Massive Rotator Cuff Tear: When to Consider Reverse Shoulder Arthroplasty

Shoulder arthroplasty in the elderly

Background

Shoulder arthroplasty is increasingly being used for definitive treatment of various shoulder pathologies, especially in more elderly patients. Controversy surrounds the optimal choice in total shoulder arthroplasty for elderly patients. In this review we discuss the options available when considering TSA for an elderly patient.

Review

Anatomical total shoulder arthroplasty (ATSA) relies upon an intact, functioning rotator cuff. Reverse total shoulder arthroplasty (RTSA) relies upon a functioning deltoid for optimal outcomes. The setting of partial cuff tears. Both options confer their own advantages and disadvantages.ATSA are a valuable treatment option for elderly patients with severe shoulder arthritis or degenerative conditions, offering significant pain relief and functional improvement. While it provides numerous advantages, including pain relief, preservation of bone stock, and natural joint mechanics, careful patient selection and consideration of potential drawbacks such as rotator cuff integrity and surgical complexity are crucial for optimising outcomes in this population.RTSA has become a valuable treatment solution for elderly patients with complex shoulder conditions, offering significant pain relief, improved functionality, and enhanced quality of life. While careful consideration of patient factors and potential complications is necessary, RTSA continues to demonstrate favourable outcomes and good survivorship in the elderly.

Discussion

Debate continues optimal shoulder arthroplasty management for elderly patients. Technology continues to advance the surgical technique for shoulder arthroplasty and address some of the challenges encountered. Research continues to try and help answer many of the debated areas of shoulder arthroplasty, but current evidence continues to show an improving trend in survivorship and long-term outcomes for most shoulder arthroplasty procedures.

Relevant treatment outcomes for individuals aged 60 and older with massive rotator cuff tears: a qualitative study with 16 patients

BACKGROUND AND PURPOSE

 Qualitative research on individuals with massive rotator cuff tears (MRCT) is scarce. This study aims to identify the perceptions, concerns, and treatment outcomes relevant to individuals with MRCT of the shoulder, as expected before treatment or experienced afterward.

METHODS

 A qualitative study was designed using a hermeneutic phenomenological methodology. Purposive sampling was employed to identify potentially eligible patients (diagnosed with MRCT and aged 60-85 years) in the trauma and orthopedic outpatient clinics of 3 hospitals in Spain. The study employed 2 segmentation criteria: type of treatment and timing (before/after treatment). 16 interviews were conducted to capture the patients' perspective: 9 were semi-structured and 7 were in-depth. Interpretative phenomenological analysis was used, and triangulation was performed by 3 researchers with diverse backgrounds.

RESULTS

 The mean age of participants (10 women and 6 men) was 71 years, with most having their dominant limb affected. The analysis revealed 4 themes (13 subthemes): MRCT impact on daily living (shoulder-derived functional limitation, pain, and emotional disturbance); treatment outcomes (recovering independence, pain relief, and social participation); clinical management (communication with health professionals, duration of the diagnostic/therapeutic process, and participation in decision-making); and characteristics of the individual (sex, work, and comorbidity). Special unmet needs were identified for women, with more prolonged diagnostic and therapeutic processes while bearing most household responsibilities.

CONCLUSION

 Recovering independence and pain relief were the principal outcomes from the perspective of patients with MRCT, and social participation and emotional well-being were closely linked. Measuring these outcomes could improve shared decision-making, while addressing systemic barriers to enhance patient participation.

Arthroscopic Subacromial Balloon Spacer for Massive Rotator Cuff Tears Demonstrates Improved Shoulder Functionality and High Revision-Free Survival Rates at a Minimum 5-Year Follow-Up

PURPOSE

To investigate the efficacy of arthroscopic subacromial balloon placement for massive rotator cuff tear (MRCT), assessing patient satisfaction, outcomes, shoulder functionality, pain scores, and revision-free survivorship up to 8 years after the initial surgery.

METHODS

In this retrospective study with prospective data collection, patients with MRCTs undergoing balloon placement from 2014 to 2017 were prospectively enrolled. Their outcomes were analyzed retrospectively over a minimum 5-year follow-up. Demographics, patient satisfaction, reoperations, and complications were documented. Minimal clinically important differences were calculated for 12-Item Short Form Health Survey scores and Constant-Murley score subscores. Pre- and postsurgery measures statistically compared for anatomic and functional evaluations.

RESULTS

In a study with 61 participants initially, 10 were lost to follow-up over 3 years. Of the remaining 51, 9 were lost at the latest follow-up. The cohort (42 participants, mean age 63.17 ± 7.66 years) was monitored for 83.98 ± 9.50 months. Seven participants required revisions within 2 years, resulting in an 83.33% revision-free survival rate. Significant improvements were observed from preoperative to latest follow-up: acromiohumeral interval decreased (7.83 to 6.56, P = .004), critical shoulder angle increased (36.10 to 38.24, P = .001), osteoarthritis grade increased (1.45 to 2.81, P = .001), 12-Item Short Form Health Survey physical score improved (27.40 to 37.69, P = .001), and Constant-Murley total scores increased (26.50 to 68.69, P = .001). Minimal clinically important difference for total Constant-Murley scores was 11.78 points. Among those without revisions, satisfaction rates were 11.43% excellent, 57.14% satisfied, and 31.43% dissatisfied.

CONCLUSIONS

Employing a balloon spacer for MRCTs yielded moderate satisfaction at the 5-year follow-up, with stable revision rates within the first 2 years. Notably, low revision surgery rates, high revision-free survival, and significant shoulder functionality improvements were observed at a minimum 5-year follow-up with arthroscopic subacromial balloon placement in conjunction with biceps tenotomy and subacromial bursectomy for MRCT.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Defining pseudoparalysis and pseudoparesis: a consensus study

BACKGROUND

The purpose of this study was to establish consensus statements via a modified Delphi process on the definition of shoulder pseudoparalysis and pseudoparesis.

METHODS

A consensus process on the definition of a diagnosis of pseudoparalysis utilizing a modified Delphi technique was conducted, and 26 shoulder/sports surgeons from 11 countries, selected based on their level of expertise in the field, participated in these consensus statements. Consensus was defined as achieving 80%-89% agreement, whereas strong consensus was defined as 90%-99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement.

RESULTS

Three statements regarding the diagnosis of pseudoparalysis reached strong (>89%) consensus: passive range of motion should be unaffected, the passive range of abduction should not be considered, and diagnosis should be excluded if lidocaine injection produces a substantial improvement in range of motion. Additionally, consensus (>79%) was reached that the active range of external rotation should not be considered for diagnosis, pain as a cause of restricted motion must be excluded, and that distinctions between restricted active flexion and external rotation should be made by range of motion rather than tear characteristics. No consensus could be reached on statements regarding the size, number of tendons or chronicity of cuff tears. Nor was there agreement on the active range of flexion permitted or on the difference between pseudoparalysis and pseudoparesis.

CONCLUSION

A modified Delphi process was utilized to establish consensus on the definition of shoulder pseudoparalysis and pseudoparesis. Unfortunately, almost half of the statements did not reach consensus, and agreement could not be reached across all domains for a unifying definition for the diagnosis of pseudoparalysis in the setting of rotator cuff tears. Furthermore, it was not agreed how or whether pseudoparalysis should be differentiated from pseudoparesis. Based on the lack of a consensus for these terms, studies should report explicitly how these terms are defined when they are used.

Electromyographic analysis of selected shoulder muscles during shoulder rehabilitation exercises in patients after reverse total shoulder arthroplasty

BACKGROUND

Reverse shoulder arthroplasty (RSA) aims to restore function in patients with rotator cuff failure and joint arthropathy. After surgery, patients are routinely referred to a rehabilitation specialist to regain range of motion, strength, and function. A key element in these programs is active exercises. The exercises are often selected based on assumed muscle activity, investigated by electromyography (EMG). In particular, in this patient population, activation of the deltoid and the scapular muscles is the focus of exercise therapy. Currently, most studies investigating muscle activity levels during exercises are performed on healthy individuals. To our knowledge, no study exists analyzing EMG activity during exercises in a population of shoulder arthroplasty patients. Therefore, the study aimed to analyze activity in the shoulder girdle muscles during 6 commonly used rehabilitation exercises 12 weeks after reverse shoulder arthroplasty surgery.

METHODS

Forty-four patients (50 shoulders) participated in this cross-sectional study, 12 weeks postoperatively (mean 99.18 ± 12.8 days), aged 68.9 ± 7.75 years. Surface EMG activity was measured in 10 shoulder girdle muscles: the 3 trapezius parts, serratus anterior, the 3 deltoid parts, latissimus dorsi, and 2 pectoralis major parts during 6 exercises, 3 in a closed chain, and 3 open chain elevation exercises.

