Superior Rotator Cuff Research Articles

Correlations Between Different Types of Posterior Superior Rotator Cuff Tears and Myoarchitecture: Insights from Magnetic Resonance Imaging

Correlations Between Different Types of Posterior Superior Rotator Cuff Tears and Myoarchitecture: Insights from Magnetic Resonance Imaging

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

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

Clinical outcomes of arthroscopic superior capsule reconstruction in patients aged over 70 with irreparable rotator cuff tears

BackgroundArthroscopic superior capsule reconstruction (SCR) was developed to restore superior shoulder stability, muscle balance, and function after irreparable posterior–superior rotator cuff tears. The purpose of this study was to investigate whether favorable clinical outcomes after SCR for irreparable rotator cuff tears would be obtained in patients older than 70 years. MethodsA total of 173 consecutive shoulders in 162 patients who underwent arthroscopic SCR using autografts of fascia lata for irreparable rotator cuff tears were allocated to three groups according to patient age at the time of surgery: Group 1, <55 years old (11 shoulders); Group 2, 55 to 70 years old (85 shoulders); and Group 3, >70 years old (77 shoulders). American Shoulder and Elbow Surgeons (ASES) and Japanese Orthopaedic Association (JOA) scores, active shoulder range of motion (ROM), and visual analog scale (VAS) were evaluated before surgery and at the final follow-up. Postoperative complications, including graft tears in MRI and donor-site morbidity, were assessed. ResultsThe mean follow-up was 3 years and 9 months. Both ASES and JOA scores and active ROM (elevation, external rotation, and internal rotation) increased significantly after arthroscopic SCR in all three groups (P < .001), and VAS decreased significantly. All three groups had low graft tear (6%–10%) and donor site morbidity (0%–1%) rates, with no significant difference among the groups. ConclusionArthroscopic SCR can lead to functional improvement and pain relief with a low rate of complications regardless of patient age.

Increased latissimus dorsi and teres major muscle volume after anterior transfer for irreparable anterior superior rotator cuff tear: correlation with improved internal rotation strength.

While the well-established correlation between increased muscle volume and enhanced muscle strength is widely recognized, there have been no studies assessing volumetric muscle changes in transfer surgery in the shoulder. This study aimed to evaluate changes in transferred muscle volume and their clinical implications in anterior latissimus dorsi and teres major (aLDTM) tendon transfer in patients with anterior superior irreparable rotator cuff tears (ASIRCTs). The study retrospectively examined 40 patients who underwent aLDTM tendon transfers for ASIRCTs between August 2018 and January 2022. Using ImageJ software, the LDTM muscle was segmented in T2-weighted oblique axial images, and total muscle volume (tLDTMV) of both immediate and postoperative 1-year were calculated. Pearson correlation analysis was used to determine the correlation between ΔtLDTMV and ΔASES scores, Δactive-ROM, and Δstrength. The current study revealed an 11.4% increase in tLDTMV at 1-year postoperative. Patients were grouped based on postoperative ASES score: Group 1 (Optimal, n = 17) and Group 2 (Suboptimal, n = 23). Although tLDTMVimmediate postoperative values were similar between groups (P = 0.954), tLDTMV1-year postoperative value was significantly higher in Group 1 compared to Group 2 (P = 0.021). In correlation analysis, ΔtLDTMV showed significant correlations with ΔASES score (r = 0.525, P < 0.001), ΔaROM of forward elevation (FE) (r = 0.476, P = 0.002), ΔaROM of internal rotation (IR) at back (r = 0.398, P = 0.011), Δstrength of FE (r = 0.328, P = 0.039), Δ strength of IR at 90° abduction (r = 0.331, P = 0.037), and IR at side (r = 0.346, P = 0.029). Significant increase in tLDTMV was observed at 1-year postoperative for ASIRCT patients. Notably, greater ΔtLDTMV exhibited a correlation with better ASES scores, increased aROM and strength in both FE and IR. Nevertheless, further research is required by employing more robust standardized measurement tools and a larger sample size.

