Clinical outcomes and temporal changes in the range of motion following superior capsular reconstruction for irreparable rotator cuff tears: comparison based on the Hamada classification, presence or absence of shoulder pseudoparalysis, and status of the subscapularis tendon

Revision rates and progression to shoulder arthroplasty after arthroscopic repair of massive rotator cuff tears

PURPOSE

The purpose of this systematic review was to assess the rate of progression to reverse total shoulder arthroplasty (RTSA) and to other interventions as revision surgeries after an arthroscopic repair of a massive rotator cuff tear (MRCT). Additionally, the review aimed at defining the best arthroscopic approach for the treatment of MRCTs in terms of failure and revision rates.

METHODS

The purpose of this systematic review and meta-analysis was to evaluate the rates of progression to reverse total shoulder arthroplasty in patients who underwent primary arthroscopic repair of an MRCT with different arthroscopic procedures. A meta-analysis was performed to compare the rate of progression to revision surgery and reverse total shoulder arthroplasty.

RESULTS

Eighteen articles were included in the qualitative synthesis and 14 articles were included in the meta-analysis. Overall, 934 patients and 950 shoulders were involved in the review. Seven-hundred and thirty patients and 735 shoulders were included in the meta-analysis. The proportion of revisions to reverse total shoulder arthroplasty was 0.9%, 3.3% and 0.1% for complete repair, partial repair and superior capsular reconstruction, respectively. No statistically significant differences were found across the groups in terms of progression to reverse total shoulder arthroplasty (n.s.). The average proportions of revisions to interventions different than reverse total shoulder arthroplasty. were 0.9% for complete repair, 2.0% for partial repair and 2.0% for superior capsular reconstruction again, no statistically relevant difference was found among the groups (n.s.).

CONCLUSIONS

The current review finds no statistically significant differences in the progression to reverse total shoulder arthroplasty or other revision procedures among partial repair, complete repair and superior capsular reconstruction for massive irreparable rotator cuff tears. It is crucial to understand the long-term outcomes of different surgical techniques for massive rotator cuff tears, particularly regarding failure rates and progression to further procedures.

LEVEL OF EVIDENCE

Level IV.

Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears Yields Good Clinical Outcomes for Patients With and Without Diabetes Mellitus

PURPOSE

To compare the clinical outcomes after superior capsule reconstruction (SCR) for irreparable rotator cuff tears (RCTs) in patients with and without diabetes mellitus (DM).

METHODS

Patients who underwent SCR using fascia lata autograft for irreparable RCTs between 2012 and 2020 with a minimum 2-year follow-up were divided into non-DM and DM groups. Propensity score matching was used to select controls matched for patients' characteristics. Only patients with glycosylated hemoglobin <8% were eligible. The visual analog scale for shoulder pain, American Shoulder and Elbow Surgeons and Japanese Orthopaedic Association scores, and acromiohumeral distance were evaluated preoperatively and at 2 years postoperatively. Shoulder active range of motion (ROM) was evaluated preoperatively and at 6 months, 1 year, and 2 years postoperatively. Graft integrity and postoperative complications that required additional surgery were evaluated. The Wilcoxon signed-rank test and Mann-Whitney U test were used to compare continuous variables. Pearson χ2 test and Fisher exact test were used for categorical variables. The interaction between the postoperative period and ROM was analyzed by the Friedman test and Wilcoxon rank-sum test with the Holm-Sidak post hoc test.

RESULTS

We studied 154 patients (non-DM, 130; DM, 24) who underwent SCR. After matching, 21 patients were selected in each group. All clinical outcomes significantly improved at 2 years (all P < .05) in both groups. We found no significant differences in clinical outcomes and rates of patients who achieved minimal clinically important differences in visual analog scale and American Shoulder and Elbow Surgeons scores between the groups (P = .10 to ≥.999). The rates of graft tear (both 9.5%) and complications (non-DM, 4.8%; DM, 0%) were not significantly different (both P ≥ .999).

CONCLUSIONS

SCR using fascia lata autograft for irreparable RCTs yields good clinical outcomes, including ROM, in patients with and without DM. No significant differences in postoperative outcomes were observed between the 2 groups.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Comparison of the clinical outcomes and temporal changes between superior capsular reconstruction and reverse total shoulder arthroplasty in patients with irreparable rotator cuff tear without osteoarthritic change

BACKGROUND

Superior capsular reconstruction (SCR) and reverse total shoulder arthroplasty (rTSA) are widely performed in patients with irreparable rotator cuff tears, including pseudoparalytic shoulder (PPS), and have shown positive clinical outcomes. However, limited studies have compared these 2 in terms of functional recovery in patients with PPS without osteoarthritic change. Thus, this study aimed to compare the clinical outcomes and to clarify the characteristics and differences in temporal changes among patients who underwent either rTSA or SCR using tensor fascia lata for PPS due to irreparable rotator cuff tear without osteoarthritic change (Hamada grade ≤3).

