless tape repair. Upper third tears of the subscapularis tendon (Lafosse type 2) were created and repairs were performed with additional contact pressure and area measurement using a pressure mapping system. Cyclic testing was performed by loading the subscapularis from 10 to 100N for 300 cycles. A position-controlled ramp protocol up to 30 and 50N was used to allow for pressure measurements. Finally, specimens were loaded to failure and failure modes were recorded. The three groups were not significantly different regarding age, gender, bone mineral density at the lesser tuberosity, subscapularis footprint size and defect area created at the upper subscapularis insertion. A significant difference was detected between group 1 (48.6 ± 13.8%) and group 2 (25.9 ± 5.7%) regarding pressurized footprint coverage (p = 0.028). Ultimate load to failure was 630.8 ± 145.3N in group 1, 586.9 ± 220.7N in group 2 and 678.2 ± 236.5N in group 3, respectively. Cyclic displacement was similar in all three groups with an average displacement of 1.2 ± 0.6mm. The highest stiffness was found in group 1 with 88 ± 30.3, which was not statistically significantly different to group 2 (65 ± 27N/mm) and group 3 (83.9 ± 32.9N/mm). The most common mode of failure was suture cut-through at the suture-tendon interface (44%). Failures in group 3 were less common associated with suture cut-through (33% vs. 50% in group 1 and 2), but no significant differences were found. All three tested single anchor repair techniques of upper third subscapularis tears were able to provide sufficient biomechanical stability. Knotted lasso-loop mattress and knotless tape repair were superior regarding pressurized footprint coverage compared to a knotted horizontal mattress technique and are, therefore, preferable techniques for upper subscapularis repair.

Arthroscopic Revision Rotator Cuff Repair: The Role of Previously Neglected Subscapularis Tears

Background: Concomitant full-thickness tear of the subscapularis tendon is often neglected during primary posterosuperior rotator cuff repair, and its significance has not been investigated by any previous clinical study. Purpose: To investigate (1) the clinical and radiological outcomes of revision arthroscopic rotator cuff repair and (2) the number of neglected concomitant subscapularis full-thickness tears in the revision of posterosuperior rotator cuff retears and their structural integrity after repair. Study Design: Case series, Level of evidence, 4. Methods: This study retrospectively examined 58 patients who underwent arthroscopic rotator cuff revision for a retear of a previously repaired posterosuperior rotator cuff. Preoperative and postoperative functional scores and active range of motion (ROM) were assessed. The initial and most recent follow-up magnetic resonance imaging scans before revision and arthroscopic findings at the time of primary repair were reviewed to determine whether the concomitant subscapularis tear was newly developed or preexisting. Final confirmation of the tendon’s full-thickness tear was made during the revision procedure. Results: At final follow-up, mean functional shoulder scores and ROM improved significantly compared with the preoperative values (P < .001). Among the 58 revision cases, 25 (43.1%) had a neglected full-thickness tear of the subscapularis tendon. The fatty infiltration grade of the neglected subscapularis tear progressed from a mean of 1.1 before primary repair to a mean of 1.6 before revision, and the change indicated statistically significant deterioration (P < .001). Despite clinical improvement after revision surgery, the retear rate was considerable in the re-repaired cuff tendons (37.9%) as well as for the repaired concomitant subscapularis tears (24%). Conclusion: Among revision rotator cuff repairs, 43.1% had neglected subscapularis tears, and fatty infiltration of these initially neglected subscapularis tendons showed further progression at the time of revision. The retear rate after the repair of neglected subscapularis tears was higher than expected. Thus, detecting and treating subscapularis tear via meticulous preoperative evaluation and thorough inspection during primary arthroscopy are essential.

