Arthroscopic Partial Repair of Irreparable Rotator Cuff Tears: Preoperative Factors Associated With Outcome Deterioration Over 2 Years

The role of Superior Capsule Reconstruction in the irreparable rotator cuff tear - A systematic review

BACKGROUND

Irreparable rotator cuff tears in active patients provide a significant challenge and a consensus on the gold standard treatment is currently lacking. Superior capsule reconstruction (SCR) has recently been advocated and functions by providing a passive biological constraint to superior humeral head migration. The aim of this study is to systematically review the literature to evaluate the role of SCR in terms of functional outcome scores and failure rates.

PATIENTS AND METHODS

A review of the online databases Medline and EMBASE was conducted in accordance with the PRISMA guidelines on the 28th January 2019. Clinical studies reporting SCR using any type of graft or surgical technique were included if reporting either functional outcome scores or rate of secondary surgery. The studies were appraised using the Methodological index for non-randomised studies tool.

RESULTS

The search strategy identified nine studies eligible for inclusion; five reported on fascia lata autografts and four studies reported on dermal allografts. All nine studies reported significant improvement in functional scores after SCR. Rates of secondary surgery were only provided in the dermal allograft studies at short-term follow-up (mean 10.9 to 32.4months) and ranged from 0 to 18.6%. Radiological assessment revealed graft failure in 5.5 to 55% of dermal allografts and 4.2 to 36.1% of fascia lata autografts.

CONCLUSION

This review demonstrates that SCR is a useful treatment modality for patients with irreparable rotator cuff tears. SCR was associated with significantly improved functional outcome scores in all studies. All studies reported a preserved or increased mean AHD. The radiological graft failure rate ranged from 4.2 to 55% and the short duration of follow-up in most studies means that this remains an important concern that requires longer-term evaluation.

LEVEL OF EVIDENCE

IV, systematic review.

Comparing Clinical Outcomes After Subacromial Spacer Insertion Versus Other Reconstruction Methods in the Treatment of Irreparable Massive Rotator Cuff Tears

Background:

Previous studies on subacromial spacer (SAS) insertion have been limited to case series that did not compare the effectiveness of this technique with other techniques.

Hypothesis:

Outcomes after SAS insertion for the treatment of irreparable massive rotator cuff tears (IMRCTs) will be similar to those of other techniques.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This retrospective study was based on data collected from patients who underwent correction of IMRCTs between January 2010 and October 2017. Group 1 patients (n = 17) received SAS insertion with or without partial repair; group 2 patients (n = 36) were treated with other techniques (isolated partial repairs or bridging grafts). Preoperative tear size and global fatty degeneration index values were evaluated. Range of motion, visual analog scale for pain, American Shoulder and Elbow Surgeons (ASES) score, Constant score, Simple Shoulder Test (SST), Disabilities of the Arm, Shoulder and Hand score, and acromiohumeral distance (AHD) were assessed preoperatively and at final follow-up at least 2 years after the surgery (range, 24-60 months). In both groups, ultrasonographic examination was performed at 3 and 6 months postoperatively, and magnetic resonance imaging (MRI) was performed at 1 year.

Results:

Tear size and preoperative global fatty degeneration index were not significantly different between the groups (all P > .05). There were no differences in functional scores between the groups at final follow-up (all P > .05). AHD was maintained at final follow-up in group 1 (mean ± SD: 6.2 ± 2.1 mm [postoperatively] vs 6.7 ± 2.3 mm [final follow-up]; P = .678), and there was no difference compared with group 2 (7.2 ± 3.2 mm; P = .244). Patients with retears in group 2 (23 of 36, 63.9%) had lower ASES (P = .041) and SST (P = .027) scores at final follow-up when compared with patients in group 1. Six patients (35.3%) in group 1 had partial repairs; these patients had better external rotation at 90° (P = .047), better SST scores (P = .036), and higher AHDs at final follow-up (P = .046) than those in group 1 who had no repair. Three patients (50%) showed retears of partially repaired tendons on MRI. Of 13 patients (76.5%) in group 1 with postoperative MRI, 12 (92.3%) showed fibrotic tissue in the subacromial space not seen preoperatively.

Conclusion:

There was no difference in outcomes between SAS and the other reconstruction methods for treating IMRCTs. However, given the high retear rate associated with other techniques and poor functional outcomes after retear, SAS insertion could be a viable option for treating IMRCTs.

An intact subscapularis tendon and compensatory teres minor hypertrophy yield lower failure rates for non-operative treatment of irreparable, massive rotator cuff tears

PURPOSE

To investigate whether subscapularis integrity and compensatory teres, minor hypertrophy is associated with maintaining relatively good function and tolerable pain levels during non-operative treatment.

METHODS

This study included 108 patients with irreparable, massive rotator cuff tears involving at least two tendons and stage III or IV muscle hypotrophy and fatty infiltration on oblique sagittal magnetic resonance imaging, in which even a partial repair does not seem feasible. All supraspinatus and infraspinatus muscles were grade IV; if the subscapularis was involved, only stage III or IV was included. Patients were divided into two groups: group A consisted of 67 patients with both an intact subscapularis and teres minor hypertrophy; group B consisted of 41 patients lacking either one or both. The Visual Analogue Scale pain score, the American Shoulder and Elbow Surgeons score, the University of California at Los Angeles shoulder score, and active range of motion (ROM) were assessed.

RESULTS

During the follow-up period, failure of non-operative treatment was found in 29 (43%) patients in group A and 28 (68%) in group B (p = 0.012). Conversion to surgery was noted in 26 (39%) patients in group A and 27 (66%) in group B (p = 0.006). Among the remaining nonsurgical patients, there were no significant differences in clinical outcomes between the groups except ROM in internal rotation at final follow-up.

CONCLUSIONS

Although conservative treatment was not always successful in patients with irreparable, massive cuff tears, patients with both an intact subscapularis tendon, and teres minor hypertrophy experienced significantly lower incidences of failure and conversion to surgery, since force couple is maintained in the setting of minimal arthritis.

LEVEL OF EVIDENCE

III.

Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears: A Systematic Review

PURPOSE

To evaluate the preliminary clinical outcomes and complications of superior capsule reconstruction (SCR) for irreparable rotator cuff tears.

METHODS

A systematic review of PubMed, MEDLINE, EMBASE, and Cochrane databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting clinical outcomes of irreparable rotator cuff tears managed by SCR were included. Clinical outcome analyses of pre- and postoperative range of motion, American Shoulder and Elbow Surgeons scores, visual analog scale pain scores, and acromiohumeral intervals (AHIs) were performed and reported as range or frequency.

RESULTS

Five studies (285 patients, 291 shoulders) of level III-IV evidence were included, with a weighted mean (± standard deviation) follow-up of 27.7 ± 17.3 months. Forward flexion improved from 91°-130° preoperatively to 147°-160° postoperatively, external rotation from 26°-41° to 41°-45°, and internal rotation from L4-L1 to L1. American Shoulder and Elbow Surgeons scores increased from 36-52.2 to 77.5-92, and visual analog scale pain scores decreased from 4.0-6.3 to 0.4-1.7. Radiographically, AHIs with acellular dermal allograft ranged from 4.5 to 7.1 mm preoperatively, improving to 7.6-10.8 mm immediately postoperation before decreasing to 6.7-9.7 mm by final follow-up. Complication and graft failure rates were 17.2% and 11.7%, respectively.