METHODS

We enrolled a total of 39 patients who underwent SCR (n = 20) or rTSA (n = 19 cases) with a follow-up period of 2 years. All patients were followed up at 2, 3, 4, 5, 6, 8, 10, 12, and 24 months postoperatively. Preoperative and postoperative range of motion (ROM), American Shoulder and Elbow Surgeons scores, and temporal changes in ROMs were compared between the 2 groups.

RESULTS

The SCR group had significantly better ROM than the rTSA group in flexion (146° ± 34° vs. 132° ± 23°, P = .022), abduction (147° ± 36° vs. 130° ± 23°, P = .0092), internal rotation (11 ± 3 Th10 vs. 6 ± 3 L3, P < .001), and American Shoulder and Elbow Surgeons score (84.1 ± 13.8 vs. 80.1 ± 6.1, P = .0096). While the rTSA group achieved 100° in flexion and abduction after 3 months postoperatively, the SCR group took approximately 5 months. However, the SCR group exceeded the rTSA group in flexion and abduction at six months postoperatively. In the SCR group, some patients with irreparable subscapularis tendon tears could not achieve 90° shoulder elevation. Both groups showed significant improvements in shoulder flexion and abduction compared to the preoperative state (P < .001).

CONCLUSION

Although SCR requires a longer rehabilitation period, it provides similar outcomes to rTSA after two years for nonosteoarthritic, irreparable cuff tears with pseudoparalysis.

Pseudoparalysis and Pseudoparesis of the Shoulder: Definitions, Management, and Outcomes

Loss of shoulder function can be a complex condition to manage. Specifically, the definition between the terms pseudoparalysis and pseudoparesis remains inconsistent in the literature based on various factors including chronicity, present pathology, and the role of pain in the loss of function. There is also debate as to the optimal management strategies for these challenging conditions. In the setting of advanced glenohumeral arthritis or arthropathy in the correct patient, arthroplasty provides consistent and reliable results. However, in younger patients or the patient without arthritis, arthroplasty may not be the best option. In some cases, addressing pain with biceps procedures, balloon spacer placement, débridement, or others may be appropriate. However, other instances may require attempts at improving shoulder kinematics with procedures such as rotator cuff repair, superior capsular reconstruction, and tendon transfer. In this review, we discuss current definitions for pseudoparalysis and pseudoparesis, in addition to reviewing the indications for the various treatment options and their respective outcomes.

Effect of Medial or Lateral Graft Failure on Graft Volume and Clinical Outcomes After Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears

BACKGROUND

Graft failure is a common complication after superior capsule reconstruction (SCR). The graft in SCR is fixed on the greater tuberosity and superior glenoid, and graft failure has been reported on both sides.

PURPOSE

To evaluate the clinical manifestations of patients with graft failure after SCR and identify the clinical and radiological differences between medial and lateral graft failure.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent SCR with a dermal allograft for symptomatic irreparable rotator cuff tears between March 2018 and September 2021 were retrospectively reviewed. All patients had minimum 2-year follow-up and underwent magnetic resonance imaging at 6 months postoperatively. Patients with graft failure were divided into 2 groups: those with lateral graft failure on the greater tuberosity side (group I) and those with medial graft failure on the glenoid side (group II). Patients with intact grafts were included in group III as a control group. Intergroup differences in clinical and radiological characteristics were analyzed, and multiple regression analysis was performed.

RESULTS

Among the 93 patients included, there were 18 patients in group I, 15 in group II, and 60 in group III. Overall, 11 patients (61.1%) in group I and 9 patients (60.0%) in group II had a partial graft rupture at one anchor. The postoperative graft volume was significantly lower in group I than in groups II and III (2514.0 ± 564.3 mm3, 3183.5 ± 547.1 mm3, and 3198.0 ± 584.8 mm3, respectively; P = .002 for group I vs II; P < .001 for group I vs III). The acromiohumeral distance (AHD) was significantly increased at 6 months postoperatively compared with before surgery in group I (6.6 ± 1.6 mm vs 4.3 ± 1.9 mm, respectively; P < .001) and group II (7.4 ± 1.3 mm vs 5.7 ± 1.7 mm, respectively; P = .002). However, group I exhibited a significantly greater decrease in the AHD over time than group II (P < .001) and a significantly lower AHD at the final follow-up than the other groups (P < .001). The postoperative American Shoulder and Elbow Surgeons score was significantly lower in group I than in the other groups (P < .001). On multiple regression analysis, fatty infiltration of the infraspinatus muscle, Hamada grade, and graft width were independent factors for lateral graft failure.