Muscle activation patterns during active external rotation after reverse total shoulder arthroplasty: an electrophysiological study of the teres minor and associated musculature

Preoperative teres minor insufficiency has been identified as a risk factor for poor restoration of external rotation (ER) after reverse total shoulder arthroplasty (RTSA). However, there has been little investigation regarding muscle activation patterns generating ER. This prospective study sought to determine the timing and activation levels of the shoulder girdle musculature during ER in well-functioning RTSAs with an intact teres minor using a lateralized design. Patients who underwent RTSA ≥1 year previously with functional ER, an American Shoulder and Elbow Surgeons (ASES) score >70, superior rotator cuff deficiency, and an intact teres minor were identified. Electrophysiological and kinematic analyses were performed during ER in the modified neutral position (arm at side with 90° of elbow flexion) and in abduction (AB) (shoulder abducted 90° with 90° of elbow flexion). Dynamometer-recorded torque and position were pattern matched to electromyography during ER. The root-mean-square and integrated electromyography (in microvolts × milliseconds with standard deviation [SD]), as well as median frequency (MF) (in hertz with SD), were calculated to determine muscle recruitment. Pair-wise t test analysis compared muscle activation (P<.05 indicated significance). After an a priori power analysis, 16 patients were recruited. The average ASES score, visual analog scale pain score, and ASES subscore for ER in AB ("comb hair") were 87.7, 0.5, and 2.75 of 3, respectively. In AB, muscle activation began with the upper trapezius, middle trapezius, and latissimus dorsi, followed by the anterior deltoid activating to neutral. With ER beyond neutral, the teres major (9.6 μV × ms; SD, 9.2 μV × ms) initiated ER, followed by the teres minor (14.1 μV × ms; SD, 18.2 μV × ms) and posterior deltoid (11.1 μV × ms; SD, 9.3 μV × ms). MF analysis indicated equal contributions of the teres major (1.1 Hz; SD, 0.5 Hz), teres minor (1.2 Hz; SD, 0.4 Hz), and posterior deltoid (1.1 Hz; SD, 0.4 Hz) in ER beyond neutral. In the modified neutral position, the upper trapezius and middle trapezius were not recruited to the same level as in AB. For ER beyond neutral, the teres major (9.5 μV × ms [SD, 9 μV × ms]; MF, 1.1 Hz [SD, 0.5 Hz]), teres minor (11.4 μV × ms [SD, 15.1 μV × ms]; MF, 1.1 Hz [SD, 0.5 Hz]), and posterior deltoid (8.5 μV × ms [SD, 8 μV × ms]; MF, 1.2 Hz [SD, 0.3 Hz]) were activated in similar sequence and intensity as AB. No differences in muscle activation duration or intensity were noted among the teres major, teres minor, and posterior deltoid (P>.05). Active ER after RTSA is complex and is not governed by a single muscle-tendon unit. This study establishes a sequence, duration, and intensity of muscle activation for ER in well-functioning RTSAs. In both tested positions, the teres major, teres minor, and posterior deltoid function equally and sequentially to power ER.

Outcomes after arthroscopically assisted lower trapezius transfer with Achilles tendon allograft