RESULTS

Gravity-minimized exercises (horizontal plane) show low activity for almost all muscles. Vertical closed kinetic chain exercises show an increased activity compared to horizontal plane exercises. Open kinetic chain exercises against gravity showed the greatest activity in deltoid and upper trapezius. For the other muscles, no consistency in progression was found.

CONCLUSION

This study offers a progression of exercises for patients after reverse shoulder arthroplasty based on increased muscle activity.

Tendon transfers for the management of irreparable subscapularis tears

Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears. The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane - anterior to the rib cage - is clearly different and does not allow it to function as an ideal transfer. Consistent relief of pain and moderate recovery of strength and function have been reported following the use of this transfer. In an attempt to improve on these results, latissimus dorsi tendon transfer was proposed as an alternative and the technique has evolved from an open to an arthroscopic procedure. Satisfactory relief of pain and improvements in functional shoulder scores have recently been reported following its use. Both pectoralis minor and upper trapezius transfers have also been used in these patients, but the outcomes that have been reported do not support their widespread use.

Effect of Tear Size and Location on Supraspinatus Tendon Strain During Activities of Daily Living and Physiotherapy

The supraspinatus tendon plays a crucial role in shoulder abduction, making it one of the common structures affected by injury. Clinically, crescent-shaped tears are the most commonly seen tear shape. By developing six specimen-specific, three-dimensional, supraspinatus-infraspinatus finite element model with heterogeneous material properties, this study aimed to examine the changes in tissue deformation (maximum principal strain) of the supraspinatus tendon due to specimen-specific material properties and rotator cuff tear size. FE models with small- and medium-sized full-thickness crescent-shaped tears were subjected to loads seen during activities of daily living and physiotherapy. Six fresh-frozen cadaveric shoulders were dissected to mechanically test the supraspinatus tendon and develop and validate FE models that can be used to assess changes in strain due to small (< 1 cm, equivalent to 20-30% of the tendon width) and medium-sized (1-3 cm, equivalent to 40-50% of the tendon width) tears that are located in the middle and posterior regions of the supraspinatus tendon. FE predictions of maximum principal strain at the tear tips were examined to determine whether failure strain was reached during activities of daily living (drinking and brushing teeth) and physiotherapy exercises (prone abduction and external rotation at 90° abduction). No significant differences were observed between the middle and posterior tear failure loads for small- and medium-sized tears. For prone abduction, there was a potential risk for tear progression (exceeded failure strain) for medium-sized tears in the supraspinatus tendon's middle and posterior regions. For external rotation at 90° abduction, one model with a middle tear and two with posterior tears experienced failure. For all daily activity loads, the strain never exceeded the failure strain. Our three-dimensional supraspinatus-infraspinatus FE model shows that small tears appear unlikely to progress based on the regional strain response; however, medium-sized tears are at higher risk during more strenuous physiotherapy exercises. Furthermore, differences in patient-specific tendon material properties are important in determining whether the tear will progress. Therefore, patient-specific management plans based on tear size may be beneficial to improve clinical outcomes.

Irreparable Cuff Injuries: Treatment Options and Clinical Outcomes

Rotator cuff tear is a common source of pain and disfunction in shoulder, with prevalence increasing with age. Nonsurgical treatment is adequate for many patients; however, for those for whom surgical treatment is indicated, rotator cuff repair provides reliable pain relief and good functional results. However, massive and irreparable tears due to tear size, tendon retraction, muscle atrophy, fatty infiltration are a significant challenge for surgeons. Whenever irreparable tears coexist with cartilage degeneration/arthritis (rotator cuff arthropathy), the indication of reverse shoulder arthroplasty is the golden standard. However, in young patients without arthritis, joint preserving procedures, from debridement to muscle transfers, are preferred. Choosing the most appropriate treatment is not quite established in literature, each treatment modality present particular indications, advantages and disadvantages.

Influence of Critical Shoulder Angle and Rotator Cuff Tear Type on Load-Induced Glenohumeral Biomechanics: A Sawbone Simulator Study

Glenohumeral (GH) biomechanics after rotator cuff (RC) tears are not fully understood. The purpose of our study was to determine if the critical shoulder angle (CSA), type of RC tears, and level of weight bearing increase GH translation, instability based on the instability ratio, muscle forces and joint reaction force (JRF), and shifts the center of force (CoF) superiorly. A GH simulator with muscle-mimicking cable systems was used to simulate 30° abduction in the scapular plane. A Sawbone humerus and five specimen-specific scapular anthropometries were used to test six types of RC tears, three weight-bearing loads, and the native and adjusted (to different CSAs) deltoid origin sites. Linear mixed effects models (CSA, RC tear type, and weight bearing) with random effects (specimen and sex) were used to assess differences in GH biomechanics. With increasing CSA, GH translation increased, JRF decreased, and the CoF position was more inferior. RC tears did not significantly alter GH translation but shifted the CoF position superiorly, close to where glenoid erosion occurs in patients with RC tears with secondary osteoarthritis. Weight bearing significantly increased GH translation and JRF. RC and deltoid muscle forces increased with the presence of RC tears and increased weight bearing. The remaining RC muscles of intact tendons compensated for the torn RC tendons but not for the altered CoF position. GH translation remained comparable to shoulders with intact RC. These findings highlight the importance of early detection, clinical management, and targeted rehabilitation strategies for patients with RC tears.

Reverse shoulder arthroplasty for massive rotator cuff tears without glenohumeral arthritis can improve clinical outcomes despite history of prior rotator cuff repair: A systematic review

IMPORTANCE

Reverse shoulder arthroplasty (RSA) is often used to surgically address massive irreparable rotator cuff tears (MIRCT) without arthritis. The impact of prior attempted rotator cuff repair (RCR) on outcomes is unclear.

OBJECTIVE

The purpose of this systematic review was to compare functional outcomes, range of motion, and complications in patients with a MIRCT without arthritis who underwent RSA as a primary procedure versus after prior RCR.

EVIDENCE REVIEW

A systematic review was performed on RSA for a MIRCT. The search was conducted from February to March of 2022 using the MEDLINE database. Patient-reported outcome measures (PROs), range of motion (ROM), and complications were extracted. These outcomes were weighted and analysed based on whether the reverse was performed as the primary procedure or following a prior RCR.

FINDINGS

Seven studies were included in the analysis, consisting of 343 cases in the primary RSA group and 95 cases in the prior RCR group, with a mean follow-up of 40.8 months. There were no demographic differences between cohorts. Postoperative PROs and ROM were comparable between groups, although the prior RCR group had a higher maximal percentage of improvement (MPI%) for the Constant-Murley Score and Simple Shoulder Test. There was a higher risk for complications (relative risk [RR] 6.26) and revisions (RR 3.91) in the prior RCR group. The most common complications were acromial stress fractures and prosthetic dislocation.

CONCLUSION AND RELEVANCE

Patients undergoing RSA for MIRCT following a prior RCR have functional outcomes that are largely comparable to those who have a primary RSA, but they may be at higher risk of complications and revision.

LEVEL OF EVIDENCE

IV.

Reversing chronic pseudoparesis secondary to massive, irreparable rotator cuff tear: superior capsular reconstruction vs. reverse total shoulder arthroplasty

INTRODUCTION

Recent studies have defined pseudoparesis as limited active forward elevation between 45° and 90° and maintained passive range of motion (ROM) in the setting of a massive rotator cuff tear (RCT). Although pseudoparesis can be reliably reversed with reverse total shoulder arthroplasty (RSA) or superior capsular reconstruction (SCR), the optimal treatment for this indication remains unknown. The purpose of this study was to compare the clinical outcomes of RSA to SCR in patients with pseudoparesis secondary to massive, irreparable RCT (miRCT).

METHODS

This was a retrospective cohort study of consecutive patients aged 40-70 years with pseudoparesis secondary to miRCT who were treated with either RSA or SCR by a single fellowship-trained shoulder surgeon from 2016 to 2021 with a minimum 12-month follow-up. Multivariate linear regression modeling was used to compare active ROM, visual analog pain scale (VAS), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score between RSA and SCR while controlling for confounding variables.