CONCLUSION

Patients with lateral graft failure had inferior clinical outcomes and lower postoperative graft volumes than those with medial graft failure after SCR using a dermal allograft. The AHD of patients with lateral graft failure improved postoperatively; however, it deteriorated over time.

Superior Capsular Reconstruction Using an Acellular Dermal Xenograft or Allograft Improves Shoulder Function but Is Associated with a High Graft Failure Rate

Objectives: The purpose of the present study was to evaluate clinical and functional outcomes, graft integrity rate and progression of osteoarthritis after superior capsular reconstruction (SCR) at short-term follow-up. Methods: Consecutive patients that underwent SCR using an acellular dermal xeno- or allograft between May 2018 and June 2020 for the treatment of irreparable posterosuperior rotator cuff tears were included. Shoulder function (American Shoulder and Elbow Surgeons [ASES] score), pain (Visual Analog Scale [VAS] for pain) and active shoulder range of motion (ROM) were evaluated preoperatively and after a minimum of 24 months postoperatively. Isometric strength was measured at follow-up and compared to the contralateral side. Magnetic resonance imaging was performed to evaluate graft integrity and osteoarthritis progression (shoulder osteoarthritis severity [SOAS] score). Results: Twenty-two patients that underwent SCR using a xeno- (n = 9) or allograft (n = 13) were evaluated 33.1 ± 7.2 months postoperatively. Four patients in the xenograft group underwent revision surgery due to pain and range of motion limitations and were excluded from further analysis (revision rate: 18.2%). Shoulder function (ASES score: 41.6 ± 18.8 to 72.9 ± 18.6, p < 0.001), pain levels (VAS for pain: 5.8 ± 2.5 to 1.8 ± 2.0, p < 0.001) and active flexion (p < 0.001) as well as abduction ROM (p < 0.001) improved significantly from pre- to postoperatively. Active external rotation ROM did not improve significantly (p = 0.924). Isometric flexion (p < 0.001), abduction (p < 0.001) and external rotation strength (p = 0.015) were significantly lower in the operated shoulder compared to the non-operated shoulder. Ten shoulders demonstrated a graft tear at the glenoid (n = 8, 44.4%) or humerus (n = 2, 11.1%). Graft lysis was observed in seven shoulders (38.9%). The graft was intact in one shoulder (5.6%), which was an allograft. A significant progression of shoulder osteoarthritis was observed at follow-up (SOAS score: 42.4 ± 10.1 to 54.6 ± 8.4, p < 0.001). Conclusions: At short-term follow-up, SCR using an acellular dermal xeno- or allograft resulted in improved shoulder function and pain with limitations in active external rotation ROM and isometric strength. Graft failure rates were high and osteoarthritis progressed significantly. Level of Evidence: Retrospective cohort study, Level III.

Influence of the rotator cuff tear pattern in shoulder stability after arthroscopic superior capsule reconstruction: a computational analysis

OBJECTIVES

To assess the ability of the arthroscopic superior capsule reconstruction (SCR) in restoring glenohumeral stability in the presence of different preoperative patterns of irreparable rotator cuff tears (RCTs).

METHODS

A computational musculoskeletal (MSK) model of the upper limb was used to simulate isolated SCR and to estimate the stability of the shoulder. Four patterns of preoperative irreparable RCTs were modeled: Supraspinatus (SSP); SSP ​+ ​Subscapularis (SSC); SSP ​+ ​Infraspinatus (ISP); and SSP ​+ ​SSC ​+ ​ISP. The muscles involved in the irreparable RCT were removed from the MSK model to simulate an irreparable full-thickness tear. In the MSK model, the muscle and joint forces were estimated for a set of upper limb positions, from four types of motions (abduction in the frontal plane, forward flexion in the sagittal plane, reaching behind the back, and combing the hair) collected in a biomechanics laboratory, through inverse dynamic analysis. The stability of the shoulder was estimated based on the tangential and compressive components of the glenohumeral joint reaction force. The comparison of pre- and post-operative conditions, for the four patterns of irreparable RCTs, with the healthy condition, was performed using ANOVA and Tukey's tests (statistical level of p ​< ​0.05).

RESULTS

In the setting of an isolated irreparable SSP tear, SCR statistically significantly improved stability compared with the preoperative condition (p ​< ​0.001). For the irreparable SSP ​+ ​SSC pattern, a statistically significant loss in stability was observed (p ​< ​0.001) when SCR was applied. For the irreparable SSP ​+ ​ISP and SSP ​+ ​SSC ​+ ​ISP patterns, the postoperative condition increased shoulder stability, compared to the preoperative condition; however, the improvement was not statistically significantly different.

CONCLUSION

Isolated SCR for irreparable RCTs extending beyond the SSP does not statistically significantly improve the stability of the glenohumeral joint.

LEVEL OF EVIDENCE

Level IV.

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.

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.

