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Lee S, Shin SJ. Postoperative Graft Volume Reduction Is Associated With Inferior Clinical Outcomes of Superior Capsule Reconstruction Using an Acellular Dermal Matrix Allograft. Arthroscopy 2024; 40:229-239. [PMID: 37394150 DOI: 10.1016/j.arthro.2023.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 06/10/2023] [Accepted: 06/16/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE To evaluate whether postoperative graft volume reduction is associated with clinical outcomes after superior capsule reconstruction (SCR) and to identify factors related to graft volume change. METHODS Between May 2018 and June 2021, patients who underwent SCR with acellular dermal matrix allograft for irreparable rotator cuff tear with a minimum 1-year follow-up and who had intact graft continuity in postoperative 6-month magnetic resonance imaging were retrospectively reviewed. The lateral half to the medial half of the graft volume ratio was defined as lateral half graft volume ratio. The difference between the preoperative and postoperative lateral half graft volume ratio was defined as lateral half graft volume change. Patients were divided into 2 groups: those with preserved graft volume (group I) and those with reduced graft volume (group II). Intergroup differences in clinical and radiological characteristics were analyzed. RESULTS A total of 81 patients were included, with 47 (58.0%) in group I and 34 (42.0%) in group II. Group I showed significantly lower lateral half graft volume change (0.018 ± 0.064 vs 0.370 ± 0.177; P < .001) than group II. Group II showed significantly greater preoperative Hamada grade (1.3 ± 0.5 vs 2.2 ± 0.6, P < .001), an anteroposterior distance of the graft at the greater tuberosity (APGT) (30.3 ± 4.8 vs 35.2 ± 3.8, P < .001), and fatty infiltration of infraspinatus (2.3 ± 0.9 vs 3.1 ± 0.8, P < .001) and subscapularis (0.9 ± 0.9 vs 1.6 ± 1.3, P = .009) than group I. Group II had a significantly lower proportion of patients achieving MIC in Constant score than group I (70.2% vs 47.1%, P = .035). The Hamada grade, APGT, and fatty infiltration of infraspinatus and subscapularis were independent factors of graft volume change. CONCLUSIONS Although SCR improved pain and shoulder function, postoperative graft volume reduction was related to a lower rate of minimal important change achievement in the Constant score compared with preserved graft volume. The preoperative Hamada grade, APGT, and fatty infiltration of infraspinatus and subscapularis were associated with graft volume reduction. LEVEL OF EVIDENCE Level III, retrospective case-control study.
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Affiliation(s)
- Sanghyeon Lee
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Sang-Jin Shin
- Department of Orthopedic Surgery, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea.
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Bi AS, Anil U, Colasanti CA, Kwon YW, Virk MS, Zuckerman JD, Rokito AS. Comparison of Multiple Surgical Treatments for Massive Irreparable Rotator Cuff Tears in Patients Younger Than 70 Years of Age: A Systematic Review and Network Meta-analysis. Am J Sports Med 2024:3635465231204623. [PMID: 38291995 DOI: 10.1177/03635465231204623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Massive irreparable rotator cuff tears (MIRCTs) remain a challenging treatment paradigm, particularly for nonelderly patients without pseudoparalysis or arthritis. PURPOSE To use a network meta-analysis to analyze comparative studies of surgical treatment options for MIRCTs in patients <70 years of age for several patient-reported outcomes, range of motion (ROM), and acromiohumeral distance (AHD). STUDY DESIGN Network meta-analysis of comparative studies; Level of evidence, 3. METHODS A systematic review of the literature, using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, of the MEDLINE, Embase, and Cochrane Library databases was conducted from 2017 to 2022. Inclusion criteria were (1) clinical comparative studies of MIRCTs (with several study-specific criteria); (2) ≥1 outcome of interest reported on, with standard deviations; (3) minimum 1-year follow-up; and (4) mean age of <70 years for both cohorts, without arthritis or pseudoparalysis. There were 8 treatment arms compared. Outcomes of interest were the American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, visual analog scale for pain, AHD, and forward flexion and external rotation ROM. A frequentist approach to network meta-analysis with a random-effects model was performed using the netmeta package Version 0.9-6 in R. RESULTS A total of 23 studies met the inclusion criteria, with 1178 patients included in the network meta-analysis. There was a mean weighted age of 62.8 years, 568 (48.2%) men, with a mean follow-up of 28.9 months. There were no significant differences between groups in regard to sex (P = .732) or age (P = .469). For the ASES score, InSpace balloon arthroplasty (mean difference [MD], 12.34; 95% CI, 2.18 to 22.50; P = .017), arthroscopic bridging graft (aBG) (MD, 7.07; 95% CI, 0.28 to 13.85; P = .041), and long head of biceps augmented superior capsular reconstruction (BSCR) (MD, 5.16; 95% CI, 1.10 to 9.22; P = .013) resulted in the highest P-scores. For the Constant-Murley score, debridement (MD, 21.03; 95% CI, 8.98 to 33.08; P < .001) and aBG (MD, 6.97; 95% CI, 1.88 to 12.05; P = .007) resulted in the highest P-scores. For AHD, BSCR resulted in the highest P-score (MD, 1.46; 95% CI, 0.45 to 2.48; P = .005). For forward flexion ROM, debridement (MD, 45.77; 95% CI, 25.41 to 66.13; P < .001) resulted in the highest P-score, while RSA resulted in the lowest P-score (MD, -16.70; 95% CI, -31.20 to -2.20; P = .024). CONCLUSION For patients <70 years with MIRCT without significant arthritis or pseudoparalysis, it appears that graft interposition repair techniques, superior capsular reconstruction using the long head of the biceps tendon, arthroscopic debridement, and balloon arthroplasty provide superiority in various outcome domains, while RSA provides the least benefit in forward flexion.
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Affiliation(s)
- Andrew S Bi
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Utkarsh Anil
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Christopher A Colasanti
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Young W Kwon
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Mandeep S Virk
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Joseph D Zuckerman
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Andrew S Rokito
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
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Kuan FC, Shih CA, Su WR, Garcia AV, Kuroiwa T, Iida N, Hsu KL. Definition of irreparable rotator cuff tear: a scoping review of prospective surgical therapeutic trials to evaluate current practice. BMC Musculoskelet Disord 2023; 24:952. [PMID: 38066535 PMCID: PMC10704799 DOI: 10.1186/s12891-023-07067-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 11/25/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND The definition of irreparable rotator cuff tear (IRCT) is controversial. This scoping review provides definitions used to describe IRCT in the literature. This scoping review (1) identified criteria used in the definition of IRCT and (2) investigated the current state of those criteria in prospective surgical therapeutic trials. METHODS This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. PubMed, Scopus, and Web of Science were searched in March 2023. Studies were screened against predetermined inclusion and exclusion criteria. Criteria regarding clinical symptoms, preoperative images, and intraoperative findings were captured respectively. RESULTS A total of 41 prospective studies were eligible for inclusion, and 35 studies (85.4%) defined IRCT. IRCT was defined on the basis of the following main criteria: preoperative image findings (28/35), intraoperative findings (24/35), and symptoms (16/35). With regard to preoperative images, IRCT was mainly defined on the basis of retraction of the tendon in the coronal plane (22/28), the severity of fatty degeneration (19/28), and ruptured tendon number or width of the defect in the sagittal plane (17/28). CONCLUSION This scoping review highlights the lack of a standardized definition for IRCT in clinical practice, with common predictive criteria including a duration of over 6 months, retraction beyond 5 cm, Goutallier grade 3 fatty infiltration, and the rupture of two or more tendons. However, surgeons should apply more than one criterion when examining preoperative images and confirm reparability during surgery. A more objective manner of evaluating intraoperative reparability is necessary.
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Affiliation(s)
- Fa-Chuan Kuan
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Rd, Tainan, Taiwan
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
- Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Division of Traumatology, National Cheng Kung University Medical Center, Tainan, Taiwan
| | - Chien-An Shih
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Rd, Tainan, Taiwan
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ren Su
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Rd, Tainan, Taiwan
- Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Ausberto Velasquez Garcia
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Orthopedic Surgery, Clinica Universidad de los Andes, Santiago, Chile
| | - Tomoyuki Kuroiwa
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Naoya Iida
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kai-Lan Hsu
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Rd, Tainan, Taiwan.
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.
- Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan.
- Division of Traumatology, National Cheng Kung University Medical Center, Tainan, Taiwan.
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
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Hoshikawa K, Yuri T, Oishi R, Uno T, Nagai J, Giambini H, Mura N. Muscle belly ratio is the most suitable estimate of the activity of the torn supraspinatus muscle. JSES Int 2023; 7:2373-2378. [PMID: 37969501 PMCID: PMC10638582 DOI: 10.1016/j.jseint.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
Background A torn rotator cuff muscle deteriorates over time leading with an increase in muscle atrophy and fatty infiltration. There are several clinical assessments for evaluating the atrophy of the torn supraspinatus muscle. However, it is unclear which approach can more accurately estimate the activity of the torn supraspinatus muscle. The purpose of this study was to determine which magnetic resonance imaging-based muscle atrophy imaging assessment currently implemented in the clinical setting accurately estimates the activity of the torn supraspinatus muscle. Methods Forty patients who were diagnosed with a rotator cuff tear and were candidates for repairs were selected for this study. Cross-sectional area, occupation ratio, and tangent sign were analyzed on T1-weighted oblique sagittal plane magnetic resonance images in which the scapular spine leads to the Y-section. Muscle belly ratio of the supraspinatus muscle was analyzed by calculating the ratio of the width of the muscle belly to the distance from the greater tubercle to the proximal end of the muscle on T1-weighted coronal plane magnetic resonance imaging images. Fatty infiltration was evaluated using the Goutallier classification system. Tear size was obtained intraoperatively by measuring the width and length of the tear and classified based on the Cofield's classification. To assess activity of the torn supraspinatus muscle, participants were first instructed to sit on a chair with the affected arm resting on a table and the shoulder abducted to 60° in the scapular plane with neutral rotation. Elasticity of the supraspinatus muscle belly was then obtained at rest and during isometric contraction using with real-time tissue elastography. Muscle activity, a surrogate for contractility, was defined as the difference between the elasticities measured at rest and during isometric contraction. A stepwise multiple regression analysis was used to investigate independent factors, such as sex, tear width, cross-sectional area, occupation ratio, tangent sign, and muscle belly ratio, related to muscle activity. Results Stepwise multiple regression analysis (R2 = 0.522, P < .001) revealed that supraspinatus muscle activity was significantly correlated with muscle belly ratio (β = 0.306, P = .044) and Goutallier stage (β = -0.490, P = .002). Conclusion Estimations of muscle belly ratio are most suitable for assessing the activity of a torn supraspinatus muscle compared to other clinical measurements.
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Affiliation(s)
- Kyosuke Hoshikawa
- Graduate School of Health Sciences, Yamagata Prefectural University of Health Sciences, Yamagata, Japan
- Department of Biomedical Engineering and Chemical Engineering, The University of Texas at San Antonio, San Antonio, TX, USA
- Department of Orthopedic Surgery, Yoshioka Hospital, Yamagata, Japan
| | - Takuma Yuri
- Graduate School of Health Sciences, Yamagata Prefectural University of Health Sciences, Yamagata, Japan
| | - Ryuta Oishi
- Department of Orthopedic Surgery, Yoshioka Hospital, Yamagata, Japan
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Tomohiro Uno
- Department of Orthopedic Surgery, Yoshioka Hospital, Yamagata, Japan
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Jun Nagai
- Department of Orthopedic Surgery, Yoshioka Hospital, Yamagata, Japan
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Hugo Giambini
- Department of Biomedical Engineering and Chemical Engineering, The University of Texas at San Antonio, San Antonio, TX, USA
| | - Nariyuki Mura
- Graduate School of Health Sciences, Yamagata Prefectural University of Health Sciences, Yamagata, Japan
- Department of Orthopedic Surgery, Yoshioka Hospital, Yamagata, Japan
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Denard PJ. An Algorithmic Approach to the Surgical Management of Massive Rotator Cuff Tears Based on Imaging, Function, and Repairability. Arthroscopy 2023; 39:2392-2397. [PMID: 37866877 DOI: 10.1016/j.arthro.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/03/2023] [Accepted: 06/04/2023] [Indexed: 10/24/2023]
Abstract
Massive rotator cuff tears are one the most challenging conditions to treat in the shoulder. A variety of surgical approaches have been used to manage massive rotator cuff tears, such as repair with or without augmentation, superior capsule reconstruction, tendon transfer, and reverse shoulder arthroplasty. The choice between joint preservation or reverse shoulder arthroplasty is first considered based on preoperative imaging and functional status, as well as patient factors. When joint preservation is the goal of treatment, a combination of repairability, patient function, and age can be used to provide an algorithmic approach to treatment. LEVEL OF EVIDENCE: Level V, expert opinion.
