Management of irreparable massive rotator cuff tears: a systematic review and meta-analysis of patient-reported outcomes, reoperation rates, and treatment response

Massive Irreparable Rotator Cuff Tears Treated With a Tuberoplasty Yield Favorable Clinical Outcomes With Variable Rates of Complications: A Systematic Review

PURPOSE

To systematically review the patient-reported outcomes and postoperative complications following tuberoplasty for the treatment of massive irreparable rotator cuff tears.

METHODS

A literature search was conducted using PubMed and EMBASE computerized databases from database inception to June 2023 in accordance with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Included studies evaluated clinical outcomes, postoperative complications, and reoperation rates following tuberoplasty for the treatment of massive irreparable rotator cuff tears. Exclusion criteria consisted of non-English language, cadaveric studies, case reports, animal studies, studies with overlapping cohorts, letters to editors, and review articles. Study quality was assessed using the Methodological Index for Non-Randomized Studies criteria. Clinical outcome scores included the visual analog scale for pain, University of California Los Angeles score, and Constant score.

RESULTS

Seven studies from 2002 to 2023 consisting of 123 patients with a mean age of 66.5 years (mean range, 63-70.4 years) were included. The mean follow-up time ranged from 18 to 98 months. The mean Methodological Index for Non-Randomized Studies score was 13.5 (range, 13-15). At final follow-up, the mean postoperative visual analog scale pain scores ranged from 2.3 to 2.5, University of California-Los Angeles shoulder score from 27.2 to 27.7, and Constant scores from 59.2 to 90.6. Postoperative active forward flexion and abduction ranged from 131° to 165°, and 123° to 160°, respectively. The change in acromiohumeral distance postoperatively ranged from -1 mm to -0.6 mm. The rate of postoperative complications ranged from 0% to 19% of patients, while 0% to 19% of patients underwent revision surgery to reverse shoulder arthroplasty.

CONCLUSIONS

Tuberoplasty for the treatment of massive irreparable rotator cuff tears results in good clinical outcomes with significant pain relief in select populations. However, the variable reoperation rates should be considered when counseling patients.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Mid-term outcomes of arthroscopically assisted lower trapezius tendon transfer using Achilles allograft in treatment of posterior-superior irreparable rotator cuff tear

BACKGROUND

Arthroscopically assisted lower trapezius tendon (aLTT) transfer is one of the treatment options for posterior-superior irreparable rotator cuff tears (PSIRCTs). Although short-term clinical outcomes have shown promising results, there are currently no reported clinical outcomes over a longer follow-up period. This study evaluated the mid-term outcomes of aLTT transfer in patients with a diagnosis of PSIRCT.

METHODS

This retrospective case-series study included patients who underwent aLTT transfer between May 2017 and May 2019. The clinical outcome assessment included the visual analog scale (VAS) pain score, Constant score, American Shoulder and Elbow Surgeons score, University of California-Los Angeles score, Activities of Daily Living Requiring Active External Rotation (ADLER) score, active range of motion, Single Assessment Numeric Evaluation score, and return-to-work rate. The radiographic analysis included the acromiohumeral distance, Hamada grade, and integrity of the transferred tendon at final follow-up. Subgroup analyses were performed based on the integrity of the transferred tendon and the trophicity of the teres minor (Tm).

RESULTS

This study enrolled 36 patients with a mean age of 63.4 years who met the inclusion criteria and were followed up for a mean of 58.2 ± 5.3 months. At final follow-up, the patients showed significant improvement in mean VAS score, Constant score, American Shoulder and Elbow Surgeons score, University of California-Los Angeles score, ADLER score, and active range of motion in all directions except internal rotation. A decrease in the acromiohumeral distance and an increase in the Hamada grade were observed at final follow-up (P = .040 and P = .006, respectively). Retears of the transferred tendon occurred in 7 patients, and postoperative infections developed in 2 individuals. An interesting finding was that the retear group still demonstrated improvement in the VAS score but did not show improvement in external rotation at the side by the final follow-up. Compared with the Tm non-hypertrophy group, the Tm hypertrophy group showed significantly better improvement in external rotation at 90° of abduction and at the side, as well as the ADLER score. Of the study patients, 30 (83.3%) were able to successfully resume their previous work.

CONCLUSION

In this study, aLTT transfer in patients with PSIRCTs demonstrated significant improvements in clinical and radiologic outcomes by the final follow-up. These findings provide support for the mid-term safety and effectiveness of aLTT transfer as a viable joint-preserving treatment option for PSIRCTs. However, larger and longer-term studies are still needed to further validate these findings.

'If he thought that I was going to go and hurt myself, he had another thing coming': Treatment experiences of those with large to massive rotator cuff tears and the perspectives of healthcare practitioners

OBJECTIVE

To explore the treatment experiences of those diagnosed with large to massive rotator cuff tears and the perspectives of healthcare practitioners providing their care.

DESIGN

A qualitative descriptive study using reflexive thematic analysis.

SETTING

In-person focus groups were undertaken in a clinical setting (private practice [n = 1]; public outpatient [n = 2]). Semi-structured interviews were conducted online via Microsoft Teams.

PARTICIPANTS

Patients diagnosed with these tears (n = 12) and healthcare practitioners (n = 11).

RESULTS

Two interlinking themes were identified based on the care received and provided for patients with symptomatic large to massive rotator cuff tears:1) Positive treatment experiences and management: Education, clear communication and reassurance around prognosis were the foundation of positive patient-clinician care. Sub-themes of pain relief, exercise prescription and confidence in their pathway underpinned this experience. This proficiency in care was affirmed by some healthcare practitioners who spoke about the importance of confidence and experience in their management plan even in times of poor progress.2) Negative treatment experiences and management: Uncertainty, delays and exacerbation of pain flawed the patient-clinician care. Sub-themes of inappropriate pain relief, inappropriate exercise prescription and uncertainty impacted their care. Some healthcare practitioners acknowledged knowledge gaps led to uncertainty especially when choosing the next step of care and were quick to escalate care to deflect this uncertainty.

CONCLUSIONS

The findings suggest discordance exists between the patient's experiences and expectations when the delivery of care was by less experienced and confident healthcare practitioners in the management of this condition. This highlights the need for improved education and support for healthcare practitioners.

Clinical results of arthroscopically-assisted lower trapezius transfer using fascia lata autograft for posterior superior irreparable rotator cuff tear

Background

Different interpositional grafts have been proposed to connect between the lower trapezius tendon (LTT) to the humerus during LTT transfer. While studies often mention the successful use of Achilles tendon allograft, there is currently no literature reporting the clinical outcomes of utilizing fascia lata autograft (FLA) in LTT transfer. Therefore, the current study aims to evaluate the clinical and radiologic results of LTT using FLA for posterior superior irreparable rotator cuff tears (PSIRCTs) without arthritis.

Patient and methods

The present study constitutes a retrospective case series involving 22 patients, with a mean follow-up of 35.9 ± 15.9 months. Pain levels were gauged using the Visual Analog Scale (VAS), while shoulder function was comprehensively assessed through the Constant and ASES (American Shoulder and Elbow Society) scores. The evaluation of shoulder activities in daily living employed the ADLER (Activities of Daily Living Requiring Active External Rotation) score. Active ROM (Range of Motion) of all directions were obtained, radiologic assessments included key parameters such as AHD (Acromion Humeral Distance) and the Hamada grade. Finally, the integrity of the transferred LTT was evaluated, and a subgroup analysis was undertaken based on Tm trophicity.

Results

By the final follow-up period, VAS, Constant, ASES, and ALDER demonstrated significant improvement. Active ROM significantly improved in (FE) forward elevation to 155° ± 29°, abduction (Abd) to 140° ± 32°, external rotation (ER) at 90° Abd to 68° ± 19°, and ER at the side to 39° ± 17°. AHD and Hamada grade showed no significant arthritic progression. Tm hypertrophy group experienced superior improvements in ER compared to that of the non-hypertrophy group. Complications included re-tear (n = 2), infection (n = 1) and donor-site morbidity (n = 1).

Conclusion

The study highlighted promising clinical outcomes of LTT transfer using FLA, with no significant complications. Along with Achilles tendon allograft, FLA can be a safe and viable alternative interpositional graft choice.

A Biological Spacer to Treat Irreparable Rotator Cuff Tears: A Biomechanical Study Utilizing a Secured Versus Unsecured Tensor Fascia Lata Graft

BACKGROUND

Designed to help treat pain and loss of function after rotator cuff repair, allograft spacer procedures utilize a graft to act as a spacer in the subacromial space, decreasing pain from impingement of the greater tuberosity on the acromion at the extremes of overhead motion.

PURPOSE

To evaluate the biomechanical characteristics of secured versus unsecured tensor fascia lata allografts used in an allograft spacer procedure.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 8 fresh-frozen cadaveric shoulder specimens were used. There were 4 conditions tested: (1) intact rotator cuff, (2) stage III rotator cuff tear (complete supraspinatus tendon and superior one-half of the infraspinatus tendon), (3) unsecured tensor fascia lata graft, and (4) secured tensor fascia lata graft. Both superior and posterior translation of the humeral head were calculated in each condition. A 4-cm × 5-cm × 6-mm tensor fascia lata graft was used in the subacromial space to act as a spacer. Grafts were secured at the lateral edge of the native rotator cuff footprint with 2 knotless anchors.

RESULTS

With unbalanced loading, both secured and unsecured grafts varied in their ability to limit superior and posterior translation at various rotation angles back to levels seen with intact rotator cuffs at 0° and 20° of abduction. During balanced loading, both unsecured and secured grafts limited superior and posterior translation more than those seen in the rotator cuff-deficient condition (P < .01) and similar to those seen in the intact condition (P > .05). The secured and unsecured grafts allowed similar amounts of translation at every position with both unbalanced and balanced loading (P > .05). Finally, total graft motion was <7 mm in all positions.

CONCLUSION

Unsecured tensor fascia lata grafts were biomechanically equivalent to secured grafts when used during allograft spacer procedures.

CLINICAL RELEVANCE

While both grafts were successful at limiting superior and posterior translation of the humeral head during early range of motion, the unsecured graft represents a cheaper, easier option to utilize during allograft spacer procedures.