Postoperative Graft Volume Reduction Is Associated With Inferior Clinical Outcomes of Superior Capsule Reconstruction Using an Acellular Dermal Matrix Allograft

PURPOSE

To evaluate whether postoperative graft volume reduction is associated with clinical outcomes after superior capsule reconstruction (SCR) and to identify factors related to graft volume change.

METHODS

Between May 2018 and June 2021, patients who underwent SCR with acellular dermal matrix allograft for irreparable rotator cuff tear with a minimum 1-year follow-up and who had intact graft continuity in postoperative 6-month magnetic resonance imaging were retrospectively reviewed. The lateral half to the medial half of the graft volume ratio was defined as lateral half graft volume ratio. The difference between the preoperative and postoperative lateral half graft volume ratio was defined as lateral half graft volume change. Patients were divided into 2 groups: those with preserved graft volume (group I) and those with reduced graft volume (group II). Intergroup differences in clinical and radiological characteristics were analyzed.

RESULTS

A total of 81 patients were included, with 47 (58.0%) in group I and 34 (42.0%) in group II. Group I showed significantly lower lateral half graft volume change (0.018 ± 0.064 vs 0.370 ± 0.177; P < .001) than group II. Group II showed significantly greater preoperative Hamada grade (1.3 ± 0.5 vs 2.2 ± 0.6, P < .001), an anteroposterior distance of the graft at the greater tuberosity (APGT) (30.3 ± 4.8 vs 35.2 ± 3.8, P < .001), and fatty infiltration of infraspinatus (2.3 ± 0.9 vs 3.1 ± 0.8, P < .001) and subscapularis (0.9 ± 0.9 vs 1.6 ± 1.3, P = .009) than group I. Group II had a significantly lower proportion of patients achieving MIC in Constant score than group I (70.2% vs 47.1%, P = .035). The Hamada grade, APGT, and fatty infiltration of infraspinatus and subscapularis were independent factors of graft volume change.

CONCLUSIONS

Although SCR improved pain and shoulder function, postoperative graft volume reduction was related to a lower rate of minimal important change achievement in the Constant score compared with preserved graft volume. The preoperative Hamada grade, APGT, and fatty infiltration of infraspinatus and subscapularis were associated with graft volume reduction.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Clinical outcomes and temporal changes in the range of motion following reverse total shoulder arthroplasty

BACKGROUND

Reverse total shoulder arthroplasty is a definitive solution for the treatment of massive rotator cuff tear and shoulder pseudoparalysis since it can improve shoulder function, especially in elderly individuals. For many elderly individuals, the concern is when they can return to their daily lives after surgery. This study aimed to clarify the characteristics of temporal postoperative values following reverse total shoulder arthroplasty and investigate the factors that affect clinical outcomes.

METHODS

This study included 52 patients (mean 79.2 years, range 70-87 years) who underwent primary reverse total shoulder arthroplasty for shoulder pseudoparalysis at a single institution by a single surgeon using the same implant between October 2014 and June 2019. We divided 52 patient into the following groups (1) female (n = 34)vs. male (n = 18) patients; (2) with (n = 19) vs. without (n = 33) arthritic changes in glenohumeral joints (Hamada grade 2, 3 vs. 4, 5); (3) with (n = 23) vs. without (n = 29) subscapularis tendon repair; and investigated the temporal changes in the range of motion (flexion, abduction, external rotation, and internal rotation) and American Shoulder and Elbow Surgeons scores.

RESULTS

Significant differences were observed in postoperative shoulder flexion (P = .046) and abduction (P = .049) between the female and male groups. The male patients were able to obtain quick functional recovery. However, no significant differences were observed in postoperative American Shoulder and Elbow Surgeons scores, and the shoulder range of motion between patients with Hamada grade 2, 3 and 4, 5, and between the subscapularis repair and no repair groups.

CONCLUSION

The factor that affected the final and temporal values of range of motion after reverse total shoulder arthroplasty was sex, rather than the arthritic changes in glenohumeral joint and the treatment of the subscapularis tendon.

Editorial Commentary: Superior Capsule Reconstruction: Acellular Allograft at 45° of Glenohumeral Abduction Improves Glenohumeral Stability, but Fascia Lata Autograft Remains Superior