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Riem L, Blemker SS, DuCharme O, Leitch EB, Cousins M, Antosh IJ, Defoor M, Sheean AJ, Werner BC. Objective analysis of partial three-dimensional rotator cuff muscle volume and fat infiltration across ages and sex from clinical MRI scans. Sci Rep 2023; 13:14345. [PMID: 37658220 PMCID: PMC10474276 DOI: 10.1038/s41598-023-41599-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/29/2023] [Indexed: 09/03/2023] Open
Abstract
Objective analysis of rotator cuff (RC) atrophy and fatty infiltration (FI) from clinical MRI is limited by qualitative measures and variation in scapular coverage. The goals of this study were to: develop/evaluate a method to quantify RC muscle size, atrophy, and FI from clinical MRIs (with typical lateral only coverage) and then quantify the effects of age and sex on RC muscle. To develop the method, 47 full scapula coverage CTs with matching clinical MRIs were used to: correct for variation in scan capture, and ensure impactful information of the RC is measured. Utilizing this methodology and automated artificial intelligence, 170 healthy clinical shoulder MRIs of varying age and sex were segmented, and each RC muscle's size, relative contribution, and FI as a function of scapula location were quantified. A two-way ANOVA was used to examine the effect of age and sex on RC musculature. The analysis revealed significant (p < 0.05): decreases in size of the supraspinatus, teres minor, and subscapularis with age; decreased supraspinatus and increased infraspinatus relative contribution with age; and increased FI in the infraspinatus with age and in females. This study demonstrated that clinically obtained MRIs can be utilized for automatic 3D analysis of the RC. This method is not susceptible to coverage variation or patient size. Application of methodology in a healthy population revealed differences in RC musculature across ages and FI level between sexes. This large database can be used to reference expected muscle characteristics as a function of scapula location and could eventually be used in conjunction with the proposed methodology for analysis in patient populations.
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Affiliation(s)
- Lara Riem
- Springbok Analytics, Charlottesville, VA, USA.
| | | | | | | | | | - Ivan J Antosh
- San Antonio Military Medical Center, San Antonio, TX, USA
| | - Mikalyn Defoor
- San Antonio Military Medical Center, San Antonio, TX, USA
| | | | - Brian C Werner
- University of Virginia Medical School, Charlottesville, VA, USA
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Ko SH, Na SC, Kim MS. Risk factors of tear progression in symptomatic small to medium-sized full-thickness rotator cuff tear: relationship between occupation ratio of supraspinatus and work level. J Shoulder Elbow Surg 2023; 32:565-572. [PMID: 36252783 DOI: 10.1016/j.jse.2022.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/07/2022] [Accepted: 09/20/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Previous studies reported that full-thickness rotator cuff tear (FTRCT) is a risk factor for tear progression. However, there is no clear consensus on the risk factors of tear progression in FTRCT. PURPOSE To identify the demographic and radiologic risk factors of tear progression in small to medium FTRCTs. METHODS We retrospectively reviewed 81 shoulders of patients diagnosed with small or medium FTRCTs using magnetic resonance imaging (MRI) who underwent conservative treatment from January 2017 to November 2021. Various demographic factors, including patient work level and radiological factors such as atrophy of rotator cuff muscles were analyzed to evaluate their association with tear progression. Work level was divided into high (heavy manual labor), medium (manual labor with less activity), and low (sedentary work activity). The atrophy of rotator cuff muscles was calculated by occupation ratio. RESULTS Tear progression was observed in 48% (39/81) of patients (criterion for tear progression was medial-lateral or anterior-posterior tear length > 5 mm). In patients with tear progression, the lengths of medial-lateral and anterior-posterior tears progressed by 6 mm and 3 mm, respectively. Among the rotator cuff muscles, fatty degeneration and occupation ratio of the supraspinatus were only worsened (P = .014, P = 0.013, respectively). The mean MRI follow-up duration was 14.8 ± 9.0 months. The significant risk factors of tear progression were high work level (odds ratio [OR], 7.728; 95% CI, 1.204-49.610; P = .031), and occupation ratio of the supraspinatus muscle (OR, 0.308; 95% CI, 0.158-0.604; P = .001). The optimal cutoff value for the occupation ratio of the supraspinatus was 0.55 (sensitivity 74%, specificity 62%). CONCLUSIONS Tear progression was observed in approximately 50% of patients with symptomatic small to medium FTRCTs. High physical work level and atrophy of the supraspinatus muscle were independent risk factors of tear progression. The risk of tear progression increases with occupation ratio of the supraspinatus muscle < 0.55 and heavy manual labor.
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Affiliation(s)
- Sang Hun Ko
- Department of Orthopaedic Surgery, Shoulder & Elbow Clinic, College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Sung Cheon Na
- Department of Orthopaedic Surgery, Shoulder & Elbow Clinic, College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Myung Seo Kim
- Department of Orthopaedic Surgery, Shoulder & Elbow Clinic, College of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea.
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Suri M, Parry S, Dham M, Verma A. Arthroscopic Biologic Tuberoplasty for Irreparable Rotator Cuff Tears: An Expedited Technique. Arthrosc Tech 2022; 11:e2265-e2270. [PMID: 36632403 PMCID: PMC9827058 DOI: 10.1016/j.eats.2022.08.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/17/2022] [Indexed: 11/18/2022] Open
Abstract
Massive irreparable rotator cuff tears in patients for whom arthroplasty is not an option can be a challenging clinical scenario for shoulder surgeons to manage. To achieve the best patient outcomes, a myriad of options has been presented in the literature, including debridement with biceps tenotomy or tenodesis, various tendon transfer procedures, superior capsular reconstruction, biceps tendon rerouting, bursal acromion resurfacing, balloon spacers, and tuberoplasty. While debridement with biceps tenotomy and superior capsular reconstruction have historically provided improvements in patient-reported outcomes, high rates of arthritis progression and failure of graft healing have been noted with these techniques, respectively. The superior capsular reconstruction has also proven to be technically challenging. The biologic tuberoplasty procedure was developed after several studies noted a lack of correlation between graft healing and improvement in patient-reported outcomes in superior capsular reconstructions, as long as the tuberosity remained covered with the graft. We present a technically efficient and expedited technique using an acellular human dermal allograft.
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Affiliation(s)
- Misty Suri
- Ochsner Hospital for Orthopedics & Sports Medicine, New Orleans, Louisiana, U.S.A.,Address correspondence to Misty Suri, M.D., Ochsner Sports Medicine Institute, S. Clearview Pkwy., New Orleans, LA, 70121, U.S.A.
| | - Steven Parry
- Ochsner Hospital for Orthopedics & Sports Medicine, New Orleans, Louisiana, U.S.A
| | | | - Arjun Verma
- Ochsner Hospital for Orthopedics & Sports Medicine, New Orleans, Louisiana, U.S.A
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Kim JY, Zhong Z, Lee HW, Lee GW, Noh KC. Quantitative Magnetic Resonance Imaging measurement of muscle atrophy and fatty degeneration after arthroscopic rotator cuff repair. J Orthop Surg (Hong Kong) 2022; 30:10225536221095276. [PMID: 35775586 DOI: 10.1177/10225536221095276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND It is unclear whether muscle atrophy (MA) and fatty degeneration (FD) have improved after arthroscopic rotator cuff repair (ARCR). Therefore, the objective of this study was to perform quantitative magnetic resonance imaging (MRI) measurement to evaluate MA and FD before and after surgery. Correlations of clinical outcome with changes in MA and FD were also analyzed. MATERIALS AND METHODS From March 2013 to March 2017, 40 patients who had no re-tear up to 1 year after ARCR were enrolled. MA and FD of supraspinatus muscle before surgery, at 3 days after surgery, and at 1 year after surgery were measured quantitatively in conventional Y-view and supraspinatus origin-view (SOV). Measurement items were muscle area (mm2), occupation ratio (%), fatty infiltration (FI, %), and fatty degenerative area (mm2). Postoperative clinical outcomes were measured at 1 year after ARCR. Correlation between measure values and outcome scores were analyzed. RESULTS Inter-measurement reliability was high (ICC = 0.933, Cronbach-α = 0.963). There was no significant change in MA in conventional Y-view at 1 year after surgery (Occupation ratio, p = 0.2770; MA, p = 0.3049) or in SOV (MA, p = 0.5953). FI and fat area measured with the conventional method on Y-view and showed significant differences (p = 0.0001). However, FI and fat area measured with the modified method on Y-view and SOV showed no significant difference (all p > 0.05). Postoperative clinical outcomes showed significant improvement compared to preoperative ones (p = 0.0001). However, there was no significant correlation between FD and FA (p = 0.653). CONCLUSION Quantitative MRI measurement was shown to be a reliable and valid method. MA and FD do not improve after ARCR considering postoperative anatomical changes of supraspinatus at 1-year follow-up. FD of the supraspinatus in conventional Y-view, but not in SOV, showed a significant change at 1 year postoperatively. MA showed no significant improvement. There was no correlation between improvement in clinical scores and changes in FD and MA.
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Affiliation(s)
- Jung Youn Kim
- Department of Orthopaedic Surgery, 65521Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Zhuan Zhong
- Department of Sports Medicine and Arthroscopy, Orthopedic Center, The 2nd Hospital, 154454Jilin Universtiy, Changchun, China
| | - Ho Won Lee
- Department of Orthopaedic Surgery, 65521Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Geun Woo Lee
- Department of Orthopaedic Surgery, 65521Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Kyu-Cheol Noh
- Department of Orthopaedic Surgery, 65521Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
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Uno T, Mura N, Yuki I, Oishi R, Takagi M. Factors correlated with the optimal tension for arthroscopic rotator cuff repair using Grasper Tensioning Attachment. J Shoulder Elbow Surg 2022; 31:e213-e222. [PMID: 34687919 DOI: 10.1016/j.jse.2021.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/17/2021] [Accepted: 10/06/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little is known about the optimal tension in arthroscopic rotator cuff repair (ARCR). This study aimed to identify preoperative, intraoperative, and postoperative factors that correlate with the tension in ARCR and to determine the optimal intraoperative tension using Grasper Tensioning Attachment, a tension meter attached to the common arthroscopic surgical grasper. METHODS This study included 63 patients with a mean age at surgery of 65.3 years (range, 45-83 years) who underwent ARCR. The mean follow-up period was 24.1 months (range, 24-28 months). We investigated the patients' demographic data, Japanese Orthopaedic Association score, DeOrio and Cofield classification, and Goutallier stage of the supraspinatus and infraspinatus muscles. We also evaluated cuff integrity based on the Sugaya classification via magnetic resonance imaging. The free edge of the torn retracted tendon was grasped, and the passive tension to the footprint was then measured with Grasper Tensioning Attachment with the arm at the side. The anteroposterior (AP) and mediolateral (ML) diameters were also measured. RESULTS The preoperative Goutallier stage of the supraspinatus muscle was stage 0 in 7 cases, stage 1 in 34, stage 2 in 20, and stage 3 in 2. The mean intraoperative rotator repair tension was 10.0 ± 2.5 N (range, 7.5-17 N). The mean AP diameter of the rotator cuff tear was 22 ± 10 mm (range, 8-50 mm), and the mean ML diameter was 24 ± 10 mm (range, 10-50 mm). Age, DeOrio and Cofield classification, Goutallier stage, AP diameter, and ML diameter correlated with rotator repair tension. The rotator repair tension in Sugaya classification type III or IV cases (n = 12, 11.4 ± 2.4 N) was significantly larger than that in type I or II cases (n = 51, 9.7 ± 2.4 N; P = .03). Tension ≥ 10 N as a cutoff value from receiver operating characteristic curve analysis was a risk factor for poor cuff integrity (95% confidence interval, 0.53-0.88). CONCLUSIONS Rotator repair tension ≥ 10 N was a risk factor for poor cuff integrity. Thus, care should be taken when performing intraoperative procedures and administering postoperative regimens.