Optimizing Tissue Engineering for Clinical Relevance in Rotator Cuff Repair

Rotator cuff tear (RCT) is the most common cause of disability in the upper extremity. It results in 4.5 million physician visits in the United States every year and is the most common etiology of shoulder conditions evaluated by orthopedic surgeons. Over 460,000 RCT repair surgeries are performed in the United States annually. Rotator cuff (RC) retear and failure to heal remain significant postoperative complications. Literature suggests that the retear rates can range from 29.5% to as high as 94%. Weakened and irregular enthesis regeneration is a crucial factor in postsurgical failure. Although commercially available RC repair grafts have been introduced to augment RC enthesis repair, they have been associated with mixed clinical outcomes. These grafts lack appropriate biological cues such as stem cells and signaling molecules at the bone-tendon interface. In addition, they do little to prevent fibrovascular scar tissue formation, which causes the RC to be susceptible to retear. Advances in tissue engineering have demonstrated that mesenchymal stem cells (MSCs) and growth factors (GFs) enhance RC enthesis regeneration in animal models. These models show that delivering MSCs and GFs to the site of RCT enhances native enthesis repair and leads to greater mechanical strength. In addition, these models demonstrate that MSCs and GFs may be delivered through a variety of methods including direct injection, saturation of repair materials, and loaded microspheres. Grafts that incorporate MSCs and GFs enhance anti-inflammation, osteogenesis, angiogenesis, and chondrogenesis in the RC repair process. It is crucial that the techniques that have shown success in animal models are incorporated into the clinical setting. A gap currently exists between the promising biological factors that have been investigated in animal models and the RC repair grafts that can be used in the clinical setting. Future RC repair grafts must allow for stable implantation and fixation, be compatible with current arthroscopic techniques, and have the capability to deliver MSCs and/or GFs.

Double tendon transfer for massive rotator cuff tear: A case report

INTRODUCTION AND IMPORTANCE

Repairing massive rotator cuff tears (MRCTs) can often be technically challenging due to tendon retraction, bursal fibrosis, and muscular fatty infiltration that usually occurs, often resulting in poor outcomes and an unpredictable prognosis. Although some other surgical management options have been reported, there is a lack of literature supporting tendon transfers in the presence of combined anterior and posterior-superior irreparable rotator cuff tears. We describe a case where a combined transfer of the latissimus dorsi and lower trapezius tendons was employed to treat an MRCT affecting the anterior and posterior superior portions of the rotator cuff.

CASE PRESENTATION

A 64-year-old male presented significant pain and limited range of motion in the right shoulder following a traumatic anterior shoulder dislocation seven months prior. MRI showed retracted tears (> 5 cm) of the supraspinatus, infraspinatus, and subscapularis tendons with significant fatty infiltration (Goutallier IV). The patient underwent an open transfer of the lower trapezius tendon to the greater tuberosity and the latissimus dorsi to the lesser tuberosity. At the final follow-up, 2.5 years postoperatively, the patient exhibited a painless functional range of motion and could resume daily activities.

CLINICAL DISCUSSION

Although there are alternative surgical options available, the positive outcomes observed in the presented case may be attributed to the restoration of rotational strength and the re-establishment of force coupling across the shoulder.

CONCLUSION

This report describes the successful implementation of a surgical treatment option for managing MRCT affecting the anterior and posterior superior portions of the rotator cuff.

Surgical Management of Massive Irreparable Cuff Tears: Superior Capsule Reconstruction and Rotator Cable Reconstruction

PURPOSE OF REVIEW

Massive irreparable rotator cuff tears (MIRCTs) present treatment challenges. Recently, superior capsule reconstruction (SCR) and anterior cable reconstruction have emerged as surgical options, but no single approach is superior. This review provides an overview of SCR and cable reconstruction techniques, including biomechanical studies, clinical outcomes, and surgical considerations.

RECENT FINDINGS

Biomechanical studies show SCR with autografts or allografts improves glenohumeral stability and mechanics. Clinical outcomes of SCR demonstrate improved range of motion, function scores, and pain relief in short-term studies. Anterior cable reconstruction reduces superior humeral head translation and subacromial pressures in biomechanical models. Early clinical studies report improved rotator cuff healing and outcomes for cable reconstruction in specific irreparable tear patterns. SCR and cable reconstruction are viable surgical options for MIRCTs based on early encouraging results. However, higher-level comparative studies with long-term follow-up are still needed. Careful consideration of tear pattern, patient factors, and surgical goals is required to optimize treatment of MIRCTs. Further research is necessary to determine the optimal role for these procedures.

Latin American formal consensus on the indications for the surgical treatment of massive and irreparable rotator cuff tears

OBJECTIVES

To implement the Formal Consensus Method among a group of experts in shoulder surgery in Latin America, in order to establish appropriate indications for the surgical treatment of massive and irreparable rotator cuff injuries.

METHODS

The Formal Consensus Method was used to develop surgical treatment recommendations for massive and irreparable rotator cuff tears (MIRCT). Three independent groups of experts in shoulder surgery were confirmed. The steering group conducted a systematic literature review and constructed a voting matrix consisting of 348 clinical scenarios. The rating group, composed of 15 members, rated each scenario on two occasions: first anonymously and then during an in-person discussion meeting. The median and voting ranges were used to classify each scenario as inappropriate, uncertain, or appropriate for each surgical technique. Finally, the reading group, consisting of 10 surgeons, reviewed, evaluated and rated the recommendations derived from the detailed analysis of the voting grids.

RESULTS

The main finding of the study reveals a high percentage (70%) of clinical scenarios in which consensus was achieved regarding the appropriateness or inappropriateness of different surgical alternatives for the treatment of massive and irreparable rotator cuff injuries. Through a detailed analysis of the voting grids, a total of 20 recommendations were elaborated concerning the appropriateness of various surgical techniques in addressing irreparable rotator cuff tears.

CONCLUSIONS

The indications for the operative treatment of MIRCT were determined based on expert consensus and the best available evidence, they seek to provide guidance on the appropriateness of various surgical techniques for different clinical scenarios.

LEVEL OF EVIDENCE

V.

Combined Anterior Latissimus Dorsi and Teres Major Tendon Transfer (aLDTM) for Irreparable Anterosuperior Rotator Cuff Tears

Background

Transfer of the anterior latissimus dorsi and teres major (LDTM) tendons has demonstrated favorable outcomes in patients with irreparable anterosuperior rotator cuff tears1. The objective of this procedure is to restore internal rotation strength, enhance active range of motion, and provide pain relief while preserving the glenohumeral joint.

Description

The incision extended from the coracoid to the inferior border of the pectoralis major tendon, following the deltopectoral interval located laterally to the coracoid. While preserving the pectoralis major tendon, the latissimus dorsi (LD) and teres major (TM) tendons are identified and detached from the humerus without separating the tendons. The LDTM tendons are grasped, and nonabsorbable sutures are placed in a continuous running-locking suture fashion. Traction is applied to the sutures while bluntly releasing the adhesions surrounding the LDTM muscles in order to enable further mobilization and excursion. With the patient's arm positioned in full internal rotation and at 45° of abduction for physiological tensioning, the LDTM tendons are attached 2 cm distal to the lateral edge of the greater tuberosity and lateral to the biceps groove with use of 1 medial anchor and 3 lateral anchors.

Alternatives

Arthroscopic partial repair, superior capsular reconstruction, pectoralis major tendon transfer, and isolated LD tendon transfer are potential alternative treatments. In cases in which these options are not feasible or have been unsuccessful, reverse total shoulder arthroplasty can be considered as a treatment option.

Rationale

Arthroscopic partial repair can provide pain relief, but its effectiveness in improving range of motion and muscle strength is limited2,3. Additionally, there is a high risk of retear, with reported rates as high as 52%4. Superior capsular reconstruction is considered a viable treatment, but it is not recommended in cases involving irreparable subscapularis tears5-7. Pectoralis major transfer may lead to less favorable clinical outcomes in cases in which an irreparable subscapularis tear and an irreparable supraspinatus tear are simultaneously present8-10. In cases of irreparable anterosuperior rotator cuff tears, the transfer of the LD tendon alone may not fully restore the superior migration and anterior subluxation of the humeral head.11. Reverse total shoulder arthroplasty may be another option in these cases, but it does not preserve the glenohumeral joint.

Expected Outcomes

The procedure involves stabilizing the superior translation of the humeral head by rebalancing the force couple, as the TM tendon exhibits scapulohumeral kinematics similar to the subscapularis tendon. Additionally, the procedure effectively reduces anterior glenohumeral subluxation through the combined effect of the posterior line of pull from the combined LDTM tendons and the scapulohumeral kinematics of the teres minor tendon. Also, by fixing the transferred LDTM tendons just distal to the greater tuberosity, the vector becomes less vertical, thereby preventing axillary nerve impingement and achieving appropriate tendon tensioning. The use of this procedure is supported by a study of 30 patients who were followed for a minimum of 2 years1. Significant improvements were observed in various scoring systems, including the pain VAS (visual analogue scale), Constant, ASES (American Shoulder and Elbow Surgeons), UCLA (University of California-Los Angeles), SANE (Single Assessment Numeric Evaluation), and ADLIR (Activities of Daily Living requiring active Internal Rotation) scores. Importantly, there was no significant progression of cuff tear arthropathy observed during the final follow-up. Additionally, preoperative anterior glenohumeral subluxation (15 of 30 patients) was restored in all patients after LDTM tendon transfer.

Important Tips

Careful attention should be paid to the anterior humeral circumflex vessels to prevent bleeding.The radial nerve, passing through the anteroinferior surface of the LDTM tendons, should be carefully identified and protected to avoid iatrogenic injury.To maintain physiologic tension, the patient's arm should be positioned in full internal rotation and 45° of abduction.To avoid axillary nerve impingement, the LDTM tendons should be fixed just distal to the greater tuberosity and lateral to the biceps groove.

Acronyms and Abbreviations

SCR = superior capsular reconstructionLDTM = latissimus dorsi combined with teres majorASRCTs = anterosuperior rotator cuff tearsA/S = arthroscopicROM = range of motionTM = teres majorTm = teres minorLD = latissimus dorsiSSC = subscapularisSSP = supraspinatusPM = Pectoralis majorPm = Pectoralis minorRSA = reverse total shoulder arthroplastyASES = American Shoulder and Elbow SurgeonsUCLA = University of California-Los AngelesADLIR = Activities of Daily Living requiring active Internal RotationGT = greater tuberosityACR = anterior capsular reconstructionFF = forward flexionER = external rotationIR = internal rotationAHD = acromiohumeral distanceMRI = magnetic resonance imagingISP = infraspinatusPEEK = polyetheretherketonePOD = postoperative dayEMG = electromyographySD = standard deviationBMI = body mass indexDM = diabetes mellitusHTN = hypertensionVAS = visual analogue scaleSANE = Single Assessment Numeric EvaluationaROM =active range of motion.