CONCLUSIONS

Preliminary results of SCR show consistent improvement in shoulder functionality and pain reduction. However, a decrease in postoperative AHIs indicates dermal allograft elongation and persistent superior migration of the humerus, potentially contributing to later graft failure. Studies with longer follow-up will be essential to evaluate the long-term utility of SCR in the treatment of irreparable rotator cuff tears.

LEVEL OF EVIDENCE

Level IV, systematic review of level III-IV studies.

Arthroscopic partial repair for massive rotator cuff tears: does it work? A systematic review

BACKGROUND

While arthroscopic complete repair of massive rotator cuff tears (MRCT) back to their anatomic footprint is preferential, there are cases where this type of repair is not applicable due to the contraction of the torn tendons. In such cases, a non-anatomic incomplete or partial repair can be performed. A number of clinical studies have investigated the clinical and functional outcomes of arthroscopic partial repair for irreparable MRCT. To our knowledge, no systematic review has been published yet to synthetically evaluate these results.

METHODS

Two reviewers independently conducted the search in a PRISMA-compliant systematic way using the MEDLINE/PubMed database and the Cochrane Database of Systematic Reviews. These databases were queried with the terms "arthroscopy"[MeSH Terms] OR arthroscopic surgical procedure [Text Word (tw)] AND massive rotator cuff tears [tw] AND arthroscopic partial repair [tw].

RESULTS

From the 55 initial studies, we finally chose 11 clinical studies which were eligible to our inclusion-exclusion criteria. The mean modified methodology Coleman score was 58/100, whereas it ranged from 41/100 to 78/100. In total, 643 patients were included in this review. All postoperative mean clinical and functional subjective scores, as well as muscle strength of patients treated with arthroscopic partial repair, were found significantly improved, when compared with the respective mean preoperative values. The rate of structural failure of the partial repair, as it was estimated by postoperative imaging modalities, was 48.9%. The overall reoperations' rate was 2.9% regarding the patients who were treated with partial repair.

CONCLUSIONS

Arthroscopic partial repair might be a safe and effective alternative treatment for irreparable contracted MRCT, where a complete repair cannot be performed. The methodological quality of the relevant, available literature is low to moderate; therefore, further studies of higher quality are required to confirm these results.

Arthroscopic-assisted Latissimus Dorsi Tendon Transfer for the Management of Irreparable Rotator Cuff Tears in Middle-aged Physically Active Patients

Background

Latissimus dorsi (LD) tendon transfer is used as a treatment option for massive irreparable posterosuperior rotator cuff tears, and recently, an arthroscopic-assisted technique was introduced. This study was undertaken to evaluate the clinical and radiological outcomes of arthroscopic-assisted LD tendon transfer for the management of irreparable rotator cuff tears in active middle-aged patients.

Methods

The records of five patients (two males) with irreparable tears involving the supraspinatus and infraspinatus tendons managed by arthroscopic-assisted LD tendon transfer were retrospectively reviewed. Clinical outcomes were assessed using the visual analogue scale (VAS) pain scale, American Shoulder and Elbow Surgeon’s (ASES) scores, the University of California Los Angeles (UCLA) scale, and ranges of motion. Postoperative integrities of transferred tendon were evaluated by magnetic resonance imaging in 4 patients and by ultrasound in one.

Results

Mean patient age was 55 years (range, 48–61 years), and mean follow-up period was 20 months (range, 12.0–27.2 months). Mean VAS score significantly improved from 6.6 ± 2.6 preoperatively to 1.8 ± 2.5 postoperatively (p=0.009), mean ASES score increased from 67.6 ± 9.2 to 84.6 ± 15.1, and mean UCLA score from 18.0 ± 1.4 to 28.8 ± 8.5 (all p<0.001). Postoperative imaging of the transferred LD tendon showed intact repair in 4 patients. The remaining patient experienced LD transfer rupture and a poor outcome.

Conclusions

Arthroscopic-assisted LD tendon transfer improved shoulder pain and function in patients with massive, irreparable rotator cuff tears, and may be an option for this condition, especially in physically active patients.

Rotator cuff tears reparability index based on pre-operative MRI: our experience

Background and aim of the work: It is recognised that a significant percetage of large and massive rotator cuff tears (RCT) cannot be anatomically repaired and this correlates with a worste outcome in terms of pain, active range of motion, increased incidence of retair. The aim of our work is to find reliable index on pre-operative MRI shoulder image to assist orthopaedist in surgical planning of rotatator cuff tears repair. Methods: We performed a retrospective study on a population on 131 patients undergoing arthroscopic cuff repair by a single expert surgeon. Pre-operative MRI images were evaluated by a single orthopaedist, trained on MRI shoulder images ad blinded to surgical outcome. For each magnetic resonance we evaluated the following 9 parameters: fatty Infiltration (FI), Patte Stage (PS), tear size measured in medial-lateral (ML) and anterior-posterior (AP) dimension, Tangent Sign (TS), Occupation Grade (OG), Acromion-Humeral Distance (AHD), Inferior Gleno-Humeral Distance (IGHD), Glenoid Version Angle (GVA). We divided population into two groups: patients who obtained a complete repair of RCT (n=110) and patients who obtained only a partial repair of RCT (n=21). For each MRI index we conducted statistical analysis (Student’s t test, Mann-Whitney U test, Shapiro-Wilk test, Chi-square test, Fisher exact test, ROC curves and maximum Youden index) to find a Cut Off value useful to predict partial repair. Results: We have found statistical significance in predicting partial repair on MRI mesurements of Fatty Infiltration (FI grade ≥3; test di Fisher p<0.001), Patte Stage (grade= 3; test di Fisher p<0.001), Tear size measured in ML (>36 mm; Mann-Whitney p<0.001), Positive Tangent Sign (Chi-quadro p<0.001; sensitivity 95,3%, specificity 83,6%), Occupation Grade (OG <0,46; t-test p<0.001). Acromion-Humeral Distance (AHD <7 mm), Inferior Gleno-Humeral Distance (IGHD >5 mm). Tear size measured in AP (>21 mm; Mann-Whitney p<0.001) seems to be dependent on the contextual size of the lesion in ML. We haven’t found statistical significance in predicting partial repair of Glenoid Version Angle. Conclusions: A systematic observation of seven independent MRI parameters (FI, PS, tear size ML, TS, OG, AHD, IGHD) can help the surgeon to predict the impossibility to obtain complete repair of RCT and to consider different surgical approach. (www.actabiomedica.it)

Management of Massive Rotator Cuff Tears: Prospective study in 218 patients

BACKGROUND

No consensus exists about the management of massive and symptomatic rotator cuff tears (RCTs). The objective of this study was to compare the 12-month clinical outcomes of various treatment options for massive RCTs.

HYPOTHESIS

Arthroscopic surgery has a role to play in the treatment of massive and apparently irreparable RCTs.