Originally, fascia lata autograft was used for superior capsule reconstruction (SCR) to restore glenohumeral stability in irreparable rotator cuff tears. Consistently excellent clinical outcomes with low graft tear rates have been reported, without repair of tears in the supraspinatus and infraspinatus tendons. On the basis of our experience and studies published in the 15 years since the first SCR using fascia lata autograft in 2007, we can say that this technique is the gold standard. SCR using fascia lata autograft can cover all irreparable rotator cuff tears (Hamada grade 1-3; although the indication for SCR using other grafts, including dermal allograft, biceps, and hamstrings, is only Hamada grade 1 or 2); creates excellent clinical outcomes with low graft tear rates in short-term, long-term, and multicenter studies; regenerates the fibrocartilaginous insertions at both the greater tuberosity and superior glenoid according to histological study; and enables complete restoration of shoulder stability and subacromial contact pressure in cadaveric biomechanical studies. In some countries, dermal allograft is preferred for SCR. However, high rates of graft tear and complications have been reported after SCR using dermal allografts, even in limited indications of irreparable rotator cuff tears (Hamada grade 1 or 2). This high failure rate results from the lack of stiffness and thickness of the dermal allograft. Dermal allografts in SCR can be elongated by 15% after only a couple of physiological shoulder movements, whereas fascia lata graft cannot. This 15% graft elongation, which creates less glenohumeral stability and high graft tear after SCR, is a fatal problem of dermal allograft for SCR in irreparable rotator cuff tears. Current research suggests that SCR using dermal allografts is not strongly recommended for the treatment of irreparable rotator cuff tears. Dermal allograft probably should be used only for augmentation of rotator cuff complete repair.

Outcomes of Isolated Biceps Tenodesis/Tenotomy or Partial Rotator Cuff Repair Associated with Biceps Tenodesis/Tenotomy for Massive Irreparable Tears: A Systematic Review

Irreparable large to massive rotator cuff tears (MIRCTs) are a prevalent cause of shoulder pain and dysfunction, and nonoperative treatment may not always be effective. Various surgical options exist, with isolated biceps tenotomy/tenodesis (BT) or arthroscopic partial repair with associated biceps tenotomy/tenodesis (PCR-BT) being the most common. The aim of this study was to systematically review the available data on the clinical and functional outcomes of BT and PCR-BT in patients with MIRCTs.

METHODS

MEDLINE, Embase, and CENTRAL databases were searched for studies on the treatment of MIRCT. We included studies with BT or PCR-BT with a minimum follow-up of 24 months. The MINORS (Methodological Index for Nonrandomized Studies) score was used to assess study quality. Outcomes included were the visual analog scale for pain, functional scores such as Constant-Murley and American Shoulder and Elbow Surgeons, range of motion, radiological measurements, and complications.

RESULTS

A total of 1101 patients (506 had a BT and 595 had a PCR-BT) from 22 studies were included (cases series = 13, case-control = 7, randomized control trial = 1, prospective cohort study = 1). The mean MINORS score was 13.2 ± 3.2. The mean age and follow-up were 67 ± 6.8 years and 4.58 ± 1.1 years (range, 2, 12), respectively. The VAS improvement showed at the last follow-up for PCR-BT (range, 1.97, 5.8) and BT (range, 4, 6.1). CMS was improved at the final follow-up for PCR-BT (range, 13, 47.6) and BT (range, 10.8, 28). Regarding the ASES, it has demonstrated significant improvements for PCR-BT (range, 31.81, 44.8) and BT (range, 30,45.8). For forward flexion, PCR-BT showed improvement (range, -14°, 59.4°), as well as the BT group (range, 2°, 27.9°).

CONCLUSIONS

This systematic review demonstrated that both BT and PCR-BT improve functional outcomes and reduce pain at midterm follow-up for MIRCT. Since we know that a failed cuff repair would worsen the shoulder, it might be beneficial in terms of the risk-benefit ratio to not repair in certain patients with MIRCT.

Structural and clinical outcomes after superior capsule reconstruction using an at least 6-mm-thick fascia lata autograft including the intermuscular septum

BACKGROUND

Superior capsule reconstruction (SCR) is a viable treatment option for irreparable rotator cuff tears. However, graft tear rate is highly variable in the previous studies, and the impact of graft tears on clinical outcomes after arthroscopic SCR remains controversial. We aimed to investigate the graft tear rate, timing of graft tear, and the impact of graft tears on clinical outcomes after arthroscopic SCR using an at least 6-mm-thick fascia lata autograft including the intermuscular septum.

METHODS

This retrospective multi-institutional study included 154 patients (79 women and 75 men; mean age, 69.9 yr; age range, 49-87 yr) with irreparable rotator cuff tears who underwent arthroscopic SCR using an at least 6-mm-thick fascia lata autograft including the intermuscular septum and completed a minimum 2-year follow-up. Postoperative graft integrity was evaluated by magnetic resonance imaging examinations performed at 3, 6, 12, and 24 mo after surgery. The presence of a full-thickness defect within the graft was diagnosed as a graft tear. In contrast, a graft without a full-thickness defect was diagnosed as a healed graft. We compared the following data between patients with and without graft tears: (1) baseline characteristics, (2) visual analog scale pain score, (3) Japanese Orthopaedic Association score, (4) American Shoulder and Elbow Surgeons shoulder score, and (5) active range of motion.