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Affiliation(s)
- Tomohiro Uno
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan; Department of Orthopaedic Surgery, Yoshioka Hospital, Yamagata, Japan.
| | - Nariyuki Mura
- Department of Orthopaedic Surgery, Yoshioka Hospital, Yamagata, Japan; Yamagata Prefectural University of Health Sciences, Yamagata, Japan
| | - Issei Yuki
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan; Department of Orthopaedic Surgery, Yoshioka Hospital, Yamagata, Japan
| | - Ryuta Oishi
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan; Department of Orthopaedic Surgery, Yoshioka Hospital, Yamagata, Japan
| | - Michiaki Takagi
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan
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Agreement in rotator cuff muscles measurement between ultrasonography and magnetic resonance imaging. Asia Pac J Sports Med Arthrosc Rehabil Technol 2022; 28:13-20. [PMID: 35415074 PMCID: PMC8983312 DOI: 10.1016/j.asmart.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 03/14/2022] [Indexed: 11/21/2022] Open
Abstract
Background/objective It is important to assess the atrophy of the rotator cuff to better understand shoulder function and pain. Previously, magnetic resonance imaging has been used for the evaluation of atrophy of rotator cuff muscles, which is time consuming. Therefore, a measurement tool requiring little time and easy accessibility is clinically desirable to be used frequently in rehabilitation. Recently, rotator cuff muscles have been evaluated using ultrasonography. However, little is known about the agreement of evaluation in rotator cuff muscles between magnetic resonance imaging and ultrasonography. The purpose of this study was to demonstrate the agreement between the muscle thickness measurements of supraspinatus, infraspinatus, and teres minor muscles by ultrasonography and the cross-sectional area measured by magnetic resonance imaging in the patient with rotator cuff tears. Methods A total of 47 patients with rotator cuff tears were enrolled. There were the 37 small tears, four medium tears, and six large tears, and the involved rotator cuff muscles were the supraspinatus in 37 shoulders, and the supraspinatus and infraspinatus in 10 shoulders. The measuring variables were muscle thickness and cross-sectional area of supraspinatus, infraspinatus, and teres minor muscles by using magnetic resonance imaging. Further, the muscle thickness of the rotator cuff were assessed using ultrasonography. A single regression model was used for demonstrating the agreement between the cross-sectional area measurement by magnetic resonance imaging and the muscle thickness measured using ultrasonography and magnetic resonance imaging of rotator cuff muscles. Additionally, the Bland-Altman plots between magnetic resonance imaging and ultrasonography was analyzed. Results The cross-sectional area were correlated with the muscle thickness measurement of rotator cuff muscles by magnetic resonance imaging, significantly (supraspinatus: r = 0.84, infraspinatus: ρ = 0.63, teres minor: ρ = 0.61, all p < 0.001). There were significant agreements between the cross-sectional area measured by magnetic resonance imaging and muscle thickness measured by ultrasonography (supraspinatus: r = 0.80, infraspinatus: ρ = 0.78, teres minor: ρ = 0.74, all p < 0.001). Bland-Altman plots revealed significant correlations between the average and the difference of the two measurements in supraspinatus (r = 0.36, p = 0.012), infraspinatus (r = 0.38, p < 0.001), and teres minor (r = 0.42, p < 0.001). These results clarified the proportional bias between MRI and US. Conclusion This study showed that, similar to magnetic resonance imaging, ultrasonography is a useful tool for assessing muscle atrophy of supraspinatus, infraspinatus, and teres minor muscles.
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Bao MH, DeAngelis JP, Wu JS. Imaging of traumatic shoulder injuries – Understanding the surgeon’s perspective. Eur J Radiol Open 2022; 9:100411. [PMID: 35265737 PMCID: PMC8899241 DOI: 10.1016/j.ejro.2022.100411] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 02/13/2022] [Accepted: 02/23/2022] [Indexed: 12/18/2022] Open
Abstract
Imaging plays a key role in the assessment and management of traumatic shoulder injuries, and it is important to understand how the imaging details help guide orthopedic surgeons in determining the role for surgical treatment. Imaging is also crucial in preoperative planning, the longitudinal assessment after surgery and the identification of complications after treatment. This review discusses the mechanisms of injury, key imaging findings, therapeutic options and associated complications for the most common shoulder injuries, tailored to the orthopedic surgeon’s perspective.
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Bogdanov J, Lan R, Chu TN, Bolia IK, Weber AE, Petrigliano FA. Fatty degeneration of the rotator cuff: pathogenesis, clinical implications, and future treatment. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:301-308. [PMID: 37588720 PMCID: PMC10426606 DOI: 10.1016/j.xrrt.2021.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Chronic rotator cuff pathology is often complicated by fatty degeneration of the rotator cuff (FDRC) muscles, an insidious process associated with poor prognosis with or without surgical intervention. Currently there is no treatment for FDRC, and many studies have described a natural course for this disease almost always resulting in further degeneration and morbidity. Recapitulating FDRC using animal injury models, and using imaging-based studies of human FDRC, the pathophysiology of this disease continues to be further characterized. Researchers studying mesenchymal stem cell-derived progenitor cells and known fibrogenic and adipogenic signaling pathways implicated in FDRC seek to clarify the underlying processes driving these changes. While new cell- and molecular-based therapies are being developed, currently the strongest available avenue for improved management of FDRC is the use of novel imaging techniques which allow for more accurate and personalized staging of fatty degeneration. This narrative review summarizes the evidence on the molecular and pathophysiologic mechanisms of FDRC and provides a clinical update on the diagnosis and management of this condition based on the existing knowledge. We also sought to examine the role of newer biologic therapies in the management of RC fatty degeneration and to identify areas of future research.
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Affiliation(s)
- Jacob Bogdanov
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Rae Lan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Timothy N. Chu
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ioanna K. Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E. Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A. Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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Kucirek NK, Hung NJ, Wong SE. Treatment Options for Massive Irreparable Rotator Cuff Tears. Curr Rev Musculoskelet Med 2021; 14:304-315. [PMID: 34581991 PMCID: PMC8497660 DOI: 10.1007/s12178-021-09714-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Natalie K. Kucirek
- School of Medicine, University of California, San Francisco, San Francisco, CA USA
| | - Nicole J. Hung
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Stephanie E. Wong
- Department of Orthopaedic Surgery, University of California, San Francisco, 1500 Owens Street, San Francisco, CA 94158 USA
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Lee S, Hwang JT, Lee SS, Lee JH, Kim TY. Greater Tuberosity Bone Mineral Density and Rotator Cuff Tear Size Are Independent Factors Associated With Cutting-Through in Arthroscopic Suture-Bridge Rotator Cuff Repair. Arthroscopy 2021; 37:2077-2086. [PMID: 33581302 DOI: 10.1016/j.arthro.2021.01.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 01/27/2021] [Accepted: 01/27/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the correlation between cutting-through at the greater tuberosity (GT) in arthroscopic suture-bridge rotator cuff repair and the bone mineral density (BMD) of the lumbar spine, hip, and ipsilateral GT of the proximal humerus and to evaluate factors and clinical outcomes related to cutting-through. METHODS This study prospectively enrolled patients who underwent arthroscopic knotted suture-bridge rotator cuff repair for full-thickness rotator cuff tears between June 2014 and October 2015 and who had undergone dual-energy X-ray absorptiometry cans within 1 month before surgery with a minimum 2-year follow-up. Cutting-through was defined as the occurrence of cortical breakage of the GT just medial to the lateral knotless anchor hole due to the tension of the sutures from the medial anchor, and it was assessed. Clinical and radiologic data were analyzed. Univariate and regression analyses were performed to evaluate factors related to cutting-through. RESULTS A total of 78 patients were analyzed. Patients were divided into 2 groups: patients who had cutting-through (46, group I) and patients who did not (32, group II). In an analysis of lumbar spine, hip, and GT BMD, GT BMD was the most effective for predicting cutting-through (area under the receiver operating characteristic curve = 0.94, 95% confidence interval 0.89-0.99). GT BMD (P < .001) and tear size (P = .004) were independent factors for cutting-through. Although a significant difference was found between the 2 groups in terms of age, sex, lumbar spine and hip BMD, fatty infiltration of the supraspinatus and infraspinatus, and atrophy of the supraspinatus, these variables were not independent factors. Clinical and structural outcomes showed no significant difference between the 2 groups, and anchor failure was not identified intraoperatively. CONCLUSIONS GT BMD and rotator cuff tear size are independent factors associated with cutting-through at the GT. A dual-energy X-ray absorptiometry scan of the proximal humerus is useful for predicting bone quality before arthroscopic suture-bridge rotator cuff repair. LEVEL OF EVIDENCE Level II, Prospective cohort study.
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Affiliation(s)
- Sanghyeon Lee
- Department of Orthopedic Surgery, College of Medicine, Ewha Womans University Seoul Hospital, Seoul
| | - Jung-Taek Hwang
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym university Medical College, Gangwon-do, Republic of Korea.
| | - Sang-Soo Lee
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym university Medical College, Gangwon-do, Republic of Korea
| | - Jun-Hyuck Lee
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym university Medical College, Gangwon-do, Republic of Korea
| | - Tae-Yeong Kim
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym university Medical College, Gangwon-do, Republic of Korea
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Abstract
Background The irreparability of rotator cuff repair is generally determined during surgery. We have been performing partial repairs for rotator cuff tears that are deemed irreparable with primary repair. The aim of this study is to report, for the first time, the long-term postoperative outcome of our partial repair method and to clarify the criteria for the irreparability of primary repair. Methods The UCLA score, radiographic findings, and magnetic resonance imaging findings of 156 shoulders that underwent rotator cuff repair (primary repair, 126 shoulders; partial repair, 30 shoulders) were retrospectively evaluated at preoperative and >10-year postoperative follow-up (mean evaluation time, 11.5 ± 1.0 years). Osteoarthritic (OA) changes were evaluated by radiographic findings, and the cuff integrity (Sugaya classification) and fatty infiltration (Goutallier classification) were evaluated by magnetic resonance imaging findings. These evaluations were compared between a primary repair group and partial repair group. Results Although no significant difference was observed between preoperative and postoperative findings for the UCLA score, the strength of forward flexion was significantly lower at 10 years postoperatively in the partial repair group. Preoperative image evaluation showed no significant difference in OA changes between the 2 groups; however, fatty infiltration showed significantly greater progression in the partial repair group than the primary repair group. At >10-year postoperative follow-up, the OA changes, cuff integrity, and fatty infiltration showed significantly greater progression in the partial repair group compared to the primary repair group. Although the long-term outcome of the partial repair group was inferior to that of the primary repair group in imaging evaluations, good functional outcome of the shoulder joint was maintained. Conclusion Our results suggested that partial repair could be an effective treatment option for irreparable rotator cuff tear. In terms of the feasibility of primary repair, the cutoff value for preoperative fatty infiltration was stage 2; thus, we believe that primary repair should be performed for cases with stage 2 fatty infiltration or lower, and partial repair should be performed for cases with stage 3 fatty infiltration or higher. However, manual workers and athletes with stage 3 fatty infiltration or higher should be advised in advance that mild muscle weakness may remain after surgery.