MATERIAL AND METHODS

A prospective multicentre non-randomised study was performed in patients with massive RCTs managed non-operatively (NONOP) or by arthroscopic tenotomy/tenodesis of the long head of biceps (aTLB), arthroscopic partial tendon repair (aPTR), arthroscopic latissimus dorsi transfer (aLDT), or reverse shoulder arthroplasty (RSA). Clinical outcomes were evaluated based on the Constant score, Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons (ASES) score after 3, 6, and 12 months.

RESULTS

The 218 included patients (mean age, 69 years) were distributed as follows: NONOP, n=71; aTLB, n=26; aPTR, n=61; aLDT, n=25; and RSA, n=35. After 12 months, the mean Constant score, SSV, and ASES score values were 70, 68%, and 73, respectively, and had improved significantly versus the preoperative values in all treatment groups. RSA was the only treatment followed by improvements in all Constant score items. Active forwards elevation improved significantly in the NONOP (+25°), aPTR (+26°), and RSA (+66°) groups. An improvement in active external rotation was seen only in the RSA group, where it was small (+10°, p=0.046). Significant increases in internal rotation were seen in the NONOP (+1.6 points) and aPTR (+1.7 points) groups.

CONCLUSION

Arthroscopic techniques (aTLB, aPTR, and aLDT) for managing massive irreparable RCTs produce significant functional gains. Partial tendon repair (aPTR) and RSA may provide better outcomes than isolated aTLB or aLDT.

LEVEL OF EVIDENCE

III, non-randomised prospective study.

The pathogenesis and management of cuff tear arthropathy

Massive rotator cuff tears may lead to the development of cuff tear arthropathy (CTA). Although this pathology has been recognized for more than 150 years, treatment strategies have continued to evolve. During the last decade, there has been increased understanding of the molecular and cellular changes that govern rotator cuff tear outcomes and development of new treatment strategies to repair or reconstruct the rotator cuff. These have included an expansion of the use of arthroscopic double-row transosseous-equivalent repairs and the development of superior capsule reconstruction. However, the greatest change in the management of CTA has been the expansion of the use of reverse total shoulder arthroplasty, which has become the standard of care for patients who do not have a repair option and when nonoperative management has failed. This review article summarizes the current literature on the management of CTA, including nonoperative, repair, reconstruction, and replacement options, with a focus on literature in the last 5 years.

Arthroscopic Superior Capsular Reconstruction With a Minimally Invasive Harvested Fascia Lata Autograft Produces Good Clinical Results

Background:

Painful dysfunctional shoulders with irreparable rotator cuff tears (IRCTs) in active patients are a challenge. Arthroscopic superior capsular reconstruction (ASCR) is a new treatment option originally described using a fascia lata autograft harvested through an open approach. However, concerns about donor site morbidity have discouraged surgeons from using this type of graft.

Hypothesis:

ASCR using a minimally invasive harvested fascia lata autograft produces good 6-month and 2-year shoulder outcomes in IRCTs, with low-impact thigh morbidity at 2 years.

Study Design:

Case series; Level of evidence, 4.

Methods:

From 2015 to 2016, a total of 22 consecutive patients (mean age, 64.8 ± 8.6 years) with chronic IRCTs (Hamada grade 1-2; Goutallier cumulative grade ≥3; Patte stage 1: 2 patients; Patte stage 2: 6 patients; Patte stage 3: 14 patients) underwent ASCR using a minimally invasive harvested fascia lata autograft. All patients completed preoperative and 6-month evaluations consisting of the Simple Shoulder Test (SST), subjective shoulder value (SSV), Constant score (CS), range of motion (ROM), acromiohumeral interval (AHI), and magnetic resonance imaging. Twenty-one patients completed the 2-year shoulder and donor site morbidity assessments.

Results:

The mean active ROMs improved significantly (P < .001): elevation, from 74.8° ± 55.5° to 104.5° ± 41.9° (6 months) and 143.8° ± 31.7° (2 years); abduction, from 53.2° ± 43.3° to 86.6° ± 32.9° (6 months) and 120.7° ± 37.7° (2 years); external rotation, from 13.2° ± 18.4° to 27.0° ± 16.1° (6 months) and 35.6° ± 17.3° (2 years); and internal rotation, from 1.2 ± 1.5 points to 2.6 ± 1.5 points (6 months) and 3.8 ± 1.2 points (2 years). The mean functional shoulder scores improved significantly (P < .001): SST, from 2.1 ± 2.9 to 6.8 ± 3.5 (6 months) and 8.6 ± 3.5 (2 years); SSV, from 33.0% ± 17.4% to 55.7% ± 25.6% (6 months) and 70.0% ± 23.0% (2 years); CS, from 17.5 ± 13.4 to 42.5 ± 14.9 (6 months) and 64.9 ± 18.0 (2 years). The mean shoulder abduction strength improved significantly (P < .001) from 0.0 to 1.1 ± 1.4 kg (6 months) and 2.8 ± 2.6 kg (2 years). The mean AHI improved from 6.4 ± 3.3 mm to 8.0 ± 2.5 mm (6 months) and decreased to 7.1 ± 2.5 mm (2 years). This 0.7 ± 1.5–mm overall decrease was statistically significant (P = .042). At 6 months, 20 of 22 patients (90.9%) had no graft tears. At 2 years, 12 of 21 patients (57.1%) were bothered by their harvested thigh, 16 (76.2%) noticed donor site changes, 16 (76.2%) considered that the shoulder surgery’s end result compensated for the thigh’s changes, and 18 (85.7%) would undergo the same surgery again.

Conclusion:

ASCR using a minimally invasive harvested fascia lata autograft produced good 6-month and 2-year shoulder outcomes in IRCTs, with low-impact thigh morbidity at 2 years.

Clinical and MRI Outcomes 10 Years After Repair of Massive Posterosuperior Rotator Cuff Tears

BACKGROUND

Massive rotator cuff tears are challenging to treat, with few or no studies on long-term outcomes of repair. The purpose of this study was to report 10-year outcomes following repair of massive posterosuperior rotator cuff tears, with and without extension into the subscapularis, and to determine prognostic factors that could influence clinical scores and retear rates.

METHODS

The records of 234 patients who underwent repair of a massive posterosuperior rotator cuff tear at a total of 15 centers were retrieved. Patients were asked to return for evaluation at 10 years; 78 patients could not be contacted, 7 had died, and 19 had undergone a reoperation. A total of 130 patients (68% men) with a mean age (and standard deviation) of 56.1 ± 7.7 years (range, 26 to 79 years) were evaluated clinically, and 102 of them were also evaluated using magnetic resonance imaging (MRI). The tear was confined to the supraspinatus and infraspinatus tendons in 94 shoulders and also involved the superior portion of the subscapularis in 36 shoulders. Univariable and multivariable regressions were performed to determine whether 10-year total Constant-Murley scores and repair integrity were associated with patient characteristics, tear patterns, or repair techniques.