Mid- to long-term outcomes of latissimus dorsi tendon transfer for massive irreparable posterosuperior rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

This study aims to analyze the mid-to long-term results of the latissimus dorsi tendon for the treatment of massive posterosuperior irreparable rotator cuff tears as reported in high-quality publications and to determine its efficacy and safety.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Scopus, and EMBASE databases were searched until December 2022 to identify studies with a minimum 4 year follow-up. Clinical and radiographic outcomes, complications, and revision surgery data were collected. The publications included were analyzed quantitatively using the DerSimonian Laird random-effects model to estimate the change in outcomes from the preoperative to the postoperative condition. The proportion of complications and revisions were pooled using the Freeman-Tukey double arcsine transformation.

RESULTS

Of the 618 publications identified through database search, 11 articles were considered eligible. A total of 421 patients (432 shoulders) were included in this analysis. Their mean age was 59.5 ± 4 years. Of these, 277 patients had mid-term follow-up (4-9 years), and 144 had long-term follow-up (more than 9 years). Postoperative improvements were considered significant for the following outcome parameters: Constant-Murley Score (0-100 scale), with a mean difference (MD) = 28 points (95% confidence interval [CI] 21, 36; I2 = 89%; P < .001); visual analog scale, with a standardized MD = 2.5 (95% CI 1.7, 3.3; P < .001; I2 = 89%; P < .001); forward flexion, with a MD = 43° (95% CI 21°, 65°; I2 = 95% P < .001); abduction, with a MD = 38° (95% CI 20°, 56°; I2 = 85%; P < .01), and external rotation, with a MD = 8° (95% CI 1°, 16°; I2 = 87%; P = .005). The overall reported mean complication rate was 13% (95% CI 9%, 19%; I2 = 0%), while the reported mean revision rate was 6% (95% CI: 3%, 9%; I2 = 0%).

CONCLUSIONS

Our pooled estimated results seem to indicate that latissimus dorsi tendon transfer significantly improves patient-reported outcomes, pain relief, range of motion, and strength, with modest rates of complications and revision surgery at mid-to long-term follow-up. In well-selected patients, latissimus dorsi tendon transfer may provide favorable outcomes for irreparable posterosuperior cuff tears.

Clinical Outcomes and Repair Integrity After Double-Row Modified Mason-Allen Repair Technique With a Single Knot in Small to Medium Supraspinatus Tears

Background

Various arthroscopic rotator cuff repair techniques are being used for the treatment of rotator cuff tears with the development of surgical instruments. However, retears after repair are not completely avoidable, and efforts to reduce retears remain a challenge.

Purpose/Hypothesis

To introduce a new repair technique, the double-row modified Mason-Allen technique with a single knot, and to compare clinical outcomes and retear rates with the single-row modified Mason-Allen technique. It was hypothesized that this new technique would have a better clinical outcome and significantly lower retear rate than the single-row modified Mason-Allen technique.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 110 patients with small- to medium-sized (<1.5 cm) full-thickness supraspinatus tears were enrolled into 2 groups, with 65 patients receiving the single-row modified Mason-Allen technique (group A) and 45 patients receiving the double-row modified Mason-Allen technique with a single knot (group B). The clinical and functional outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) score; Disabilities of the Arm, Shoulder and Hand (DASH) score; and visual analog scale (VAS) for pain and satisfaction scores. All patients enrolled in this study were monitored for a minimum of 24 months. Magnetic resonance imaging was performed to analyze the integrity of tendons and retear at 6 months after surgery.

Results

No statistically significant differences between the 2 groups were found regarding the VAS for pain, ASES, and DASH scores. However, retear was found in 9 patients (13.8%) in group A and 1 patient (2.2%) in group B. The difference in the retear rate was statistically significant between the 2 groups (P = .037).

Conclusion

A significantly lower retear rate and comparable clinical outcomes were seen after the double-row modified Mason-Allen repair technique with a single knot when compared with the single-row modified Mason-Allen technique. Based on these findings, the double-row modified Mason-Allen repair technique with a single knot can be considered a surgical treatment option that can provide sufficient stability in small- to medium-sized supraspinatus tears.

Combined Lower Trapezius and Middle Trapezius Tendon Transfer for Posterior Superior Irreparable Rotator Cuff Tears: A Case Report

Introduction

Irreparable rotator cuff tears (IRCTs) often deteriorate shoulder function, necessitating careful consideration of treatment approaches. While reverse total shoulder arthroplasty (RTSA) is the first line of treatment in patients with arthropathy, preserving the joint is crucial for highly demand patients without arthritis. For those patients, various tendon transfer techniques have been established to address different types of IRCTs, including lower trapezius tendon (LTT) transfer for posterior superior IRCTs (PSIRCTs) and middle trapezius tendon (MTT) transfer for isolated supraspinatus IRCTs (ISIRCTs).

Case Report

A 66-year-old male with persistent right shoulder pain and weakness for 2 years, diagnosed with PSIRCTs, sought an alternative to RTSA due to occupational concerns as a restaurant owner. Preoperatively, patients showed limited range of motion (ROM) and weakness, especially in forward elevation (FE) and external rotation (ER). Radiography and magnetic resonance imaging (MRI) scan indicated superior humeral head translation without advanced arthritis and concurrent tears in the supraspinatus and infraspinatus with atrophy. After the consultation, patients underwent a combined transfer of LTT and MTT with a split Achilles tendon allograft in Y-configuration. By postoperative 1 year, the patient exhibited notable improvement, including reduced pain (VAS 4-2), enhanced function (ASES 50-83, Constant 42-78), and increased ROM (FE, 120°-160° and ER, 10°-40°). Radiographic assessments demonstrated an increased in acromiohumeral distance without arthritic progression. Post-operative MRI confirmed tendon integrity, and the patient successfully resumed work at 6 months.

Conclusion

A combined transfer of the MTT and LTT with a split Achilles tendon allograft in Y-configuration has been shown to alleviate pain, enhance functional scores, and improve the ROM in patients with PSIRCTs without arthritis.

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

INTRODUCTION

While the well-established correlation between increased muscle volume and enhanced muscle strength is widely recognized, there have been no studies assessing volumetric muscle changes in transfer surgery in the shoulder. This study aimed to evaluate changes in transferred muscle volume and their clinical implications in anterior latissimus dorsi and teres major (aLDTM) tendon transfer in patients with anterior superior irreparable rotator cuff tears (ASIRCTs).

MATERIALS AND METHODS

The study retrospectively examined 40 patients who underwent aLDTM tendon transfers for ASIRCTs between August 2018 and January 2022. Using ImageJ software, the LDTM muscle was segmented in T2-weighted oblique axial images, and total muscle volume (tLDTMV) of both immediate and postoperative 1-year were calculated. Pearson correlation analysis was used to determine the correlation between ΔtLDTMV and ΔASES scores, Δactive-ROM, and Δstrength.

RESULTS

The current study revealed an 11.4% increase in tLDTMV at 1-year postoperative. Patients were grouped based on postoperative ASES score: Group 1 (Optimal, n = 17) and Group 2 (Suboptimal, n = 23). Although tLDTMVimmediate postoperative values were similar between groups (P = 0.954), tLDTMV1-year postoperative value was significantly higher in Group 1 compared to Group 2 (P = 0.021). In correlation analysis, ΔtLDTMV showed significant correlations with ΔASES score (r = 0.525, P < 0.001), ΔaROM of forward elevation (FE) (r = 0.476, P = 0.002), ΔaROM of internal rotation (IR) at back (r = 0.398, P = 0.011), Δstrength of FE (r = 0.328, P = 0.039), Δ strength of IR at 90° abduction (r = 0.331, P = 0.037), and IR at side (r = 0.346, P = 0.029).

CONCLUSIONS

Significant increase in tLDTMV was observed at 1-year postoperative for ASIRCT patients. Notably, greater ΔtLDTMV exhibited a correlation with better ASES scores, increased aROM and strength in both FE and IR. Nevertheless, further research is required by employing more robust standardized measurement tools and a larger sample size.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

IV.

Postoperative results of arthroscopic superior capsule reconstruction using fascia lata: a retrospective cohort study

BACKGROUND

Superior capsule reconstruction (SCR) was developed to improve shoulder function and alleviate pain in patients with primary irreparable rotator cuff tears. Although suitable clinical results of SCR have been reported, only a few studies have investigated the clinical outcomes of arthroscopic superior capsule reconstruction (ASCR) using tensor fascia at a minimum follow-up period of 2 years after surgery.

METHODS

Among 100 consecutive patients who underwent ASCR since April 2010, this retrospective cohort study included 49 patients with a Hamada classification of ≤3 who were available for at least 2-year follow-up after surgery. The mean follow-up period was 34.5 (24-74) months. We analyzed preoperative and postoperative Japanese Orthopaedic Association (JOA) scores, University of California at Los Angeles (UCLA) shoulder scores, preoperative and postoperative active elevation angles, external and internal rotations with the arms in the anatomical position, manual muscle test (MMT) scores, preoperative and postoperative acromiohumeral distance (AHD), and cuff integrity on postoperative magnetic resonance imaging using the Hasegawa classification. We compared 27 pseudoparalyzed (elevation of <90°) shoulders with 22 nonpseudoparalyzed shoulders. We also evaluated the treatment of patients with subscapularis tendon tears and compared the outcomes of patients with good graft repair and those with graft retear.

RESULTS

The JOA score, UCLA score, active elevation angle, internal and external rotation angles, and muscle strength (MMT) significantly improved at the time of investigation preoperatively and 2 years postoperatively. The mean AHD also improved from 5 ± 2.6 mm preoperatively to 9 ± 2.8 mm postoperatively. No significant difference in graft tear rate was observed between pseudoparalyzed shoulder and nonpseudoparalyzed shoulder groups. The subscapularis tendon was torn in 26 of 49 (53%) patients, and all patients underwent repair. The graft repair group showed a significant improvement in JOA scores, UCLA shoulder scores, joint range of motion, MMT, and AHD postoperatively, but not in internal rotation strength. In contrast, the graft tear group did not show any significant improvement. All patients could return to work, except for those performing heavy labor. Complications included graft tear in five patients, postoperative infection in two patients, and progressive postoperative arthropathic changes in one patient.

CONCLUSION

Good clinical results of ASCR were obtained using tensor fascia lata at 2 years after surgery, with few complications and low graft tear rates.

