Massive rotator cuff tears in patients younger than 65 years. What treatment options are available?

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.

Arthroscopic advancement of the supraspinatus muscle and tendon for posterosuperior massive rotator cuff tears

The tension-free repair of retracted supraspinatus tears with the open muscle and tendon advancement technique first described by Debeyre in 1965 gave satisfactory clinical results. The purpose of this anatomical study was to test the feasibility of an arthroscopic supraspinatus advancement technique. A total of 10 cadaveric shoulders were operated. We assessed the feasibility, measured the slide distance, and recorded the position of the suprascapular nerve (SSN) for each shoulder. Reattachment of the tendon to its native footprint was achieved in all cases. The mean slide distance was 38.8 mm ± 3.6 (33-44). The SSN was released and tension-free in all shoulders. Arthroscopic advancement of the supraspinatus muscle and tendon enables complete rotator cuff repair in irreparable retracted posterosuperior tears and is a noteworthy alternative to the other techniques. Level of Evidence: IV.

Does arthroscopic superior capsule reconstruction using porcine dermal xenograft represent a viable option in case of massive irreparable posterosuperior rotator cuff tear?

INTRODUCTION

The aim of the present study was to evaluate clinical and structural outcomes of patients with a massive irreparable rotator cuff tear treated with arthroscopic superior capsule reconstruction using an acellular porcine dermal xenograft. We hypothesized that this procedure would lead to improvement in clinical and functional results and that structural failure would not influence the final clinical results.

MATERIALS AND METHODS

A retrospective analysis on arthroscopic superior capsule reconstruction performed from October 2016 to January 2019 was conducted. The procedure was performed in patients with a massive irreparable posterosuperior rotator cuff tear without a severe glenohumeral arthropathy (Hamada I and II) and complaining a painful pseudoparalysis. Clinical evaluation and MRI study were performed before surgery and after at least 14 months.

RESULTS

A comprehensive group of 21 patients with 11 females and 10 males and a mean age of 57 ± 8.5 years underwent arthroscopic superior capsule reconstruction. The graft had a thickness of 1.5 mm in the first 9 cases (43%) since it was used in a single layer. The graft was thereafter doubled for technique evolution in the following 12 cases (57%) achieving a graft thickness of 3 mm. Active ROM significantly improved with a mean increase of active forward flexion from 72.8° ± 7.5° to 120.6° ± 4.5°, active abduction from 68.3° ± 10.2° to 140.2° ± 8.8° and external rotation from 38.2° ± 11.2° to 56.7° ± 6.8° at the last follow-up. The mean Constant score significantly improved from 40.4 ± 6.7 to 73.3 ± 8.2. A graft tear revealed in 52% (11/21) of overall patients was significantly more frequent in single layer graft when compared to double layer (77% vs 33%, p < 0.05). Location and type of graft tear significantly influenced final outcomes. Patients with a healed (graft continuity with bone at medial and lateral insertion) or medial graft tear showed statistically significant better outcomes when compared with patients in which the graft was completely reabsorbed or torn on humeral side (p < 0.05).

CONCLUSION

Arthroscopic superior capsule reconstruction using an acellular porcine dermal xenograft may be a viable alternative to treat massive posterosuperior rotator cuff tear in patients with a painful pseudoparalysis without anterosuperior escape. Structural failure may strongly influence final outcomes with significant role played by tear location.

Outcomes and complications of primary reverse shoulder arthroplasty with minimum of 2 years' follow-up: a systematic review and meta-analysis

BACKGROUND

Primary reverse shoulder arthroplasty (rTSA) is an effective treatment option for reducing pain and improving function for patients with rotator cuff tear arthropathy, irreparable rotator cuff tears, glenoid deformity, and other challenging clinical scenarios, including fracture sequelae and revision shoulder arthroplasty. There has been a wide range of reported outcomes and postoperative complication rates reported in the literature. The purpose of this systematic review and meta-analysis is to provide an updated review of the clinical outcomes and complication rates following primary rTSA.

METHODS

A systematic review and meta-analysis was performed to evaluate outcomes and complications following primary rTSA according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Demographics, range of motion, patient-reported outcome measures (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Constant scores), number of complications, and revisions were extracted, recorded, and analyzed from the included articles.

