Combination of arthroscopic biologic tuberoplasty and bursal acromial reconstruction

Editorial Commentary: Bursal Acromial Resurfacing Offers Improved Biomechanics in Laboratory Studies but There Is No Consensus on Indications, Technique, or Graft Type, and Clinical Results Are Lacking

Bursal acromial reconstruction/resurfacing, acromiograft, and biologic tuberoplasty are all terms used to describe the concept of fixing a graft (human dermal allograft or fascia lata) to the undersurface of the acromion or onto the greater tuberosity with the aim of achieving pain relief and improved function in patients with massive irreparable cuff tears. The rationale for these procedures is based on the biomechanical concept that an interpositional spacer can reverse superior migration of the humeral head, increase acromiohumeral distance, reduce subacromial contact pressure, and limit painful bone-on-bone contact. These types of procedures are postulated to offer potential advantages (cost savings related to use of implants, long-term biologic solution, technical ease of surgery, and short surgical time) over other options for massive irreparable cuff tears, particularly superior capsule reconstruction and in some respects the subacromial balloon. However, these advantages remain unproven because published clinical studies are sparse. Furthermore, there is no current consensus on indications, technique, or optimum graft choice.

Editorial Commentary: Tuberoplasty Is a Reliable Option to Address Pain in Massive Irreparable Rotator Cuff Tears

The massive irreparable rotator cuff tear remains a challenging condition for which there are many reported treatment options, including biceps tenotomy or tenodesis, subacromial decompression, cuff debridement, partial or augmented rotator cuff repair, bursal acromial reconstruction, balloon spacer placement, superior capsular reconstruction, reverse total shoulder arthroplasty, and tendon transfer, among others. Optimally treating the condition relies on paying attention to several patient factors, including correctly identifying whether function loss is driven by pain or compromised shoulder kinematics. If pain is the primary limiting factor, then tuberoplasty, or "reversed subacromial decompression," seems to be a reliable option that can afford encouraging results in terms of pain and range of motion in correctly indicated individuals. It is important to note, however, that these results should not be expected in the patient with anterior-superior humeral escape or pseudoparalysis, in whom a kinematic-restoring option may be more appropriate. Considering a history of inconsistent terminology and definitions when it comes to defining massive tears, when they are irreparable, and when the patient has pseudoparesis versus pseudoparalysis, it is paramount to accurately describe patient factors, including preoperative function, in ongoing research.