RESULTS

Twenty-seven patients were included in the RSA cohort and 23 patients were included in the SCR cohort with similar mean follow-up times (26.2 ± 21.1 vs. 21.9 ± 14.7 months, respectively). The patients in the RSA group were significantly older than those in the SCR group (65.2 ± 4.4 vs. 54.2 ± 7.8 years, P < .001) and had more severe arthritis (1.8 ± 0.9 vs. 1.2 ± 0.5 Samilson-Prieto, P = .019). The pseudoparesis reversal rate among the RSA and SCR cohorts was 96.3% and 91.3%, respectively. On univariate analysis, the RSA cohort demonstrated significantly greater mean improvement in active FF (89° ± 26° vs. 73° ± 30° change, P = .048), greater postoperative SSV (91 ± 8% vs. 69 ± 25%, P < .001), lower postoperative VAS pain scores (0.6 ± 1.2 vs. 2.2 ± 2.9, P = .020), and less postoperative internal rotation (IR; 4.6° ± 1.6° vs. 6.9° ± 1.8°, P = .004) compared with SCR. On multivariate analysis controlling for age and osteoarthritis, RSA remained a significant predictor of greater SSV (β = 21.5, P = .021) and lower VAS scores (β = -1.4, P = .037), whereas SCR was predictive of greater IR ROM (β = 3.0, P = .043).

CONCLUSION

Although both RSA and SCR effectively reverse pseudoparesis, patients with RSA have higher SSV and lower pain scores but less IR after controlling for age and osteoarthritis. The results of this study may inform surgical decision making for patients who are suitable candidates for either procedure.

Joint-preserving treatment for global irreparable rotator cuff tears: combined anterior Latissimus dorsi and Teres major tendon transfer

INTRODUCTION

Treating global irreparable rotator cuff tears (GIRCTs) that involve both antero-and postero-superior cuff tendon tears could be a challenging problem. There has been limited joint-preserving treatment options in high-demand patients with minimal glenohumeral arthritis. The study aims to assess the clinical outcome of combined anterior latissimus dorsi and teres major tendon (aLDTM) transfer for patients with both GIRCTs and minimal glenohumeral arthritis.

MATERIALS AND METHODS

This retrospective study included patients who underwent combined aLDTM transfer for GIRCTs between 2018 May and 2020 October. Clinical outcomes include pain VAS, Constant, American Shoulder and Elbow Society (ASES), University of California Los Angeles (UCLA), activities of daily living requiring active internal rotation (ADLIR) score, active range of motion (aROM), strength, rates of pseudoparalysis or pseudoparesis reversal and return to work. Radiographic assessment included the acromiohumeral distance (AHD), Hamada grade, and transferred tendon integrity at final follow-up.

RESULTS

23 patients (mean age: 64.7 ± 5.9 years [55-74]) were included and the mean follow-up period was 28.2 ± 4.3 [24‒36] months. Postoperatively, VAS, Constant, ASES, UCLA, and ADLIR scores significantly improved at final follow-up (P < .001). Postoperative aROM was significantly improved in forward elevation (FE) to 129° ± 29°, abduction (ABD) to 105° ± t3°, and internal rotation (IR) at back to 5.9 ± 2.5. Strength of both FE and IR were also significantly improved (P < .001). Patients with preoperative pseudoparalysis (2 of 4 patients) and pseudoparesis (6 of 6 patients) experienced a reversal. No significant change in AHD and hamada grade was confirmed at final follow-up. 3 patients experienced partial tear of the transferred tendon.

CONCLUSIONS

In this study, we found significant improvement in clinical outcomes with no significant progression of arthritis by final follow-up. The aLDTM transfer could be an alternative choice of joint-preserving treatment option for young and active patients with GIRCTs and minimal glenohumeral arthritis. However, large and long-term studies should be conducted to establish its adequacy.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

IV.

The influence of rotator cuff tear type and weight bearing on shoulder biomechanics in an ex vivo simulator experiment

Glenohumeral biomechanics after rotator cuff (RC) tears have not been fully elucidated. This study aimed to investigate the muscle compensatory mechanism in weight-bearing shoulders with RC tears and asses the induced pathomechanics (i.e., glenohumeral translation, joint instability, center of force (CoF), joint reaction force). An experimental, glenohumeral simulator with muscle-mimicking cable system was used to simulate 30° scaption motion. Eight fresh-frozen shoulders were prepared and mounted in the simulator. Specimen-specific scapular anthropometry was used to test six RC tear types, with intact RC serving as the control, and three weight-bearing loads, with the non-weight-bearing condition serving as the control. Glenohumeral translation was calculated using instantaneous helical axis. CoF, muscle forces, and joint reaction forces were measured using force sensors integrated into the simulator. Linear mixed effects models (RC tear type and weight-bearing) with random effects (specimen and sex) were used to assess differences in glenohumeral biomechanics. RC tears did not change the glenohumeral translation (p > 0.05) but shifted the CoF superiorly (p ≤ 0.005). Glenohumeral translation and joint reaction forces increased with increasing weight bearing (p < 0.001). RC and deltoid muscle forces increased with the presence of RC tears (p ≤ 0.046) and increased weight bearing (p ≤ 0.042). The synergistic muscles compensated for the torn RC tendons, and the glenohumeral translation remained comparable to that for the intact RC tendons. However, in RC tears, the more superior CoF was close to where glenoid erosion occurs in RC tear patients with secondary osteoarthritis. These findings underscore the importance of early detection and precise management of RC tears.

Pseudoparesis and pseudoparalysis in the setting of massive irreparable rotator cuff tear: demographic, anatomic, and radiographic risk factors

BACKGROUND

The primary purpose of this study was to identify demographic, anatomic, and radiographic risk factors for active forward elevation (AFE) <90° in the setting of massive, irreparable rotator cuff tear (miRCT). The secondary purpose was to identify characteristics differentiating between patients with pseudoparalysis (AFE <45°) and pseudoparesis (AFE >45° but <90°).

METHODS

This was a retrospective case-control study reviewing patients with miRCTs at a single institution between January 12, 2016 and November 26, 2020. Patients were separated into 2 cohorts based on presence or absence of preoperative AFE <90° with maintained passive range of motion. Demographics, RCT pattern, and radiographic parameters were assessed as risk factors for AFE <90°. A secondary analysis was conducted to compare patients with pseudoparalysis and pseudoparesis.

RESULTS

There were 79 patients in the AFE <90° cohort and 50 patients in the control cohort. Univariate analysis confirmed significant differences between the AFE <90° and control cohort in age (71.9 ± 11.0 vs. 65.9 ± 9.1 years), arthritis severity (34.2% vs. 16.0% grade 3 Samilson-Prieto), acromiohumeral distance (AHD; 4.8 ± 2.7 vs. 7.6 ± 2.6 mm), fatty infiltration of the supraspinatus (3.3 ± 0.9 vs. 2.8 ± 0.8) and subscapularis (2.0 ± 1.2 vs. 1.5 ± 1.0), and proportion of subscapularis tears (55.7% vs. 34.0%). On multivariate analysis, age (odds ratio [OR] 1.08, P = .014), decreased AHD (OR 0.67, P < .001), severe arthritis (OR 2.84, P = .041), and subscapularis tear (OR 6.29, P = .015) were independent factors predictive of AFE <90°. Secondary analysis revealed tobacco use (OR 3.54, P = .026) and grade 4 fatty infiltration of the supraspinatus (OR 2.22, P = .015) and subscapularis (OR 3.12, P = .042) as significant predictors for pseudoparalysis compared to pseudoparesis.

CONCLUSIONS

In patients with miRCT, increased age, decreased AHD, severe arthritis, and subscapularis tear are associated with AFE <90°. Furthermore, patients with AFE <90° tend to have greater supraspinatus and subscapularis fatty infiltration. Lastly, among patients with AFE <90°, tobacco use and grade 4 fatty infiltration of the supraspinatus and subscapularis are associated with pseudoparalysis compared with pseudoparesis.

Subacromial Balloon Spacer for Irreparable Rotator Cuff Tear Treatment Shows Improved Pain and Strength at 5-Year Follow-Up

PURPOSE

To report on minimum 5-year outcomes following subacromial balloon spacer implantation (SBSI), in terms of survivorship, pain reduction, functional outcomes, complications, and reoperations.

METHODS

Data were prospectively collected and retrospectively analyzed for consecutive patients undergoing SBSI between April 1, 2012, and June 30, 2016. Patients completed preoperative and postoperative follow-up for minimum 5 years on the following patient-reported outcomes (PROs): Constant-Murley Score (CMS), visual analog scale for pain (VAS), strength, and patient satisfaction. Reoperations and complications were recorded. Minimal detectable change (MDC) was calculated and the proportion of patients achieving MDC for CMS and VAS were calculated.