RESULTS

In the study cohort, complications were noted in 14 shoulders (11%) (stiffness in 10 and infection in 4). For the 130 shoulders evaluated clinically, the mean total Constant-Murley score improved from 53.1 ± 15.9 (range, 14 to 83) preoperatively to 78.5 ± 11.3 (range, 36 to 98) at 10 years. Of the 102 shoulders evaluated using MRI, 32 had a retear (Sugaya type IV or V). Of the 19 shoulders that underwent a reoperation (excluded from the study cohort), 9 had a retear. The overall prevalence of retears was 34%. Multivariable regression analysis revealed a significant association between the 10-year Constant-Murley score and preoperative retraction of the infraspinatus tendon, but no association between retears and any of the variables. Involvement of the subscapularis had no significant effect on preoperative or postoperative Constant-Murley scores or retear rates.

CONCLUSIONS

Patients who had repair of a massive posterosuperior rotator cuff tear maintained considerable improvements in clinical and radiographic outcomes at 10 years. Partial concomitant tears of the subscapularis did not affect the total postoperative Constant-Murley scores or retear rates.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Nonarthroplasty Surgical Treatment Options for Massive, Irreparable Rotator Cuff Tears

Massive, irreparable rotator cuff tears (MIRCTs) provide a significant dilemma for orthopaedic surgeons. One treatment option for MIRCTs is reverse total shoulder arthroplasty. However, other methods of treating these massive tears have been developed. A search of the current literature on nonoperative management, arthroscopic debridement, partial repair, superior capsular reconstruction (SCR), graft interposition, balloon spacer arthroplasty, trapezius transfer, and latissimus dorsi transfer for MIRCTs was performed. Studies that described each surgical technique and reported on clinical outcomes were included in this review. Arthroscopic debridement may provide pain relief by removing damaged rotator cuff tissue, but no functional repair is performed. Partial repair has been suggested as a technique to restore shoulder functionality by repairing as much of the rotator cuff tendon as possible. This technique has demonstrated improved clinical outcomes but also fails at a significantly high rate. SCR has recently gained interest as a method to prohibit superior humeral head translation and has been met with encouraging early clinical outcomes. Graft interposition bridges the gap between the retracted tendon and humerus. Balloon spacer arthroplasty has also been recently proposed and acts to prohibit humeral head migration by placing a biodegradable saline-filled spacer between the humeral head and acromion; it has been shown to provide good clinical outcomes. Both trapezius and latissimus dorsi transfer techniques involve transferring the tendon of these respective muscles to the greater tuberosity of the humerus; these 2 techniques have shown promising restoration in shoulder function, especially in a younger, active population. Arthroscopic debridement, partial repair, SCR, graft interposition, balloon spacer arthroplasty, trapezius transfer, and latissimus dorsi transfer have all been shown to improve clinical outcomes for patients presenting with MIRCTs. Randomized controlled trials are necessary for confirming the efficacy of these procedures and to determine when each is indicated based on specific patient and anatomic factors.

Is augmentation with the long head of the biceps tendon helpful in arthroscopic treatment of irreparable rotator cuff tears?

BACKGROUND

Although various surgical techniques have been used to treat irreparable rotator cuff tears (RCTs), debate remains regarding which treatment is most effective. The purpose of our study was to compare the outcomes of partial rotator cuff repair versus repair with augmentation of the tenotomized long head of the biceps tendon (LHBT).

METHODS

This study included 76 patients with large to massive RCTs. Arthroscopic rotator cuff repair with LHBT augmentation was performed in 39 patients (group I), while partial repair was performed in 37 patients (group II). Clinical and functional outcomes were compared with a visual analog scale for pain and the American Shoulder and Elbow Surgeons score, Constant score, and Korean Shoulder Score. Magnetic resonance imaging was performed 12 months after surgery.

RESULTS

The mean follow-up period was 29.6 ± 7.8 months (range, 24-51 months). Significant improvements in pain and clinical scores were observed in both groups at the last follow-up. However, there were no significant differences in pain, clinical scores, or range of motion between the 2 groups at any time point. Retears were observed in 16 patients in group I (41.0%) and 14 in group II (37.8%, P = .78). Augmented LHBT pathology was observed in 10 patients (25.6%).

CONCLUSIONS

Both partial repair and repair with LHBT augmentation were effective in improving clinical and radiologic outcomes. No significant differences in clinical outcomes or repaired cuff integrity were observed between the groups. The investment of operation time and effort in augmenting the LHBT in the treatment of irreparable RCTs is not recommended.

Options for Failed Rotator Cuff Repair

Failed rotator cuff repairs can pose a clinical challenge to the treating orthopedic surgeon. There are many nonsurgical and surgical options available to address the failed rotator cuff repair. Surgical options include revising the primary repair, partial or nonanatomic repair, tendon transfer, biological augmentation or use of tissue-engineered grafts for reconstruction, or total joint arthroplasty (typically with a modern reverse total shoulder arthroplasty system). The treating surgeon must assess the patient's functional status, health status, and expectations in order to customize the appropriate treatment plan for addressing the failed rotator cuff repair. With the abundance of treatment options available, there is typically an adequate solution to help the patient regain function and experience less pain.

Optimizing a 3D model system for molecular manipulation of tenogenesis

PURPOSE

Tendon injuries are clinically challenging due to poor healing. A better understanding of the molecular events that regulate tendon differentiation would improve current strategies for repair. The mouse model system has been instrumental to tendon studies and several key molecules were initially established in mouse. However, the study of gene function has been limited by the absence of a standard in vitro tendon system for efficiently testing multiple mutations, physical manipulations, and mis-expression. The purpose of this study is therefore to establish such a system.

METHODS

We adapted an existing design for generating three-dimensional (3D) tendon constructs for use with mouse progenitor cells harboring the ScxGFP tendon reporter and the Rosa26-TdTomato Cre reporter. Using these cells, we optimized the parameters for construct formation, inducing tenogenesis via transforming growth factor-β2 (TGFβ2), and genetic recombination via an adenovirus encoding Cre recombinase. Finally, for proof of concept, we used Smad4 floxed cells and tested the robustness of the system for gene knockdown.

RESULTS

We found that TGFβ2 treatment induced a tenogenic phenotype depending on the timing of initiation. Addition of TGFβ2 after 3D "tensioning" enhanced tendon differentiation. Interestingly, while TGFβ2-induced proliferation depended on Smad4, tenogenic parameters such as ScxGFP expression and fibril diameter were independent of Smad4.

CONCLUSIONS

Our results demonstrate the feasibility of this optimized system for harnessing the power of mouse genetics for in vitro applications.

Arthroscopic Incomplete Repair Using a "Hybrid Technique" for Large to Massive Rotator Cuff Tears: Clinical Results and Structural Integrity

PURPOSE

The first aim of this study was to introduce the concept of hybrid repair (incomplete repair) for large to massive rotator cuff tears and to report clinical results and structural integrity of patients with a minimum 2-year follow-up. The second aim was to compare arthroscopic hybrid repair with partial repair for large to massive rotator cuff tears.