Lower Trapezius Transfer Improves Clinical Outcomes With a Rate of Complications and Reoperations Comparable to Other Surgical Alternatives in Patients with Functionally Irreparable Rotator Cuff Tears: A Systematic Review

PURPOSE

To analyze the clinical outcomes of lower trapezius transfer (LTT) for patients with functionally irreparable rotator cuff tears (FIRCT) and summarize the available literature regarding complications and reoperations.

METHODS

After registration in the International prospective register of systematic reviews (PROSPERO [CRD42022359277]), a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Inclusion criteria were English, full-length, peer-reviewed publications with a level of evidence IV or higher reporting on clinical outcomes of LTT for FIRCT. Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus via Elsevier databases were searched. Clinical data, complications and revisions were systematically recorded.

RESULTS

Seven studies with 159 patients were identified. The mean age range was 52 to 63 years, 70.4% of the patients included were male, and the mean follow-up time ranged between 14 and 47 months. At final follow-up, LTT lead to improvements in range of motion, with reported forward elevation (FE) and external rotation (ER) mean gains of 10° to 66° and 11° to 63°, respectively. ER lag was present before surgery in 78 patients and was reversed after LTT in all shoulders. Patient-reported outcomes were improved at final follow-up, including the American Shoulder and Elbow Society score, Shoulder Subjective Value and Visual Analogue Scale. The overall complication rate was 17.6%, and the most reported complication was posterior harvest site seroma/hematoma (6.3%). The most common reoperation was conversion to reverse shoulder arthroplasty (5%) with an overall reoperation rate of 7.5%.

CONCLUSIONS

Lower trapezius transfer improves clinical outcomes in patients with irreparable rotator cuff tears with a rate of complications and reoperations comparable to other surgical alternatives in this group of patients. Increases in forward flexion and ER are to be expected, as well as a reversal of ER lag sign when present before surgery.

LEVEL OF EVIDENCE

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

When is a Reverse Shoulder Arthroplasty Indicated for a Rotator Cuff Tear?

Rotator cuff tears are the most frequent shoulder injury in patients over 50 years old. Treatment of rotator cuff tears is individualized based on the age, demands, and symptoms of the patient. Nonoperative treatment may often be effective, especially in lower-demand or elderly patients. Surgical repair is indicated after failure of nonoperative treatment or in patients whose high-demand lifestyle requires full strength and function of the shoulder. In older patients, larger tears are less likely to heal and rotator cuff repair may not reliable. In cases of failed previous rotator cuff repair, there may not be enough viable tissue for complete repair. If there is underlying arthritis, a rotator cuff repair is unlikely to resolve all symptoms, and treatment to care for the arthritis and rotator cuff tear is indicated. Reverse shoulder arthroplasty provides the surgical answer for these scenarios and is now being used for numerous indications of shoulder pathology.

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

IMPORTANCE

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

OBJECTIVE

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

EVIDENCE REVIEW

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

FINDINGS

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

CONCLUSION AND RELEVANCE

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

LEVEL OF EVIDENCE

IV.

Quantifying Threshold Scores for Patient Satisfaction After Massive Rotator Cuff Repair for the Interpretation of Mid-Term Patient-Reported Outcomes

PURPOSE

To establish minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) values for 4 patient-reported outcomes (PROs) in patients undergoing arthroscopic massive rotator cuff repair (aMRCR): American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), Veterans Rand-12 (VR-12) score, and the visual analog scale (VAS) pain. In addition, our study seeks to determine preoperative factors associated with achieving clinically significant improvement as defined by the MCID and PASS.

METHODS

A retrospective review at 2 institutions was performed to identify patients undergoing aMRCR with minimum 4-year follow-up. Data collected at the 1-year, 2-year, and 4-year time points included patient characteristics (age, sex, length of follow-up, tobacco use, and workers' compensation status), radiologic parameters (Goutallier fatty infiltration and modified Collin tear pattern), and 4 PRO measures (collected preoperatively and postoperatively): ASES score, SSV, VR-12 score, and VAS pain. The MCID and PASS for each outcome measure were calculated using the distribution-based method and receiver operating characteristic curve analysis, respectively. Pearson and Spearman coefficient analyses were used to determine correlations between preoperative variables and MCID or PASS thresholds.

RESULTS

A total of 101 patients with a mean follow-up of 64 months were included in the study. The MCID and PASS values at the 4-year follow-up for ASES were 14.5 and 69.4, respectively; for SSV, 13.7 and 81.5; for VR-12, 6.6 and 40.3; and for VAS pain, 1.3 and 1.2. Greater infraspinatus fatty infiltration was associated with failing to reach clinically significant values.

CONCLUSIONS

This study defined MCID and PASS values for commonly used outcome measures in patients undergoing aMRCR at the 1-year, 2-year, and 4-year follow-up. At mid-term follow-up, greater preoperative rotator cuff disease severity was associated with failure to achieve clinically significant outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Top 50 most impactful publications on massive rotator cuff tears

Background

Bibliometric analysis is a useful tool for measuring the scholarly impact of a topic and its more and less heavily studied aspects. The purpose of this study is to use bibliometric analysis to comprehensively analyze the 50 articles with the highest citation indices in studies evaluating the treatment and outcomes of massive rotator cuff tears (mRCTs).

Methods

This cross-sectional study identified articles within the Scopus database published through December 2022. Keywords used were "massive rotator cuff tear." Articles were sorted in chronological order. The year published and number of citations were recorded. A citation index (CI) was calculated for each article by dividing the number of citations by number of years published [1 citation/1 year published (2021) = CI of 1]. Of these, the 50 articles with the highest CIs were carried forward for evaluation. Frequencies and distributions were assessed for data of each variable collected.

Results

These search methods produced 625 articles regarding mRCT research (ranging from January 1986 to December 2022). Four of the top 10 most impactful articles were published in the 2010s. The level of evidence (LOE) published with the greatest frequency was level of evidence 4 (41%). The journal Arthroscopy published the highest number within the top 50 (26%) followed by the Journal of Bone and Joint Surgery and the American Journal of Sports Medicine (20% each). Clinical studies composed 88% of the top 50. Case series (38%) predominated, while systematic reviews (20%) and randomized control trials (8%) were less prevalent. The majority of studies concentrated on the clinical outcomes of certain interventions (62%), mainly comparing multiple interventions.

Conclusion

Despite the relatively high prevalence of mRCTs (40% of all tears), this topic comprises only a small proportion of all rotator cuff research. This analysis has identified gaps within and limitations of the findings concerning mRCTs for researchers to propose research questions targeting understudied topics and influence the future treatment and outcomes of this clinically difficult diagnosis.

Mini-Open Fascia Lata Interposition Graft Results In Superior 2-Year Clinical Outcomes When Compared to Arthroscopic Partial Repair for Irreparable Rotator Cuff Tear: A Single-Blind Randomized Controlled Trial

PURPOSE

To evaluate and compare the results of surgical treatment for irreparable rotator cuff tear (IRCT) by the mini-open interposition procedure using fascia lata autograft against outcomes of the arthroscopic partial repair technique.

METHODS

An interventional, prospective, controlled, randomized, single-blinded study involving 2 study groups was conducted. The graft group (n = 20) underwent the mini-open interposition procedure using fascia lata autograft. The control group (n = 22) underwent arthroscopic partial repair. Patients were evaluated using the University of California Los Angeles (UCLA) Shoulder scale, the American Shoulder and Elbow Surgeons (ASES) score, the Constant-Murley (Constant) score, the visual analogue scale (VAS) pain score, active range of motion, frontal flexion strength, retear rates evaluated by magnetic resonance imaging analysis, occurrence of complications, and the minimal clinically important difference (MCID).

RESULTS

The graft group had better UCLA (31.5 vs 28.18, P = .035) (100% exceeded the MCID for the graft group and 95% for the control group), ASES (88.62 vs 77.06, P = .016) (100% exceeded the MCID for both groups), Constant (78.85 vs 61.68, P < .001), and VAS (0.95 vs 2.59, P = .01) scores at the 24-month follow-up. For active forward elevation range, both groups showed no statistically significant differences (168.5 vs 164.54, P = .538). The results for active external and internal rotation were better in the graft group (60.25 vs 40, and 9.1 vs 6.9, P < .001), as was frontal flexion strength (4.24 vs 2.67, P = .005). The graft group also had lower retear rates (15% vs 45.5%, P = .033). No complications were reported.

CONCLUSIONS

Outcomes of surgeries for IRCT by the mini-open interposition procedure using fascia lata autograft and by the arthroscopic partial repair technique showed good results in both groups over time and exceeded the MCID. However, most comparative outcomes between groups showed better results for the interposition procedure.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Massive and irreparable rotator cuff tear treatment by arthroscopic partial repair with long head of the biceps tendon augmentation provides better healing and functional results than partial repair only

BACKGROUND

The aim of this study was to compare the clinical and radiologic outcomes of 2 treatment methods for massive and irreparable rotator cuff tears (RCTs): partial repair (PR) and PR with long head of the biceps tendon (LHBT) augmentation. Biceps tendon augmentation is believed to promote better healing at the bone-tendon junction, leading to improved clinical and radiologic outcomes.

METHODS

This retrospective comparative study included patients with chronic, massive and irreparable RCTs involving both the supraspinatus (SSP) and infraspinatus muscles. Only patients with failure of nonoperative treatment and at least 1 year of follow-up between 2013 and 2018 were analyzed. The patients were divided into 2 groups based on the chosen treatment method. Irreparability was defined intraoperatively as the inability to achieve sustainable repair of the SSP after complete release, typically corresponding to a Goutallier classification of stage ≥ 3 and Patte classification of stage 3. The clinical assessment protocol involved measurements of range of motion and shoulder strength, as well as the Constant-Murley score (CMS) and Simple Shoulder Test score. Radiologic assessment comprised measurements of the acromiohumeral distance, Hamada classification, Sugaya classification, and Goutallier classification of both the SSP and infraspinatus.

RESULTS

The study included data from 60 patients (30 in each group) with a mean age of 62.5 years and a mean follow-up period of 34.5 months. The retear rate was 43.3% for PR with LHBT augmentation and 73.3% for PR alone (P = .036). During the final examination, statistically significant differences in favor of PR with LHBT augmentation were observed for the CMS (76.2 ± 10.9 vs. 70.9 ± 11.5, P = .034), Sugaya classification (3.5 ± 1.1 vs. 4.1 ± 0.9, P = .035), and acromiohumeral distance (5.8 ± 2 mm vs. 4.7 ± 1.3 mm, P = .021). There were no significant differences between the groups in range of motion, shoulder strength, Hamada classification, Simple Shoulder Test score, and postoperative Goutallier stage.