RESULTS

During the study period, SBSI was performed in 36 patients. Three patients were deceased within 5 years. Of the remaining 33 patients, follow-up was available on 29 patients (80.6%). Mean age at the time of operation was 72.7 ± 4.5 years, and 69% of the patients were males. Mean follow-up time was 72.5 months. Significant improvements from preoperative to last follow-up were demonstrated in CMS (36.08 vs. 63.88; P < .001), VAS (6.72 vs. 1.68; P < .001), and strength (3.8 vs 5.87 kg; P < .001). These improvements were demonstrated at 3 weeks, 6 months, 12 months, 24 months, and 60 months. Mean patient satisfaction at last follow-up was 8.72. The MDC for both CMS and VAS was achieved by 75.9% (22/29) of patients. Four patients underwent conversion to a reverse total shoulder arthroplasty (RTSA). Complications included one patient with balloon dislocation and one patient with a secondary infection due to urinary tract infection.

CONCLUSIONS

Pain reduction and functional improvements are sustained at minimum 5 years after SBSI in patients with irreparable rotator cuff tears. The 5-year conversion rate to an RTSA was 13.79%.

LEVEL OF EVIDENCE

Level IV, retrospective case-series.

Subacromial Balloon Spacer Versus Partial Rotator Cuff Repair in the Treatment of Massive Irreparable Rotator Cuff Tears: Facility Personnel Allocation and Procedural Cost Analysis

Background The subacromial balloon is a novel technology that has shown promise in managing a select patient population with massive irreparable rotator cuff tears. The purpose of this study was to quantify the true facility cost difference between subacromial balloon placement (SBP) and partial rotator cuff repair (PCR). Methodology A prospective cohort of patients with massive irreparable rotator cuff tears randomized to SBP versus PCR between 2015 and 2018 was retrospectively reviewed. Demographic variables, medical comorbidities, and range-of-motion (ROM) outcomes for all patients were recorded. True facility costs with respect to personnel were calculated using a time-driven activity based-costing (TDABC) algorithm and were classified into personnel costs and supply costs. Results Seven patients were treated with PCR compared to nine treated with SBP. No significant differences were observed with respect to demographic characteristics. Postoperative mean external rotation was 37° in SBP patients significantly higher than that of PCR patients at 8° (P = 0.023). Personnel time and cost differences while in the operating room (OR) were significantly less for the SBP ($605.58) compared to PCR ($1362.76) (P < 0.001). Implant costs were higher for SBP when compared to PCR, whereas disposable equipment costs were higher for PCR when compared to SBP. The total mean true facility cost was $7658.00 for SBP, significantly higher than that of PCR at $3429.00 (P < 0.001). Conclusions Despite the substantial reduction in personnel costs seen with SBP, the true facility cost of SBP was significantly higher than that of PCR. As this novel technology is used more ubiquitously and its price is negotiated down, the cost savings seen in personnel and OR time will become more significant. Future prospective cost analyses should follow up on the changes in implant costs and account for potential anesthesia cost savings.

Massive and Irreparable Rotator Cuff Tears: A Review of Current Definitions and Concepts

Background

While massive and irreparable rotator cuff tears (MIRCTs) have been abundantly studied, inconsistent definitions in the literature and theories about pain and dysfunction related to them can be difficult to navigate when considering an individual patient.

Purpose

To review the current literature for definitions and critical concepts that drive decision-making for MIRCTs.

Study Design

Narrative review.

Methods

A search of the PubMed database was performed to conduct a comprehensive literature review on MIRCTs. A total of 97 studies were included.

Results

Recent literature reflects added attention to clarifying the definitions of "massive, "irreparable," and "pseudoparalysis." In addition, numerous recent studies have added to the understanding of what generates pain and dysfunction from this condition and have reported on new techniques for addressing them.

Conclusion

The current literature provides a nuanced set of definitions and conceptual foundations on MIRCTs. These can be used to better define these complex conditions in patients when comparing current surgical techniques to address MIRCTs, as well as when interpreting the results of new techniques. While the number of effective treatment options has increased, high-quality and comparative evidence on treatments for MIRCTs is lacking.

Onlay versus inlay humeral components in reverse shoulder arthroplasty: A systematic review and meta-analysis

Background

Advances have been made to the traditional inlay Grammont Reverse Shoulder Arthroplasty (RSA) design such as the onlay humeral component prosthesis. Currently, there is no agreement in the literature regarding the best option for the humeral component when comparing inlay and onlay designs. This review compares the outcomes and complications between onlay versus inlay humeral components for RSA.

Methods

A literature search was conducted using PubMed and Embase. Only studies reporting outcomes comparing onlay versus inlay RSA humeral components were included.

Results

Four studies with 298 patients (306 shoulders) were included. Onlay humeral components were associated with better external rotation (ER) (p < 0.0001). No significant difference in forward flexion (FF) or abduction was found. Constant scores (CS) and VAS scores did not differ. Increased scapular notching was found in the inlay group (23.18%) versus the onlay group (7.74%) (p = 0.02). Postoperative scapular fractures and acromial fractures did not differ.

Conclusion

Onlay and inlay RSA designs are associated with improved postoperative range of motion (ROM). Onlay humeral designs may be associated with greater ER and lower rate of scapular notching; however, no difference was found in Constant and VAS scores, so further studies are required to assess the clinical significance of these differences.

Management of Massive Rotator Cuff Tears Without Arthropathy

Arthroplasty is not an optimal treatment for massive rotator cuff tears in patients who are active and without glenohumeral arthritis. Several surgical techniques have been developed for these patients, including arthroscopic rotator cuff repair with single-/double-row repair (with or without interval slides, margin convergence, graft augmentation), graft bridging, superior capsular reconstruction, tuberoplasty, and tendon transfers. Complete, tension-free, anatomic repair is ideal; however, tendon atrophy and retraction associated with massive tears often complicate repairs. All surgical treatments significantly increase patient-reported functional outcomes 1 year after intervention, with many treatments demonstrating improved mid-term and long-term outcomes. [Orthopedics. 2023;46(1):e1-e12.].

Clinical outcomes of reverse shoulder arthroplasty and rotator cuff repair in patients with massive rotator cuff tears without osteoarthritis: comparison using propensity score matching

BACKGROUND

The optimal management for massive rotator cuff tears (MRCTs) without osteoarthritis (OA) remains controversial. The purpose of this study was to evaluate and compare the clinical outcomes of reverse shoulder arthroplasty (RSA) vs. rotator cuff repair (RCR) in patients with MRCTs without OA.

METHODS

We conducted a retrospective data analysis of 68 patients treated for MRCTs via RSA and 215 patients treated for MRCTs via arthroscopic RCR between January 2014 and April 2019. Through propensity score matching, patients were matched for sex, age, tear size, and global fatty degeneration index. Thirty-nine patients in each group were included, and all patients had completed minimal 2-year follow-up. Postoperative radiologic evaluations of healing failure were performed. The visual analog scale score for pain, range of motion, and functional outcome measures including the American Shoulder and Elbow Surgeons score, QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score, Simple Shoulder Test score, and Constant score were assessed and compared between the 2 groups.

RESULTS

Healing failure was observed in 10 patients in the RCR group (32.3%). No statistically significant differences in preoperative range of motion and functional scores were found between the RCR and RSA groups. Both groups showed significant pain relief and functional improvement at final follow-up. Patients in the RCR group showed significantly greater forward elevation (156.4° ± 23.8° vs. 139.7° ± 22.4°, P < .001) and internal rotation (thoracic vertebra, T8.2 ± 1.2 vs. T9.7 ± 2.6, P = .001). The average American Shoulder and Elbow Surgeons score was 88.3 ± 12.2 in the RCR group and 81.8 ± 16.1 in the RSA group (P = .045). The QuickDASH score was significantly higher in the RCR group (P = .019). A significantly higher Simple Shoulder Test score (9.7 ± 2.8 vs. 8.1 ± 3.0, P = .01) and a significantly higher Constant score (67.2 ± 6.5 vs. 63.2 ± 7.1, P = .011) were seen in the RCR group.

CONCLUSION

Both RSA and RCR are effective and reliable treatment options for MRCTs without OA. However, the RCR group showed better shoulder function improvement than the RSA group. Considering the possible implications of RSA, RCR should be referred to as a first-line treatment option for patients with MRCTs without OA with proper indications.

Reverse shoulder arthroplasty after failed tendon transfer for irreparable posterosuperior rotator cuff tears

BACKGROUND

Tendon transfers (TTs) can be successful for the management of selected posterosuperior functionally irreparable rotator cuff tears. However, when these procedures fail to provide adequate pain relief or functional improvement, reverse shoulder arthroplasty (RSA) is commonly considered the next treatment option. The effect of prior TT on RSA remains largely unknown. The purposes of this investigation were to evaluate the outcomes of RSA after previous TT performed for posterosuperior functionally irreparable rotator cuff tears and to determine the effect of various TT types on RSA.