METHODS

We retrospectively evaluated 65 patients who underwent arthroscopic incomplete (hybrid) repair (45 patients) or partial repair (20 patients) for large to massive cuff tears from March 2011 to January 2015. The pain visual analog scale, function visual analog scale, American Shoulder and Elbow Surgeons, and Constant scores and range of motion (ROM) (active flexion, elevation, abduction, external rotation, and internal rotation) were assessed preoperatively, at first follow-up (approximately 6 months postoperatively), at second follow-up (1 year postoperatively), and at final follow-up (2 years postoperatively). The healing status of the repaired tendon was evaluated with postoperative magnetic resonance imaging, with a focus on tendon integrity.

RESULTS

Comparisons of the preoperative values and final follow-up results of hybrid repair showed significant improvement in the mean pain visual analog scale score (5.56 and 0.93, respectively), mean function visual analog scale score (4.77 and 8.59, respectively), and questionnaire results (American Shoulder and Elbow Surgeons score, 44.89 and 84.67, respectively; Constant score, 44.27 and 73.46, respectively) (all P ≤ .001). Most shoulder ROM measures showed some improvement compared with presurgical ROM at last follow-up (≥2 years). However, there was no statistical significance. Retears occurred in 9 patients (20%) in the hybrid-repair group. Most of the postoperative clinical outcomes showed excellent results with hybrid repair compared with partial repair.

CONCLUSIONS

Arthroscopic incomplete repair (hybrid technique) showed more satisfactory clinical trial outcomes than partial repair of large to massive rotator cuff tears. Therefore, we propose the use of incomplete repair, which provides improvements in both pain and functional outcomes, as another repair option for large to massive rotator cuff tears.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Editorial Commentary: What's in a Name: Is There a Difference Between Incomplete and Partial Rotator Cuff Repairs?

For the treatment of large to massive rotator cuff repairs, not all partial repairs are equivalent. The technique of rotator cuff repair in large to massive rotator cuff tears matters. By using mobilization techniques to mobilize the rotator cuff to obtain anatomic or near anatomic coverage, double-row techniques to increase footprint coverage, and medial mobilization to decrease tension on the repair, exposure of the humeral head can be minimized, which can improve outcomes.

A Rotator Cuff Tear Concomitant With Shoulder Stiffness Is Associated With a Lower Retear Rate After 1-Stage Arthroscopic Surgery

BACKGROUND

Few studies have reported on the radiological characteristics and repair integrity of coexistent rotator cuff tears (RCTs) and shoulder stiffness after simultaneous arthroscopic rotator cuff repair and capsular release.

PURPOSE

To evaluate the radiological characteristics and repair integrity of 1-stage arthroscopic surgery of RCTs concomitant with shoulder stiffness.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Among patients who underwent arthroscopic repair of full-thickness RCTs, the stiff group underwent simultaneous capsular release for shoulder stiffness, and the nonstiff group had no stiffness. Symptom duration, prevalence of diabetes, tear size, tendon involvement (type 1, supraspinatus; type 2, supraspinatus and subscapularis; and type 3, supraspinatus and infraspinatus; type 4, supraspinatus, subscapularis, and infraspinatus), and fatty infiltration (Goutallier stages 0-4) were evaluated. A retear was appraised using magnetic resonance imaging, and clinical outcomes were assessed using range of motion, the Korean Shoulder Scoring System (KSS), and the University of California, Los Angeles (UCLA) shoulder score.

RESULTS

The stiff group showed a significantly lower retear rate (1/39, 2.6%) than the nonstiff group (47/320, 14.7%) ( P = .043). There were significant differences in symptom duration (7.4 ± 6.6 vs 15.0 ± 23.7 months, respectively; P < .001), mediolateral tear size (18.9 ± 8.9 vs 24.1 ± 12.0 mm, respectively; P = .002), tendon involvement (94.9%, 5.1%, 0.0%, and 0.0% vs 85.3%, 6.9%, 7.8%, and 0.0%, respectively; P = .048), and fatty infiltration of the subscapularis (66.7%, 33.3%, 0.0%, 0.0%, and 0.0% vs 31.9%, 61.3%, 5.6%, 1.3%, and 0.0%, respectively; P < .001) and teres minor (74.4%, 20.5%, 5.1%, 0.0%, and 0.0% vs 47.2%, 48.8%, 3.8%, 0.0%, and 0.3%, respectively; P = .007) between the stiff and nonstiff groups. Preoperatively, the stiff group showed significantly worse forward flexion (95.9° ± 23.6° vs 147.7° ± 4.2°, respectively; P < .001), external rotation (17.4° ± 10.1° vs 51.6° ± 12.1°, respectively; P < .001), and internal rotation (L5 vs L2, respectively; P < .001) and lower KSS (52.1 ± 13.8 vs 66.3 ± 13.5, respectively; P < .001) and UCLA scores (18.7 ± 4.8 vs 22.5 ± 4.5, respectively; P < .001) than the nonstiff group. However, these differences became insignificant from 3 months postoperatively for forward flexion ( P > .05) and KSS ( P > .05) and UCLA scores ( P > .05), from 1 year postoperatively for external rotation ( P > .05), and at the last follow-up for internal rotation ( P > .05). A multiple logistic regression analysis revealed that only mediolateral tear size (odds ratio, 1.043; P = .014) and type 2 tendon involvement (odds ratio, 4.493; P = .003) were independent predictors of a retear.

CONCLUSION

RCTs concomitant with shoulder stiffness showed a smaller mediolateral tear size, anterosuperior tendon involvement, and less severe fatty infiltration preoperatively and better repair integrity postoperatively than RCTs without stiffness. Furthermore, the clinical outcomes and range of motion at final follow-up were similar between the 2 groups.

Current concepts in the primary management of irreparable posterosuperior rotator cuff tears without arthritis

Various procedures exist for patients with irreparable posterosuperior rotator cuff tears (IRCT). At present, no single surgical option has demonstrated clinical superiority.There is no panacea for treatment and patients must be aware, in cases of palliative or non-prosthetic options, of an alarming rate of structural failure (around 50%) in the short term.The current review does not support the initial use of complex and expensive techniques in the management of posterosuperior IRCT.Further prospective and comparative studies with large cohort populations and long-term follow-up are necessary to establish effectiveness of expensive or complicated procedures such as superior capsular reconstruction (SCR), subacromial spacers or biological augmentation as reliable and useful alternative treatments for IRCT. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.180002.

Novel Arthroscopic Tendon Transfers for Posterosuperior Rotator Cuff Tears: Latissimus Dorsi and Lower Trapezius Transfers

Background

Massive irreparable rotator cuff tears in both the primary and the revision setting are challenging problems. There remains controversy over the ideal treatment methods for these patients. In the case of an irreparable posterosuperior rotator cuff tear, tendon transfers^1-12 have emerged as a reliable option, with a durable outcome. The most commonly used tendon transfer options are the latissimus dorsi (LD)^1-6and the lower trapezius (LT)¹².

Description

The LD transfer is performed by first harvesting the LT tendon from the humeral shaft. It is critical to release the many adhesions to the muscle belly as well as to separate it from the teres major muscle. The tendon is then transferred intra-articularly, in an interval between the deltoid and the teres minor. The tendon is anchored arthroscopically after preparation of the anterolateral aspect of the tuberosity. The LT transfer is performed by harvesting the LT muscle and tendon off its insertion on the medial aspect of the scapular spine. It should be mobilized to maximize excursion by releasing adhesions. An Achilles tendon allograft is anchored into the anterior aspect of the greater tuberosity arthroscopically. The Achilles tendon is then secured to the LT tendon.