Lower trapezius tendon transfer is 1 option to improve pain and function with massive irreparable rotator cuff tears. Magnetic resonance imaging (MRI) evaluation of tendon healing with the procedure has not yet been reported. The purpose of this study was to evaluate early tendon transfer healing using postoperative MRI scans and to assess early clinical outcomes in patients after arthroscopically assisted lower trapezius tendon transfer (AALTT) for massive irreparable rotator cuff tears. This was a single institution retrospective review of consecutive patients with massive irreparable rotator cuff tears who underwent AALTT with a single surgeon from January 2017 to July 2020 with a minimum 6-month follow-up. Patient information including age, sex, follow-up, prior surgical history, and type of work (sedentary or labor-intensive) was recorded. Preoperative and postoperative range of motion, external rotation strength, presence of a lag sign, and pain visual analog scale data were extracted from medical records. Patient-reported outcomes were extracted from patient charts. Six-month postoperative MRIs were reviewed for tendon transfer healing at both the greater tuberosity and the trapezius-allograft interface. A total of 19 patients met inclusion criteria with average age 56.7 (range, 29-72years). Of these patients, 17 (89.5%) were male. The average follow-up was 14.6 (range, 6-45) months. Fifteen (78.9%) patients had unsuccessful previous rotator cuff repair. Six-month MRI demonstrated complete healing of the transferred tendon in 17 of 19 patients (89.5%). There were significant improvements in postoperative pain visual analog scale (5.9±2 vs. 1.8±2), ASES score (44.6±18 vs. 71.2±24), and Patient Reported Outcomes Measurement Information System Physical (46.3±6 vs. 51.3±11) and in external rotation motion (10.5±17° vs. 40.5±13°) and strength (2.8/5±1 vs. 4.7/5±0.5) at final follow-up. All patients with a preoperative external rotation lag sign had reversal of their lag sign at final follow-up (15/15). Of 17 work-eligible patients, 13 (76.4%) were able to return to work. In this series, AALTT showed a high rate of healing of the transferred tendon on MRI by 6months postoperatively. The current findings of a high rate of early tendon transfer healing are consistent with the good early and mid-term outcomes that have been observed in AALTT and provide support for surgeon and patient expectations, postoperative rehabilitation, and return to work following AALTT for massive posterior superior rotator cuff tears.

Evaluation of the Painful Total Shoulder Arthroplasty.

Despite the overall success of anatomic and reverse total shoulder arthroplasties (aTSA and rTSA), some patients continue to have or develop pain postoperatively. As the number of shoulder arthroplasties continues to increase in the United States, it is important that surgeons are able to recognize, diagnose, and treat the various pathologies. Some painful etiologies are specific to either aTSA or rTSA, and others can occur with both implant types. Infections, stiffness, neurologic syndromes, polyethylene wear, aseptic implant loosening, and metal allergies occur, regardless of implant choice. However, after an aTSA, subscapularis repair failure, superior rotator cuff tear, and joint overstuffing can result in shoulder pain. After a rTSA, specific causes of postoperative pain include instability, scapular notching, acromial or scapular spine fractures, subcoracoid pain, and neurologic injury. Regardless of the diagnosis, the surgeon must be methodical in the evaluation and, when appropriate, use blood work, advanced imaging studies, joint aspirations, shoulder arthroscopy, and nerve studies. Once diagnosed, appropriate treatment should be undertaken to resolve the cause of the pain or at least minimize the effect of the pain on the patient's outcome.

“Functional outcomes and MRI-based tendon healing after (antero-) superior rotator cuff repair among patients under 50 years: retrospective analysis of traumatic versus non-traumatic rotator cuff tears”

BackgroundRotator cuff tears among patients under 50 years either result from an adequate trauma or are considered non-traumatic due to work-related or athletic overuse. The impact of these different mechanisms on postoperative functional outcomes and tendon healing has not yet been fully understood. Therefore, it was the purpose of this study to investigate the influence of etiology of (antero-)superior rotator cuff tears on postoperative outcomes and the healing rates after arthroscopic rotator cuff repair in a young patient population.MethodsPatients under 50 years who underwent arthroscopic rotator cuff repair between 2006–2017 for an anterosuperior rotator cuff tear with a minimum follow up of 24 months were included in this study. Revision surgeries or reconstructive concomitant procedures other than long head of the biceps tenodesis were excluded. Patients were divided into two groups according to the etiology of their rotator cuff tear (traumatic vs. non-traumatic). Demographic and outcome scores including the American Shoulder and Elbow Surgeons (ASES) score, the Constant Score (CS), bilateral strength measurements and postoperative tendon integrity evaluated on magnetic resonance imaging (MRI) were assessed and compared between both groups.ResultsThe mean follow up for this study was 55.6 months (24 – 158). Twenty-one patients (50.0%) had a traumatic RCT and 21 patients (50.0%) had a non-traumatic tear. Outcome scores did not differ significantly between groups. Strength measurements of the supraspinatus revealed significantly decreased force of the affected side as opposed to the contralateral side (p = 0.001), regardless of etiology. Retear rates were similar in both groups (37.5% and 33.3%, p = n.s.). Cuff integrity at follow-up was not predictive of superior scores or strength.ConclusionSurgical treatment of traumatic and non-traumatic RCT yields good clinical results in patients under the age of 50. The etiology of the rotator cuff tear did not significantly affect postoperative outcomes or healing rates. About one third of the patients suffered from a retear postoperatively, however retears were not predictive of inferior outcomes at midterm follow-up.Study designLevel III.Trial registrationRetrospectively registered.