METHODS

A retrospective review of 2 institutional databases identified 33 patients who underwent RSA implantation between 2006 and 2019 with a previous failed tendon transfer (FTT) of the shoulder and at least 2 years of clinical follow-up. FTTs included 21 latissimus dorsi transfers, 6 latissimus dorsi and teres major (LD-TM) transfers, and 6 lower trapezius transfers. RSAs were performed at an average of 5.5 years (range, 0.3-28 years) after FTT, with a mean follow-up period of 4.1 ± 2.0 years. Outcomes evaluated included the visual analog scale pain score, range of motion, absolute Constant-Murley score (CS) and relative CS, American Shoulder and Elbow Surgeons score, Subjective Shoulder Value, complications, and implant survivorship free of reoperation or revision.

RESULTS

RSA significantly improved pain and function, with improvements in the visual analog scale pain score (6.2 preoperatively vs. 2.2 at most recent follow-up, P < .001), active elevation (85° vs. 111°, P < .001), American Shoulder and Elbow Surgeons score (51 vs. 74, P = .001), absolute CS (34 vs. 48, P = .003), and relative CS (42% vs. 59%, P = .002), exceeding the minimal clinically important difference threshold. There were 7 complications (21%) across the entire cohort, with dislocation (n = 3, 9.1%) as the most common complication. Comparison across TT groups showed that LD-TM transfer had the highest complication rate (3 shoulders, 50%), followed by lower trapezius transfer (1 shoulder, 16.7%); latissimus dorsi transfer had the lowest rate (3 shoulders, 14.3%; P = .037). Survivorship free of revision or reoperation was estimated to be 90.1% at 1 year, 84.9% at 2 years, and 71.2% at 5 years, with no difference among TT groups (P = .654).

CONCLUSIONS

RSA can serve as a viable salvage option for FTT procedures. At mid-term follow-up, RSA led to significant improvements in pain, range of motion, and patient-reported outcomes. Patients with prior LD-TM transfers may have a higher complication rate, but no other differences were found between TT groups.

Posterior decentering of the humeral head in patients with arthroscopic rotator cuff repair

Background: In some patients with rotator cuff tear (RCT), the axial view of magnetic resonance imaging (MRI) shows subtle posterior decentering (PD) of the humeral head from the glenoid fossa. This is considered to result from a loss of centralization that is typically produced by rotator cuff function. There are few reports on PD in RCT despite the common occurrence of posterior subluxation in degenerative joint disease. In this study, we investigated the effect of PD in arthroscopic rotator cuff repair (ARCR). Methods: We conducted a retrospective study of consecutive patients who underwent ARCR at our institute and were followed-up for at least 1 year. PD was identified as a 2 mm posterior shift of the humeral head relative to the glenoid fossa in the axial MRI view preoperatively. The tear size and fatty degeneration (FD, Goutallier classification) were also evaluated using preoperative MRI. Retears were evaluated through MRI at 1 year postoperatively. Results: We included 135 shoulders in this study. Ten instances of PD (including seven retears) were observed preoperatively. Fifteen retears (three and 12 retears in the small/medium and large/massive tear groups, respectively) were observed postoperatively. PD was significantly correlated with tear size, FD, and retear occurrence (p<0.01 each). The odds ratio for PD in retears was 33.8, which was greater than that for tear size ≥3 cm and FD grade ≥3. Conclusions: We concluded that large tear size and FD contribute to the occurrence of PD. Furthermore, PD could be a predictor of retear after ARCR.

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

BACKGROUND

With an increase in the treatment options available for massive rotator cuff tears, understanding the long-term outcomes of the chosen modality is important.

QUESTIONS/PURPOSE

The purpose of this study was to systematically review the available literature on repair of massive rotator cuff repairs and learn the longevity of outcomes, the failure rate, outcomes after failure, and any contributing factors to poor outcomes or failure.

METHODS

We conducted a systematic review of the MEDLINE, Cochrane, and Embase databases to find studies that investigated the long-term results of repair of massive rotator cuff repairs. Studies were excluded if they did not stratify results of massive tears, provide a definition for a massive rotator cuff tear, or report isolate patients with long-term follow-up.

RESULTS

Six studies met the inclusion criteria, for a total of 472 shoulders; average patient age was 57.6 years. Follow-up ranged from 119 to 240 months. Outcome scores improved significantly following repair and were maintained throughout follow-up. The repair failure rate across studies was 39.2%. Patients who suffered retear had significantly worse outcome scores than patients with intact tendons at long-term follow-up.

CONCLUSIONS

The existing literature on long-term follow-up after massive rotator cuff repair is scarce and not of high level of evidence. This review found repair of massive rotator cuff tears leads to long-term maintained improvements in outcome measures. Failure of repair is quite common, but results following failure are superior to preoperative outcomes.

Reverse Shoulder Arthroplasty After Prior Rotator Cuff Repair: A Matched Cohort Analysis

INTRODUCTION

Rotator cuff repair (RCR) is commonly performed before reverse shoulder arthroplasty (RSA) with conflicting evidence on the effect on arthroplasty outcomes. The purpose of this investigation was to evaluate the effect of a prior RCR on the outcomes and complications of primary RSA.

METHODS

Between 2007 and 2017, 438 RSAs performed in patients with a prior RCR and 876 case-matched controls were identified from a multicenter database. Patients were grouped based on a preoperative diagnosis of glenohumeral osteoarthritis (GHOA) and rotator cuff tear arthropathy (CTA). Data collected included range of motion, strength, complications, and revisions. Additional clinical metrics included American Shoulder and Elbow Society score, Constant score, Shoulder Pain and Disability Index, Simple Shoulder Test, and the University of California Los Angeles shoulder score.

RESULTS

Compared with controls, both GHOA and CTA study groups demonstrated lower postoperative forward elevation (FE) (133° versus 147°, P < 0.001; 133° versus 139°, P = 0.048) and FE trength (6.5 versus 8.2, P = 0.004; 6.1 versus 7.3, P = 0.014). In addition, inferior improvements were observed in the GHOA and CTA study groups with respect to abduction (38° versus 52°, P = 0.001; 36° versus 49°, P = 0.001), FE (41° versus 60°, P < 0.001; 38° versus 52°, P = 0.001), ER (16° versus 25°, P < 0.001; 10° versus 17°, P = 0.001), and Constant score (28.4 versus 37.1, P < 0.001; 26.2 versus 30.9, P = 0.016). Compared with controls, no differences were observed in the GHOA and CTA study groups with respect to notching (11.2% versus 5.6%, P = 0.115; 5.8% versus 7.9%, P = 0.967), complications (4.3% versus 1.6%, P = 0.073; 2.5% versus 2.7%, P = 0.878), and revision surgery (3.1% versus 0.9%, P = 0.089; 1.1% versus 1.3%, P = 0.822).

CONCLUSION

RSA after a prior RCR improves both pain and function, without increasing scapular notching, complications, or revision surgery. However, compared with patients without a prior RCR, postoperative shoulder function may be slightly decreased.

LEVEL OF EVIDENCE

III; Retrospective Cohort Study.

Outcomes of Reverse Shoulder Arthroplasty Following Failed Superior Capsular Reconstruction

Background

History of prior rotator cuff repair (RCR) may adversely affect the outcomes of reverse total shoulder arthroplasty (RTSA), but there is no information regarding the influence of prior superior capsular reconstruction (SCR) surgery on the outcomes of RTSA. The purpose of this study is to evaluate the outcomes of RTSA following failed arthroscopic SCR.

Methods

All patients who underwent RTSA for failed SCR (SCR cohort) at our institution were identified from our institutional database. A comparative cohort of patients who had RTSA with a history of failed RCR (Control cohort) was also reviewed. Demographic information, 90-day complication rate, 90-day emergency department visits, length of stay, and outcome scores (patient-reported outcomes measurement information system [PROMIS] physical function upper extremity, Visual Analog Scale score, and range of motion) were compared.