Alternatives

In addition to tendon transfer, options include:Partial or complete attempted repair^13-17.Augmentation or bridging with allografts^18-23.Superior capsular reconstruction²⁴.Subacromial balloon²⁵.

Rationale

There remains a paucity of literature comparing tendon transfers with alternatives. However, when considering a tendon transfer, certain principles are critical in order to achieve an optimal outcome:The recipient and transferred tendons must have similar musculotendinous excursion.The recipient and transferred tendons should have similar lines of pull.One tendon (the transferred) should be designed to replace 1 function (of the recipient).The function of the transferred tendon and muscle should be expendable without substantial donor site morbidity.The strength of the transferred muscle must be at least grade 4.When deciding between the LT and LD transfer, certain considerations should be taken into account. The LD transfer has a proven history of successfully treating massive irreparable posterosuperior rotator cuff tears in studies with long-term follow-up^1-6. Alternatively, although the LT transfer has only recently gained popularity, it has the advantage of "in-phase" muscle function, since the trapezius naturally contracts during shoulder external rotation. Furthermore, its line of pull almost completely mimics the infraspinatus.

Fatty Degeneration of the Rotator Cuff Reflects Shoulder Strength Deficits in Patients With Rotator Cuff Tears

Fatty degeneration is an important clinical factor in patients with rotator cuff tears. Goutallier grade, occupation ratio, and tangent sign help identify fatty degeneration; however, little is known about how closely these measurement techniques correlate with actual muscle strength deficits. The authors evaluated each method's ability to determine the correlation between fatty degeneration and muscle strength deficits. The authors included 203 patients who underwent full-thickness rotator cuff repair (mean age, 61.29±7.92 years). All patients were evaluated with preoperative magnetic resonance imaging to identify fatty degeneration and with an isokinetic test to determine actual shoulder strength. Fatty degeneration was evaluated using Goutallier grade, occupation ratio, and tangent sign. The actual shoulder strength deficit was evaluated by abduction, whereas external and internal rotation were tested using the isokinetic test. More severe fatty degeneration was correlated with lower degrees of abduction, external rotation, and internal rotation. The occupation ratio was more closely correlated with actual muscle strength deficits. However, in patients with massive tears, the correlation between fatty degeneration and muscle strength was less pronounced. Tangent sign (+) findings had a significantly lower strength of external rotation and abduction. The fatty degeneration of the rotator cuff muscle measured by each method was correlated with actual shoulder strength deficits in patients with rotator cuff tears. However, the correlations were less clear in patients with massive rotator cuff tears. Therefore, in cases of massive rotator cuff tears, fatty degeneration was correlated with muscle strength deficits but was not directly proportional to their extent. [Orthopedics. 2018; 41(1):e15-e21.].

Arthroscopic Partial Repair of Irreparable Rotator Cuff Tears: Factors Related to Greater Degree of Clinical Improvement at 2 Years of Follow-Up

PURPOSE

This study aimed to evaluate the clinical outcomes of irreparable rotator cuff tears (RCT) treated with an arthroscopic partial repair, as well as the preoperative factors that may be related to greater improvement of clinical outcomes at short-term follow-up.

METHODS

We retrospectively reviewed patients with irreparable RCT who underwent arthroscopic partial rotator cuff repair between January 2011 and April 2014. Minimal follow-up of 24 months was required. Partial repair was defined as repairing the less retracted posterosuperior rotator cuff with a residual defect of the tendon-footprint junction. Tearing involving the subscapularis tendon was excluded. Factors collected included age, sex, diabetes, smoking, night pain, duration of symptoms, pain visual analog scale (VAS) score, acromiohumeral distance (AHD), and American Shoulder and Elbow Surgeons (ASES) score. Magnetic resonance images without intra-articular contrast were assessed for healing 6 months after surgery for all patients. Functional outcome was evaluated with ASES score. Degree of functional improvement was defined as the difference of ASES scores pre- and postoperatively (d-ASES). Paired t-test and simple linear analysis were used for statistical analysis.

RESULTS

Thirty-seven patients were included with a mean follow-up period of 29.6 ± 6.6 months. VAS score improved from 5.22 to 1.51 (P < .001). ASES score improved from 46.0 to 78.6 (P < .001). The incidence of night pain improved from 70.3% to 8.1% (P < .001). Only a preoperative lower ASES score, higher VAS score, and night pain were related to the higher d-ASES score (P < .001, P = .005, P = .017, respectively). The rate of repair failure was 41.6% at a mean follow-up of 6.4 months.

CONCLUSIONS

Arthroscopic partial repair of irreparable RCTs is an effective treatment to improve the shoulder function and decrease the pain, despite the high repair failure rate of 41.6%. Patients with preoperative lower functional score, higher VAS score, or night pain experienced a greater degree of functional improvement from the surgery. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Long Head of the Biceps as a Suitable Available Local Tissue Autograft for Superior Capsular Reconstruction: "The Chinese Way"

Massive irreparable rotator cuff tears remain a challenging condition during daily clinical practice. Irreversible fatty infiltration of muscles and excessive chronic retraction of tendons predispose to high failure rates of their surgical treatment. Superior capsular reconstruction with either fascia lata autograft or a dermal allograft patch is a newly described solution that could prevent superior humeral head migration and restore the anteroposterior shoulder muscle force couples. The purpose of this article is to propose a technical modification of superior capsular reconstruction using long head of the biceps tendon autograft. The tendon's insertion into the glenoid is left intact, whereas laterally, it is tenotomized, transferred, and sutured with anchors onto the footprint of the supraspinatus tendon acting as a superior static stabilizer of the shoulder joint. Although this surgical modification has theoretical biological advantages, could be performed with the least technical demands, and simplifies the original demanding procedure, further prospective studies with large cohort populations and long-term follow-up are necessary to establish its effectiveness.

Ten-Year Multicenter Clinical and MRI Evaluation of Isolated Supraspinatus Repairs

BACKGROUND

Early repair of isolated supraspinatus tears could prevent further deterioration of the rotator cuff; however, there is no consensus on the management of such tears because of a lack of long-term outcome studies. The purposes of this study were to report the 10-year outcomes of isolated supraspinatus repairs and to investigate the factors that favor healing and recovery.

METHODS

We retrieved the records of all 511 patients who, in 2003, underwent repair of full-thickness isolated supraspinatus tears, performed by 15 surgeons at 15 centers. In 2014, the patients were asked to return for evaluation at a minimum follow-up of 10 years. One hundred and eighty-eight patients could not be reached, and 35 were excluded because they had a reoperation (17 had a retear, 7 had conversion to an arthroplasty, and 11 had other causes). A total of 288 patients (50% were men) who had a mean age (and standard deviation) at index surgery of 56.5 ± 8.3 years (range, 32 to 77 years) were evaluated clinically, and 210 of them were also evaluated using magnetic resonance imaging (MRI).