The Utility of Lower Trapezius Transfers in Massive Irreparable Posterior- Superior Rotator Cuff Tears

The Utility of Lower Trapezius Transfers in Massive Irreparable Posterior- Superior Rotator Cuff Tears

Determination of rotator cuff tear reparability: an ultrasound-based investigation.

The use of ultrasound as a viable diagnostic tool for routine office visit evaluation of rotator cuff integrity is slowly gaining acceptance in orthopedic practice. However, the reliability of accurately assessing rotator cuff tear reparability by ultrasound has limited evidence in the literature. The purpose of this study was to compare preoperative assessment of cuff tear reparability via ultrasound with the arthroscopic determination of reparability at the time of surgery. We prospectively collected preoperative ultrasound and arthroscopic imaging data on 145 patients (80 or 55% men and average age of 60.7 years) who underwent arthroscopic posterior superior rotator cuff repair. Three independent experienced orthopedic surgeons retrospectively reviewed all ultrasound studies and arthroscopic imaging and determined if the posterior superior rotator cuff tendon edge was able to be viewed via ultrasound and determined with the arthroscopic images if the tear was reparable. On review of the ultrasound and arthroscopic data, if the edge of the rotator cuff tendon was able to be viewed on the coronal ultrasound image, it was most likely reparable with a positive predictive value of 97.6% and a positive likelihood ratio of 5.8. Sensitivity was 84.4%, and specificity was 76.9%. The negative predictive value was 37.5%, and the negative likelihood ratio was 0.17. The interobserver reliability was 0.63, and the observers were unanimous in determining the tendon edge was able to be visualized in 99 of 145 cases (68%). Preoperative ultrasound evaluation of the shoulder for posterior superior rotator cuff tears is a useful tool for assessing rotator cuff integrity and may help predict intraoperative reparability of the tendon. This study demonstrates that if the cuff tear edge is able to be visualized, there is a high probability of successful arthroscopic restoration of the tendon to its native attachment. Conversely, if the tear edge is unable to be visualized, there is a moderate chance of the tear being irreparable. These results help expand the knowledge base of the usefulness of in-office ultrasound performed by the surgeon in predicting the results of surgical intervention for rotator cuff tears.

Radiological and clinical evaluation of long head of biceps tendon function in the glenohumeral joint.

The aim of the study was to investigate the relationship between biceps pathologies and radiological measurements in massive rotator cuff tears treated arthroscopically. Between December 2015 and December 2018, a total of 145 patients (56 males, 89 females; mean age: 62.2±9.7 years; range, 28 to 87 years) with supraspinatus and/or infraspinatus full-thickness tear larger than 3 cm and who underwent arthroscopic rotator cuff repair were retrospectively analyzed. Biceps pathologies detected during arthroscopy were divided into four groups. Group 1: biceps tendinitis or without biceps pathology; Group 2: biceps partial/degeneration tear; Group 3: biceps dislocation/instability; Group 4: complete biceps head rupture. Radiological measurements were calculated from the preoperative magnetic resonance imaging and anteroposterior X-ray images of the patients. A total of 65.5% of the lesions were on the right arm and 34.5% were on the left arm. All patients had posterior superior rotator cuff tears which could be surgically repaired. A total of 22.1% of the patients had no biceps tendinitis/biceps pathology, 20.7% had biceps instability/dislocation, 28.3% had biceps degeneration/partial rupture, and 29% of patients had biceps total rupture. Patients in Group 4 had a statistically significantly higher superior migration of the humeral head distance (p=0.012) than Group 2, and patients in Group 2 had a statistically significantly higher coracohumeral distance (p=0.042) than patients in Group 4. There was no significant difference in the other measurements among the groups. The long head of the biceps, of which function has not yet been clearly elucidated, is one of the superior and anterior stabilizing forces of the humeral head.