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Viswanath A, Drew S. Subacromial balloon spacer - Where are we now? J Clin Orthop Trauma 2021; 17:223-232. [PMID: 33898241 PMCID: PMC8056261 DOI: 10.1016/j.jcot.2021.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/21/2021] [Accepted: 03/22/2021] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Rotator cuff tears are a common cause of disability and pain. The ideal treatment for truly irreparable rotator cuffs is still debated, and one recent surgical advance is the development of the subacromial balloon spacer. This review aims to clarify the current evidence and indications for this device. METHODS A comprehensive literature search was undertaken using the MeSH search terms combining "balloon spacer" and "irreparable cuff tear". A total of 20 studies using the balloon spacer as a treatment modality in more than two patients, were analysed. RESULTS A total of 513 patients were analysed, representing 83% of those initially identified as meeting the inclusion criteria. The majority of studies recommended the device, with only four suggesting it was not recommended based on their results. Notable bias was present in the studies analysed, and there were no papers providing greater than level III evidence. CONCLUSION The subacromial balloon spacer is one possible treatment option for older, low-demand patients with a full thickness rotator cuff tear involving only the supraspinatus tendon, who also have no arthritis and have preserved active elevation beyond 90°. However, the results of two large randomised prospective trials are awaited to provide satisfactory evidence regarding the use of the balloon spacer.
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Affiliation(s)
- Aparna Viswanath
- Corresponding author. 29 Brook Road, Brentwood, CM14 4PT, United Kingdom.
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18
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Smith JM, Cancienne JM, Brockmeier SF, Werner BC. Vitamin D deficiency and total shoulder arthroplasty complications. Shoulder Elbow 2021; 13:99-105. [PMID: 33717223 PMCID: PMC7905506 DOI: 10.1177/1758573220906520] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 11/12/2019] [Accepted: 01/24/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The primary objective of this study was to examine the relationship between vitamin D deficiency and implant-related and medical complications following total shoulder arthroplasty. METHODS Using the PearlDiver database, patients who underwent total shoulder arthroplasty from 2005 to 2016 with vitamin D deficiency were identified. These were compared to a 3:1 control group matched by age, sex, and presence of a concomitant osteoporosis diagnosis. Primary outcome measures were implant-related complications (loosening, periprosthetic fracture, periprosthetic joint infection, and revision total shoulder arthroplasty) in addition to medical complications within 90 days of surgery. A multivariable logistic regression analysis was utilized to control for patient demographics and comorbidities. RESULTS One thousand and six hundred and seventy-four patients with vitamin D deficiency were identified and compared to 5022 controls. There was a significantly higher rate of revision total shoulder arthroplasty in the vitamin D deficient patients compared to controls (2.3% versus 0.8%, odds ratio 3.3, p < 0.0001). After controlling for confounding variables, there were no significant differences in any of the remaining implant-related or medical complications with the exception of higher rates of urinary tract infections in patients with vitamin D deficiency. CONCLUSIONS Vitamin D deficiency is associated with a higher rate of all-cause revision total shoulder arthroplasty but not medical complications compared to controls.Level of evidence: Level III case control study.
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Affiliation(s)
- J Michael Smith
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, USA
| | | | - Stephen F Brockmeier
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, USA,Brian C Werner, Department of Orthopaedic Surgery, University of Virginia Health System, PO Box 800159, Charlottesville, VA, USA.
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The Utility of Modified Dixon Turbo Spin Echo Shoulder Magnetic Resonance Arthrography in Assessing Rotator Cuff Disorder and Evaluating the Rotator Cuff Muscles. Acad Radiol 2021; 28:233-242. [PMID: 32063493 DOI: 10.1016/j.acra.2020.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/03/2020] [Accepted: 01/05/2020] [Indexed: 11/21/2022]
Abstract
RATIONALE AND OBJECTIVES To compare the diagnostic ability of modified Dixon (mDixon) turbo spin echo (TSE) T1-weighted (T1W) shoulder magnetic resonance arthrography (MRA) with that of conventional shoulder MRA, and evaluate the feasibility of mDixon TSE in-phase (IP) images in measuring the fat fraction and size of rotator cuff muscles. MATERIALS AND METHODS This retrospective study included 57 patients who underwent 3T shoulder MRA examinations with conventional and mDixon TSE T1W images (mean age: 56.7 years; range: 20-78 years). Two musculoskeletal radiologists independently evaluated the rotator cuff tendons with fat saturated T1W images and mDixon TSE T1W water images. Occupation ratios measured on T1W and mDixon TSE T1W IP images were compared. The fat fraction of the supraspinatus from the mDixon TSE T1W images was calculated and correlated with fatty infiltration of the supraspinatus on T1W images. RESULTS For tendon pathology, the kappa value for inter-sequence and inter-reader agreement was 0.957 (95% confidence interval [CI]: 0.923-0.990) and 0.839 (95% CI: 0.778-0.899), respectively. For retear, the kappa value for inter-sequence and inter-reader agreement was 0.913 (95% CI: 0.796-1.000) and 0.779 (95% CI: 0.594-0.963), respectively. The intraclass correlation coefficient for both occupation ratios was 0.986 (95% CI: 0.973-0.993). Comparison of mDixon TSE T1W fat fraction with Goutallier grade showed a strong positive linear correlation (r = 0.929). CONCLUSIONS The mDixon TSE T1W sequence is a good alternative to conventional sequences in shoulder MRA for evaluating rotator cuff pathology. Furthermore, this sequence provides information on the size and fat infiltration of rotator cuff muscles.
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Jeong HJ, Kwon J, Rhee SM, Oh JH. New quantified measurement of fatty infiltration of the rotator cuff muscles using magnetic resonance imaging. J Orthop Sci 2020; 25:986-991. [PMID: 32070650 DOI: 10.1016/j.jos.2020.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 12/01/2019] [Accepted: 01/17/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The degree of fatty infiltration of the rotator cuff muscle is typically evaluated using the Goutallier-Fuchs grading system, but its consistency remains controversial. This study aimed to evaluate a new quantified measurement of fatty infiltration based on three-dimensionally reconstructed volumetric data obtained from magnetic resonance images of non-pathologic shoulders using open-source software. METHODS Fourteen shoulder 3-T magnetic resonance images (8 men, 6 women) without lesions obtained between 2010 and 2017 were analysed. Slicer version 4.6.2 was used to semi-automatically reconstruct the three-dimensional volumetric data from T2 sagittal oblique images and to differentiate fat tissue from rotator cuff muscle using the difference in signal intensity. RESULTS The cutoff value for dividing muscle and fat was 508.9. The inter-class and intra-class correlations of each rotator cuff muscle and fat tissue were >0.9 (all P < 0.001). The mean muscle volume of the supraspinatus, infraspinatus, teres minor, and subscapularis were 15.2, 20.9, 13.3, and 29.7 mL, respectively. The muscle volume of the men was greater than that of the women (all P < 0.001), and the fat infiltration ratio was positively correlated with body mass index (all P < 0.05). CONCLUSIONS The semi-automated quantified measurement of fatty infiltration of the rotator cuff muscles using magnetic resonance imaging and Slicer software presented excellent consistency. This technique could be an alternative measurement to complement the weak consistency of the Goutallier-Fuchs grading system. However, to reduce the error of measurement, this study evaluated non-pathologic shoulders. Therefore, further study using magnetic resonance imaging of pathologic shoulders is necessary for actual clinical application. LEVEL OF EVIDENCE Level IV, case series, diagnostic study.
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Affiliation(s)
- Hyeon Jang Jeong
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Republic of Korea
| | - Jieun Kwon
- Department of Orthopaedic Surgery, Ewha Womans University College of Medicine, Ewha Womans University Mokdong Hospital, Republic of Korea.
| | - Sung-Min Rhee
- Department of Orthopaedic Surgery, Kyung Hee University Medical Center, Republic of Korea
| | - Joo Han Oh
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Republic of Korea
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Jung SW, Jin JW, Kim DH, Kim HS, Lee GE, Kim JW, Jang MJ. Diagnostic value of the axial view of magnetic resonance imaging to identify two-dimensional shapes of full-thickness rotator cuff tears. Acta Radiol 2020; 61:1545-1552. [PMID: 32077302 DOI: 10.1177/0284185120905098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Coronal and sagittal views of magnetic resonance imaging (MRI) were used to determine rotator cuff tear size and fatty infiltration, but these images were not enough to identify the tear shape. PURPOSE To correlate the preoperative axial MRI views and arthroscopic surgical findings to identify the two-dimensional shapes in rotator cuff tears. MATERIAL AND METHODS This study included 166 patients who underwent arthroscopic repair between 2015 and 2018. Preoperative coronal, sagittal, and axial MRI views were evaluated for tear size and geographic configuration in axial sections, and the length and the width were measured and were matched with arthroscopic surgical views by lateral portals. RESULTS The agreement of axial MRI views with the arthroscopic view was 88.0% in crescent, 97.2% in longitudinal, 78.6% in massive, and 100% in rotator cuff tear arthropathy. The mean agreement rate of axial MRI views with arthroscopic view was 81.9%. Mean mediolateral and anteroposterior tear sizes on axial MRI were 16.68 mm and 19.33 mm, respectively. Mean mediolateral and anteroposterior tear sizes by arthroscopic view were 21.49 mm and 21.04 mm, respectively. Tear sizes by MRI axial images were 71.3% of arthroscopic view. SST/IST degenerative changes were noted in most patients with massive tears and rotator cuff arthropathy (P = 0.001). CONCLUSION Rotator cuff tear shape on preoperative axial MRI view had close agreement (81.9%) with arthroscopic findings by lateral portal, and tear size by preoperative axial MRI views was 71.3% of that of arthroscopic view. Axial MRI views helped to predict the geometric tear shape of rotator cuff tears.
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Affiliation(s)
- Sung-Weon Jung
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Geyongsangnam-do, Republic of Korea
| | - Jin-Woo Jin
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Geyongsangnam-do, Republic of Korea
| | - Dong-Hee Kim
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Geyongsangnam-do, Republic of Korea
| | - Hyeon-Soo Kim
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Geyongsangnam-do, Republic of Korea
| | - Gwang-Eun Lee
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Geyongsangnam-do, Republic of Korea
| | - Jin-Woo Kim
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Geyongsangnam-do, Republic of Korea
| | - Min-Jae Jang
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Geyongsangnam-do, Republic of Korea
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Sun Y, Lin J, Luo Z, Chen J. Preoperative Lymphocyte to Monocyte Ratio Can Be a Prognostic Factor in Arthroscopic Repair of Small to Large Rotator Cuff Tears. Am J Sports Med 2020; 48:3042-3050. [PMID: 32931300 DOI: 10.1177/0363546520953427] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Complete arthroscopic repair can treat small to large rotator cuff tears (RCTs) with good outcomes; however, the repair might be compromised by inflammation. PURPOSE To investigate the prognostic value of preoperative lymphocyte to monocyte ratio (LMR), a marker of systemic inflammation before surgery, in arthroscopic rotator cuff repair. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Between January 2014 and January 2016, primary small to large RCTs without stiffness, significant muscle fatty infiltration, or atrophy were completely repaired in 110 consecutive patients and followed. Preoperative LMR was obtained from blood routinely examined 1 day before surgery. Descriptive data and pre- and intraoperative variables were collected. Correlation analysis and multivariable linear regression analysis were used to determine the relationship between preoperative LMR and recovery including American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, Fudan University Shoulder Score (FUSS), visual analog scale (VAS) score for pain, and range of motion (ROM). Poor recovery was defined as ASES score <80, shoulder stiffness as external rotation ≤20°, and pain as VAS score >3. The predictive value of preoperative LMR was determined by receiver operating characteristic (ROC) curve. RESULTS A total of 99 patients (101 shoulders) were followed for 2.88 ± 0.43 years. Overall, mean ASES, Constant-Murley, FUSS, and VAS scores were significantly improved at the final follow-up; however, 27 cases had either ASES <80, shoulder stiffness, pain, or a combination of these. Correlation analysis and multivariable linear analysis showed that preoperative LMR was the only factor independently associated with functional recovery, pain, and ROM. Patients with poor recovery had lower preoperative LMR than those with good recovery. Based on the ROC curve, the cutoff value of preoperative LMR was 4.760. Patients with preoperative LMR <4.760 had significantly inferior clinical outcomes compared with their counterparts. The corresponding specificity was 0.542, and sensitivity was 0.779. CONCLUSION Arthroscopic repair for small to large RCTs yielded good outcomes; however, some patients still had inferior functional scores, shoulder stiffness, or pain, which correlated with the level of preoperative systemic inflammation. As a marker of systemic inflammation, preoperative LMR could be prognostic for rotator cuff repair.