RESULTS

Thirty shoulders (10.4%) had complications, including stiffness (20 shoulders), infection (1 shoulder), and other complications (9 shoulders). The total Constant score improved from a mean of 51.8 ± 13.6 points (range, 19 to 87 points) preoperatively to 77.7 ± 12.1 points (range, 37 to 100 points) at 10 years. At the 10-year follow-up evaluation, the mean Subjective Shoulder Value (SSV) was 84.9 ± 14.8 (range, 20 to 100), and the mean Simple Shoulder Test (SST) was 10.1 ± 2.2 (range, 3 to 12). Of the 210 shoulders evaluated using MRI, the repair integrity was Sugaya type I in 26 shoulders (12%), type II in 85 (41%), type III in 59 (28%), type IV in 27 (13%), and type V in 13 (6%). The total Constant score at the final follow-up was significantly associated with tendon healing (p < 0.005) and was inversely associated with preoperative fatty infiltration (p < 0.001). Neither the surgical approach nor the preoperative retraction influenced the outcomes.

CONCLUSIONS

Repairs of isolated supraspinatus tears maintained considerable improvement in clinical and radiographic outcomes at 10 years. Preoperative fatty infiltration and postoperative retear have a significantly detrimental effect on the long-term functional outcome of rotator cuff repair.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Should massive rotator cuff tears be reconstructed even when only partially repairable?

PURPOSE

(1) To evaluate midterm functional outcomes of arthroscopic repair of massive rotator cuff tears and (2) to determine the prognostic factors that could influence outcome. The hypothesis was that both partial and complete repairs would result in equivalent improvement of clinical score.

METHODS

From a prospective series of 525 rotator cuff repairs, we analysed records of the 73 patients who were treated for massive tears. The median follow-up was 41 months (range 29-55), and functional outcome was evaluated using the Constant score, shoulder strength, and subjective shoulder value.

RESULTS

The median CS improved from 34 points to 81 points (p < 0.001). The scores were better for both types of two-tendon tears, posterosuperior (83, n = 33) and anterosuperior (85, n = 13) (n.s.), than for three-tendon tears (74, n = 27) (p < 0.001). The scores were also better when fatty infiltration was of stage I (84, n = 28) than of stage II (78, n = 34) (p < 0.001) or stage III (74, n = 11) (p = 0.04). The scores were only slightly higher for completely reparable tears (81.5, n = 50) than for partially reparable tears (79, n = 23) (n.s.). Ultrasonic examination revealed incomplete healing, in 10 of the 50 completely repaired tears, and in 11 of the 23 partially repaired tears.

CONCLUSIONS

The results of the present study compare favourably with those in recent literature and confirm the hypothesis that both partial and complete repairs of massive rotator cuff tears produce equivalent improvements of Constant scores. The clinical relevance of these observations is that even if repairs of two-tendon tears result in superior functional outcomes, repairs of three-tendon tears produce equivalent 'relative' improvement that grants sufficient patient satisfaction and autonomy.

LEVEL OF EVIDENCE

Comparative case series, Level IV.

Arthroscopic Repair of Anterosuperior Massive Rotator Cuff Tears: Does Repair Integrity Affect Outcomes?

BACKGROUND

The purpose of this study was to investigate clinical outcomes and structural integrity after arthroscopic repair of anterosuperior massive rotator cuff tears (RCTs) and to compare clinical outcomes between healed and retear groups.

HYPOTHESIS

The authors hypothesized that although both groups would exhibit improved clinical outcomes compared with their preoperative status, the healed group would have better clinical outcomes than the retear group, and in the retear group, the subscapularis retear subgroup would have inferior outcomes compared with the intact subscapularis repair subgroup.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This study included 73 of 90 eligible patients who underwent arthroscopic repair of an anterosuperior massive RCT. Functional outcomes after 2-year follow-up were assessed using the visual analog scale (VAS) pain score, subjective shoulder value (SSV), American Shoulder and Elbow Surgeons (ASES) score, University of California, Los Angeles (UCLA) shoulder score, and active range of motion. Patients were assigned to the healed group (group H, n = 34) or retear group (group R, n = 39) based on magnetic resonance arthrography results at 6 months postoperatively. Group R was composed of subgroup R1 (subscapularis retear) and subgroup R2 (intact subscapularis repair).

RESULTS

Retearing occurred in 53% of patients. At 2-year follow-up, group H exhibited better outcomes for all functional scores versus group R, respectively ( P < .001): VAS pain score (1.0 vs 2.1), SSV (90.2 vs 77.4), ASES score (90.8 vs 76.6), and UCLA shoulder score (31.0 vs 24.9). Within both groups, all scores improved significantly compared with preoperative values ( P < .001). At follow-up, group H had significantly better forward flexion ( P = .018) and internal rotation ( P = .002) than group R; within both groups, active range of motion improved in all planes compared with the preoperative condition ( P < .001). Subgroup R1 exhibited inferior outcomes versus subgroup R2, respectively: VAS pain score (2.6 vs 1.5; P = .012), ASES score (70.9 vs 83.6; P = .013), SSV (70.9 vs 85.4; P = .005), and UCLA shoulder score (22.0 vs 28.5; P = .001).

CONCLUSION

After arthroscopic repair of anterosuperior massive RCTs, 53% of patients exhibited retearing. The healed group had better functional outcomes than the retear group. The subscapularis retear subgroup exhibited significantly inferior outcomes compared with the intact subscapularis repair subgroup.

Supraspinatus muscle occupation ratio predicts rotator cuff reparability

BACKGROUND

We wished to determine the correlation between supraspinatus muscle occupation ratio and reparability of rotator cuff muscles and that of each occupation ratio with 1-muscle, 2-muscle, and 3-muscle rotator cuff injury.

METHODS

We evaluated 170 patients (average age, 62.3 [40-83] years) with complete (type II) or incomplete (type III) rotator cuff repair by arthroscopy. Type II repair was defined as complete repair but less optimal coverage of the entire medial-lateral footprint. Type III repair was defined as incomplete repair; a small portion (<10 mm) of the humeral head is exposed. Patients were divided into 2 groups: 96 and 74 patients who underwent type II and type III repair, respectively. Patients were also categorized into 4 groups: isolated supraspinatus tears, supraspinatus and infraspinatus tears, supraspinatus and subscapularis tears, and tears in all 3 muscles. Supraspinatus muscle atrophy was evaluated by the occupation ratio on the most lateral T1-weighted sagittal oblique view in which the scapular spine contacted the scapular body. The supraspinatus muscle occupation ratio was measured by 2 independent observers.

RESULTS

On magnetic resonance imaging, the supraspinatus muscle occupation ratio was significantly different between the completely repaired and incompletely repaired groups. The mean occupation ratio of the completely repaired group (42.39 ± 10.1) was significantly higher than that of the incompletely repaired group (36.64 ± 6.94). The cutoff value of the supraspinatus muscle occupation ratio (complete to incomplete repair) was 41. The supraspinatus muscle occupation ratio significantly decreased as the tear increased (P < .001).