RESULTS

The overall graft tear rate was 11.7% (18 of 154 patients). Of 18 graft tears, 14 (77.8%) occurred within 6 mo after SCR. Two additional graft tears were diagnosed at 12 mo postoperatively and another 2 at 24 mo after SCR. The visual analog scale, American Shoulder and Elbow Surgeons, and Japanese Orthopaedic Association scores improved significantly after SCR in both patients with and without graft tears (all P < .0001). However, patients with graft tears showed significantly inferior postoperative visual analog scale, American Shoulder and Elbow Surgeons, and Japanese Orthopaedic Association scores (1.9, 75.2, and 77.4, respectively) than those without graft tears (0.5, 93.1, and 92.3, respectively; all P < .01).

CONCLUSIONS

The overall graft tear rate after arthroscopic SCR using an at least 6-mm-thick fascia lata autograft including the intermuscular septum was low (11.7%), relatively to that reported in previous studies. The majority of graft tears (77.8%) occurred within 6 mo after SCR. Graft healing was associated with more favorable clinical outcomes after SCR.

Acellular Dermal Allograft and Tensor Fascia Lata Autograft Show Similar Patient Outcome Improvement and High Rates of Complications and Failures at a Minimum Two-Year Follow-up: A Systematic Review

PURPOSE

To compare clinical and radiologic outcomes following superior capsular reconstruction (SCR) using dermal allograft versus tensor fascia lata (TFL) autograft for massive rotator cuff tears with a minimum 2-year follow-up.

METHODS

A literature search was performed by querying Scopus, EMBASE, and PubMed computerized databases from database inception through September 2022 in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies evaluating clinical and radiologic outcomes, as well as complications following SCR for the treatment of massive rotator cuff tears were included. Study quality was assessed via the Newcastle-Ottawa Scale and the National Institutes of Health Quality Assessment. The mean change from preoperative to postoperative values (delta) was calculated for each outcome.

RESULTS

Seventeen studies, consisting of 519 patients were identified. Mean duration of follow-up ranged from 24 to 60 months. Mean reduction in visual analog scale pain score ranged from 2.9 to 5.9 points following use of dermal allograft, and 3.4 to 7.0 points following TFL autograft reconstruction. Mean improvements in American Shoulder and Elbow Surgeons score were similar between groups (dermal allograft: 28.0-61.6; TFL autograft: 24.7-59.3). The mean increase in forward flexion ranged from 31° to 38° with dermal allograft, versus 19° to 69° with TFL autograft. Average improvement in active external rotation with dermal allograft ranged from -0.4° to 11° and from 2° to 22.4° using TFL autograft. A similar change in acromiohumeral distance following SCR (dermal allograft: 0.9-3.2 mm; TFL autograft: 0.3-3.6 mm) was appreciated. The rate of complications within the dermal allograft group ranged from 4.5% to 38.2% versus 13.3% to 86.4% following TFL autograft. Failure rate ranged from 4.5 to 38.2% following dermal allograft versus 4.5 to 86.4% with TFL autograft.

CONCLUSIONS

Acellular dermal allograft versus TFL autograft for SCR both demonstrate improved VAS and American Shoulder and Elbow Surgeons scores, with increased values in flexion and external rotation, and increased visual analog scale, although with high variability. Both grafts demonstrate high rates of complications and failures at minimum 2-year follow-up.

LEVEL OF EVIDENCE

IV; systematic review of level II-IV studies.

Outcomes of combined anterior latissimus dorsi and teres major tendon transfer for irreparable anterosuperior rotator cuff tears

BACKGROUND

Irreparable anterosuperior rotator cuff tears (IASRCTs) can result in loss of active elevation, loss of internal rotation, and pseudoparalysis. Joint-preserving treatment options for IASRCTs in young and high-demand elderly patients are limited. The purpose of this study was to evaluate the clinical and radiologic outcomes of combined anterior latissimus dorsi and teres major (aLDTM) tendon transfer in patients with IASRCTs without reconstruction of the superior rotator cuff and capsular portion.

METHODS

This retrospective study was conducted between 2015 and 2018. We included patients who underwent combined aLDTM tendon transfer for IASRCTs. Clinical outcomes included visual analog scale for pain, Constant score, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder scores, activities of daily living requiring active internal rotation score, active range of motion, subscapularis-specific physical examination, and rate of return to work. Radiographic analyses included the assessment of acromiohumeral distance, Hamada grade for cuff tear arthropathy, rate of anterior glenohumeral subluxation reduction, and transferred tendon integrity at 2 years postoperatively.