Results

From 2015 to 2020, 87 arthroscopic SCRs were performed at our institution and of these, 13 patients underwent RTSA at a mean time of 14.6 months (5.8-32.4) after SCR and were followed up for an average of 17.9 months (1.6-44.6). The average number of shoulder surgeries prior to RTSA was 2.8 (1-7), with the last surgery being SCR. During the same period, we identified 15 patients who underwent an RTSA after a failed RCR (control cohort). The RTSA in the control cohort was performed on average at 12.8 months (1.5-39.5) following the last RCR, and patients were followed up for an average of 27.7 months (2.8-53.9). The average number of shoulder surgeries before the RTSA in the control cohort was 1.4 (1-3). Although the SCR cohort had significant improvements in pain scores and forward flexion (FF), there was only a modest functional improvement with PROMIS scores and no meaningful improvement with external rotation. Complications (23%) in the SCR cohort included 1 periprosthetic joint infection requiring 2-stage revision, 1 acromion stress fracture, and 1 ulnar neuritis. Overall, compared to the SCR cohort, patients in the control cohort had better function (PROMIS physical function upper extremity), lower Visual Analog Scale score, and greater range of motion (FF and external rotation) preoperatively and at last follow-up, but there were no differences in the length of stay and 90-day emergency department visits, infection, and complication rate between the 2 cohorts.

Conclusion

RTSA after failed SCR improves pain and FF but is associated with modest functional improvements and high complication rates. However, these findings will require confirmation in a larger cohort with longer follow-up.

Reverse total shoulder arthroplasty in massive rotator cuff tears: does the Hamada classification predict clinical outcomes?

INTRODUCTION

Reverse total shoulder arthroplasty (RTSA) is a widely recognized treatment to reduce pain and improve shoulder function for patients in various disease stages of cuff tear arthropathy (CTA). However, it remains unclear whether outcomes after RTSA depend on the preoperative stage of CTA. Therefore, this study evaluated whether the Hamada classification influences midterm clinical outcomes after RTSA.

MATERIALS AND METHODS

In this multicenter observational study, patients underwent inverted bearing RTSA for massive rotator cuff tears or CTA. Shoulders were grouped into those with (Hamada grades 4a, 4b, and 5) and those without (Hamada grades 1, 2, and 3) glenohumeral arthritis. Clinical outcomes, including range of motion, Constant score, American Shoulder and Elbow Surgeons score, and visual analog scale for pain and satisfaction, were determined preoperatively and at 24 and > 30 months. All complications were recorded, and survival free from any implant component revision was calculated.

RESULTS

Overall, 202 patients (211 shoulders) were treated with RTSA at a mean age of 75.8 ± 6.6 years (range 41.9-91.6 years). Of these, 144 patients (151 shoulders) were available for a mean follow-up of 79.9 ± 24.7 months (range 30.2-132.3 months). No significant between-group differences were found for clinical outcomes at 24 and > 30 months (P > 0.05). Furthermore, the Hamada classification did not correlate with clinical outcomes at 24 (P = 0.98) and > 30 months (P = 0.29). Revision-free implant component survival was similar between groups (P = 0.17). Postoperative complications were found in 11 shoulders, of which 10 required revision.

CONCLUSIONS

Inverted bearing RTSA was found to be an effective treatment with similarly good midterm clinical outcomes, similar revision rates, and high implant survival rates in every stage of massive rotator cuff tears. Overall, the preoperative Hamada classification did not influence clinical outcomes or complications after RTSA.

Does preoperative disease severity influence outcomes in reverse shoulder arthroplasty for cuff tear arthropathy?

BACKGROUND

The degree of symptomatic disease and functional burden has been demonstrated to influence patient results and satisfaction in total hip and knee arthroplasty. Although the relationship between preoperative diagnosis and patient outcomes has been an area of study for reverse total shoulder arthroplasty (RTSA), the influence of the progression of cuff tear arthropathy (CTA) has not yet been examined. The purpose of this study was to evaluate whether preoperative radiographic disease burden and scapular geometry impact patient outcomes and satisfaction in a cohort of patients with CTA treated with RTSA.

METHODS

Eighty-six patients were treated for CTA with RTSA performed by the senior author (B.G.) between September 2016 and September 2018 and were enrolled in an institutional registry. At the time of initial evaluation, the baseline American Shoulder and Elbow Surgeons (ASES) score, patient demographic characteristics, history of shoulder surgery, and presence of pseudoparalysis were collected. Radiographs were obtained to evaluate the critical shoulder angle, acromial index, and progression of CTA as assessed by Hamada grading and the Seebauer classification. Patients were contacted to reassess the ASES score and their satisfaction with the improvement in their shoulder function.

RESULTS

A total of 79 patients (91.6%) were available for evaluation at a minimum of 24 months of follow-up. Multivariate logistic regression modeling revealed that scapular geometry measurements (critical shoulder angle and acromial index) and the degree of CTA (Seebauer and Hamada classifications) were not associated with worse outcomes as assessed by the ASES score. However, degenerative changes as assessed by the Hamada grade (odds ratio, 0.13 [95% confidence interval, 0.02-0.86]; P = .03) and preoperative ASES score (odds ratio, 1.04 [95% confidence interval, 1.01-1.07]; P = .008) were independently associated with higher satisfaction at 24 months of follow-up.

CONCLUSION

The results indicate that patients with greater CTA disease progression did not show differing outcomes after RTSA compared with patients with milder disease. In contrast, both poorer preoperative function and degenerative changes as assessed by the Hamada classification were associated with greater satisfaction after RTSA for CTA. Given the broad spectrum of disease in CTA, there is likely a corresponding range in patient expectations that requires further study to maximize patient satisfaction.

Reverse total shoulder arthroplasty for patients with preserved active elevation and moderate-to-severe pain: a matched cohort study

Background

Patients undergoing reverse total shoulder arthroplasty (RTSA) predictably report reduced pain and improved function postoperatively. However, it is not known if patients with differing preoperative active motion achieve the same benefit after surgery. The purpose of the present study is to evaluate patient-reported outcomes (PROs), range of motion (ROM), and satisfaction after RTSA in patients with moderate-to-severe pain with preserved active preoperative ROM compared with matched controls with restricted preoperative active ROM.

Methods

A multicenter shoulder arthroplasty registry was utilized to identify patients with at least two-year clinical follow-up after RTSA with a 135° implant. The study cohort with preserved motion included patients with greater than one standard deviation above the overall mean for preoperative forward elevation (FE) (140°) as well as a preoperative visual analog pain scale (VAS) ≥ 5.0. The control cohort with more restricted motion had preoperative FE of less than 140° and also with preoperative VAS ≥5.0. The control patients were matched 2:1 to study patients by age (±2 years), sex, and preoperative VAS (±1.5). Outcomes measured were as follows: PROs, ROM, strength, and strength and satisfaction.

Results

Twenty-seven patients were identified that comprised the preserved preoperative FE study cohort; 54 patients were included in the restricted elevation cohort as controls. The groups were similar at baseline for demographics, surgical diagnoses, and most PROs, other than the Constant-Murley, which was higher in the preserved motion cohort. At two years postoperatively, both cohorts demonstrated similar PROs, strength, and ROM (other than internal rotation with the arm abducted 90 degrees) and had a similar number of patients who rated the RTSA as meeting or exceeding their expectations. The change in ROM from preoperatively was significantly different with the restricted cohort, achieving a larger increase in forward flexion (51 ± 26° vs. −13 ± 35°, P < .001).

Conclusion

Patients indicated for RTSA with preserved preoperative FE and moderate pain achieve similar final ROM, pain reduction, increases, and strength compared with patients who undergo RTSA with restricted preoperative FE. Despite losing on average 13 degrees of FE from preoperatively by two years postoperatively, patients with preserved preoperative FE are comparably satisfied with their outcome.

Treatment Options for Massive Irreparable Rotator Cuff Tears

PURPOSE OF REVIEW

Massive irreparable rotator cuff tears present a significant challenge to the orthopedic surgeon. No single treatment, particularly among joint-preserving options, has been shown to be superior. The purpose of this review is to discuss recent advances in the treatment of massive irreparable rotator cuff tears, including partial repair with and without graft augmentation, interposition grafts, superior capsule reconstruction, subacromial balloon spacers, tendon transfer, and reverse total shoulder arthroplasty. We will also offer guidance on surgical indications based on our clinical experience.

RECENT FINDINGS

Partial repair may offer reasonable clinical improvement for patients with lower preoperative function despite high re-tear rates. Additionally, several types of interposition grafts have shown promising short-term results and may outperform repair alone. Subacromial balloon spacers may lead to clinical improvement, especially in patients without glenohumeral osteoarthritis or pseudoparalysis, and recently received FDA approval for use in the USA. Superior capsule reconstruction is a technically demanding procedure that appears to produce excellent short-term results particularly when performed at high volume, but long-term studies in heterogeneous study groups are needed. Tendon transfers improve function by restoring force coupling in the shoulder, offering a promising option for younger patients. Reverse total shoulder arthroplasty (RTSA) is a reliable option for treatment of irreparable cuff tears in elderly patients with lower functional demands. Irreparable cuff tears remain a difficult condition to treat. Recommended treatment for younger patients without glenohumeral osteoarthritis is particularly controversial. For older patients with low-demand lifestyles and glenohumeral osteoarthritis, RTSA is an effective treatment option. For all discussed procedures, patient selection appears to play a critical role in clinical outcomes.