RESULTS

Of the 1415 studies screened, 52 studies met the inclusion criteria comprising a total of 5824 shoulders. The mean age at the time of surgery was 72 years (range: 34-93), and the mean follow-up was 3.9 years (range: 2-16). Patients demonstrated a mean improvement of 56° in active flexion, 50° in active abduction, and 14° in active external rotation. Regarding functional outcome scores, rTSA patients demonstrated a mean clinically significant improvement of 37 in Constant score (minimal clinically important difference [MCID] = 5.7) and ASES score (42.0; MCID = 13.6). The overall complication rate for rTSA was 9.4% and revision rate of 2.6%. Complications were further subdivided into major medical complications (0.07%), shoulder- or surgical-related complications (5.3%), and infections (1.2%). The most frequently reported shoulder- or surgical-related complications were scapular notching (14.4%), periprosthetic fracture (0.8%), glenoid loosening (0.7%), and prosthetic dislocation (0.7%).

DISCUSSION

Primary rTSA is a safe and reliable procedure with low complication, revision, infection, and scapular notching rates. Additionally, patients demonstrated clinically significant improvements in both range of motion and clinical outcome scores.

Early outcomes of augmented glenoid components in anatomic total shoulder arthroplasty: a systematic review

BACKGROUND

The objective was to evaluate the short-term clinical and radiological outcomes following augmented anatomic total shoulder arthroplasty in patients with posterior glenoid deficiency.

METHODS

An electronic search of EMBASE, MEDLINE, and PubMed identified studies reporting clinical and radiographic outcomes following augmented anatomic total shoulder arthroplasty among patients with posterior glenoid deficiency.

RESULTS

Nine studies including 312 shoulders underwent anatomic total shoulder arthroplasty using an augmented glenoid implant between 2015 and 2020. A statistically significant improvement in range of motion (ROM), visual analog scale (VAS), American Shoulder & Elbow Surgeons (ASES), Constant, University of California - Los Angeles and Simple Shoulder Test (SST) scores was demonstrated at mean follow-up of 37.1 months. Glenoid retroversion improved from 21.8° to 9.5°. At final follow-up, radiolucency was reported in 35.1% of shoulders. The 16° full-wedge augment led to higher and more severe radiographic lucency, while high peg perforation rates (44%) were observed among 5-mm augment stepped implants. The overall rate of complication was 2.6%. Rate of revision surgery was 1.9%.

CONCLUSIONS

Overall, early- to mid-term outcomes following augmented anatomic total shoulder arthroplasty for posterior glenoid deficiency demonstrate good to excellent overall clinical results. More radiographic and clinical failures were reported in larger full wedge (16°) augments and stepped augments (5 mm). Prospective studies examining mid- and long-term outcomes will help further elucidate safety and efficacy of these relatively new implants.

Multiple Treatment Comparisons for Large and Massive Rotator Cuff Tears: A Network Meta-analysis

BACKGROUND

There is no consensus about the best choice between all the options available for large and massive rotator cuff tear (mRCTs) management.

OBJECTIVE

To determine the comparative effectiveness of current treatment options for management of large and mRCTs.

DESIGN

Network meta-analysis.

SETTING

We searched the Cochrane systematic reviews, MEDLINE and EMBASE databases for all trials of adults with large and mRCTs that report preoperative and postoperative functional scores after an intervention option.

PATIENTS

The network meta-analysis included 20 trials with 1233 patients with 37.24 months follow-up.

INTERVENTIONS

Eight treatment options for management of large and mRCTs were compared.

MAIN OUTCOME MEASURES

The primary effectiveness outcome was the functional score.

RESULTS

This meta-analysis did not show statistically significant differences between conservative, partial repair, patch or platelet rich plasma (PRP) augmentation, reverse total shoulder arthroplasty, and complete repair. Latissimus dorsi (LD) transfer was ranked first for effectiveness [standardized mean difference (SMD): 2.17, 0.28-4.07] and debridement ranked last (SMD: -2.15, -3.13 to -1.17).

CONCLUSIONS

Latissimus dorsi transfer seems to be most effective for management of large and mRCTs, although some heterogeneity was observed in this network meta-analysis of full text reports. The choice of the operating technique depends on the patient's general health status and his expectations. When a decision has been reached to perform surgery, a repair, even if partial, should be attempted. Procedures involving biologic augmentation (eg, PRP) seem to convey no additional benefit while introducing more risk. Debridement alone should be avoided.