CONCLUSION

PR with LHBT augmentation for patients with irreparable, massive RCTs provides a lower retear rate and better humeral head centralization, as well as improved results measured by the CMS, compared with PR alone.

Changes in the Lateral Acromion Angle in Rotator Cuff Tear Patients with Acromioplasty

BACKGROUND

Arthroscopic surgery has been established as an efficacious intervention for the treatment of rotator cuff tears. The primary aim of this study was to analyze the modifications in the lateral acromial angle (LAA) subsequent to rotator cuff repair surgery using single-row rivet fixation and double-row rivet fixation techniques. Furthermore, we sought to investigate the influence of LAA on the prognosis of rotator cuff repair surgery.

METHOD

This observational study retrospectively enrolled 105 patients diagnosed with degenerative rotator cuff tears who underwent arthroscopic rotator cuff repair between 2016 and 2019. Following the exclusion of two patients with subscapularis or superior labrum anterior and posterior (SLAP) tears, as well as three patients who were lost to follow-up, a cohort of 100 patients was included for clinical and imaging evaluation. Among these individuals, 50 were assigned to the double-row repair group, whereas the remaining 50 comprised the single-row repair group. Bilateral shoulder magnetic resonance imaging (MRI) scans were conducted no less than 24 months post-surgery. Experienced arthroscopic surgeons, blinded to the LAA measurements, assessed the rotator interval (RI) using a control MRI. Functional assessment was performed using the University of California, Los Angeles (UCLA) quick disability of the shoulder and arm, shoulder and hand (qDASH) score. The Wilcoxon signed-rank test for dependent samples was employed to compare data between the pre- and post-intervention groups. Pearson correlation coefficients were calculated to evaluate the relationship between different parameters.

RESULTS

The study population consisted of 73 female patients and 27 male patients, with a mean age of 58.32 ± 5.29 years and a mean follow-up duration of 25.88 ± 8.11 months. Preoperatively, the mean LAA was 75.81° ± 11.28°, RI was 4.78 ± 0.62, UCLA score was 17.54 ± 2.44, and qDASH score was 2.45 ± 0.25. The average tear size was 8.95 ± 2.11 mm. A statistically significant difference in LAA was observed between the preoperative and postoperative measurements, with the double-row repair group exhibiting a greater LAA than the single-row repair group. Finally, a significant correlation was identified between LAA, RI, and qDASH scores after a 24-month follow-up period.

CONCLUSION

According to our findings, the utilization of double-row rivet fixation has a greater LAA angle than single-row rivet fixation. Moreover, this preservation of LAA is significantly associated with the functional recovery of the shoulder joint.

Midterm outcomes of autologous bridging of rotator cuff tears with an autologous tendon patch (TEAR patch)

BACKGROUND

Large and massive rotator cuff tears and tears after failed surgical repair are a challenging clinical problem with different treatment options. The purpose of the study was to evaluate the midterm outcomes after rotator cuff repair (RCR) with autologous hamstring tendon graft bridging (tissue-enhanced autologous rotator cuff repair [TEAR] patch) with the hypothesis that outcomes would be reasonable and complication rates would be low.

METHODS

This is a retrospective case series study of patients who underwent open RCR using a TEAR patch from June 2015 to March 2019. The exclusion criteria included evidence of cuff tear arthropathy, advanced fatty infiltration, moderate-to-severe arthropathy, and workers compensation board or litigation involved. Clinical outcome measures were Constant score; Disabilities of the Arm, Shoulder and Hand score; Simple Shoulder Test; Subjective Shoulder Value; range of motion (ROM); and manual muscle test for forward elevation, abduction, external and internal rotation, patient satisfaction, and willingness to perform the operation again. Radiographic outcome measures were magnetic resonance imaging, ultrasound, and radiographs: graft integrity and acromiohumeral distance (AHD).

RESULTS

A total of 44 patients were followed (89%) for ≥2 years (45 shoulders, mean age 60.3 years [48-76 years], mean follow-up 4.3 years [2-6 years]). All clinical outcome measures (Constant score, Disabilities of the Arm, Shoulder and Hand score, Simple Shoulder Test, Subjective Shoulder Value, ROM, and manual muscle test) demonstrated significant improvement except active external and internal rotation. At 2 years of follow-up, the mean patient satisfaction was high (12.2 of 15 points), and 33 of 38 patients (73.3%) would perform the operation again. A perfect graft integration was observed in 30 (66.7%), a small gap in 7 (15.6%), a retear in 3 (7%), and a complete failure of the tendon patch in 5 (11%) patients. Graft integrity was strongly correlated with the postoperative AHD (r = 0.599, P = .001) and the gain in AHD (r = 0.599, P = .001) but not with ROM or patient-reported outcome measures or patient satisfaction. Four patients required revision surgeries (3 due to deep infection and 1 for poor function and pain).

CONCLUSIONS

Midterm clinical and radiographic outcomes after RCR with graft bridging using a TEAR patch were reasonable. The procedure resulted in improved shoulder function and a high level of patient satisfaction. The revision rate is acceptable in view of the specific patient group and treatment alternatives. The described technique of the TEAR patch can be a valuable alternative to existing methods and a new autograft source for rotator cuff surgeries that need bridging of a tendon defect.

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

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.

Changes in in vivo three dimensional shoulder kinematics following latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears: A systematic review with meta-analysis

BACKGROUND

Latissimus dorsi transfer is a surgical procedure that can be used for treating posterosuperior rotator cuff tears. The procedure leads to improved shoulder function via alterations in the force vector couple around the shoulder. However, there is still no consensus on the biomechanical changes resulting from latissimus dorsi transfer.

METHODS

We performed a systematic review of the literature on 3D motion analysis studies evaluating the effects of latissimus dorsi transfer on shoulder kinematics. The available data on segment and joint range of motion was extracted and subject to meta-analysis when consistent across the studies.

FINDINGS

Our meta-analysis of pre- and post-operative studies revealed a significant improvement in forward flexion and abduction following latissimus dorsi transfer. When comparing the latissimus transferred shoulder with an uninjured contralateral side the meta-analysis found no significant difference in flexion range of motion, while abduction and external rotation was significantly higher in the uninjured shoulders. The overall risk of bias was moderate to high. High heterogeneity was found in the reporting of data, which limited our ability to perform a meta-analysis across the studies for all interest outcomes.

INTERPRETATIONS

Our findings suggest that latissimus dorsi transfer for posterosuperior rotator cuff tears effectively improves shoulder flexion and abduction. External rotation is also expected to improve but at inferior levels as compared to the unaffected side. However, the heterogeneity of the reported data on 3D motion analysis studies highlights the need for better standardization in research and reporting as to conclude the impact of different joints.

Subacromial Balloon Spacer Implantation Is a Promising Alternative for Patients With Massive Irreparable Rotator Cuff Tears: A Systematic Review

PURPOSE

To provide an overview of the existing literature on subacromial balloon spacers for the treatment of massive irreparable rotator cuff tears, in an effort to inform surgeons of the procedure's clinical effectiveness.

METHODS

The PubMed, Scopus, and Ovid EMBASE databases were queried to identify studies evaluating the clinical, radiographic, and patient-reported outcomes of patients indicated for subacromial balloon spacer implantation. The following datapoints were extracted: study demographics, patient baseline characteristics, and postoperative outcomes of interest. Outcomes were evaluated at baseline and at the longest available follow-up period.

RESULTS

A total 766 patients were included among 22 included studies, with an average follow-up of 27.54 months. Improvements were seen for all clinical and patient-reported outcomes: forward elevation (ranging from 9.20 to 90.00° improvement), external rotation (ranging from 2.00 to 22.00°), abduction (ranging from 14.00 to 95.00°), Total Constant Score (ranging from 7.70 to 50.00), American Shoulder and Elbow Surgeons score (ranging from 24.60 to 59.84), Oxford Shoulder Score (ranging from 7.20 to 22.20), and pain score (ranging from 3.57 to 6.50). Minimal differences were seen in acromiohumeral interval (ranging from -2.00 to 1.27). Reoperation and complication rates ranged from 0% to 33% and 0% to 19.64%, respectively.

CONCLUSIONS

The short-term results of subacromial balloon spacers for management of massive rotator cuff tears demonstrate clinically relevant improvements in shoulder range of motion and substantial improvements in patient-reported outcome measures. Of note, minimal change in acromiohumeral interval was seen on postoperative radiography, and wide variations in complication and reoperation rates were reported across studies.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

Evaluation of spin in reviews of biodegradable balloon spacers for massive irreparable rotator cuff tears

HYPOTHESIS

Clinical studies are often at risk of spin, a form of bias where beneficial claims are overstated while negative findings are minimized or dismissed. Spin is often more problematic in abstracts given their brevity and can result in the misrepresentation of a study's actual findings. The goal of this study is to aggregate primary and secondary studies reporting the clinical outcomes of the use of subacromial balloon spacers in the treatment of massive irreparable rotator cuff tears to identify the incidence of spin and find any significant association with study design parameters.

MATERIALS AND METHODS

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Independent searches were completed on 2 databases (PubMed and Embase) for primary studies, systematic and current concepts reviews, and meta-analyses and the results were compiled. Two authors independently screened the studies using a predetermined inclusion criteria and aggregated data including titles, publication journals and years, authors, study design, etc. Each study was independently assessed for the presence of 15 different types of spin. Statistical analysis was conducted to identify associations between study characteristics and spin.

RESULTS

Twenty-nine studies met the inclusion criteria for our analysis, of which 10 were reviews or meta-analyses and 19 were primary studies. Spin was identified in every study except for 2 (27/29, 93.1%). Type 3 spin, "Selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention" and type 9 spin, "Conclusion claims the beneficial effect of the experimental treatment despite reporting bias" were most frequently noted in our study, both observed in 12/29 studies (41.4%). Date of publication, and adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses or "The International Prospective Register of Systematic Reviews" were study characteristics associated with a higher rate of certain types of spin. There was a statistically significant association between disclosure of external study funding source and the presence of spin type 4, but none of the other forms of spin.

CONCLUSION

Spin is highly prevalent in the abstracts of primary studies, systematic reviews, and meta-analyses discussing the use of subacromial balloon spacer technology in the treatment of massive irreparable rotator cuff tears. Our findings revealed that spin in the abstract tended to favor the balloon spacer intervention. Further efforts are required in the future to mitigate spin within the abstracts of published manuscripts.