A Longitudinal Analysis of the Internal Rotation and Shift (IRO/Shift) Test Following Arthroscopic Repair of Superior Rotator Cuff Lesions.

Although the use of clinical tests to diagnose superior rotator cuff pathology is common, there is paucity in the research regarding the accuracy of such tests following arthroscopic repair. The aim of this study was to determine the accuracy of the IRO/Shift test compared to the Jobe test at 3 months and 6 months post-surgery for superior rotator cuff repair. Arthroscopic repair was conducted on 51 patients who were subsequently seen for clinical evaluation at 3 and 6 months following surgery. At 3 months post-surgery only 27% of the patients had a negative IRO/Shift test and 18% had a negative Jobe test. However, at 6 months 88% of the patients presented with a negative IRO/Shift test and 61% a negative Jobe test. When compared to each other, the IRO/Shift test and the Jobe test had 90% agreement pre-operatively, 71% agreement at 3 months post-surgery, and 67% agreement at 6 months. These results demonstrate that the accuracy of the IRO/Shift test and the Jobe test improved between 3 and 6 months following arthroscopic surgery of the superior rotator cuff, with the IRO/Shift test having better accuracy.

The effect of postoperative sling immobilization and early mobilization on clinical and functional outcomes after arthroscopic rotator cuff repair: A propensity score-matched analysis.

Optimal postoperative management is controversial after arthroscopic rotator cuff repair (ARCR). The aim of the study was to evaluate outcomes of patients with and without postoperative sling immobilization after undergoing arthroscopic RCR rotator cuff repair. 369 arthroscopic full thickness superior rotator cuff tears (RCT) with a minimum follow-up of 6 months were included in this study. Propensity score matching was performed for age, sex, BMI, and tear size. Pain (VAS score), shoulder range of motion (ROM), functional outcome (ASES, Constant-Murley [CM] and Oxford shoulder score [OSS]), and health related quality of life (SF-36) scores were compared between patients with and without sling immobilization. According to the propensity match score, 92 patients (50 sling immobilization and 42 no sling immobilization) were matched to be almost identical in age (62.5 ± 8.0 vs. 61.8 ± 5.9), sex (female 78% vs. 76.2%), BMI (28.1 ± 2.8 vs. 27.8 ± 2.6), and tear size (2.7 ± 1.1 vs. 2.9 ± 0.8). The postoperative physical functioning domain of SF-36 scores was found to be significantly higher in the no sling group (p= 0.034). Early mobilization after arthroscopic small and medium sized full thickness superior rotator cuff repair is associated with improved ROM and quality of life scores.

Outcomes of combined anterior latissimus dorsi and teres major tendon transfer for irreparable anterosuperior rotator cuff tears.