Latissimus dorsi tendon transfer for massive unrepairable rotator cuff tears: A case report

Introduction: Massive and irreparable posterior-superior rotator cuff tears present a difficult treatment problem. Chronic rotator cuff tears can cause tendon retraction and fatty atrophy of the muscles. Full-thickness rotator cuff tears involves more than one tendon cause superior migration of the humeral head in relation to the glenoid with altered glenohumeral forces, and ultimately leading to rotator cuff arthropathy. Transfer of the latissimus dorsi muscle is considered a surgical option in the treatment of younger patients without glenohumeral arthritis and with functional deficits caused by an irreparable posterior-superior rotator cuff tear.Presentation of Case: This report presents a case of Right Supraspinatus and Infraspinatus Chronic tear with Subscapularis tear. The case was chronic with non-subsidence of symptoms in spite of conservative treatment. Our treatment in this case consisted of Right Subscapularis and Infraspinatus Repair with Lattisimus Dorsi Transfer to Greater Tubercle. Post operatively ultrasling was used to keep the shoulder in neutral with slight abduction. Rehabilitation protocol was begun after 3 weeks of immobilization. Discussion: Latissimus Dorsi Tendon Transfer has been considered to be a means of restoring function and providing pain relief in patients with irreparable tears involving the infraspinatus and supraspinatus tendons in the absence of substantial glenohumeral arthritis.The aim of this case presentation is to report an example for this case, highlight the difficulties in diagnosis and the treatment options.Conclusion: The Latissimus Dorsi Tendon Transfer for irreparable postero-superior cuff deficiency in selected patients reduce pain and improve shoulder function in the medium term.

Management of Irreparable Rotator Cuff Tears: Superior Capsular Reconstruction vs. Marginal Convergence (236)

Objectives:Irreparable rotator cuff tears can be challenging to manage in younger patients who are not well indicated for reverse total shoulder replacement. Treatment options in this patient population include both marginal convergence (MC) and superior capsular reconstruction (SCR). While both treatment options have demonstrated good short term outcomes, they have vastly different associated costs and operative times. Thus, the purpose of this study was to compare range of motion (ROM), patient reported outcomes, and re-operation rates following MC and SCR. We hypothesized that SCR would outperform MC regarding functional and subjective outcomes.Methods:A retrospective review was conducted on 44 patients from two surgeons with irreparable rotator cuff tears that underwent either MC (28 patients, 28 shoulders) or SCR (16 patients, 16 shoulders) from 2014-2019 at a single academic center. Patient inclusion criteria were the following: failed conservative or prior surgical management, no or mild glenohumeral arthritis, Goutallier grade 3 or 4 fatty infiltration of the involved muscles, Hamada grade 1 or 2 rotator cuff arthropathy, intact or repairable subscapularis tear and minimum of 1 year follow-up. Visual Analogue Scale (VAS) for pain, active forward flexion (FF) and external rotation (ER) range of motion, reoperation rate, and rate of conversion to reverse total shoulder arthroplasty were evaluated. For statistical analysis, t-tests were used to determine differences in functional outcomes and VAS, while Chi-Squared tests were used to determine differences in the rate of re-operation and conversion to arthroplasty (*p < 0.05).Results:The mean age at the time of surgery for the MC and SCR groups was 64.4 and 58.5 years, respectively, with an average follow-up of 31.5 months for the MC group and 17.8 months for the SCR group. There were no significant differences in the mean age at the time of surgery, gender, body mass index, pre-operative FF and ER, and pre-operative VAS between the groups. The MC group did not have a significant improvement FF with a mean pre-operative FF of 144.4°(range: 30-170°) and post-operative FF of 150.5°(range: 90-180). The same was true for the SCR group, with a mean pre-operative FF 127.5°(range: 40-170°) and post-operative FF of 146.3°(range: 40-170). There was also no significant improvement in ER post-operatively in either group. Both the MC and SCR group had significant improvements in VAS for pain from an average of 7.3 (range: 1-10) pre-operatively to 2.5 (range: 0-10) post-operative for the MC group (p < 0.01) and from 7.3 (range: 3-10) pre-operatively to 1 (range: 0-4) post-operative for the SCR group (p < 0.01). There were no significant differences in the post-operative FF or ER, change in FF or ER, post-operative VAS, or change in VAS between the two treatment groups. The rate of conversion to arthroplasty was not significantly different between the groups at 3.6% for the MC group and 12.5% for the SCR group. Additionally, the overall reoperation rate was not significantly different between the MR and SCR groups at 10.7% and 12.5%, respectively.Conclusions:There were no significant differences between the MC and SCR treatment groups. While both MC and SCR were effective in improving VAS for pain, neither treatment consistently resulted in significant improvement in ROM. Further studies with long term outcomes are needed to determine if there are certain indications for which one treatment results in better outcomes.