Evaluation of spin in systematic reviews on the use of tendon transfer for massive irreparable rotator cuff tears

PURPOSE

To identify, describe and account for the incidence of spin in systematic reviews and meta-analyses of tendon transfer for the treatment of massive, irreparable rotator cuff tears. The secondary objective was to characterize the studies in which spin was identified and to determine whether identifiable patterns exist among studies with spin.

METHODS

This study was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Each abstract was assessed for the presence of the 15 most common types of spin derived from a previously established methodology. General data that were extracted included study title, authors, publication year, journal, level of evidence, study design, funding source, reported adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, preregistration of the study protocol, and methodologic quality per A Measurement Tool to Assess Systematic Reviews Version 2 (AMSTAR 2).

RESULTS

The search yielded 53 articles, of which 13 were included in the final analysis. Articles were excluded if they were not published in a peer reviewed journal, not written in English, utilized cadaveric or nonhuman models, or lacked an abstract with accessible full text. 53.8% (7/13) of the included studies contained at least 1 type of spin in the abstract. Type 5 spin ("The conclusion claims beneficial effect of the experimental treatment despite a high risk of bias in primary studies") was the most common, appearing in 23.1% (3/13) of included abstracts. Nine of the spin categories did not appear in any of the included abstracts. A lower AMSTAR 2 score was significantly associated with the presence of spin in the abstract (P < .006).

CONCLUSION

Spin is highly prevalent in the abstracts of systematic reviews and meta-analyses concerning tendon transfer for massive rotator cuff tears. A lower overall AMSTAR 2 rating was associated with a higher incidence of spin. Future studies should continue to explore the prevalence of spin in orthopedic literature and identify any factors that may contribute to its presence.

Definition of irreparable rotator cuff tear: a scoping review of prospective surgical therapeutic trials to evaluate current practice

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.

Improved Yet Varied Clinical Outcomes Observed With Comparison of Arthroscopic Superior Capsular Reconstruction Versus Arthroscopy-Assisted Lower Trapezius Transfer for Patients With Irreparable Rotator Cuff Tears

PURPOSE

To evaluate the outcomes of arthroscopic superior capsular reconstruction (SCR) and arthroscopy-assisted lower trapezius tendon transfer (LTT) for posterosuperior irreparable rotator cuff tears (IRCTs).

METHODS

Over an almost 6-year period (October 2015 to March 2021), all patients who underwent IRCT surgery with a minimum 12-month follow-up period were identified. For patients with a substantial active external rotation (ER) deficit or lag sign, LTT was preferentially selected. Patient-reported outcome scores included the visual analog scale (VAS) pain score, strength score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Single Assessment Numeric Evaluation (SANE) score, and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score.

RESULTS

We included 32 SCR patients and 72 LTT patients. Preoperatively, LTT patients had more advanced teres minor fatty infiltration (0.3 vs 1.1, P = .009), a higher global fatty infiltration index (1.5 vs 1.9, P = .035), and a higher presence of the ER lag sign (15.6% vs 48.6%, P < .001). At a mean follow-up of 2.9 ± 1.3 years (range, 1.0-6.3 years), no differences in patient-reported outcome scores were observed. Postoperatively, SCR patients had a lower VAS score (0.3 vs 1.1, P = .017), higher forward elevation (FE) (156° vs 143°, P = .004), and higher FE strength (4.8 vs 4.5, P = .005) and showed greater improvements in the VAS score (6.8 vs 5.1, P = .009), FE (56° vs 31°, P = .004), and FE strength (1.0 vs 0.4, P < .001). LTT patients showed greater improvement in ER (17° vs 29°, P = .026). There was no statistically significant between-cohort difference in complication rate (9.4% vs 12.5%, P = .645) or reoperation rate (3.1% vs 10%, P = .231).

CONCLUSIONS

With adequate selection criteria, both SCR and LTT provided improved clinical outcomes for posterosuperior IRCTs. Additionally, SCR led to better pain relief and restoration of FE whereas LTT provided more reliable improvement in ER.

LEVEL OF EVIDENCE

Level III, treatment study with retrospective cohort comparison.

Superior capsular reconstruction using the long head of the biceps to treat massive rotator cuff tears improves patients shoulder pain, mobility and function

PURPOSE

Arthroscopic superior capsule reconstruction (SCR) with the long head of the biceps (LHBT) was performed to restore structural stability, force couple balance, and shoulder joint function. This study aimed to evaluate the functional outcomes of SCR using the LHBT over at least 24 months of follow-up.

METHOD

This retrospective study included 89 patients with massive rotator cuff tears who underwent SCR using the LHBT, met the inclusion criteria and underwent follow up for at least 24 months. The preoperative and postoperative shoulder range of motion (forward flexion, external rotation, and abduction), acromiohumeral interval (AHI), visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score and Constant-Murley score were obtained, and the tear size, and Goutallier and Hamada grades were also investigated.

RESULTS

Compared with those measured preoperatively, the range of motion, AHI, and VAS, Constant-Murley, and ASES scores were significantly improved immediately postoperatively (P < 0.001) and at the 6-month, 12-month, and final follow-ups (P < 0.001). At the last follow-up, the postoperative ASES score and Constant-Murley score increased from 42.8 ± 7.6 to 87.4 ± 6.1, and 42.3 ± 8.9 to 84.9 ± 10.7, respectively; with improvements of 51 ± 21.7 in forward flexion, 21.0 ± 8.1 in external rotation, and 58.5 ± 22.5 in abduction. The AHI increased 2.1 ± 0.8 mm and the VAS score significantly changed from 6.0 (5.0, 7.0) to 1.0 (0.0, 1.0), at the final follow-up. Eleven of the 89 patients experienced retears, and one patient needed reoperation.

CONCLUSION

In this study with at least 24-months of follow-up, SCR using the LHBT for massive rotator cuff tears could effectively relieve shoulder pain, restore shoulder function and increase shoulder mobility to some extent.

LEVEL OF EVIDENCE

IV.

The Effects of Pre-existing Mood Disorders on Patient-Reported Outcomes After Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis

BACKGROUND

The purpose of this study was to systematically review the literature to evaluate the effect of pre-existing mood disorders on patient-reported outcomes after arthroscopic rotator cuff repair (ARCR).

METHODS

Two independent reviewers performed a literature search using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using PubMed, Embase, Cochrane Library, and Scopus databases. Only studies which grouped as either having a pre-existing mood disorder (namely anxiety and/or depression) or not and evaluated patient-reported outcomes following ARCR procedures were considered for inclusion. Meta-analysis was performed on outcomes using RevMan, with a p-value <0.05 being deemed statistically significant.

RESULTS

Our search found 8 studies including 1,166 shoulders (58.9% males), with an average age of 57.7 ± 3.2 years (21-81) and mean follow-up of 20.8 ± 16.7 months (3-77) which met our inclusion criteria. There were a total of 262 patients (22.5%; mean age 59.9 ± 1.4 years) with pre-existing anxiety and/or depression and 904 patients (77.5%; mean age 59.7 ± 1.7 years) in the control group who underwent ARCR, respectively. Meta-analysis found significantly lower American Shoulder and Elbow Surgeons scores as well as Simple Shoulder Test scores in patients with pre-existing anxiety and/or depression when compared with a control (mean difference [MD] -7.92 [-9.45, -6.40], p < 0.0001, I2 = 0%; MD -1.56 [-2.54, -0.59], p = 0.002, I2 = 80%, respectively) In addition, meta-analysis demonstrated significantly higher Visual Analog Scale scores for pain in patients with pre-existing anxiety and/or depression when compared with a control (MD 0.70 [0.02, 1.38], p = 0.04, I2 = 71%). Furthermore, meta-analysis performed found that ARCR resulted in significant changes in the rates of reported anxiety and/or depression in patients with pre-existing anxiety and/or depression (MD 4.06[-2.47, 6.68], p < 0.0001, I2 = 0%).

CONCLUSION

Our review found that patients with pre-existing mood disorders were significantly more likely to report higher rates of postoperative pain and poorer functional outcomes following ARCR procedures, when compared with controls without mood disorders. Therefore, the presence of pre-existing anxiety and/or depression warrants consideration in the management paradigm for patients with rotator cuff tears. More optimistically, however, ARCR resulted in significant improvements in anxiety and/or depressive symptoms postoperatively.

LEVEL OF EVIDENCE

Level III; systematic review of retrospective comparative studies. See Instructions for Authors for a complete description of levels of evidence.

American Shoulder and Elbow Surgeons score: what does it tell us about patients selecting operative treatment of a rotator cuff injury?

Background

As shared decision-making rises in importance and minimum clinically important differences become benchmarks for treatment success or failure based on the increased usage of patient-reported outcomes, it is important to understand the breadth of starting points for patients as that should affect the interpretation of individual postoperative score changes.

Methods

This is a retrospective data review of prospectively collected American Shoulder and Elbow Surgeons (ASES) score of patients electing to undergo rotator cuff repair with 1-year follow-up. A residual improvement: possible to achieve ratio (RIPAR) was calculated to demonstrate what percent of maximal possible improvement was gained at 1 year. A minimal clinically important difference (MCID) of 12 was used.

Results

Three hundred thirty-five patients with an age range of 32-79 years form the population. Baseline ASES score ranged from 0 to 97.5, with a mean of 47.8. At 1 year, the mean was 84.7 (range, 30-100). There was no statistical difference by age, but men reported more overall preoperative dysfunction than women (50.3 vs. 44.1, P < .001). The RIPAR was on average 67%. Seventy-eight percent of the population demonstrated RIPAR scores >50% which showed improvement of over half of their preoperative deficit. Eighty-nine percent of patients achieved a positive MCID and 3% achieved a negative MCID.

Conclusions

The ASES scores showed a broad range of baseline scores for patients choosing to undergo rotator cuff repair highlighting the need for individual patient rather than population review of patient-reported outcome measures. As shared decision-making is taking on a larger role in clinical care, it is important to counsel patients accurately. Evaluating the ASES score by MCID and maximal possible improvement provides different population perspectives with the concept of RIPAR allowing for personalization of decision-making on the individual patient level.

Subacromial Balloon Implantation for the Treatment of Irreparable Posterosuperior Rotator Cuff Tears

Despite the development of various therapeutic options, surgical management of irreparable rotator cuff tears (IRCTs) remains controversial. Recently, implantation of a biodegradable subacromial balloon spacer (InSpace, Stryker Corporation; Kalamazoo, MI) has gained considerable interest for the treatment of certain IRCTs. The reported outcome of balloon implantation has not been consistent, likely due to differing indications and technical approaches. The purpose of this article is to present a reproducible arthroscopic technique for implantation of a subacromial balloon and to review the literature published to date, regarding the efficacy and outcomes of this procedure.