Anchor Site Fracture Following Arthroscopic Rotator Cuff Repair - A Case Report and Review of the Literature

Introduction

Fractures at the anchor site following arthroscopic rotator cuff repair are rare and only a few case reports have been described. We report two additional well-documented cases of this uncommon post-operative complication and provide a review of the current literature.

Case Report

A 48-year-old male underwent arthroscopic rotator cuff repair (ARCR) due to a massive rotator cuff tear. Nine weeks postoperatively, the patient suffered a humeral head fracture at the anchor site of the ARCR after trauma. Despite subsequent surgical treatment with open reduction and internal fixation, the patient demonstrates with excellent functional outcome scores at 2-year follow-up.

Conclusion

Humeral head fractures are a rare complication after ARCR. The use of intraosseous anchors requires careful consideration regarding positioning and quantity used.

Arthroscopic Side-to-Side Repair of Massive Rotator Cuff Tears Maintains Adequate Functional Improvement at 12 to 14 Years' Follow-up

BACKGROUND

Rotator cuff tears are common shoulder injuries that often cause pain and loss of function. Nonanatomic side-to-side techniques facilitate repair by minimizing tensions within tendons to improve healing and optimize the thickness of sutured tissues.

PURPOSE/HYPOTHESIS

The purpose was to evaluate long-term clinical and radiographic outcomes of arthroscopic side-to-side repair of massive rotator cuff tears (mRCTs). The hypothesis was that, at a minimum follow-up of 12 years, arthroscopic side-to-side repair maintains clinically important improvements.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors reviewed records of all patients who underwent arthroscopic repair of mRCTs over 2 consecutive years. A total of 30 adult patients met the eligibility criteria and underwent side-to-side repair. Patients were evaluated clinically using the Constant score (CS) and ultrasound to assess retears at 3 timepoints after surgery: 2 to 4 years, 5 to 7 years, and 12 to 14 years.

RESULTS

At first follow-up (3.2 ± 0.5 years), all 30 patients had clinical and ultrasound assessment, which revealed 13 retears (43%). At second follow-up (6.2 ± 0.5 years), all 30 patients had clinical and ultrasound assessment, which revealed 2 new retears (total 50%). At final follow-up (13.0 ± 0.7 years), only 21 patients had clinical assessment (1 died and 8 could not be reached), and only 19 patients had ultrasound assessment, which revealed 6 new retears (total 79%). Both absolute CS and age-/sex-adjusted CS improved significantly from baseline values at first follow-up (73.5 and 96.6, respectively), and remained stable at second follow-up (69.0 and 91.9, respectively), and final follow-up (64.4 and 87.0, respectively). Compared to shoulders with intact repairs, those with retears tended to have lower absolute CS at all follow-up visits, although differences were not statistically significant.

CONCLUSION

Patients with mRCTs maintain satisfactory clinical scores at 12 to 14 years after arthroscopic side-to-side repair despite a high incidence of retears. Repair is a safe and effective treatment for mRCTs, providing a less invasive and less complex alternative to reverse shoulder arthroplasty and tendon transfer procedures.

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

BACKGROUND

There is no consensus on the treatment of irreparable massive rotator cuff tears. The goal of this systematic review and meta-analysis was to (1) compare patient-reported outcome scores, (2) define failure and reoperation rates, and (3) quantify the magnitude of patient response across treatment strategies.

METHODS

The MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and Scopus databases were searched for studies including physical therapy and operative treatment of massive rotator cuff tears. The criteria of the Methodological Index for Non-randomized Studies were used to assess study quality. Primary outcome measures were patient-reported outcome scores as well as failure, complication, and reoperation rates. To quantify patient response to treatment, we compared changes in the Constant-Murley score and American Shoulder and Elbow Surgeons (ASES) score with previously reported minimal clinically important difference (MCID) thresholds.

RESULTS

No level I or II studies that met the inclusion and exclusion criteria were found. Physical therapy was associated with a 30% failure rate among the included patients, and another 30% went on to undergo surgery. Partial repair was associated with a 45% retear rate and 10% reoperation rate. Only graft interposition was associated with a weighted average change that exceeded the MCID for both the Constant-Murley score and ASES score. Latissimus tendon transfer techniques using humeral bone tunnel fixation were associated with a 77% failure rate. Superior capsular reconstruction with fascia lata autograft was associated with a weighted average change that exceeded the MCID for the ASES score. Reverse arthroplasty was associated with a 10% prosthesis failure rate and 8% reoperation rate.