RESULTS

The mean follow-up period was 38.1 ± 13.7 (range: 24-63) months. Of the patients, 30 (mean age: 64.1 years) met the study criteria. Postoperatively, mean Constant, American Shoulder and Elbow Surgeons, University of California Los Angeles, and activities of daily living requiring active internal rotation scores improved from 47.4 to 69.9 (P < .001), 44.9 to 79.2 (P < .001), 20.0 to 28.7 (P < .001), and 13.2 to 26.9 (P < .001), respectively. The mean active range of motion was significantly increased postoperatively for both forward elevation (P < .001) and internal rotation at the back (P < .001). Of the patients, 24 (83%) returned to their previous work. No significant progression of cuff tear arthropathy was observed at final follow-up (Hamada grade: preoperative 1.3 ± 0.5 to postoperative 1.5 ± 0.7; p=0.155). Fifteen of 30 patients (50%) restored the anterior glenohumeral subluxation that was apparent preoperatively. One patient presented with transient axillary nerve palsy after surgery. Two patients presented with partial nonretracted tears of the transferred tendon.

CONCLUSION

This minimum 2-year follow-up study demonstrated that combined aLDTM tendon transfer without reconstruction of the superior rotator cuff and capsular portion was a viable treatment option with favorable clinical and radiologic outcomes for patients with IASRCTs.

Outcomes of reverse shoulder arthroplasty following failed superior capsular reconstruction

BACKGROUND

Superior capsular reconstruction (SCR) can be used for massive irreparable rotator cuff tears in the absence of significant degenerative changes; however, those who fail an SCR may require reverse shoulder arthroplasty (RSA). The effect of a previously performed SCR on outcomes following RSA remains unknown.

METHODS

Subjects who underwent RSA from May 2015 to January 2021 at 2 separate institutions were retrospectively identified through prospectively collected databases. Patients who underwent RSA after failed SCR were matched to those who underwent RSA after failed rotator cuff repair (RCR) based on the number of previous ipsilateral shoulder procedures (n = 1, 2, ≥3) and secondarily by age within 5 years. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain, and Western Ontario Osteoarthritis of the Shoulder index (WOOS) scores were compared between groups. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) thresholds were calculated to determine clinically relevant differences between groups.

RESULTS

Forty-five patients were included (32 RSA following RCR, 13 following SCR). There were more smokers (P = .001) and worker's compensation cases (P = .034) in the SCR group. The RCR cohort was older (P = .007) and had a greater incidence of mental health (P > .999) and somatic disorders (P = .698), although these did not reach statistical significance. The mean follow-up for the RCR and SCR groups were 24.2 ± 23.3 and 20.4 ± 14.9 months following RSA, respectively (P = .913). The time from index RCR or SCR to RSA were 94.4 ± 22.2 and 89.2 ± 5.3 months, respectively (P = .003). Pre- and postoperative range of motion were similar between groups, as was the overall change in forward flexion (P = .879), abduction (P = .971), and external rotation (P = .968) following RSA. The RCR group had lower postoperative VAS pain (P = .009), higher SANE (P = .015), higher ASES (P = .008), and higher WOOS (P = .018) scores. The percentage achieving the MCID (P = .676) and SCB (P > .999) were similar; however, 56.7% of the RCR group met the SANE PASS threshold compared with 0.0% in the SCR group (P = .005). There were no differences in postoperative complications (P = .698) or revision rates (P = .308) following RSA between cohorts.

CONCLUSION

When matched for number of previous procedures to the ipsilateral extremity and age, patients who underwent RSA following failed SCR had worse clinical outcome scores than their RSA following failed RCR counterparts. No patient in the SCR group met the SANE PASS threshold, whereas more than half of the RCR group did.

Acromial and humeral head osteolysis following superior capsular reconstruction using autologous tensor fascia lata graft

BACKGROUND

Graft tear is a critical complication following superior capsular reconstruction (SCR) as it directly links with clinical outcomes. No previous reports have described acromial and humeral head osteolysis following SCR. Acromial and humeral head osteolysis may incidentally occur after SCR using autologous tensor fascia lata graft. This study aimed to demonstrate the incidence of osteolysis following SCR using autologous tensor fascia lata graft and investigate the factors that affect osteolysis.

METHODS

This retrospective cohort study included patients who underwent SCR for irreparable rotator cuff tears between June 2014 and June 2019. The patients were divided into 2 groups-those with no osteolysis and those with osteolysis-and were compared. For subanalysis, patients in the osteolysis group were further divided into 3 groups according to the location of the osteolysis-acromial osteolysis, humeral head osteolysis, and acromial and humeral head osteolysis-to clarify the factors determining the location of osteolyses. The shoulder range of motion was evaluated preoperatively and 24 months postoperatively. Additionally, the following items were evaluated: condition of the subscapularis tendon, Hamada classification (grade 2 or 3), critical shoulder angle, acromiohumeral distance measured preoperatively and 24 months postoperatively, graft size, and graft thickness. In addition, the graft condition was evaluated using magnetic resonance imaging 12 months postoperatively.