Risk Factors for Rotator Cuff Repair Failure and Reliability of the Rotator Cuff Healing Index (RoHI) in Thai Patients: Comparison of the RoHI With a Modified Scoring System

Background

The success rate of surgical treatment for rotator cuff (RC) tear ranges from 16% to 94%. The Rotator Cuff Healing Index (RoHI) is a system for predicting failure after RC repair and is based on a combined score of factors, including age, anteroposterior (AP) tear size, tendon retraction, fatty infiltration of the infraspinatus muscle, bone mineral density (BMD), and level of work activity.

Purpose

To determine the factors leading to RC repair failure in a Thai population, to test the reliability of the RoHI in this population, and to compare the RoHI with a modified RoHI (m-RoHI) based on the factors for repair failure as determined.

Study Design

Case-control study; Level of evidence, 3.

Methods

This study included 133 Thai patients who underwent arthroscopic RC repair between February 2012 and February 2021. Postoperative magnetic resonance imaging was performed at 6 to 24 months to evaluate RC healing. Variables that might affect failure rates were evaluated, including demographic characteristics, AP tear size and retraction, radiographic measurements, and magnetic resonance imaging findings. The m-RoHI was created using factors that significantly predicted repair failure on multivariate analysis. The area under the receiver operating characteristic curve was calculated to determine the reliability of the RoHI and to compare the reliability of the RoHI and m-RoHI to predict failure rates.

Results

Multivariate logistic regression analysis revealed that body mass index ≥23 (adjusted odds ratio [OR], 9.02; P = .034), high work activity (adjusted OR, 19.53; P = .008), AP tear size ≥2.5 cm (adjusted OR, 19.04; P = .001), and a retraction size of 2 to <3 cm (adjusted OR, 20.36; P = .013) were the independent factors that predicted repair failure in our population. BMD was not independently predictive of repair failure. We used these 4 significant independent factors to generate the m-RoHI. The area under the curve of the final adjusted m-RoHI was slightly improved as compared with the original RoHI, but this difference was not significant (0.827 [95% CI, 0.741-0.913] vs 0.780 [95% CI, 0.686-0.875], respectively; P = .447).

Conclusion

The m-RoHI had a similar predictive value for repair failure to the original RoHI in our study population, but it did not require obtaining BMD. The m-RoHI may be useful in populations where BMD is not routinely obtained.

Editorial Commentary: Superior Capsular Reconstruction Employing Allograft Heals and Functions Well if the Graft Is Sufficiently Thick and Stiff

Superior capsular reconstruction (SCR) has fallen into disrepute, and the numbers performed appear to be on the decline because it is technically demanding and time-consuming, requires a long postoperative recovery, and does not always heal or function as expected. In addition, two "new kids on the block," the subacromial balloon spacer and the lower trapezius tendon transfer, have emerged as viable alternatives for low-demand patients who cannot tolerate a lengthy recovery and for high-demand patients who lack external rotation strength, respectively. However, carefully selected patients continue to do well after SCR, when surgery is meticulously performed using a graft that is sufficiently thick and stiff. The clinical results and healing rates after SCR using allograft tensor fascia lata are comparable with those after SCR using tensor fascia lata autograft and without donor-site morbidity. Robust comparative clinical study is needed to sort out the optimal graft type and thickness for SCR and the precise indications for each of the surgical treatment options for the irreparable rotator cuff tear, but let's not "throw the baby out with the bathwater" and abandon SCR altogether.

Irreparable Rotator Cuff Tear Treated With Combined Reconstruction of the Superior Capsule and Rotator Cuff: Technique Guidelines

Irreparable rotator cuff tears in young patients can be challenging for the patient and orthopaedic surgeon. Interposition rotator cuff reconstruction has gained popularity in patients with retracted tears and a viable rotator cuff muscle belly. Superior capsular reconstruction is an emerging treatment option that was developed to restore native glenohumeral joint mechanics by creating a superior constraint, which provides a stable glenohumeral fulcrum. Reconstructing both the superior capsule and rotator cuff tendon in the setting of an irreparable tear may improve clinical results in younger patients with viable rotator cuff muscle belly and a maintained acceptable acromiohumeral distance.

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

Background

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

Purpose

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

Study Design

Narrative review.

Methods

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

Results

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

Conclusion

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

Better functional outcomes and a lower infection rate can be expected after superior capsular reconstruction in comparison with latissimus dorsi tendon transfer for massive, irreparable posterosuperior rotator cuff tears: a systematic review

BACKGROUND

Massive, irreparable rotator cuff tears, if left untreated, may result in cuff tear arthropathy, which causes shoulder disability and pain. The primary outcome of this systematic review was to evaluate differences in functional outcomes between the arthroscopic superior capsular reconstruction (SCR) and latissimus dorsi tendon transfer (LDTT) for the treatment of massive, irreparable posterosuperior rotator cuff tears without arthritis. The secondary outcome was to compare complication and reoperation rates between the 2 surgical procedures.

METHODS

The PubMed, MEDLINE, Scopus, and Cochrane Central databases were searched using keywords, and 20 studies were included in this review. Data extracted for quantitative analysis included the American Shoulder and Elbow Surgeons score, the Constant-Murley score, the subjective shoulder value, the range of motion, the visual analog scale for pain, numbers and types of complications, and reoperation rate. The preoperative fatty degeneration of the muscles and the preoperative and follow-up acromiohumeral distance and glenohumeral osteoarthritis according to the Hamada grading system were also reported.

RESULTS

A total of 1112 patients were identified, among whom 407 and 399 underwent SCR and LDTT, respectively. The SCR group showed a higher mean age at the time of operation (64.5 ± 7.8 vs. 62.1 ± 8.9 years; P < .001). The SCR group showed a lower rate of previous surgical procedures on the shoulder (35 out of 407 vs. 111 out of 399; P < .001) and a shorter mean follow-up (30.4 ± 7.5 vs. 36.3 ± 10.3 months; P < .001). Patients who underwent SCR reported significantly better functionality and residual pain as measured by the Constant-Murley score (75.5 ± 11.2 vs. 65.6 ± 22.8, P < .001), the American Shoulder and Elbow Surgeons score (84.3 ± 13 vs. 67.7 ± 23, P < .001), the subjective shoulder value (79.4 ± 13 vs. 64.4 ± 23, P < .001), and the visual analog scale (1.4 ± 2 vs. 2.8 ± 3, P < .001) than patients who underwent LDTT. A greater acromiohumeral distance (5.8 ± 2.5 vs. 7.6 ± 2.7, P < .001) was found in the SCR group. The SCR group showed a significantly lower infection rate (0.2% vs. 2.8%., P = .003) and a higher graft failure rate (12.3% vs. 6.8%, P = .012). No differences in terms of reoperation for graft failure (1% vs. 2.3% for SCR and LDTT, respectively; P = .172) or for conversion to reverse total shoulder arthroplasty (1.7% vs. 2% for SCR and LDTT, respectively; P = .800) were found.

CONCLUSION

Patients undergoing SCR report better functional outcomes and greater acromiohumeral distance than those undergoing LDTT. The LDTT group shows a significantly higher infection rate, while the SCR group shows a significantly higher graft failure rate, but there are no differences in terms of reoperation between the 2 surgical procedures.

Massive Irreparable Rotator Cuff Tears: Which Patients Will Benefit from Physiotherapy Exercise Programs? A Narrative Review

Massive irreparable rotator cuff tears can cause significant shoulder pain, disability and reduction in quality of life. Treatment approaches can be operative or non-operative. Operative approaches include reverse total shoulder arthroplasty, arthroscopic debridement, partial rotator cuff repair, subacromial balloon spacers, superior capsule reconstruction, and tendon transfer procedures. Non-operative approaches include physiotherapy exercise programs and corticosteroid injections. There are no randomized controlled trials comparing the different treatment approaches. It is therefore challenging for clinicians to advise patients on what is their best treatment pathway. Physiotherapy exercise programs are less expensive and have lower risks for patients than surgical approaches. However, the success of physiotherapy in patients with massive irreparable rotator cuff tears is highly variable with published success rates of 32-96%. Several cohort studies have sought to identify if certain factors are predictive of success with physiotherapy. Several biomechanical factors were identified as possibly being related to a successful or unsuccessful outcome following physiotherapy, with complete tear of subscapularis demonstrating the strongest evidence. However, there were no appropriately designed prognostic studies. There has been a strong emphasis on biomechanical factors. Other domains such as psychosocial factors, which are important in similar patient populations, have not been explored. We recommend that further research is needed in this area and should include randomized controlled trials comparing treatment approaches and longitudinal prospective prognostic studies to identify predictors of treatment success.

Arthroscopic Superior Capsule Reconstruction with Combined Fascia Lata Autograft and Synthetic Scaffold Patch Graft for the Treatment of Irreparable Rotator Cuff Tears Yields Favorable Clinical and Radiographic Outcomes at Minimum Two-Year Follow-Up

PURPOSE

To report the results of the arthroscopic superior capsule reconstruction (ASCR) technique with a combined fascia lata autograft and synthetic scaffold patch graft for irreparable massive rotator cuff tears (RCTs).

METHODS

The period for this retrospective study was between December 2016 and December 2020. The criteria for inclusion were patients treated arthroscopically for an incompletely reparable massive RCT (dimension > 5 cm and two tendons fully torn, intact or reparable subscapularis tendons and teres minor tendon with or without irreparable infraspinatus, a radiological Hamada classification between grade 0 and 4, and a minimum 24-month postoperative follow-up).. Clinical outcomes were evaluated pre-operatively and at a final follow-up by a visual analog scale (VAS) for pain and range of motion along with the American Shoulder and Elbow Surgeons score (ASES), the University of California Los Angeles score (UCLA), and the Constant-Murley score (CMS). Radiological outcomes were assessed according to the rotator cuff arthropathy (RCA) and the acromiohumeral distance (AHD) stages. Graft integrity and muscle fatty infiltration were evaluated by magnetic resonance imaging (MRI).