Preoperative factors associated with loss of range of motion after reverse shoulder arthroplasty

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) is a successful procedure, often allowing patients to achieve better range of motion (ROM) compared with their preoperative baseline. However, there is a subset of patients who either fail to improve or lose ROM postoperatively. These patients are at increased risk of poor satisfaction and patient-reported outcomes. To date, characteristics of this subset of patients have not been well described. The purpose of this study is to determine risk factors associated with loss of ROM after primary RTSA.

METHODS

A retrospective review using a commercial international RTSA database (Exactech Inc., Gainesville, FL, USA) of patients who underwent primary RTSA between 2007 and 2017 was performed. A total of 123 (7.7%) shoulders lost ≥10° of forward elevation (FE) (group 1, P₁) and 183 (11.4%) lost ≥10° of external rotation (ER) (group 2, P₂). Univariate and multivariate analyses were performed comparing these patients with control cohorts to evaluate risk factors for loss of motion.

RESULTS

Better preoperative abduction, FE, ER, and internal rotation were each associated with greater loss of FE (P₁ < .001) and ER (P₂ < .001) postoperatively. Higher preoperative Simple Shoulder Test (P₁ < .001, P₂ < .001), Constant (P₁ < .001, P₂ < .001), Shoulder Pain and Disability Index (P₁ < .001, P₂ < .001), American Shoulder Elbow Surgeons (P₁ < .001), and University of California at Los Angeles (P₁ < .001) scores were also strongly associated with loss of ROM postoperatively. Other factors associated with a higher risk of losing ROM included a diagnosis of irreparable rotator cuff tear (P₁ = .038), rotator cuff arthropathy (P₁ = .017, P₂ ≤ .001), and inflammatory arthropathy (P₁ = .021). After multivariate analysis, higher preoperative FE (P₁ < .001), internal rotation (P₁ = -.018), and weight (P₁ = .008) remained significant predictors of loss of FE. Better preoperative FE (P₂ = .003), ER (P₂ < .001), and University of California at Los Angeles score (P₂ < .001) remained significant predictors of loss of ER. Patients who lost FE or ER were more likely to report lower satisfaction scores than their counterparts who did not lose ROM (P₁ < .001, P₂ < .001).

CONCLUSION

Patients with greater preoperative shoulder ROM or higher patient-reported outcomes are at higher risk of losing ROM after primary RTSA. They are also at higher risk of reporting lower postoperative satisfaction, though the majority were still satisfied. Surgeons should strongly counsel patients with well-preserved preoperative function on the risk of loss of ROM.

Consensus statement on the treatment of massive irreparable rotator cuff tears: a Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons

BACKGROUND

Management of massive irreparable rotator cuff tears (MIRCTs) remains controversial owing to variability in patient features and outcomes contributing to a lack of unanimity in treatment recommendations. The purpose of this study was to implement the Delphi process using experts from the Neer Circle of the American Shoulder and Elbow Surgeons to determine areas of consensus regarding treatment options for a variety of MIRCTs.

METHODS

A panel of 120 shoulder surgeons were sent a survey regarding MIRCT treatments including arthroscopic débridement and partial cuff repair, graft augmentation, reverse shoulder arthroplasty (RSA), superior capsular reconstruction (SCR), and tendon transfer. An iterative Delphi process was then conducted with a first-round questionnaire consisting of 13 patient factors with the option for open-ended responses to identify important features influencing the treatment of MIRCTs. The second-round survey sought to determine the importance of patient factors related to the 6 included treatment options. A third-round survey asked participants to classify treatment options for 60 MIRCT patient scenarios as either preferred treatment, acceptable treatment, not acceptable/contraindicated, or unsure/no opinion. Patient scenarios were declared to achieve consensus for the preferred and not acceptable/contraindicated categories when at least 80% of the survey respondents agreed on a response, and a 90% threshold was required for the acceptable treatment category, defined by an acceptable treatment or preferred treatment response.

RESULTS

Seventy-two members agreed to participate and were deemed to have the requisite expertise to contribute based on their survey responses regarding clinical practice and patient volume. There were 20 clinical scenarios that reached 90% consensus as an acceptable treatment, with RSA selected for 18 scenarios and arthroscopic débridement and/or partial repair selected for 2. RSA was selected as the singular preferred treatment option in 8 scenarios. Not acceptable/contraindicated treatment options reached consensus in 8 scenarios, of which, 4 related to SCR, 3 related to RSA, and 1 related to partial repair with graft augmentation.

CONCLUSION

This Delphi process exhibited significant consensus regarding RSA as a preferred treatment strategy in older patients with pseudoparesis, an irreparable subscapularis, and dynamic instability. In addition, the process identified certain unacceptable treatments for MIRCTs such as SCR in older patients with pseudoparesis and an irreparable subscapularis or RSA in young patients with an intact or reparable subscapularis without pseudoparesis or dynamic instability. The publication of these scenarios and areas of consensus may serve as a useful guide for practitioners in the management of MIRCTs.

Does preoperative diagnosis impact patient outcomes following reverse total shoulder arthroplasty? A systematic review

BACKGROUND

The indications for reverse total shoulder arthroplasty (rTSA) have expanded to include the treatment of a wide variety of shoulder pathologies, and there may be significant differences in patient outcomes based on preoperative diagnosis.

METHODS

A systematic review of the orthopedic literature contained in the PubMed, Cochrane, and Embase databases was performed on November 14, 2019. Studies investigating rTSA indicated for 7 distinct preoperative diagnoses (massive rotator cuff tear [MCT] without glenohumeral osteoarthritis [GHOA], MCT with GHOA or cuff tear arthropathy, primary GHOA, inflammatory arthritis with MCT, failed shoulder arthroplasty, proximal humeral fracture [PHF], and sequelae following PHF) were included. The main outcomes of interest included functional outcomes (abduction, external rotation, and forward flexion) and patient-reported outcome measures (American Shoulder and Elbow Surgeons shoulder score and Constant-Murley score). Because of significant variation in measurement and reporting, data on internal rotation were not extracted. In addition, radiographic outcomes and complication rates were extracted and recorded for each of the included studies.

RESULTS

In total, 47 studies, comprising 2280 patients, met the inclusion criteria. Significant improvements in functional outcomes and patient-reported outcome measures were found across the preoperative diagnostic groups. There were no significant differences between the diagnostic groups regarding improvement between preoperative and postoperative values for the outcomes of interest, with the exception that the inflammatory arthropathy group had significantly less improvement in the Constant-Murley score than the primary GHOA and revision arthroplasty groups. Although there were few differences in improvement between groups, there were significant differences regarding the level of postoperative functional performance, which was not as consistent in the context of trauma or revision operations (ie, complex PHF, fracture sequela, and revision arthroplasty groups).

CONCLUSION

Reverse total shoulder arthroplasty can provide reliable improvement in clinical outcomes regardless of preoperative diagnosis, with few differences across diagnostic groups regarding preoperative to postoperative improvement. The groups with primary GHOA and MCTs with or without GHOA demonstrated the most reliable postoperative functional outcomes of the examined diagnostic groups. Postoperative outcomes were not as consistent in the context of trauma or revision operations, and these groups may benefit from a variety of modern advancements in rTSA, although further research into these modalities for these groups is needed. Finally, rTSA remains an important treatment option in the context of rheumatoid arthritis, with similar outcomes and complication rates compared with the 6 other operative indications.

Polyethylene Liner Dissociation after Reverse Shoulder Arthroplasty Dislocation: a Case Series

Reverse shoulder arthroplasty is a common procedure. While dislocation is a common complication, there are few reports documenting dislocation with associated polyethylene liner dissociation from the humeral tray. There have been 4 instances of this occurrence over 9 years at our institution, and there are specific radiographic clues for diagnosis. Recognizing polyethylene liner dissociation on imaging is important prior to treatment. In a "routine" dislocation, closed reduction may be attempted but when the polyethylene is dissociated, open reduction is the only treatment option, as closed reduction can damage the components. Dislocations with polyethylene dissociation may not be initially recognized, prompting a non-operative period leading to wear and metallosis. These 4 cases demonstrate key findings present on imaging to recognize the difference between a dislocation with and without polyethylene liner dissociation, namely the subluxation appearance rather than dislocation.