CONCLUSION

A supraspinatus muscle occupation ratio of <41 can be the cutoff value for greater tuberosity coverage vs. incomplete coverage. There was a significant correlation between tear pattern and supraspinatus muscle atrophy ratio. The supraspinatus tear group had the lowest degree of muscle atrophy.

Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty

PURPOSE

We sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation can be durably improved using a conservative surgical procedure that smoothes the interface between the proximal humeral convexity and the concave undersurface of the coracoacromial arch followed by immediate range of motion exercises.

METHODS

We reviewed 151 patients with a mean age of 63.4 (range 40-90) years at a mean of 7.3 (range 2-19) years after this surgery.

RESULTS

In 77 shoulders with previously unrepaired irreparable tears, simple shoulder test (SST) scores improved from an average of 4.6 (range 0-12) to 8.5 (range 1-12) (p < 0.001). Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points. For 74 shoulders with irreparable failed prior repairs, SST scores improved from 4.0 (range 0-11) to 7.5 (range 0-12) (p < 0.001). Fifty-four patients (73%) improved by the MCID of 2 SST points.

CONCLUSION

Smoothing of the humeroscapular interface can improve symptomatic shoulders with irreparable cuff tears and retained active elevation. This conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears.

LEVEL OF EVIDENCE

Level IV.

Impact of rotator cuff tendon reparability on patient satisfaction

Background

The primary purpose of this study was to explore the relationship between patient satisfaction and rotator cuff tendon reparability.

Materials and methods

This was a secondary analysis of prospectively collected data of consecutive patients who underwent arthroscopic repair of full-thickness rotator cuff tear and were followed up for 2 years. The satisfaction level was rated on a 6-point Likert scale. Patient-oriented disability measures included the American Shoulder and Elbow Surgeons score, the short version of the Western Ontario Rotator Cuff index, the Constant-Murley score, and the Quick Disabilities of the Arm, Shoulder, and Hand. Partial repair was defined as repair with >1 cm residual gap.

Results

There were 145 patients (65 women, 80 men; mean age, 62 years) who met the inclusion criteria. There were 12 massive, 31 large, and 102 small or moderate rotator cuff tears. Of 43 large or massive tears, 23 had a partial repair. There was a statistically significant relationship between satisfaction and tendon reparability (P = .01). Patients with work-related shoulder injury reported less satisfaction with surgery (P = .005). Age, gender, or tear size did not affect satisfaction with surgery. Satisfaction was a predictor of all postoperative outcome scores after being adjusted for preoperative scores (P = .001 to P < .0001).

Conclusion

In this study, patients with partial repair and those with an active compensable injury were less satisfied with surgery than their counterparts were. Older age, female sex, or a larger tear was not a negative predictor of patient satisfaction.

Quality of Life and Functional Results of Arthroscopic Partial Repair of Irreparable Rotator Cuff Tears

PURPOSE

To evaluate the minimum 2-year results and possible outcomes of arthroscopic partial repair in different patterns of irreparable rotator cuff tears (RCTs).

METHODS

Patients suffering from an irreparable supraspinatus and a reparable infraspinatus tendons who underwent arthroscopic partial repair with a minimum 24-month follow-up were included in this study. The Constant and Murley score (CMS) was used to assess patients' functionality pre- and postoperatively. Postoperative patient assessment included the Simple Shoulder Test (SST) and the Short Form Health Survey questionnaire (SF-36). A postoperative range of motion, CMS, and strength were compared with the contralateral side. Postoperative SF-36 was compared with age- and sex-matched norms.

RESULTS

Ninety patients (95 shoulders) were reviewed after a mean follow-up of 7 (range 2-12) years. The subscapularis tendon was intact in 80 shoulders and torn but completely reparable in the remaining 15 shoulders. The CMS improved from 39.1 ± 8.4 (10-61) to 76.3 ± 9.7 (32-93) (P < .001). The mean postoperative SST was 9.1 ± 2.2 (1-12). Although the patients had lower postoperative abduction and internal rotation, strength in abduction and CMS in comparison with the measurements from the contralateral side, the median postoperative SF-36 physical and mental component summaries were 98% and 100% of the matched norms. No significant differences were found in postoperative outcomes according to the RCT pattern. Males showed significantly higher strengths in abduction (B = -1.384, 95% confidence interval [CI] -2.144 to -0.624, η² = 0.123, P < .001, 95% power), external rotation (B = -3.646, 95% CI -5.2 to -2.092, η² = 0.189, P < .001, 100% power), and internal rotation (B = -3.867, 95% CI -5.676 to -2.057, η² = 0.162, P < .001, 99% power) than females. Significantly higher ranges of abduction (η² = 0.431, P = .019, 98% power) and external rotation (η² = 0.417, P < .03, 97% power) were noted in younger patients. Higher strengths in abduction (η² = 0.495, P = .002, 100% power) and internal rotation (η² = 0.464, P = .006, 99% power) were also reported in these patients.

CONCLUSIONS

When there is an irreparable supraspinatus but there is still the possibility to repair the infraspinatus and subscapularis, the arthroscopic partial cuff repair should be considered as an effective surgical option. Indeed, a significant clinical improvement can be achieved and, differently from pure symptomatic surgical procedures, this technique represents a reasonable effort to restore, at least in part, the shoulder joint functionality. Successful and reliable results can be expected at an average 7-year follow-up, regardless of the RCT pattern. Female and older patients have a greater likelihood of lower functional outcomes.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Partial rotator cuff repair and biceps tenotomy for the treatment of patients with massive cuff tears and retained overhead elevation: midterm outcomes with a minimum 5 years of follow-up

BACKGROUND

A subset of patients with massive irreparable rotator cuff tears present with retained overhead elevation and pain as their primary complaint. Our aim was to evaluate the outcomes of partial arthroscopic rotator cuff repair with biceps tenotomy and to report the failure rate of this procedure for patients with >5 years of follow-up.

METHODS

Thirty-four patients underwent partial rotator cuff repair and biceps tenotomy for treatment of a massive rotator cuff tear. Patients had preoperative active forward elevation >120° and no radiographic evidence of glenohumeral arthritis. Patients were followed up clinically and radiographically, and 28 patients had a minimum of 5 years of follow-up. Failure was defined as an American Shoulder and Elbow Surgeons score of <70, loss of active elevation >90°, or revision to reverse shoulder arthroplasty during the study period.

RESULTS

Patients demonstrated improvements in average preoperative to postoperative American Shoulder and Elbow Surgeons scores (46.6 to 79.3 [P < .001]) and Simple Shoulder Test scores (5.7 to 9.1 [P < .001]) along with decrease in visual analog scale for pain scores (6.9 to 1.9 [P < .001]). No significant change in forward elevation (168° to 154° [P = .07]), external rotation (38° to 39° [P = 1.0]), or internal rotation (84% to 80% [P = 1.0]) was identified; 36% of patients had progression of the Hamada stage. The failure rate was 29%; 75% of patients were satisfied with their index procedure.

CONCLUSION

Partial rotator cuff repair and biceps tenotomy for patients with massive irreparable rotator cuff tears with retained overhead elevation and pain as the primary complaint produced reasonable outcomes at midterm follow-up of at least 5 years.