CONCLUSION

There is a lack of high-quality comparative studies to guide treatment recommendations. Compared with surgery, physical therapy is associated with less improvement in perceived functional outcomes and a higher clinical failure rate.

Implantable Subacromial Balloon Spacers in Patients With Massive Irreparable Rotator Cuff Tears: A Systematic Review of Clinical, Biomechanical, and Financial Implications

Purpose

To determine the clinical, biomechanical, and financial impact of the use of subacromial balloon spacers in the surgical management of massive, irreparable rotator cuff tears (RCTs).

Methods

All studies assessing the use of implantable subacromial balloon spacers for management of massive, irreparable RCTs were systematically searched. Risk of bias was assessed using Methodological Index for Non-Randomized Studies criteria. Data extraction and analysis was performed for pain and function scores, shoulder range of motion (ROM), glenohumeral contact pressure and vertical migration of humeral head, and cost. Subjective synthesis was performed with forest plots when outcomes were reported in 3 or more studies.

Results

In total, 19 studies met inclusion criteria for analysis; 337 patients (mean age 68 years) had 343 subacromial balloon spacer implantations. Throughout a mean follow-up of 33 months, there was significant improvement in the Total Constant Score (preoperative: 22.5-41.8; postoperative: 51.4-72.3), Oxford Shoulder Score (preoperative: 21.3-26; postoperative: 34.39-48.2), American Shoulder and Elbow Surgeons score (preoperative: 24.5-59.1; postoperative: 72.5-85.7), and shoulder ROM parameters. Subacromial balloon spacer placement resisted superior humeral head migration (range of preoperative to postoperative difference: 2.8-6.2 mm) and decreased peak subacromial pressure during shoulder ROM.

Conclusions

Existing literature of subacromial balloon spacers has a high risk of bias, lack of appropriate control, and low levels of evidence. A qualitative synthesis indicates that subacromial balloon spacer implantation in patients with massive irreparable RCTs is cost-effective and leads to improved function (Total Constant Score and Oxford Shoulder Score) and ROM. In cadaveric studies, subacromial balloon spacers resist superior humeral head migration and reduce subacromial pressure. The theoretical risk of biodegradation of the balloon spacer has not been substantiated in study of up to 5-years follow-up, and the risk of complications from this procedure appears to be minimal.

Level of Evidence

IV; Systematic review of level III-IV studies.

Complications and implant survivorship following primary reverse total shoulder arthroplasty in patients younger than 65 years: a systematic review

BACKGROUND

Concerns exist regarding the complication rates and implant survivorship of reverse total shoulder arthroplasty (RTSA) in younger patients.

METHODS

A systematic review of the literature regarding the existing evidence on RTSA in patients younger than 65 years was performed using the CENTRAL (Cochrane Central Register of Controlled Trials), PubMed, and Embase databases on June 9, 2019. Articles published between 1995 and 2019 with combinations of the following keywords were identified: "reverse shoulder arthroplasty" and "65," "60," and/or "55." Complications, reoperations, and revisions were recorded. Reoperation-free survival and implant survival rates were grouped at 2, 5, and 10 years. Range of motion and clinical outcomes, along with postoperative radiographic results, were recorded.

RESULTS

Data from 7 studies with a total of 286 shoulders were obtained for quantitative analysis. The mean patient age was 58.4 years (mean age range, 48.9-60.4 years), and the mean follow-up period was 4.7 years (mean follow-up range, 3.0-7.8 years). The overall rate of complications was 18.6%; reoperations, 14.4%; and revisions, 11.2%. The reoperation-free survival rate was 97% at 2 years, 88%-90% at 5 years, and 76% at 10 years. The implant survival rate was 99% at 2 years, 91%-98% at 5 years, and 88% at 10 years. Active abduction, forward elevation, and external rotation significantly improved from preoperatively to postoperatively. All clinical outcome measures significantly improved from preoperatively to postoperatively, with no decline seen over time. The overall rate of infrascapular notching was 22.7% at final follow-up.

CONCLUSION

RTSA is safe and effective in patients younger than 65 years. Complication, reoperation, and revision rates were similar to those seen in older patient cohorts, without an increase in revisions owing to aseptic loosening. Clinical outcome scores showed significant and lasting improvements.