Irreparable anterosuperior rotator cuff tears (IASRCTs) can result in loss of active elevation, loss of internal rotation, and pseudoparalysis. Joint-preserving treatment options for IASRCTs in young and high-demand elderly patients are limited. The purpose of this study was to evaluate the clinical and radiologic outcomes of combined anterior latissimus dorsi and teres major (aLDTM) tendon transfer in patients with IASRCTs without reconstruction of the superior rotator cuff and capsular portion. This retrospective study was conducted between 2015 and 2018. We included patients who underwent combined aLDTM tendon transfer for IASRCTs. Clinical outcomes included visual analog scale for pain, Constant score, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder scores, activities of daily living requiring active internal rotation score, active range of motion, subscapularis-specific physical examination, and rate of return to work. Radiographic analyses included the assessment of acromiohumeral distance, Hamada grade for cuff tear arthropathy, rate of anterior glenohumeral subluxation reduction, and transferred tendon integrity at 2years postoperatively. The mean follow-up period was 38.1±13.7 (range: 24-63) months. Of the patients, 30 (mean age: 64.1years) met the study criteria. Postoperatively, mean Constant, American Shoulder and Elbow Surgeons, University of California Los Angeles, and activities of daily living requiring active internal rotation scores improved from 47.4 to 69.9 (P<.001), 44.9 to 79.2 (P<.001), 20.0 to 28.7 (P<.001), and 13.2 to 26.9 (P<.001), respectively. The mean active range of motion was significantly increased postoperatively for both forward elevation (P<.001) and internal rotation at the back (P<.001). Of the patients, 24 (83%) returned to their previous work. No significant progression of cuff tear arthropathy was observed at final follow-up (Hamada grade: preoperative 1.3 ± 0.5 to postoperative 1.5 ± 0.7; p=0.155). Fifteen of 30 patients (50%) restored the anterior glenohumeral subluxation that was apparent preoperatively. One patient presented with transient axillary nerve palsy after surgery. Two patients presented with partial nonretracted tears of the transferred tendon. This minimum 2-year follow-up study demonstrated that combined aLDTM tendon transfer without reconstruction of the superior rotator cuff and capsular portion was a viable treatment option with favorable clinical and radiologic outcomes for patients with IASRCTs.

Bubble Sign: An Arthroscopic Technical Trick to Differentiate Between Partial- and Full-Thickness Rotator Cuff Tears

Distinguishing between partial-thickness and small focal full-thickness tears of rotator cuff may be important for determining the appropriate surgical treatment options and repair constructs in the care of patients with rotator cuff pathology. This article presents a simple intraoperative technical trick to aid in identification of small full-thickness tears of the superior rotator cuff. The relatively higher-pressured subacromial space and the low-pressured glenohumeral joint are separated by the supraspinatus tendon. When this barrier is compromised due to a full-thickness tear, free fluid flows from high to low pressure down the native pressure gradient. This is seen as the movement of air bubbles into the glenohumeral joint from the subacromial space and can be used to identify the presence of a full-thickness rotator cuff tear on diagnostic arthroscopy.

Effect of Abduction Brace Wearing Compliance on the Results of Arthroscopic Rotator Cuff Repair

Background:The benefit of protective bracing after rotator cuff reconstruction has been debated for many years, although immobilization compliance has never been assessed objectively to date. In a previous study, compliance with the wearing of an abduction brace was measured for the first time with use of temperature-sensitive sensors. The purpose of the present follow-up study was to assess the effect of immobilization compliance on tendon-healing after rotator cuff repair.Methods:The clinical and radiographic outcomes for 46 consecutive patients with objectively assessed abduction brace wearing compliance after arthroscopic repair of a superior rotator cuff tear were prospectively analyzed. Rotator cuff integrity was examined with ultrasound. Clinical outcomes were assessed with the relative Constant-Murley score (RCS), the Subjective Shoulder Value (SSV), and pain and patient satisfaction ratings. Receiver operating characteristic (ROC) curves were used to determine the optimal cutoff value of abduction brace compliance for discriminating between shoulders that will and will not have a retear and the association of compliance with the failure of rotator cuff repair.Results:After a mean duration of follow-up of 20 ± 9 months, the odds ratio for having a rotator cuff repair failure was 13-fold higher for patients with a compliance rate of <60% (p = 0.037). The retear rate was 3% (1 of 35 patients) in the high-compliance cohort (≥60% compliance) and 27% (3 of 11) in the low-compliance cohort (<60% compliance) (p = 0.037). No differences in RCS, SSV, pain, or postoperative patient satisfaction were observed between patients with ≥60% compliance and those with <60% compliance.Conclusions:Patients with a compliance rate of <60% had a 13-fold increase in the risk of rotator cuff retear. The 2 patients with the lowest compliance rates (11% and 22%) both had retears. Due to the small sample size, no final conclusions can be drawn regarding the influence of immobilization compliance on tendon-healing after rotator cuff repair. These findings justify a prospective trial with a larger cohort to confirm or disprove the value of compliance with abduction bracing.Level of Evidence:Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The internal rotation and shift-test for the detection of superior lesions of the rotator cuff: reliability and clinical performance.