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Affiliation(s)
- Yaying Sun
- Department of Sports Medicine, Huashan Hospital, Shanghai, China
| | - Jinrong Lin
- Department of Sports Medicine, Huashan Hospital, Shanghai, China
| | - Zhiwen Luo
- Department of Sports Medicine, Huashan Hospital, Shanghai, China
| | - Jiwu Chen
- Department of Sports Medicine, Huashan Hospital, Shanghai, China
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Park I, Kang JS, Lee HA, Jo YG, Shin SJ. A Novel Reparability Assessment Scoring System for Full-Thickness Rotator Cuff Tears. Orthop J Sports Med 2020; 8:2325967120940979. [PMID: 32844101 PMCID: PMC7418268 DOI: 10.1177/2325967120940979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 03/12/2020] [Indexed: 11/16/2022] Open
Abstract
Background: It is difficult to predict the arthroscopic reparability of rotator cuff tears preoperatively when the repair is challenging. This can result in unsatisfactory outcomes and a high retear rate. Purpose: To develop an assessment score reflecting factors in rotator cuff tears that can predict reparability before surgery. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively enrolled 170 patients with rotator cuff tears larger than 2 cm who underwent arthroscopic repair. Patients were categorized into “complete repair” and “partial repair” groups based on the area of the exposed footprint after arthroscopic rotator cuff repair. In each group, preoperative magnetic resonance imaging factors (tear size, fatty infiltration, remnant tendon length, atrophy), clinical factors (range of motion, American Shoulder and Elbow Surgeons score, Constant score), and patient demographics were evaluated. Receiver operating characteristic curve analysis was used to choose the optimal cutoff value. A reparability assessment score was formulated through stepwise selection using variables that showed significant between-group differences on univariate analysis. We selected 4 variables and assigned a relative score for each variable based on estimated coefficient values. The sum of the scores for each factor ranged from 0 to 5. Results: The average rotator cuff tear size was 28 × 26 mm. The torn rotator cuff was repaired completely in 74 patients (43.5%) and partially in 96 patients (56.5%). The following factors were chosen for the reparability assessment score: positive tangent sign (odds ratio [OR], 5.969; P = .001), fatty infiltration of the infraspinatus of grade ≤2 (OR, 3.537; P = .001), coronal tear size ≥26 mm (OR, 3.315; P = .002), and remnant tendon length <15 mm (OR, 2.584; P = .017). Complete repair was possible if the sum of the scores was <3 (area under curve, 0.803; 95% CI, 0.739-0.867; sensitivity, 51.0%; specificity, 95.9%). Conclusion: In patients with a score of <3 on the novel reparability assessment score, complete repair was obtainable, whereas in patients with a score of ≥3, complete repair was difficult and other methods such as biologic grafts or arthroplasty had to be considered for a favorable prognosis.
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Affiliation(s)
- In Park
- Department of Orthopedic Surgery, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
| | - Jun-Seok Kang
- Department of Orthopedic Surgery, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
| | - Hye-Ah Lee
- Clinical Trial Center, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Yoon-Geol Jo
- Department of Orthopedic Surgery, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
| | - Sang-Jin Shin
- Department of Orthopedic Surgery, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
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Factors Related to Symptomatic Failed Rotator Cuff Repair Leading to Revision Surgeries After Primary Arthroscopic Surgery. Arthroscopy 2020; 36:2080-2088. [PMID: 32339635 DOI: 10.1016/j.arthro.2020.04.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 03/28/2020] [Accepted: 04/01/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the clinical characteristics of patients with symptomatic failed rotator cuff repair who required revision surgeries and to identify clinical and radiologic factors related to the need for revision surgery. METHODS Ninety-eight patients who were diagnosed with rotator cuff retear within 2 years after primary arthroscopic surgery were included. Patients were divided into 2 groups: patients who underwent revision surgery within 2 years postoperatively (44 patients, group I) and patients who did not require additional treatment due to minimal discomfort during the same period (54 patients, group II). Demographic and radiographic factors related to cuff healing were analyzed. Univariate and multivariate analyses were performed to evaluate factors related to revision surgery. RESULTS Group I showed significantly inferior clinical outcomes at the time of revision compared to group II (American Shoulder and Elbow Surgeons score; 54.0 ± 12.1 vs 86.5 ± 12.2, Constant score; 65.2 ± 10.8 vs 84.0 ± 11.4, P < .001). Total cholesterol level (210.2 ± 40.0 vs 189.7 ± 39.1, P = .012), low-density lipoprotein level (130.7 ± 28.7 vs 115.5 ± 26.9, P = .008), and fatty infiltration of the infraspinatus (20.5% vs 3.7%, P = .011) were significantly greater in group I than in group II. On postoperative magnetic resonance imaging, retear of the infraspinatus tendon occurred significantly more frequently in group I (81.8%) than in group II (37.0%, P < .001). In group I, relative changes in anteroposterior (AP) (19.2 ± 37.8) and mediolateral retear size (29.6 ± 90.7) were significantly greater than in group II (AP; -39.5 ± 19.2, mediolateral; -29.2 ± 26.8, P < .001). Relative change in AP retear size was the most powerful independent predictor of symptomatic failed rotator cuff repair (odds ratio 1.19, confidence interval 1.08-1.31, P < .001). CONCLUSIONS Preoperative serum total cholesterol level, low-density lipoprotein levels, and fatty infiltration of the infraspinatus were significantly related to symptomatic failed rotator cuff repair. Relative change in AP retear size was the most powerful independent predictor of symptomatic failed rotator cuff repair. LEVEL OF EVIDENCE Level III, Case-control study.
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Hosseinzadeh S, DeAngelis JP, Komarraju A, Wu AC, Wu JS. Imaging of Acute Shoulder Trauma. Semin Roentgenol 2020; 56:5-21. [PMID: 33422184 DOI: 10.1053/j.ro.2020.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Acute injuries to the shoulder girdle are common and frequently encountered by the practicing radiologist. The type of injury is highly dependent on the age of the patient and mechanism of trauma with injuries occurring at the site of greatest mechanical weakness. In this review, we discuss the main clinical features and key imaging findings for the most common shoulder injuries. For each injury, we also provide a section on the important features that the orthopedic surgeon needs to know in order to guide surgical versus nonsurgical management.
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Affiliation(s)
- Shayan Hosseinzadeh
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Joseph P DeAngelis
- Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Aparna Komarraju
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Allison C Wu
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jim S Wu
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Abstract
Introduction A prerequisite for a satisfying functional result in the treatment of an irreparable rotator cuff rupture is a significant reduction of shoulder pain and better range of motion with an increase in anatomic glenohumeral joint stability. Purpose Prospective study to examine the outcome after superior capsular reconstruction using a porcine extracellular matrix dermal graft. A special emphasis was primarily on the functional outcome, secondarily on radiographic shoulder changes, that superior capsular reconstruction might yield. Methods Clinical results were evaluated using the Constant score and Western Ontario Rotator Cuff (WORC) index over a 2-year period. All patients had magnetic resonance imaging (MRI) of the injured shoulder after 1 year. Graft integration and durability were qualitatively estimated as well as any graft deterioration or resorption. Results Thirteen patients with 13 superior capsular reconstructions were included over a 3-year period. Mean age was 61 years (range 50-70) at the time of surgery. At final follow-up (mean 24 months, range 23-32), the mean Constant score had improved from an average of 24.9-55.7 points. The mean WORC index had increased from a percentage average of 32.3%-61.9%. Eleven of 13 grafts were intact on follow-up MRI. Conclusion Our hypothesis was that successful implantation of a dermal xenograft would correlate with both better functional outcome and stabilized glenohumeral radiographic features. We saw a group of patients with variable but significant increases in functional results and in general with limited pain and with an intact xenograft on an MRI scan. We did not find a positive correlation between functional outcome scores and graft durability nor with single cuff tendon defects vs. larger rotator cuff defects.This study suggests that a superior capsular reconstruction can yield results that are comparable or superior to other known salvage treatment options in patients with large to massive rotator cuff defects without significant cuff tear arthropathy. The hypothesis that superior capsular reconstruction can be a relevant treatment method for irreparable rotator cuff tears could not be refuted despite a fairly low patient inclusion number. With these results, selected patients can be considered for a different treatment than reverse shoulder arthroplasty, débridement, or tendon transfer.
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Affiliation(s)
- Anton Ulstrup
- Department of Orthopaedic Surgery, Holbæk Hospital, Holbæk, Denmark
| | - Michael Reinhold
- Department of Orthopaedic Surgery, Holbæk Hospital, Holbæk, Denmark
| | - Otto Falster
- Department of Orthopaedic Surgery, Holbæk Hospital, Holbæk, Denmark
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Jensen AR, Taylor AJ, Sanchez-Sotelo J. Factors Influencing the Reparability and Healing Rates of Rotator Cuff Tears. Curr Rev Musculoskelet Med 2020; 13:572-583. [PMID: 32681307 DOI: 10.1007/s12178-020-09660-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF THE REVIEW To discuss tear- and patient-related factors that influence the healing potential of rotator cuff tears and to clarify the terminology surrounding this topic. RECENT FINDINGS Over the last few years, further insight has been gained regarding rotator cuff tear features that are associated with poor healing rates after rotator cuff repair. Some of these features have been incorporated in prediction models developed to accurately predict rotator cuff healing rates utilizing preoperative risk factors weighted by importance. Rotator cuff tears may be considered functionally irreparable based on their size, chronicity, absence of adequate tendon length, atrophy, and fatty infiltration. Furthermore, advanced age, use of tobacco products, diabetes, and other patient-related factors may impair tendon healing. Careful analysis and discussion of all these factors with patients is essential to determine if surgical repair of a rotator cuff tear should be recommended, or if it is best to proceed with one of the several salvage procedures reviewed in this topical collection, including augmentation of the repair, superior capsular reconstruction, tendon transfers, and other.
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Affiliation(s)
- Andrew R Jensen
- Department of Orthopaedic Surgery, University of California, Los Angeles, CA, 90403, USA
| | - Adam J Taylor
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - Joaquin Sanchez-Sotelo
- Department of Orthopaedic Surgery, Harbor-UCLA Medical Center, Torrance, CA, 90502, USA.
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Systematic review of reversing pseudoparalysis of the shoulder due to massive, irreparable rotator cuff tears. J Shoulder Elbow Surg 2020; 29:S87-S91. [PMID: 32643613 DOI: 10.1016/j.jse.2020.04.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 04/16/2020] [Accepted: 04/21/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Correcting pseudoparalysis of the shoulder due to massive rotator cuff tear is challenging. The most reliable treatment for restoring active shoulder elevation is debatable. Therefore, the purpose of this systematic review was to evaluate the success of various treatment options for reversing pseudoparalysis due to massive rotator cuff tear. METHODS A search was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines of the MEDLINE database, Cochrane database, Sportdiscus, and Google Scholar database for articles evaluating shoulder pseudoparalysis due to massive rotator cuff tears. RESULTS Nine articles evaluating reverse total shoulder arthroplasty (RTSA), superior capsular reconstruction (SCR), and rehabilitation programs were included in the study. Though there was variability, the definition of pseudoparalysis was active forward elevation (AFE) less than 90° with preserved passive range of motion (ROM). Reversal of pseudoparalysis was defined as restoration of AFE greater than 90°. The overall rate of reversal of pseudoparalysis across studies was similar for RTSA (96% ± 17%) and SCR (94% ± 3%). However, there was a difference in average improvement in AFE for RTSA (56° ± 11°) and SCR (106° ± 20°). A progressive rehabilitation program described improvements in a single study with 82% reversal of pseudoparalysis. CONCLUSION The available Level IV evidence suggests that RTSA and SCR reliably reverse pseudoparalysis in most patients with massive, irreparable rotator cuff tears. However, the dissimilar improvements in ROM suggest that a more consistent definition of pseudoparalysis is warranted. Future randomized controlled trials are needed to determine the best treatment approach for patients with massive irreparable rotator cuff tears.