RESULTS

In total, 57 patients were enrolled and followed up for a minimum of 2 years (follow-up rate, 92% [57 of 62 cases]). Overall, the incidence of osteolysis following SCR was 35.1% (20 of 57 cases; acromial osteolysis in 7, humeral head osteolysis in 3, and acromial and humeral head osteolysis in 10). Compared with the group with no osteolysis, the osteolysis group had no inferior clinical outcomes or higher graft tear rates. The proportions of Hamada grade 3 (P = .041) and involvement of the subscapularis tendon (P = .020) were significantly higher in the osteolysis group. The relative risks of subscapularis involvement and Hamada grade 3 for osteolysis were 2.9 and 5.1, respectively. In the subanalysis, the factors determining the location of the osteolysis could not be clarified.

CONCLUSIONS

This study suggested that the progression of the Hamada classification and condition of the subscapularis tendon affect the occurrence of osteolyses. However, these osteolyses were not associated with clinical outcomes, including graft tear rate and shoulder range of motion.

Editorial Commentary: Determination of Meaningful, Clinically Significant Outcome Thresholds for Superior Capsular Reconstruction of the Shoulder: Predicting Those Patients Who Improve and Those Who Don't!

Since the introduction of superior capsular reconstruction (SCR) for the treatment of irreparable rotator cuff tears nearly 10 years ago, we have witnessed widespread adoption by the arthroscopic shoulder community alongside an exponential increase in use within North America. To date, more than 42,000 acellular dermal allografts have been implanted in the United States alone, and our indications and surgical technique have been progressively refined in response to the evolving body of clinical outcomes research. However, with P values set aside, the real question still remains: how do our patients actually do after SCR? With the advent of clinically significant outcomes such as the patient acceptability symptomatic state and substantial clinical benefit, investigators have sought to establish more practical, patient-centered benchmarks for success after an intervention. Rather than just seeking the baseline expectations via the minimally clinically important difference (i.e., "I am better"), substantial clinical benefit (i.e., "I am so much better") and patient acceptability symptomatic state (i.e., "I am 'okay' with how I feel") truly clarify patient satisfaction and provide measurable units of patient improvement. These must be assessed on an individual basis, as aggregated averages introduce outliers that can distort the outcomes. Based on these end points, prognostic factors may allow a more concrete assessment of surgical risk while equipping physicians with appropriate information to guide ideal patient selection and optimize chances of success. Patients of female sex, older age, worker's compensation status, and those with subscapularis involvement are less likely to achieve clinically significant outcomes at minimum 1-year follow-up after SCR. Based on the current study, surgeons should exercise caution in recommending SCR for patients of advancing chronological age and significant subscapularis involvement, particularly if irreparable or untreated.

Superior Capsular Reconstruction Using Acellular Dermal Allograft Combined With Remaining Rotator Cuff Augmentation Improved Shoulder Pain and Function at 1 Year After The Surgery

PURPOSE

The purpose of this study is to report structural integrity and clinical outcomes of superior capsular reconstruction (SCR) using a 4- to 5-mm acellular dermal allograft combined with augmentation of the remaining rotator cuff to the graft.

METHODS

We prospectively recruited 21 patients with symptomatic irreparable rotator cuff tear who required SCR. At least 6 months after the SCR, we evaluated each patient's graft healing by magnetic resonance imaging (MRI). We also assessed the range of motion (ROM), strength for forward flexion and external rotation, visual analog scale for pain (PVAS), American Shoulder and Elbow Surgeon (ASES) score, and Constant score. At minimum of 1 year after the surgery, we evaluated the number of patients with minimal clinically important differences (MCIDs) for each score to compare patients with healed and unhealed grafts.

RESULTS

Postoperative MRI showed the grafts intact in 14 patients (66.7%). Among 7 patients with unhealed grafts, tears were observed in 3 patients (42.9%) on the glenoid side, 3 (42.9%) on the humeral side, and 1 (14.3%) on both sides. PVAS, ASES score, and the Constant score improved after surgery (4.0 to 0.7 for PVAS [P < .001], 55.5 to 87.0 for ASES score [P < .001], and 56.0 to 65.9 for Constant score [P = .007]). However, there were no differences in postoperative ROM and muscle strength compared to preoperative measurements. MCIDs were reached in 90.5% of patients (n = 19) for the PVAS and in 71.4% of patients (n = 15) for the ASES score. Only 33.3% of patients (n = 7) obtained MCIDs for the Constant score, and none of the patients with a graft tear obtained MCIDs in the Constant score (P = .047).

CONCLUSION

The graft complete healing rate was 66.7%, although pain relief and functional improvement were satisfactory regardless of graft structural integrity. However, muscle strength recovery was not optimal until 1 year after surgery.

LEVEL OF EVIDENCE

Level IV; case series.