BackgroundUsing reliable and valid clinical tests are essential for proper diagnosis and clinical outcomes among injuries involving the rotator cuff. The addition of a new clinical examination test could improve the clinical diagnosis and informative value of the sensitivity and specificity of pathology. This study of diagnostic accuracy evaluated the use of a new rotator cuff test, called the internal rotation and shift-test (IRO/shift-test), to determine its reliability and clinical performance (sensitivity, specificity, positive (PPV)/negative predictive value (NPV)). Clinical diagnostic outcomes were confirmed with radiological findings (MRI).Methods100 patients from a specialized shoulder unit participated (64 male, 36 female, mean age: 55 ± 13.5 years). A single-blinded (no knowledge of prior clinical or technical diagnostics) study design was used with two experienced physicians performing the IRO/shift-test. For clinical performance, all clinical testing was compared with MRI.ResultsThe intra-rater (ICC = 0.73, 95% CI: 60-82) and inter-rater (ICC = 0.89, 95% CI: 81-94) coefficients for the IRO/shift-test showed good-to-excellent reliability. 75% of the patients showed a positive IRO/shift-test, while 65% had a radiologically diagnosed superior rotator cuff tear. 60% of these patients had both a positive IRO/shift-test and objective rotator cuff tear via MRI. The sensitivity of the IRO/shift-test to detect superior rotator cuff lesions based on MRI diagnosis was calculated at 92% (95% CI: 86-99%), while specificity was 67% (95% CI: 50-84%). Predictive values were also found to be high with 86% PPV (95% CI: 78-94%) and 80% NPV (95% CI: 64-96%).ConclusionOur results demonstrate that the IRO/shift-test is a reliable and valid tool for assessing superior rotator cuff pathology. With good-to-excellent intrarater and inter-rater reliability and strong sensitivity and specificity this test should be considered a valuable addition to clinicians’ cadre of clinical evaluation tools.

Arthroscopic Long Head of the Biceps Transposition for Superior Capsular Augmentation Results in Comparable Clinical Outcomes to Arthroscopic Partial Repair for Irreparable Rotator Cuff Tears

PurposeTo describe a modified arthroscopic technique of long head of biceps transposition (LHBT) for superior capsular augmentation; to investigate the outcomes and effectiveness of LHBT in patients with irreparable rotator cuff tears; and to compare the results with those of arthroscopic partial repair (APR) after a 2-year minimum follow-up.MethodsWe retrospectively reviewed patients who underwent arthroscopic repair of large to massive superior rotator cuff tears. The inclusion criteria were an irreparable rotator cuff with inability of the tendon to reach the original footprint and postoperative follow-up for a minimum of 2 years. We investigated 22 patients followed up for 30.7 months (mean); 10 patients underwent isolated partial repair and 12 patients underwent LHBT combined with partial repair. The acromiohumeral interval (AHI) was measured using anteroposterior radiographs. Cuff integrity was defined using Sugaya’s classification 2 years postoperatively. Clinical outcomes were assessed preoperatively and during postoperative follow-up (minimum 2 years) using the American Shoulder and Elbow Surgeons and University of California, Los Angeles shoulder rating scales.ResultsPostoperative functional scores significantly improved in both groups. In the LHBT group, both American Shoulder and Elbow Surgeons and University of California, Los Angeles scores significantly improved postoperatively from 52.0 ± 14.6 to 89.3 ± 10.4 points (P = .002) and 15.2 ± 2.2 to 32.5 ± 2.6 points (P = .002), respectively. In addition, the AHI at the final follow-up was significantly greater in the LHBT group (7.5 ± 2.0 mm) than in the APR group (5.8 ± 1.9 mm) (P = .032). The retear rate, forward flexion, and postoperative functional scores at the final follow-up were better in the LHBT group; however, the intergroup differences were not statistically significant.ConclusionsArthroscopic LHBT for irreparable rotator cuff tears showed comparable clinical outcomes and improvement in postoperative AHI compared with APR after a minimum 2-year follow-up.Level of EvidenceLevel III, retrospective comparative trial.