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Tenbrunsel TN, Whaley JD, Golchian D, Malone DL, Lima DJL, Sabesan VJ. Efficacy of Imaging Modalities Assessing Fatty Infiltration in Rotator Cuff Tears. JBJS Rev 2020; 7:e3. [PMID: 30969180 DOI: 10.2106/jbjs.rvw.18.00042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Fatty atrophy is a diagnosis characterized by the combination of fatty infiltration and muscle atrophy of the rotator cuff. Studies have shown a strong positive correlation between the level of fatty infiltration and the risk of experiencing a chronic rotator cuff tear. Therefore, the purpose of the present study was to review the current literature on radiographic imaging of fatty infiltration and fatty atrophy to better aid surgeons in predicting functional outcome and to help guide patient decisions. METHODS We conducted a literature search in PubMed. The exact search queries included "rotator cuff" in the MeSH Terms field; "fatty atrophy," fatty infiltration," and "fatty muscle degeneration" in the Title/Abstract field; and various combinations of these searches. We initially found 184 articles using these keywords, including both human and animal studies. The 25 animal studies were excluded, leaving 159 articles. The abstracts of all remaining articles were reviewed and selected on the basis of our inclusion criteria of focusing on patients with rotator cuff tears (preoperatively and postoperatively), fatty infiltration, fatty atrophy, and imaging modalities. We excluded an additional 127 articles, leaving 32 articles that were selected for the final review and inclusion in this study. RESULTS Among 45 shoulder specialists across different studies, interrater agreement for Goutallier staging with use of magnetic resonance imaging (MRI) ranged from 0.24 to 0.82 and intrarater agreement for supraspinatus fatty changes ranged from 0.34 to 0.89. Our review also showed strong positive correlations when assessing the severity of fatty atrophy of the rotator cuff between MRI and ultrasound or ultrasound modalities such as sonoelastography. CONCLUSIONS Increasing fatty infiltration of the rotator cuff is associated with greater repair failure rates and hence poorer overall clinical outcomes. MRI remains the gold standard for the imaging of rotator cuff tears and postoperative healing. Ultrasound can decrease health-care expenditures associated with the assessment of repair integrity postoperatively, although ultrasound is not as precise and has some limitations compared with MRI.
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Affiliation(s)
- Troy N Tenbrunsel
- Department of Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - James D Whaley
- Department of Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - David Golchian
- Department of Orthopaedic Surgery, Beaumont Health, Taylor, Michigan
| | - Danielle L Malone
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Diego J L Lima
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Vani J Sabesan
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
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Abstract
Muscle atrophy in shoulders with rotator cuff tendon tears is a negative prognosticator, associated with decreased function, decreased reparability, increased retears after repair, and poorer outcomes after surgery. Muscle edema or atrophy within a neurologic distribution characterizes denervation. Because most nerve entrapments around the shoulder are not caused by mass lesions and show no nerve findings on routine MR imaging sequences, pattern of muscle denervation is often the best clue to predicting location of nerve dysfunction, which narrows the differential diagnosis and guides clinical management. The exception is suprascapular nerve compression in the spinoglenoid notch caused by a compressing cyst.
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Affiliation(s)
- David A Rubin
- All Pro Orthopedic Imaging Consultants, LLC, St Louis, MO, USA; Radsource, Brentwood, TN, USA; NYU Langone Medical Center, New York, NY, USA.
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31
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Superior Capsular Reconstruction for the Operatively Irreparable Rotator Cuff Tear: Clinical Outcomes Are Maintained 2 Years After Surgery. Arthroscopy 2020; 36:373-380. [PMID: 31864817 DOI: 10.1016/j.arthro.2019.08.035] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 08/18/2019] [Accepted: 08/19/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the results of arthroscopic superior capsular reconstruction (SCR) after 2-year minimum follow-up and to compare the results with those seen in a previously studied group of patients at 1 year postoperatively. METHODS The retrospective study period was October 2014 through September 2016. Inclusion criteria were arthroscopic dermal allograft SCR performed for operatively irreparable posterosuperior rotator cuff tear with intact or repairable subscapularis tendon, failure of nonoperative treatment, and clinical follow-up at 1 and minimum 2 years postoperatively. Patients lost to follow-up or undergoing revision of the SCR were excluded from the analysis. The primary outcome measure was American Shoulder and Elbow Surgeons (ASES) score (mean, [95% confidence interval], P value). Secondary outcomes included visual analog pain rating (0-10), subjective shoulder value, and active forward elevation and external rotation (degrees). Radiographic analysis included acromiohumeral interval (millimeters) and graft integrity 1-year postoperation. Complications and reoperations were reviewed from the medical record. RESULTS Forty-one patients met inclusion criteria at mean 34 months postoperatively, and 8 were excluded. ASES score improved from 52 (46-57) preoperative to 90 (87-92; P < .0001) and 89 (86-92; P < .0001) at 1-year postoperation and at final follow-up without diminishing in the interim (P = .9). All secondary clinical outcomes improved from preoperative to final follow-up. Subjective shoulder value diminished 5% between 1 year and final follow-up (P = .03), whereas active external rotation improved 11° during this time (P = .02). In total, 85% of grafts were fully healed, with acromiohumeral interval improved from 7 (6-8) mm to 8 mm (7-9; P = .04). There were 2 (5%) revisions and 6 (14%) failures to reach the minimally clinically important improvement in ASES score: a 19% rate of unsatisfactory outcomes. There was an additional 1 reoperation (2%) and 1 (2%) medical complication. CONCLUSIONS Arthroscopic joint preservation surgery for massive, operatively irreparable posterosuperior rotator cuff tears with dermal allograft SCR and associated procedures results in improved clinical outcomes that are durable between 1 and minimum 2-year follow-up. LEVEL OF EVIDENCE IV retrospective case series.
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Barreto RPG, Braman JP, Ludewig PM, Ribeiro LP, Camargo PR. Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain. J Shoulder Elbow Surg 2019; 28:1699-1706. [PMID: 31279721 DOI: 10.1016/j.jse.2019.04.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 04/01/2019] [Accepted: 04/04/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is commonly used to diagnose structural abnormalities in the shoulder. However, subsequent findings may not be the source of symptoms. The aim of this study was to determine comparative MRI findings across both shoulders of individuals with unilateral shoulder symptoms. MATERIALS AND METHODS We prospectively evaluated 123 individuals from the community who had self-reported unilateral shoulder pain with no signs of adhesive capsulitis, no substantial range-of-motion deficit, no history of upper-limb fractures, no repeated shoulder dislocations, and no neck-related pain. Images in the coronal, sagittal, and axial planes with T1, T2, and proton density sequences were generated and independently and randomly interpreted by 2 examiners: a board-certified, fellowship-trained orthopedic shoulder surgeon and a musculoskeletal radiologist. Absolute and relative frequencies for each MRI finding were calculated and compared between symptomatic and asymptomatic shoulders. Agreement between the shoulder surgeon and the radiologist was also determined. RESULTS Abnormal MRI findings were highly prevalent in both shoulders. Only the frequencies of full-thickness tears in the supraspinatus tendon and glenohumeral osteoarthritis were higher (approximately 10%) in the symptomatic shoulder according to the surgeon's findings. Agreement between the musculoskeletal radiologist and shoulder surgeon ranged from slight to moderate (0.00-0.51). CONCLUSION Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders. Clinicians should be aware of the common anatomic findings on MRI when considering diagnostic and treatment planning.
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Affiliation(s)
- Rodrigo Py Gonçalves Barreto
- Laboratory of Analysis and Intervention of the Shoulder Complex, Department of Physical Therapy, Universidade Federal de São Carlos, São Carlos, Brazil
| | - Jonathan P Braman
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Paula M Ludewig
- Division of Physical Therapy, Department of Rehabilitation Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA; Division of Rehabilitation Science, Department of Rehabilitation Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Larissa Pechincha Ribeiro
- Laboratory of Analysis and Intervention of the Shoulder Complex, Department of Physical Therapy, Universidade Federal de São Carlos, São Carlos, Brazil
| | - Paula Rezende Camargo
- Laboratory of Analysis and Intervention of the Shoulder Complex, Department of Physical Therapy, Universidade Federal de São Carlos, São Carlos, Brazil.
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Naimark M, Trinh T, Robbins C, Rodoni B, Carpenter J, Bedi A, Miller B. Effect of Muscle Quality on Operative and Nonoperative Treatment of Rotator Cuff Tears. Orthop J Sports Med 2019; 7:2325967119863010. [PMID: 31428659 PMCID: PMC6683312 DOI: 10.1177/2325967119863010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Rotator cuff muscle atrophy and fatty infiltration are predictors of negative outcomes after rotator cuff repair. However, the impact of muscle degeneration on nonsurgical treatment is unknown. Hypothesis Rotator cuff muscle atrophy and fatty infiltration will reduce the outcomes of operative repair while having a minimal effect on nonsurgical treatment. Additionally, in the setting of atrophy and fatty infiltration, surgical and nonsurgical treatment will produce equivalent outcomes. Study Design Cohort study; Level of evidence, 2. Methods Patients undergoing operative and nonoperative treatment of full-thickness rotator cuff tears were prospectively enrolled into a nonrandomized cohort study. Muscle quality was assessed on magnetic resonance imaging by use of the supraspinatus tangent sign, Warner atrophy, and Goutallier fatty infiltration classifications. Grading was performed by 2 independent observers who were blinded to patient treatment and outcomes. Normalized Western Ontario Rotator Cuff (WORC) index was the primary patient-reported outcome. Multivariate linear regression analysis was used to determine the impact of muscle quality on treatment outcomes. Results The cohort consisted of 157 patients, 89 (57%) surgical and 68 (43%) nonsurgical, with a mean follow-up of 2.4 years (range, 1-5 years). Tangent sign had the best inter- and intrarater reliability, with kappa statistics of 0.81 and 0.86, respectively. Reliability for Warner atrophy was 0.69 to 0.76 and for Goutallier classification was 0.54 to 0.64. Overall, improvement in WORC scores was higher in the surgical group than the nonsurgical group (39.3 vs 21.2; P < .001). A positive tangent sign was the only independent predictor (P < .01) of worse outcomes in the surgical group, accounting for an estimated 22-point lower improvement in WORC scores. Conclusion A positive tangent sign was predictive of worse operative outcomes, resulting in equivalent improvements between surgical and nonsurgical treatment. The tangent sign is a reliable, prognostic indicator that clinicians can use when counseling patients on the optimal treatment of rotator cuff tears.
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Affiliation(s)
- Micah Naimark
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Thai Trinh
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher Robbins
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Bridger Rodoni
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - James Carpenter
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Asheesh Bedi
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Bruce Miller
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Ciccone W. Editorial Commentary: What's Hamada With Partial Rotator Cuff Repair? Arthroscopy 2019; 35:351-352. [PMID: 30712614 DOI: 10.1016/j.arthro.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 11/05/2018] [Indexed: 02/02/2023]
Abstract
Early repair of acute traumatic rotator cuff tears has been shown to restore functional range of motion, whether or not there is complete healing. The ability to predict those cuff tears that can achieve only a partial repair can help with preoperative patient counseling. The Hamada classification can be predictive in determining outcomes in the treatment of massive rotator cuff tears.