Low level of evidence for all treatment modalities for irreparable posterosuperior rotator cuff tears

PURPOSE

This systematic review assesses evidence for improvements in outcome for all reported types of treatment modalities [physical therapy, tenotomy or tenodesis of the long head of the biceps, debridement, partial repair, subacromial spacer, deltoid flap, muscle transfer, rotator cuff advancement, graft interposition, superior capsular reconstruction (SCR), and reversed shoulder arthroplasty (RSA)] used for irreparable posterosuperior rotator cuff tears without glenohumeral osteoarthritis. The primary aim was to be able to inform patients about expectations of the amount of clinical improvement after these treatments.

METHODS

A systematic search was conducted in MEDLINE, EMBASE, CINAHL, and Cochrane databases for studies on irreparable posterosuperior rotator cuff lesions without glenohumeral osteoarthritis, published from January 2007 until January 2019, with minimum 2-year follow-up. Studies with pre-operative and/or intra-operative determination of cuff tear irreparability were included. We defined the non-adjusted Constant Score as the primary outcome.

RESULTS

Sixty studies (2000 patients) were included with a fair mean quality score, according to the Modified Coleman Methodology Score. The employed definitions of 'irreparable' were mainly based on MRI criteria and were highly variable among studies. The smallest weighted mean preoperative to post-operative improvements in Constant Score were reported for biceps tenotomy/tenodesis (10.7 points) and physical therapy (13.0). These were followed by debridement (21.8) and muscle transfer (27.8), whereas the largest increases were reported for partial repair (32.0), subacromial spacer (32.5), rotator cuff advancement (33.2), RSA (34.4), graft reconstruction (35.0), deltoid flap (39.8), and SCR (47.4). Treatment using deltoid flap showed highest mean weighted improvement in Constant Score among studies with available medium-term (4-5-year) follow-up. Treatments deltoid flap, muscle transfer, and debridement were the only treatments with available long-term (8-10-year) follow-up and showed similar improvements in Constant Score at this time point.

CONCLUSION

The variability in patient characteristics, co-interventions, outcome reporting, and length of follow-up in studies on irreparable rotator cuff tears without osteoarthritis complicates sound comparison of treatments. Clinically important treatment effects were seen for all 11 different treatment modalities.

LEVEL OF EVIDENCE

IV.

Treatment of Large and Massive Rotator Cuff Tears: Does Infraspinatus Muscle Tear Affect Repair Integrity?

Background

Clinical outcomes and prognosis of large and massive rotator cuff tears are known to be unpredictable not only in degeneration of the rotator cuff, but also due to a high rate of retear.

Methods

Totally, 81 patients who had undergone arthroscopic rotator cuff repair from May 2008 to February 2016 were evaluated in our study. Clinical and functional evaluations were performed with the Constant score and the University of California, Los Angeles (UCLA) score, as well as full physical examination of the shoulder. All patients were confirmed to have magnetic resonance imaging (MRI) of tendon healing at least 1 year postoperatively.

Results

The average age at the time of surgery was 65 years (range, 47–78 years). The average duration of postoperative time in which a follow-up MRI was performed was 36.1 months (range, 12–110 months). Large tears were present in 48 cases (59.3%) and massive tears in 33 cases (40.7%). Overall, there were 33 retear cases (40.7%). All the average clinical outcome scores were significantly improved at the last follow-up (p<0.001), although repair integrity was not maintained. Compared to type A, types C, and D of the Collin’s classification showed significantly higher retear rates (p=0.036).

Conclusions

Arthroscopic rotator cuff repair yields improved clinical outcomes and a relatively high degree of patient satisfaction, despite the repair integrity not being maintained. Involvement of the subscapularis muscle or infraspinatus muscle had no effect on the retear rate.

Anatomic Augmented Glenoid Implants for the Management of the B2 Glenoid

The B2 glenoid is defined by Walch et al. as a glenoid that is biconcave with posterior erosion accompanied by posterior humeral head subluxation. This creates unique challenges for the treating orthopedic surgeon. Bone loss, excessive retroversion, and posterior subluxation make anatomic shoulder arthroplasty in this setting fraught with increased complications, including instability, glenoid component loosening, and poor clinical outcomes. Many techniques have been devised to treat the arthritic shoulder with a B2 glenoid, including hemiarthroplasty, total shoulder arthroplasty using eccentric reaming, bone grafting and custom implantation, and reverse total shoulder arthroplasty. In this review, we will focus on anatomic total shoulder arthroplasty using augmented glenoid implants to treat the B2 glenoid. Indications, clinical results, and basic science analyses of augmented anatomic glenoids are also discussed.