Arthroscopic superior capsule reconstruction using semitendinosus tendon autograft for irreparable rotator cuff tears: Preliminary results

BackgroundTo examine prospectively the functional and structural results of arthroscopic superior capsule reconstruction using semitendinosus tendon autograft for irreparable superior rotator cuff tears. Methods5 patients (40.8 months average follow-up) were evaluated clinical preoperatively and at the end of the follow-up. Magnetic resonance imaging (MRI) was used preoperatively and at 12 months. ResultsThe mean ASES and the Constant scores increased from 56.2 to 92 and 46.8 to 82.8. The MRI showed continuity of the ligamentoplasty. ConclusionsGiven the small number of cases, few conclusions can be drawn. Nonetheless, the results regarding this technique may be considered promising. Level of evidenceLevel IV; Case series; Treatment Study.

Biomechanical Comparison of a Prepared Thick Fresh Frozen Irradiated Fascia Lata Allograft to the Native Superior Capsule (212)

Objectives:Superior Capsule Reconstruction (SCR) has been described as treatment option for irreparable tears of the superior rotator cuff. Reported outcomes on the success of the surgery have been variable, with graft choice seeming to be one of the most important factors. Fascia Lata (FL) allograft has been proposed as a potential option as it provides adequate graft thickness while avoiding the morbidity of an autograft harvest. The purpose of this study was to compare the biomechanical characteristics of an SCR with FL allograft (FL-SCR) to a native superior capsule in a cadaveric specimen.Methods:Eight cadaver shoulder specimens were used. Each specimen was tested with a custom shoulder system twice. Initial testing was performed after the specimen was dissected of all soft tissue except for the native superior capsule. Subsequent testing was performed after FL-SCR was done. All allografts were fresh frozen and irradiated. Capsule and graft dimensions were recorded before testing. Biomechanical values recorded were cyclic and load to failure for both the native capsule and FL-SCR, and fixation displacement for the SCR-FL construct. A Paired T-test was performed to compare the biomechanical values of the native superior capsule to the FL-SCR.Results:The mean thickness of the NSC was 2.4 ± 0.6 mm and 7.4 ± 1.2mm for the FL graft. The native superior capsule had an average linear stiffness of 94.5 ± 20.4 N/mm, yield load of 386.9 ± 63.6 N, ultimate load of 444.9 ± 67.7 N and energy absorbed of 1418.4 ± 248.8 N-mm. The FL-SCR construct had an average linear stiffness of 28.0 ± 1.6 N/mm, yield load of 123.8 ± 54.3 N, ultimate load of 369.0 ± 43.4 N and energy absorbed of 5021.2 ± 755.1 N-mm. Comparing the two groups there was a statistically significant difference for stiffness (P = 0.013), yield load (P = 0.03) and energy absorbed (P = 0.003). There was no statistically significant difference between ultimate load. The total displacement of the FL-SCR fixation was 5.8 ± 0.6 mm after 1 cycle, 8.5 ± 0.7 mm after 30 cycles, 11.4 ± 1.8 mm at the yield load and 29.5 ± 1.8 mm at the ultimate load. For the failure mode, 8/8 NSC specimens failed at the mid-substance. The FL-SCR, 3/8 specimens failed at the suture tendon interface and 4/8 had medial anchor pull out.Conclusions:Performing SCR with FL allograft in a cadaver model creates a construct that is sufficiently strong enough to withstand normal physiologic loading of the shoulder, although it does not fully re-create the biomechanical characteristics of a native shoulder superior capsule.