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Di Benedetto P, Beltrame A, Cicuto C, Battistella C, Gisonni R, Cainero V, Causero A. Rotator cuff tears reparability index based on pre-operative MRI: our experience. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:36-46. [PMID: 30714997 PMCID: PMC6503408 DOI: 10.23750/abm.v90i1-s.8074] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 01/10/2019] [Indexed: 12/16/2022]
Abstract
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)
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Arthroscopic single-row repair of massive potentially irreparable postero-superior cuff tear. Musculoskelet Surg 2018; 102:13-19. [PMID: 30343476 DOI: 10.1007/s12306-018-0555-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 07/02/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE We retrospectively evaluated the results of complete repair of massive potentially irreparable postero-superior tears in a consecutive cohort of patients. With the increasing and widespread use of superior capsular reconstruction, a complete repair of the superior cuff, also if not functional, may be a valuable option for irreparable cuff lesions. METHODS A consecutive case series of massive potentially irreparable postero-superior cuff tears that underwent complete repair was included in the study. Irreparability of cuff tear was defined when on preoperative MRI images, a positive tangent sign, a Goutallier 3-4 stage of fatty infiltration, and an absent acromion-humeral distance were present. A single-row complete repair was performed using triple-loaded titanium suture anchors. Operative time was recorded, as well as intra- and postoperative complications. Patients were followed for 12 months post-op; they were clinically evaluated with the use of constant score (CS) and subjective shoulder value (SSV) at 3, 6, and 12 months; a 12-month postoperative ultrasound evaluation was obtained. RESULTS Thirty-two patients satisfying the inclusion criteria were enrolled. The mean age was 52 years (range 41-58). The repair was completed with a mean use of 2.4 triple-loaded suture anchors (range 2-4); the mean operative time was 70 min (range 45-90). The mean preoperative CS was 55 (range 45-75, SD 17), while the SSV was 40 (range 30-70, SD 22). At the final follow-up, the mean CS and SSV were 72 (range 62-85, SD 8) and 80 (range 60-90, SD 10) (p < 0.001 with respect to the preoperative scores), respectively. At the final follow-up, sonography showed a complete healing of the cuff in 20 cases (62.5%). No intra-operative complications occurred; at the final follow-up, five patients (15, 6%) were not satisfied of the results and asked for revision surgery. CONCLUSIONS The complete repair of massive potentially irreparable rotator cuff tear in patients younger than 60 years old yielded good results at a short-term follow-up, with a sonographic re-tear rate of about 20%. Even if it is logical to consider a tendon with severe fatty degeneration as non-functional, the superior soft tissue reconstruction we achieved may have at least the same results of a superior capsular reconstruction, with obvious lower costs. LEVEL OF EVIDENCE Level 4, case series with no comparison group.
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Kim IB, Jung DW, Suh KT. Prediction of the Irreparability of Rotator Cuff Tears. Arthroscopy 2018; 34:2076-2084. [PMID: 29789254 DOI: 10.1016/j.arthro.2018.02.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 02/08/2018] [Accepted: 02/14/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the influence of preoperative factors on reparability of rotator cuff tears (RCTs) and yield a predictive model for predicting irreparability preoperatively. METHODS Among patients with full-thickness RCTs, the reparable group underwent arthroscopic rotator cuff repairs for reparable RCTs whereas the irreparable group underwent alternative surgical procedures for irreparable RCTs. We analyzed age, sex, chronic pseudoparalysis (CPP), mediolateral and anteroposterior tear sizes, acromiohumeral distance (AHD), tangent sign, fatty infiltration (FI) (group 1, Goutallier stage 0 or 1; and group 2, Goutallier stage 2, 3, or 4), and tendon involvement (TI) (type 1, supraspinatus; type 2, supraspinatus and subscapularis; type 3, supraspinatus and infraspinatus; and type 4, all 3 tendons). RESULTS The irreparability rate was 12.5%. Between the reparable (663 patients) and irreparable (95 patients) groups, significant differences were found in age (58.8 ± 8.3 years vs 65.6 ± 8.0 years, P < .001); female sex (46.9% vs 63.2%, P = .014); CPP (6.5% vs 36.8%, P < .001); mediolateral tear size (23.7 ± 12.1 mm vs 47.4 ± 9.1 mm, P < .001); anteroposterior tear size (17.9 ± 11.5 mm vs 43.4 ± 16.2 mm, P < .001); AHD (9.0 ± 1.7 mm vs 5.8 ± 1.6 mm, P < .001); tangent sign (2.9% vs 61.1%, P < .001); group 2 FI of the subscapularis (6.9% vs 20.0%, P < .001), supraspinatus (12.1% vs 58.9%, P < .001), infraspinatus (26.8% vs 69.5%, P < .001), and teres minor (4.2% vs 10.5%, P = .008); and type 1, 2, 3, and 4 TI (88.1%, 6.2%, 5.4%, and 0.3%, respectively, vs 29.5%, 21.1%, 28.4%, and 21.1%, respectively; P < .001). Multiple logistic regression analysis showed CPP, mediolateral tear size, AHD, tangent sign, group 2 FI of the supraspinatus, and type 4 TI were significant independent predictors of irreparability, with odds ratios of 3.539 (P = .007), 1.087 (P < .001), 0.624 (P < .001), 6.141 (P < .001), 2.233 (P = .034), and 12.350 (P = .016), respectively. These factors yielded a predictive model for irreparability as follows: Logit P = 1.264 × CPP + 0.084 × Mediolateral tear size - 0.472 × AHD + 0.804 × Group 2 FI of supraspinatus + 1.815 × Tangent sign + 2.514 × Type 4 TI - 3.460. CONCLUSIONS The irreparability of RCTs is strongly associated with CPP, mediolateral tear size, AHD, tangent sign, group 2 FI of the supraspinatus, and type 4 TI and can be preoperatively calculated using the predictive equation. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- In-Bo Kim
- Department of Orthopaedic Surgery, Bumin Busan Hospital, Busan, Republic of Korea.
| | - Dong Wook Jung
- Department of Orthopaedic Surgery, Bumin Busan Hospital, Busan, Republic of Korea
| | - Kuen Tak Suh
- Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, Busan, Republic of Korea
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Lädermann A, Collin P, Athwal GS, Scheibel M, Zumstein MA, Nourissat G. Current concepts in the primary management of irreparable posterosuperior rotator cuff tears without arthritis. EFORT Open Rev 2018; 3:200-209. [PMID: 29951257 PMCID: PMC5994621 DOI: 10.1302/2058-5241.3.180002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
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.
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Sheean AJ, Hartzler RU, Denard PJ, Lädermann A, Sanders TG, Zlatkin MB, Burkhart SS. Preoperative Radiographic Risk Factors for Incomplete Arthroscopic Supraspinatus Tendon Repair in Massive Rotator Cuff Tears. Arthroscopy 2018; 34:1121-1127. [PMID: 29273256 DOI: 10.1016/j.arthro.2017.09.046] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 09/17/2017] [Accepted: 09/20/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine if preoperative imaging findings of massive rotator cuff (RC) tears were associated with (1) incomplete arthroscopic repair and (2) the use of advanced mobilization techniques (interval slides) and/or the use of a load-sharing rip stop repair construct. METHODS Eighty-six consecutive patients who underwent arthroscopic repair for massive RC tears performed by a single surgeon between July 2013 and July 2015 were retrospectively evaluated. Previously proposed radiographic risk factors for irreparability (acromiohumeral distances, tangent sign, and the Goutallier stage of fatty infiltration for the supraspinatus) were analyzed. Associations between preoperative imaging characteristics and intraoperative results of RC surgery were determined using binary logistic regressions and Fisher's exact tests. The interobserver reliability of imaging characteristics was determined using intraclass correlation coefficients (ICCs). RESULTS Seventy-six massive RC tears were fully reparable (88%). In the case of 10 RC tears (12%), a complete repair was not obtained. Inability to obtain a complete repair of the supraspinatus was associated with a positive tangent sign (30% irreparable) versus a negative tangent sign (6.3% irreparable, odds ratio [OR] = 6.3, P = .0102) and with Goutallier grade 3-4 fatty infiltration of the supraspinatus (42.9% irreparable) versus grade 0-2 fatty infiltration (5.7% irreparable, OR = 11.8, P = .001). Advanced arthroscopic techniques (interval slides or load-sharing rip stop) for dealing with poor-quality or retracted tendon were used in 62% of cases; however, no associations were found between preoperative imaging characteristics and these techniques. Interobserver reliability was moderate (ICC = 0.75-0.90) for the tangent sign (ICC = 0.78) and high-grade (Goutallier 3-4) fatty infiltration of the supraspinatus (ICC = 0.74). CONCLUSIONS A positive tangent sign and/or high-grade fatty infiltration (Goutallier 3-4) of the supraspinatus were risk factors for incomplete RC repair. However, these were not completely predictive of reparability because the majority of massive RC tears with these imaging characteristics were still fully reparable. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Andrew J Sheean
- San Antonio Military Medical Center, San Antonio, Texas, U.S.A.; San Antonio Orthopaedic Group, Burkhart Research Institute for Orthopaedics, San Antonio, Texas, U.S.A..
| | - Robert U Hartzler
- San Antonio Orthopaedic Group, Burkhart Research Institute for Orthopaedics, San Antonio, Texas, U.S.A
| | - Patrick J Denard
- Southern Oregon Orthopedics, Medford, Oregon, U.S.A.; Department of Orthopaedics and Rehabilitation, Oregon Health Science University, Portland, Oregon, U.S.A
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | | | | | - Stephen S Burkhart
- San Antonio Orthopaedic Group, Burkhart Research Institute for Orthopaedics, San Antonio, Texas, U.S.A
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Yoon JP, Jung JW, Lee CH, Kim YG, Chung SW, Kim JY, Lee HJ, Yoon JW, Lee H. Fatty Degeneration of the Rotator Cuff Reflects Shoulder Strength Deficits in Patients With Rotator Cuff Tears. Orthopedics 2018; 41:e15-e21. [PMID: 29136253 DOI: 10.3928/01477447-20171106-02] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 09/19/2017] [Indexed: 02/03/2023]
Abstract
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.].
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Chen KH, Chiang ER, Wang HY, Ma HL. Arthroscopic Partial Repair of Irreparable Rotator Cuff Tears: Factors Related to Greater Degree of Clinical Improvement at 2 Years of Follow-Up. Arthroscopy 2017; 33:1949-1955. [PMID: 28866339 DOI: 10.1016/j.arthro.2017.06.047] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 04/17/2017] [Accepted: 06/16/2017] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Kun-Hui Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - En-Rung Chiang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsin-Yi Wang
- Department of Anaesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiao-Li Ma
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Niglis L, Collin P, Dosch JC, Meyer N, Kempf JF. Intra- and inter-observer agreement in MRI assessment of rotator cuff healing using the Sugaya classification 10years after surgery. Orthop Traumatol Surg Res 2017; 103:835-839. [PMID: 28655629 DOI: 10.1016/j.otsr.2017.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 05/15/2017] [Accepted: 06/01/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The long-term outcomes of rotator cuff repair are unclear. Recurrent tears are common, although their reported frequency varies depending on the type and interpretation challenges of the imaging method used. The primary objective of this study was to assess the intra- and inter-observer reproducibility of the MRI assessment of rotator cuff repair using the Sugaya classification 10years after surgery. The secondary objective was to determine whether poor reproducibility, if found, could be improved by using a simplified yet clinically relevant classification. HYPOTHESIS Our hypothesis was that reproducibility was limited but could be improved by simplifying the classification. MATERIAL AND METHOD In a retrospective study, we assessed intra- and inter-observer agreement in interpreting 49 magnetic resonance imaging (MRI) scans performed 10years after rotator cuff repair. These 49 scans were taken at random among 609 cases that underwent re-evaluation, with imaging, for the 2015 SoFCOT symposium on 10-year and 20-year clinical and anatomical outcomes of rotator cuff repair for full-thickness tears. Each of three observers read each of the 49 scans on two separate occasions. At each reading, they assessed the supra-spinatus tendon according to the Sugaya classification in five types. RESULTS Intra-observer agreement for the Sugaya type was substantial (κ=0.64) but inter-observer agreement was only fair (κ=0.39). Agreement improved when the five Sugaya types were collapsed into two categories (1-2-3 and 4-5) (intra-observer κ=0.74 and inter-observer κ=0.68). CONCLUSION Using the Sugaya classification to assess post-operative rotator cuff healing was associated with substantial intra-observer and fair inter-observer agreement. A simpler classification into two categories improved agreement while remaining clinically relevant. LEVEL OF EVIDENCE II, prospective randomised low-power study.