RESULTS

A total of 43 patients were enrolled in the study with a mean follow-up duration of 45.6 months (range 24 to 64). All clinical scores also improved at the two-year follow-up (mean VAS 0.7 [SD 0.7] vs. 5.4 [SD 1.1], P < 0.001; mean ASES 92.6 [SD 8.0] vs. 34.8 [SD 13.4], P < 0.001; mean UCLA 31.5 [SD 3.9] vs. 11.0 [SD 3.2], P < 0.001; and mean CMS 86.6 [SD 7.2] vs. 40.0 [SD 11.6], P < 0.001), and 39 of 43 fascia lata grafts were fully intact on MRI (91%).

CONCLUSIONS

ASCR with a combined fascia lata autograft and synthetic scaffold patch graft resulted in good functional outcomes, with a high rate of graft healing at the two-year follow-up. All patients achieved clinically relevant improvement (met minimal clinically important differences (MCID)) on ASES, UCLA, and VAS with improved abduction strength restoration.

Subacromial Balloon Spacer for Massive Irreparable Rotator Cuff Tears

Massive irreparable rotator cuff tears (MIRCTs) represent 10% to 40% of cases of rotator cuff abnormality and are challenging to treat. When MIRCTs are unresponsive to nonoperative treatment, surgery may be considered. An arthroscopically inserted biodegradable subacromial balloon spacer (InSpace; Stryker) has grown in popularity in recent years for treatment of patients with MIRCTs. The balloon spacer is made of a copolymer of poly-L-lactide-eco-ε-caprolactone and is expected to fully resorb within 12 months after implantation. Research has suggested the balloon spacer becomes progressively compressed and is slowly replaced with fibrous tissue between the humeral head and the acromion, which may support a prolonged benefit following resorption. Clinical benefits may be achieved through reduced acromiohumeral abutment and subacromial friction during shoulder movement by lowering the humeral head and facilitating humeral gliding. The primary population indicated for use of the implant are patients older than 40 years with persistent shoulder pain and functional disability due to MIRCTs. Contraindications include irreparable subscapularis tears, moderate to severe arthritis, axillary nerve palsy, and known allergy to the implant material. There are not clear indications for use of the implant for treatment of partial-thickness tears or repairable complete rotator cuff tears. Familiari et al. reported that treatment with the balloon spacer was associated with a significant improvement in shoulder function, limited need for revision surgery, and high satisfaction at mean 3-year follow-up. More recently, a prospective multicenter randomized controlled trial was conducted to evaluate the efficacy and safety of the balloon spacer in 93 patients compared to 91 patients undergoing arthroscopic partial repair. Significant and clinically relevant improvements in the American Shoulder and Elbow Surgeons score from baseline were noted in both groups up to the 2-year follow-up.

Long Head of the Biceps Autograft Performs Biomechanically Similar to Human Dermal Allograft for Superior Capsule Reconstruction After Rotator Cuff Tear

PURPOSE

To provide a biomechanical comparison between human dermal (HD) allograft and long head of biceps tendon (LHBT) autograft with and without posterior side-to-side suturing for superior capsule reconstruction.

METHODS

Eight fresh-frozen cadaveric shoulder specimens were tested in 5 conditions: (1) intact, (2) complete supraspinatus tear, (3) LHBT, (4) LHBT with side-to-side suturing, and (5) HD allograft with side-to-side suturing. Functional abduction force, superior translation of humeral head, translational range of motion, and rotational range of motion were tested at 0°, 30°, 60°, and 90° of abduction within each condition. Data were analyzed using analysis of variance with post-hoc Tukey testing for pairwise comparison, with a significance value set at .05.

RESULTS

Functional abduction force in the LHBT, LHBT + suture, and HD + suture conditions was significantly increased compared with the supraspinatus tear condition at abduction angles of 30° (P = .011, .001, and .017, respectively), 60° (P = .004, .001, and .002, respectively), and 90° (P = .013, .001, and .038, respectively). In addition, superior translation of the humeral head in the LHBT, LHBT + suture, and HD + suture conditions was significantly decreased compared with the tear condition at abduction angles of 30° (P = .03, .049, .03, respectively) and 60° (P = .02, .04, .03, respectively). All 3 reconstructive techniques were statistically identical to the intact rotator cuff condition in regard to translational and rotational range of motion.

CONCLUSIONS

Superior capsule reconstruction with LHBT autograft without side-to-side suturing, LHBT with posterior side-to-side suturing, and HD allograft with posterior side-to-side suturing all equivalently restore functional abduction force and decrease superior translation of the humeral head after a complete supraspinatus tear.

CLINICAL RELEVANCE

Superior capsule reconstruction with long head of the biceps tendon autograft and human dermal allograft both restore functional abduction force and decrease superior translation of the humeral head, while displaying no losses in the range of motion in a cadaveric model.

Effects of ultrasound-guided platelet-rich plasma combined with sodium hyaluronate on shoulder function recovery, pain degree and mental health of patients with rotator cuff injury

Rotator cuff injury is a common condition that affects the shoulder and is characterized by damage to the tendons and muscles in the shoulder area. This type of injury can lead to decreased shoulder function, pain, and decreased quality of life for those affected. As such, finding effective treatments for rotator cuff injury is important for improving patient outcomes and reducing the impact of this condition on patients and society. The purpose of this study was to evaluate the effectiveness of SH (Sodium Hyaluronate) and PRP (Platelet-Rich Plasma) in treating rotator cuff injuries in the shoulder. Patients who were diagnosed with Rotator Cuff Injury (RCI) and received treatment at the hospital were selected as the study subjects and divided into four groups. Various treatments were given to patients in each group. Two-way ANOVA and Mann-Whitney tests were used to analyze the results. The study found that patients who received ultrasound-guided platelet-rich plasma combined with sodium hyaluronate had significantly higher shoulder function recovery rates and better quality of life compared to the other groups. They also reported significantly lower pain scores compared to the other groups. The results suggest that ultrasound-guided platelet-rich plasma combined with sodium hyaluronate can effectively improve the shoulder function of patients with rotator cuff injury, reducing pain and improving their overall well-being. This has implications for improving patient outcomes and reducing the impact of rotator cuff injury on patients and society by providing a promising treatment option for this common condition.

Treatment options for massive irreparable rotator cuff tears: a review of arthroscopic surgical options

While functional reconstruction of massive irreparable rotator cuff tears remains a challenge, current techniques aimed at recentering and preventing superior migration of the humeral head allow for clinical and biomechanical improvements in shoulder pain and function. Recentering of the glenohumeral joint reduces the moment arm and helps the deltoid to recruit more fibers, which compensates for insufficient rotator cuff function and reduces joint pressure. In the past, the concept of a superior capsular reconstruction with a patch secured by suture anchors has been used. However, several innovative arthroscopic treatment options have also been developed. The purpose of this article is to present an overview of new strategies and surgical techniques and if existing present initial clinical results. Techniques that will be covered include rerouting the long head of the biceps tendon, utilization of the biceps tendon as an autograft to reconstruct the superior capsule, utilization of a semitendinosus tendon allograft to reconstruct the superior capsule, superior capsular reconstruction with dermal allografts, and subacromial spacers.

Arthroscopic Superior Capsular Reconstruction with Tensor Fascia Lata Allograft for Irreparable Rotator Cuff Tears: Clinical and Radiologic Outcomes for a Minimum 1-Year Follow-Up

PURPOSE

To confirm the radiologic and clinical outcomes after performing arthroscopic superior capsular reconstruction (ASCR) using a tensor fascia lata (TFL) allograft.

METHODS

Thirty-three patients with irreparable rotator cuff tears were treated with ASCR with a TFL allograft. The mean age and follow-up period were 62 years and 20.1 months, respectively. TFL allografts were used as 3, 4, and 6 layers, and the graft thickness was 3.7, 3.9, and 5.4 mm, respectively. Range of motion, visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons score, and Constant score were evaluated preoperatively and at the final follow-up. The pre-, postoperative, and final acromiohumeral distances (AHD) were compared. The graft integrity was checked through a follow-up magnetic resonance imaging at least 6 months after surgery.

RESULTS

Torn grafts were identified in 6 cases (19%). AHD significantly increased from 5.0 to 8.0 mm postoperatively (P < .0001). However, there was no significant difference of 5.0 mm at the final follow-up AHD. Five cases (83%) of torn grafts were induced in the 3-layered graft sheet group, but the difference was not statistically significant (P = .067). Visual analog scale, forward elevation, internal rotation, American Shoulder and Elbow Surgeons, and Constant scores significantly improved at the last follow-up. Two cases of early infection were confirmed and the graft materials were all removed.

CONCLUSIONS

Despite the possibility of early infection, ASCR using TFL allograft is a reliable procedure for the irreparable rotator cuff tear. In particular, if the number of layers of TFL allograft increases, it is judged that it could become a more effective graft.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Biomechanical outcomes of superior capsular reconstruction for irreparable rotator cuff tears by different graft materials-a systematic review and meta-analysis

Background

Irreparable rotator cuff tears (IRCT) are defined as defects that cannot be repaired due to tendon retraction, fat infiltration, or muscle atrophy. One surgical remedy for IRCT is superior capsular reconstruction (SCR), which fixes graft materials between the larger tuberosity and the superior glenoid.

Patients and methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) criteria were followed for conducting the systematic review and meta-analysis. From their inception until February 25, 2022, Pubmed, Embase, and Cochrane Library's electronic databases were searched. Studies using cadavers on SCR for IRCT were also included. The humeral head's superior translation and subacromial peak contact pressure were the primary outcomes. The humeral head's anteroposterior translation, the kind of graft material used, its size, and the deltoid load were the secondary outcomes.

Results

After eliminating duplicates from the search results, 1,443 unique articles remained, and 20 papers were finally included in the quantitative research. In 14 investigations, the enhanced superior translation of the humeral head was documented in IRCTs. In 13 studies, a considerable improvement following SCR was found, especially when using fascia lata (FL), which could achieve more translation restraints than human dermal allograft (HDA) and long head of bicep tendon (LHBT). Six investigations reported a subacromial peak contact pressure increase in IRCTs, which could be rectified by SCR, and these studies found a substantial increase in this pressure. The results of the reduction in subacromial peak contact pressure remained consistent regardless of the graft material utilized for SCR. While there was a statistically significant difference in the change of graft material length between FL and HDA, the change in graft material thickness between FL and HDA was not significant. The humeral head's anterior-posterior translation was rising in IRCTs and could be returned to its original state with SCR. In five investigations, IRCTs caused a significant increase in deltoid force. Furthermore, only one study showed that SCR significantly decreased deltoid force.

Conclusion

With IRCT, SCR might significantly decrease the glenohumeral joint's superior and anterior-posterior stability. Despite the risks for donor-site morbidity and the longer recovery time, FL is still the best current option for SCR.