Ultrasound of the symptomatic shoulder arthroplasty: Spectrum and prevalence of periarticular soft tissue pathology.

To describe our experience using ultrasound (US) to evaluate postoperative complications in the presence of in situ shoulder arthroplasty. Review of patients who underwent US evaluation following total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RTSA) or hemiarthroplasty from 2007 to 2020. All studies were reviewed independently by two musculoskeletal radiologists to assess for joint effusion, periarticular collection, and characterization of associated rotator cuff tears. Tendon tears were assessed with respect to (1) thickness: low grade (<50% thickness), high grade (>50% thickness), full thickness; (2) morphology (focal vs. diffuse) and location (insertion vs. critical zone). Inter-reader agreements were determined using Cohen's kappa test. Ninety-seven studies were performed in 72 patients following TSA, RTSA, or hemiarthroplasty. Thirty-seven exams were solely for diagnostic purposes, and 59 were for guiding joint or periarticular collection aspiration. Twenty-eight studies assessed the cuff tendons post TSA. The mean time between surgery and US examination was 29.2 months. Complete or high-grade tears were identified in 8/28 (28.6%) diagnostic exams. The most commonly torn tendon among TSA patients was the subscapularis, with 13/28 (46.4%) demonstrating at least partial tearing. Inter-reader agreement was excellent for presence of effusion (k=0.79, p < .001) and periarticular collection (k=0.87, p < .001), and excellent agreement for presence of subscapularis tear (k=0.78, p < .001), with fair agreement for assessment of supraspinatus (k=0.66, p < .001) and infraspinatus (k=0.60, p < .001) tears. The most commonly torn tendon following anatomic TSA identified by US was the subscapularis, which was torn or deficient in 46.4% of cases. The majority of studies were performed for the guidance of percutaneous aspiration.

Diagnostic Accuracy of Clinical Tests for Subscapularis Tears: A Systematic Review and Meta-analysis

Background:Previous systematic reviews and meta-analyses on the diagnostic accuracy of shoulder clinical tests do not reach conclusions regarding subscapularis tears.Purpose:To compare the diagnostic accuracy of commonly used clinical tests for subscapularis tears.Study Design:Systematic review; Level of evidence, 3.Methods:An electronic literature search was conducted using Medline, Embase, and the Cochrane Library/Central. Eligibility criteria were original clinical studies reporting the diagnostic accuracy of clinical tests to diagnose the presence of rotator cuff tears involving the subscapularis.Results:The electronic literature search returned 2212 records, of which 13 articles were eligible. Among 8 tests included in the systematic review, the lift-off test was most frequently reported (12 studies). Four tests were eligible for meta-analysis: bear-hug test, belly-press test, internal rotation lag sign (IRLS), and lift-off test. The highest pooled sensitivity was 0.55 (95% CI, 0.28-0.79) for the bear-hug test, while the lowest pooled sensitivity was 0.32 (95% CI, 0.13-0.61), for the IRLS. In all tests, pooled specificity was >0.90.Conclusion:Among the 4 clinical tests eligible for meta-analysis (bear-hug test, belly-press test, IRLS, and lift-off test), all had pooled specificity >0.90 but pooled sensitivity <0.60. No single clinical test is sufficiently reliable to diagnose subscapularis tears.Registration:PROSPERO (CRD42019137019).