Does Having a Rotator Cuff Repair Before Total Shoulder Arthroplasty Influence Outcomes?

Background:

The number of rotator cuff repairs (RCRs) is increasing each year. Total shoulder arthroplasty (TSA) is a successful treatment option for patients with glenohumeral osteoarthritis with a functioning rotator cuff.

Purpose/Hypothesis:

The purposes of this study were to report the outcomes of TSA in patients with ipsilateral RCR and determine whether patients with a history of ipsilateral RCR who subsequently underwent TSA had differences in outcomes compared with matched controls who underwent TSA with no history of RCR. We hypothesized that patients with prior RCR will have significant improvements in clinical outcome scores, with no difference in outcomes after TSA compared with those with no prior RCR.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients eligible for inclusion were those with a history of prior RCR who underwent TSA at a single institution with a minimum 2-year follow-up between 2000 and 2015. Outcomes for this group, including American Shoulder and Elbow Surgeons (ASES) scores, were reported and then compared with a matched control group of patients who underwent TSA with no history of prior RCR. Controls were matched based on age, sex, and preoperative ASES score.

Results:

Overall, 14 patients (64% males; mean ± SD age, 65.1 ± 11.1 years) underwent prior ipsilateral RCR before TSA. ASES scores significantly improved from 42.9 to 78.5 at 2 years and to 86.6 at 5 years. When compared with 42 matched control patients (matched 1:3) who underwent TSA with no history of RCR, there was no significant difference in ASES scores at 2 years (78.5 vs 85.3; P = .19) and 5 years (86.6 vs 90.9; P = .72) between the prior RCR and no RCR groups.

Conclusion:

TSA in patients with a history of prior ipsilateral RCR led to significant improvements in clinical outcomes. No difference in clinical outcomes at 2 or 5 years after TSA was found between patients with and without a history of prior ipsilateral RCR.

Effectiveness of formal physical therapy following total shoulder arthroplasty: A systematic review

BACKGROUND

Physical therapy is considered routine practice following total shoulder arthroplasty. To date, current regimens are based on clinical opinion, with evidence-based recommendations. The aim of this systematic review was to evaluate the effectiveness of total shoulder arthroplasty physical therapy programmes with a view to inform current clinical practice, as well as to develop a platform upon which future research might be conducted.

METHODS

An electronic search of MEDLINE, EMBASE, CINAHL and Cochrane Library to March 2018 was complemented by hand and citation-searching. Studies were selected in relation to pre-defined criteria. A narrative synthesis was undertaken.

RESULTS

A total of 506 papers were identified in the electronic database search, with only one study showing moderate evidence of early physical therapy promoting a more rapid return of short-term improvement in function and pain. No studies evaluated the effectiveness of physical therapy programmes in reverse total shoulder arthroplasty procedures.

DISCUSSION

Restoring range of motion and strength following total shoulder arthroplasty is considered important for patients to obtain a good outcome post-surgery and, when applied early, may offer more rapid recovery. Given the rising incidence of total shoulder arthroplasties, especially reverse total shoulder arthroplasty, there is an urgent need for high-quality, adequately powered randomised controlled trials to determine the effectiveness of rehabilitation programmes following these surgeries.

[Research progress of greater tubercle fixation and rotator cuff repair in humeral head replacement]

OBJECTIVE

To summarize the research progress of the greater tubercle fixation and the rotator cuff repair in humeral head replacement.

METHODS

The literature about proximal humerus fracture and humeral head replacement in recent years was extensively consulted and analyzed.

RESULTS

The greater tubercle fixation and the attached rotator cuff repair have great influence on the function of shoulder joint after humeral head replacement. It is difficult to make an objective comparison because of lack of direct comparison between various methods, unified standards of grading, and limited number of cases.

CONCLUSION

It is an important factor of reduction and fixation of greater tubercle to obtain better effectiveness in humeral head replacement. However, one-stage repair of rotator cuff is more important than greater tubercle fixation for functional recovery of shoulder joint.

Arthroscopic Superior Capsular Reconstruction With Acellular Porcine Dermal Xenograft for the Treatment of Massive Irreparable Rotator Cuff Tears

Purpose

To evaluate the short-term clinical outcomes and the complications related to arthroscopic superior capsular reconstruction (SCR) with acellular porcine dermal xenograft for the treatment of irreparable massive rotator cuff tears.

Methods

A prospective observational study of patients treated with arthroscopic SCR for irreparable massive rotator cuff tears in the period from 2016 to 2017 was performed. Range of motion and Shoulder Pain and Disability Index (SPADI) scores were assessed preoperatively, at 6 months postoperatively, and at 12 months postoperatively.

Results

A total of 20 shoulders in 19 patients, with an average age of 60 years, were included in the study. Twelve patients met the criterion for the minimal clinically important difference in the SPADI score. The mean SPADI score showed significant improvement from 51.3% to 10.4% at 1-year follow-up. Active abduction improved from 65.4° to 149.3° and active forward flexion improved from 68.6° to 151.4° at 1-year follow-up. The procedure had a 30% complication rate, including a 15% rate of immunologic rejection of the xenograft. Five patients underwent revision procedures, including arthroscopic debridement and removal of xenograft residuals, implantation of a balloon spacer, and revision SCR with a fascia lata autograft.

Conclusions

Arthroscopic SCR with an acellular porcine dermal xenograft led to a successful outcome in 60% of cases. The procedure showed a quite high complication rate; the most severe cases were related to acute immunologic rejection of the xenograft.

Level of Evidence

Level IV, case series.

Evaluation of an Incorporated Superior Capsular Reconstruction Graft: A Case Report

CASE

A 66-year-old man presented with 2 years of atraumatic right shoulder pain and difficulty with overhead activities. Radiographs and magnetic resonance imaging demonstrated Hamada stage I changes and a massive irreparable rotator cuff tear involving the supraspinatus and infraspinatus. He underwent superior capsular reconstruction with acellular human dermal matrix (SCR with ADM) allograft. Diagnostic arthroscopy and humeral avulsion of the glenohumeral ligament repair 1 year postoperatively showed that the SCR appeared intact and vascularized.

CONCLUSIONS

This is the first study to confirm visually that SCR with ADM allograft is well-vascularized and intact 1 year post-operatively.

Predicting outstanding results after reverse shoulder arthroplasty using percentage of maximal outcome improvement

BACKGROUND

The purpose of this study was to determine whether thresholds regarding the percentage of maximal improvement in the Simple Shoulder Test (SST) score and American Shoulder and Elbow Surgeons (ASES) score exist that predict excellent patient satisfaction after reverse shoulder arthroplasty (RSA).

METHODS

Patients undergoing RSA with a single implant system were evaluated preoperatively and at a minimum 2-year follow-up. Receiver operating characteristic curve analysis determined thresholds to predict excellent patient satisfaction by evaluating the percentage of maximal improvement for SST and ASES scores. Preoperative factors were analyzed as independent predictors for achieving SST and ASES score thresholds.

RESULTS

There were 198 (SST score) and 196 (ASES score) patients who met inclusion criteria. For SST and ASES scores, receiver operating characteristic curve analysis identified 61.3% (P < .001) and 68.2% (P < .001) maximal improvement as the threshold for maximal predictability of excellent satisfaction, respectively. Significant positive correlation between the percentage of maximum score achieved and excellent patient satisfaction for both groups was found (r = 0.440 [P < .001] for SST score; r = 0.417 [P < .001] for ASES score). Surgery on the dominant hand, greater baseline visual analog scale pain score, and cuff arthropathy were independent predictors for achieving the SST and ASES score threshold.

CONCLUSION

Thresholds for the achievement of excellent satisfaction after RSA were 61.3% of maximal SST score improvement and 68.3% of maximal ASES score improvement. Independent predictors of achieving these thresholds were dominant-sided surgery and higher baseline visual analog scale pain scores for the SST score and rotator cuff arthropathy for the ASES score.

Arthroscopic Massive Rotator Cuff Repair and Techniques for Mobilization

Massive rotator cuff tears, as classified by size or tendon involvement, are challenging to repair due to scarring, retraction of the tendons, and difficult visualization. Left untreated, these injuries can lead to fatty infiltration and reduced acromiohumeral distance that precludes future repair. The high rate of failure in these patients often impedes an anatomical repair. However, advanced mobilization techniques of the supraspinatus help facilitate a reduction of an otherwise irreparable tear. By performing this repair, more costly procedures may be avoided, such as a superior capsular reconstruction and reverse total shoulder arthroplasty. This Technical Note presents our preferred technique of an all-arthroscopic, medialized repair with double interval slides for the treatment of a massive rotator cuff tear.