Clinical and MRI Outcomes 10 Years After Repair of Massive Posterosuperior Rotator Cuff Tears

BACKGROUND

Massive rotator cuff tears are challenging to treat, with few or no studies on long-term outcomes of repair. The purpose of this study was to report 10-year outcomes following repair of massive posterosuperior rotator cuff tears, with and without extension into the subscapularis, and to determine prognostic factors that could influence clinical scores and retear rates.

METHODS

The records of 234 patients who underwent repair of a massive posterosuperior rotator cuff tear at a total of 15 centers were retrieved. Patients were asked to return for evaluation at 10 years; 78 patients could not be contacted, 7 had died, and 19 had undergone a reoperation. A total of 130 patients (68% men) with a mean age (and standard deviation) of 56.1 ± 7.7 years (range, 26 to 79 years) were evaluated clinically, and 102 of them were also evaluated using magnetic resonance imaging (MRI). The tear was confined to the supraspinatus and infraspinatus tendons in 94 shoulders and also involved the superior portion of the subscapularis in 36 shoulders. Univariable and multivariable regressions were performed to determine whether 10-year total Constant-Murley scores and repair integrity were associated with patient characteristics, tear patterns, or repair techniques.

RESULTS

In the study cohort, complications were noted in 14 shoulders (11%) (stiffness in 10 and infection in 4). For the 130 shoulders evaluated clinically, the mean total Constant-Murley score improved from 53.1 ± 15.9 (range, 14 to 83) preoperatively to 78.5 ± 11.3 (range, 36 to 98) at 10 years. Of the 102 shoulders evaluated using MRI, 32 had a retear (Sugaya type IV or V). Of the 19 shoulders that underwent a reoperation (excluded from the study cohort), 9 had a retear. The overall prevalence of retears was 34%. Multivariable regression analysis revealed a significant association between the 10-year Constant-Murley score and preoperative retraction of the infraspinatus tendon, but no association between retears and any of the variables. Involvement of the subscapularis had no significant effect on preoperative or postoperative Constant-Murley scores or retear rates.

CONCLUSIONS

Patients who had repair of a massive posterosuperior rotator cuff tear maintained considerable improvements in clinical and radiographic outcomes at 10 years. Partial concomitant tears of the subscapularis did not affect the total postoperative Constant-Murley scores or retear rates.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Short-term results of rotator cuff repair using GraftJacket as an interpositional tissue-matched thickness graft

We report outcomes of using GraftJacket to repair massive rotator-cuff-tears. Twenty patients with a mean age of 64.6y over 12-month duration were reviewed. Two patients had a single GraftJacket repair (group1), whilst 18 had the GraftJacket sheet doubled (group2). Pre and post oxford shoulder scores (OSS) and patient related outcome measures were evaluated. A statistically significant improvement of OSS was demonstrated in-group 2 from a mean of 22 to 45.5 (p < 0.00148) over a follow up of 18 months. GraftJacket is a safe and effective procedure to use as an interpositional graft and doubling the graft may improve outcomes.

Isolated loss of active external rotation: a distinct entity and results of L'Episcopo tendon transfer

BACKGROUND

The purpose of this study was to characterize a subgroup of cuff-deficient patients with isolated loss of active external rotation (ILER) but preserved active elevation and to evaluate the outcomes of the L'Episcopo procedure to restore horizontal muscle balance.

METHODS

During a 10-year period, 26 patients (14 men, 12 women) were identified with ILER in the setting of massive irreparable posterosuperior cuff tears. A modified L'Episcopo tendon transfer was performed to restore active external rotation and to improve shoulder function. The mean age at surgery was 64.5 years (29-83 years). Patients were evaluated with a mean follow-up of 52 months (range, 24-104 months).