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Affiliation(s)
- L Niglis
- Service de chirurgie orthopédique du membre supérieur, CCOM, 10, avenue Achille-Baumann, 67400 Illkirch, France.
| | - P Collin
- CHP Saint-Grégoire, 6, avenue de la Boutière, 35760 Saint-Grégoire, France
| | - J-C Dosch
- Service de radiologie, CCOM, 10, avenue Achille-Baumann, 67400 Illkirch, France
| | - N Meyer
- Laboratoire de biostatistique, hôpital civil, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - J-F Kempf
- Service de chirurgie orthopédique du membre supérieur, CCOM, 10, avenue Achille-Baumann, 67400 Illkirch, France
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- Société française de chirurgie orthopédique et traumatologique, 56, rue Boissonade, 75014 Paris, France
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Kim JY, Park JS, Rhee YG. Can Preoperative Magnetic Resonance Imaging Predict the Reparability of Massive Rotator Cuff Tears? Am J Sports Med 2017; 45:1654-1663. [PMID: 28273425 DOI: 10.1177/0363546517694160] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Numerous studies have shown preoperative fatty infiltration of rotator cuff muscles to be strongly negatively correlated with the successful repair of massive rotator cuff tears (RCTs). PURPOSE To assess the association between factors identified on preoperative magnetic resonance imaging (MRI), especially infraspinatus fatty infiltration, and the reparability of massive RCTs. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS We analyzed a total of 105 patients with massive RCTs for whom MRI was performed ≤6 months before arthroscopic procedures. The mean age of the patients was 62.7 years (range, 46-83 years), and 46 were men. Among them, complete repair was possible in 50 patients (48%) and not possible in 55 patients (52%). The tangent sign, fatty infiltration of the rotator cuff, and Patte classification were evaluated as predictors of reparability. Using the receiver operating characteristic curve and the area under the curve (AUC), the prediction accuracy of each variable and combinations of variables were measured. RESULTS Reparability was associated with fatty infiltration of the supraspinatus ( P = .0045) and infraspinatus ( P < .001) muscles, the tangent sign ( P = .0033), and the Patte classification ( P < .001) but not with fatty infiltration of the subscapularis and teres minor ( P = .425 and .132, respectively). The cut-off values for supraspinatus and infraspinatus fatty infiltration were grade >3 and grade >2, respectively. The examination of single variables revealed that infraspinatus fatty infiltration showed the highest AUC value (0.812; sensitivity: 0.86; specificity: 0.76), while the tangent sign showed the lowest AUC value (0.626; sensitivity: 0.38; specificity: 0.87). Among 2-variable combinations, the combination of infraspinatus fatty infiltration and the Patte classification showed the highest AUC value (0.874; sensitivity: 0.54; specificity: 0.96). The combination of 4 variables, that is, infraspinatus and supraspinatus fatty infiltration, the tangent sign, and the Patte classification, had an AUC of 0.866 (sensitivity: 0.28; specificity: 0.98), which was lower than the highest AUC value (0.874; sensitivity: 0.54; specificity: 0.96) among the 2-variable combinations. CONCLUSION The tangent sign or Patte classification alone was not a predictive indicator of the reparability of massive RCTs. Among single variables, infraspinatus fatty infiltration was the most effective in predicting reparability, while the combination of Goutallier classification <3 of the infraspinatus and Patte classification ≤2 of the rotator cuff muscles was the most predictive among the combinations of variables. This information may help predict the reparability of massive RCTs.
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Affiliation(s)
- Jung Youn Kim
- Department of Orthopaedic Surgery, Graduate School, Kyung Hee University, Seoul, Republic of Korea.,Department of Orthopaedic Surgery, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Ji Seon Park
- Department of Radiology, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Yong Girl Rhee
- Shoulder and Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
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Lädermann A, Burkhart SS, Hoffmeyer P, Neyton L, Collin P, Yates E, Denard PJ. Classification of full-thickness rotator cuff lesions: a review. EFORT Open Rev 2017; 1:420-430. [PMID: 28461921 PMCID: PMC5367545 DOI: 10.1302/2058-5241.1.160005] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Rotator cuff lesions (RCL) have considerable variability in location, tear pattern, functional impairment, and repairability. Historical classifications for differentiating these lesions have been based upon factors such as the size and shape of the tear, and the degree of atrophy and fatty infiltration. Additional recent descriptions include bipolar rotator cuff insufficiency, ‘Fosbury flop tears’, and musculotendinous lesions. Recommended treatment is based on the location of the lesion, patient factors and associated pathology, and often includes personal experience and data from case series. Development of a more comprehensive classification which integrates historical and newer descriptions of RCLs may help to guide treatment further.
Cite this article: Lädermann A, Burkhart SS, Hoffmeyer P, et al. Classification of full thickness rotator cuff lesions: a review. EFORT Open Rev 2016;1:420-430. DOI: 10.1302/2058-5241.1.160005.
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Affiliation(s)
- Alexandre Lädermann
- La Tour Hospital; University of Geneva; Geneva University Hospitals, Switzerland
| | - Stephen S Burkhart
- The San Antonio Orthopaedic Group; University of Texas Health Science Center, San Antonio, Texas, USA
| | | | | | - Philippe Collin
- Centre Hospitalier Privé Saint-Grégoire, Saint- Grégoire, France
| | - Evan Yates
- St Francis Memorial Hospital, San Francisco, USA
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Kim SJ, Park JS, Lee KH, Lee BG. The development of a quantitative scoring system to predict whether a large-to-massive rotator cuff tear can be arthroscopically repaired. Bone Joint J 2017; 98-B:1656-1661. [PMID: 27909128 DOI: 10.1302/0301-620x.98b12.bjj-2016-0316] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/16/2016] [Indexed: 12/16/2022]
Abstract
AIMS The aim of the study was to develop a quantitative scoring system to predict whether a large-to-massive rotator cuff tear was arthroscopically reparable prior to surgery. PATIENTS AND METHODS We conducted a retrospective review of the pre-operative MR imaging and surgical records of 87 patients (87 shoulders) who underwent arthroscopic repair of a large-to-massive rotator cuff tear. Patients were divided into two groups, based on the surgical outcome of the repair. Of the 87 patients, 53 underwent complete repair (Group I) and 34 an incomplete repair (Group II). Pre-operative MR images were reviewed to quantify several variables. Between-group differences were evaluated and multiple logistic regression analysis was used to calculate the predictive value of significant variables. The reparability index (RI) was constructed using the odds ratios of significant variables and a receiver operating characteristic curve analysis performed to identify the optimal RI cutoff to differentiate between the two groups. RESULTS The following variables were identified as independent predictors of arthroscopic reparability: the size of the defect with medial-lateral diameter (cutoff, 4.2 cm) and anterior-posterior diameter (cutoff, 3.7cm); Patte's grade of muscle atrophy (cutoff, grade 3) and Goutallier grade of fatty degeneration (cutoff, grade 3). An RI cutoff value of 2.5 provided the highest differentiation between groups I and II, with an area under the curve of 0.964, and a sensitivity of 73.5% and specificity of 96.2%. CONCLUSION The RI developed in our study may prove to be an efficient clinical scoring system to predict whether a large-to-massive rotator cuff tear is arthroscopically reparable. Cite this article: Bone Joint J 2016;98-B:1656-61.
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Affiliation(s)
- S-J Kim
- Hallym University Dongtan Sacred Heart Hospital, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, South Korea
| | - J-S Park
- Hanyang University College of Medicine, 17, Haengdang-dong, Seongdong-gu, Seoul, South Korea
| | - K-H Lee
- Hanyang University College of Medicine, 17, Haengdang-dong, Seongdong-gu, Seoul, South Korea
| | - B-G Lee
- Hanyang University College of Medicine, 17, Haengdang-dong, Seongdong-gu, Seoul, South Korea
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When Is the Rotator Cuff Not Repairable? Tech Orthop 2016. [DOI: 10.1097/bto.0000000000000171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Denard PJ, Lädermann A, Brady PC, Narbona P, Adams CR, Arrigoni P, Huberty D, Zlatkin MB, Sanders TG, Burkhart SS. Pseudoparalysis From a Massive Rotator Cuff Tear Is Reliably Reversed With an Arthroscopic Rotator Cuff Repair in Patients Without Preoperative Glenohumeral Arthritis. Am J Sports Med 2015; 43:2373-8. [PMID: 26297521 DOI: 10.1177/0363546515597486] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pseudoparalysis is defined as active forward flexion less than 90° with full passive motion. There is controversy about the ideal surgical management of a massive rotator cuff tear with pseudoparalysis. PURPOSE/HYPOTHESIS The purpose of this study was to prospectively analyze the ability to reverse pseudoparalysis with an arthroscopic rotator cuff repair (ARCR). The hypothesis was that in the absence of substantial glenohumeral arthritis, preoperative fatty infiltration of grade 3 or higher and an acromiohumeral interval (AHI) of less than 7 mm would not prevent reversal of pseudoparalysis with an ARCR. STUDY DESIGN Case series; Level of evidence, 4. METHODS A prospective multicenter study of ARCR performed for preoperative pseudoparalysis was conducted. The minimum follow-up was 1 year. The mean patient age was 63 years, and pseudoparalysis was present for a mean of 4.2 months preoperatively. Preoperative radiographic evaluation included plain film evaluation of the AHI and Hamada classification and MRI evaluation of fatty degeneration and rotator cuff retraction. Functional outcome was determined by the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) Shoulder Score, visual analog scale (VAS), and subjective shoulder value (SSV). RESULTS Of the 58 patients enrolled, 56 had at least 1 year of follow-up. Mean active forward flexion improved from 47° preoperatively to 159° postoperatively (P < .001). Statistically significant improvements were seen in the SST (from 2.8 preoperatively to 10.1 postoperatively), SSV (from 28 to 83), ASES Shoulder Score (from 37 to 88), and VAS (from 5.7 to 1.1) (P < .001). Pseudoparalysis was reversed in 53 of 56 patients (95%). There was no difference in the rate of reversal of pseudoparalysis between those patients with an AHI of less than 7 mm (88.2%) and those with an AHI of 7 mm or more (96.9%) (P =.289). Pseudoparalysis was reversed in all 8 of the patients with fatty degeneration of grade 3 or higher in 1 or more of the rotator cuff muscles. CONCLUSION ARCR can lead to reversal of preoperative pseudoparalysis in patients with minimal preoperative glenohumeral arthritis. ARCR is a viable first line of treatment for patients with pseudoparalysis in the absence of advanced glenohumeral arthritis.
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Affiliation(s)
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | - Paul C Brady
- Tennessee Orthopaedic Clinics, Knoxville, Tennessee, USA
| | - Pablo Narbona
- Department of Shoulder Surgery, Sanatorio Allende, Córdoba, Argentina
| | | | - Paolo Arrigoni
- Policlinico San Donato, Università degli Studi di Milano, Milan, Italy
| | - Dave Huberty
- Oregon Orthopedic and Sports Medicine Clinic LLP, West Linn, Oregon, USA
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Lädermann A, Denard PJ, Collin P. Massive rotator cuff tears: definition and treatment. INTERNATIONAL ORTHOPAEDICS 2015; 39:2403-14. [PMID: 25931202 DOI: 10.1007/s00264-015-2796-5] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 04/06/2015] [Indexed: 01/29/2023]
Abstract
PURPOSE The aim of this review is to summarise tear pattern classification and management options for massive rotator cuff tears (MRCT), as well as to propose a treatment paradigm for patients with a MRCT. METHOD Data from 70 significant papers were reviewed in order to define the character of reparability and the possibility of alternative techniques in the management of MRCT. RESULTS Massive rotator cuff tears (MRCT) include a wide panoply of lesions in terms of tear pattern, functional impairment, and reparability. Pre-operative evaluation is critical to successful treatment. With the advancement of medical technology, arthroscopy has become a frequently used method of treatment, even in cases of pseudoparalytic shoulders. Tendon transfer is limited to young patients with an irreparable MRCT and loss of active rotation. Arthroplasty can be considered for the treatment of a MRCT with associated arthritis. CONCLUSION There is insufficient evidence to establish an evidence-based treatment algorithm for MRCTs. Treatment is based on patient factors and associated pathology, and includes personal experience and data from case series.
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Affiliation(s)
- Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Rue J.-D. Maillard 3, 1217, Meyrin, Switzerland. .,Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, 1211, Geneva 4, Switzerland. .,Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.
| | - Patrick J Denard
- Southern Oregon Orthopedics, Medford, OR, USA.,Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Philippe Collin
- Saint-Grégoire Private Hospital Center, Boulevard Boutière 6, 35768, Saint-Grégoire Cedex, France
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