Medium- to long-term clinical and functional outcomes of isolated and combined subscapularis tears repaired arthroscopically.

IntroductionThe purpose of this study was twofold. First, the efficacy of arthroscopic repair in patients with full thickness, isolated subscapularis tendon tears (I-STTs) or combined subscapularis tendon tears (C-STTs) involving the rotator cuff tendons was evaluated. Second, the outcomes between these two groups were compared. The influence of age and gender on the cohort clinical outcomes was also analysed. Our hypothesis was that satisfactory functional results could be obtained arthroscopically in both groups without any influence of age or gender.Material and methodsSeventy-nine patients were enrolled: 15 with I-STTs and 64 with C-STTs. The clinical outcomes were assessed using Constant and Disabilities of the Arm, Shoulder and Hand (DASH) scores, Numeric Rating Scale (NRS) for pain and Visual Analogue Scale (VAS) for satisfaction. The subscapularis strength was assessed using a comparative dynamometric bear-hug test. Group outcomes were compared, including statistical analysis.ResultsFor each group, there were no differences regarding the subscapularis strength of the operated and non-operated shoulders. A comparison of the post- with the pre-operative outcomes showed an increase in the Constant score and a decrease in the NRS. Comparing the two groups, we found no difference in strength of the operated and non-operated shoulders, but a significant difference in relation to pre-operative Constant score and pre-operative NRS. Age was negatively correlated with both pre-operative and post-operative Constant scores. No association was found between gender and the outcomes, although the DASH score was higher in women.ConclusionsArthroscopic repair of STTs provided functional restoration, pain relief and patient satisfaction in both groups. Age and gender did not affect the clinical outcomes achieved by arthroscopic STT repair.

Full-Thickness Rotator Cuff Tears Can Be Safely Treated With a Resorbable Bioinductive Bovine Collagen Implant: One-Year Results of a Prospective, Multicenter Registry

PurposeThe purpose of this study was to prospectively collect safety and efficacy data in a large group of patients undergoing arthroscopic repair of full-thickness rotator cuff tears augmented with a resorbable bioinductive bovine collagen implant designed to promote healing.MethodsSeventeen centers across the United States enrolled patients in an institutional review board-approved registry to collect outcomes data on the implant. Patients undergoing surgical management of full-thickness rotator cuff tears augmented with the implant were enrolled. Inclusion criteria were age of ≥21 years, willingness to participate and the ability to read and speak English. Exclusion criteria included hypersensitivity to bovine-derived products. Patients were assessed before and after surgery at up to 1 year with outcomes including the single-assessment numeric evaluation (SANE), Veterans RAND 12-Item (VR-12) mental components and physical components (VR-12 PCS), American Shoulder and Elbow Surgeons (ASES), and Western Ontario Rotator Cuff (WORC) outcome measures. Ad hoc analyses were performed to compare these outcomes at all time points depending on tear size (small/medium vs large/massive). Serious complications were collected.ResultsOf 210 patients enrolled, 192 had 1-year follow-up data available. The patients experienced statistically significant improvement between baseline and 1 year for mean SANE, VR-12 PCS, ASES, and WORC scores (40.0-82.0, 33.5-47.3, 46.2-87.8, and 36.2-81.0, respectively; P < .001 for all results). Ad-hoc analysis demonstrated that similar results were obtained at 1 year regardless of tear size. Twenty patients (10.4%) experienced serious complications (10.4%), including revision surgery (n = 18), proximal humerus fracture/partial subscapularis tear resulting from multiple falls (n = 1), and adhesive capsulitis (n = 1).ConclusionsThe safety and efficacy of a bioinductive implant in the surgical management of full-thickness rotator cuff tears at 1 year was shown in this study. Implant efficacy appears to be comparable regardless of the underlying tear size.Level of EvidenceLevel IV, therapeutic case series.