RESULTS

Preoperatively, despite maintained active elevation (average of 161°), ILER patients complained about loss of spatial control of the arm and difficulties with activities of daily living. On computed tomography scan or magnetic resonance imaging, there was severe fatty infiltration of infraspinatus and absent or atrophic teres minor. After L'Episcopo transfer, 84% of patients were satisfied. The gain in active external rotation was +26° in arm at the side and +18.5° in 90° abduction. Adjusted Constant score and Simple Shoulder Value increased from 63.6% to 86.9% and from 36.9% to 70.8%, respectively (P < .001). The ADLER score increased from 10 to 24.5 points (P < .002). Two patients with advanced cuff tear arthropathy (Hamada stage 3 and 4) required conversion to a reverse shoulder arthroplasty (RSA) 7 and 9 years after the index surgery.

CONCLUSIONS

ILER is a distinct entity that is a cause of severe handicap because of loss of spatial control of the upper limb. This symptom is related to absent or atrophied infraspinatus and teres minor. In properly selected cases (Hamada stage 1 or 2), the modified L'Episcopo transfer is effective at restoring anterior-posterior rotator cuff force balance. In more advanced cuff tear arthropathy (Hamada stage ≥3), the tendon transfer should be performed with an RSA because of possible secondary degeneration of the glenohumeral joint.

Early promising outcome following arthroscopic implantation of the subacromial balloon spacer for treating massive rotator cuff tear

BACKGROUND

Massive rotator cuff tear (RCT) can result in disability and severe pain. When conservative treatment fails, surgical treatment should be considered, as various surgical options can provide relatively satisfactory results. However, choosing an optimal treatment remains controversial. A relatively new treatment for irreparable RCT is the arthroscopic implantation of a biodegradable balloon spacer into the subacromial space. Here, we examined whether placement of this balloon spacer reduces pain and improves functional outcome in patients with an irreparable RCT. Patients were followed for 1 year following implantation.

METHODS

In this prospective single-arm study, a biodegradable balloon spacer was implanted into the subacromial space of patients with a massive RCT. Pain was evaluated using a numeric rating scale (NRS), and functional outcome was evaluated using the Oxford shoulder score (OSS) and the Constant-Murley shoulder score (CMS). Five follow-up visits were performed during the first postoperative year.

RESULTS

Forty-six shoulders in 44 patients with massive RCT were treated by surgical implantation of the subacromial balloon spacer. The mean reduction in NRS score was 3.5 points (95% CI 2.5-4.4), and 74% of patients achieved the minimal clinically important difference of 2 points by the 1-year follow-up visit. Functional outcome improved significantly based on OSS and CMS scores, and 80% of patients reported that they were satisfied with their outcome. No surgical or postoperative medical complications due to implantation of the balloon spacer were reported.

CONCLUSIONS

Our results suggest that arthroscopic implantation of a biodegradable balloon spacer in the subacromial space significantly reduces pain and improves activities of daily living in patients with massive RCT during 1 year of follow-up. The specific contribution of the balloon with respect to improved clinical outcome needs further study, ideally in a randomized controlled trial.

Reverse shoulder arthroplasty for irreparable massive rotator cuff tears: a systematic review with meta-analysis and meta-regression

BACKGROUND

Massive rotator cuff tears (MRCTs) are very large tears that are often associated with an uncertain prognosis. Indeed, some MRCTs even without osteoarthritis are considered irreparable, and nonanatomic solutions are needed to improve the patient's symptoms. Reverse shoulder arthroplasty (RSA) is an option that can provide a more predictable pain relief and recovery of function. Nonetheless, outcomes after RSA for irreparable MRCTs have not been well defined. The aim of this study was to quantitatively aggregate the findings associated with the use of RSA in this subset of patients and analyze the effect on patient functional status and pain.

METHODS

A comprehensive search was performed until October 2015 using MEDLINE, Scopus, Cochrane Database of Systematic Reviews, and Central Register of Controlled Trials databases. Studies that assessed the outcomes of RSA in patients with irreparable MRCT without osteoarthritis (with at least 2 years of follow-up) were included. If the results of MRCT without osteoarthritis were not possible to subgroup, the study was excluded. Methodologic quality was assessed using the Coleman Methodology Score.

RESULTS

Included were 6 studies (266 shoulders) with a follow-up ranging from 24 to 61.4 months. The mean Coleman Methodology Score was 58.2 ± 11.8 points. There was an overall improvement from preoperative to postoperative assessments of the clinical score (Cohen d = 1.35, P < .001), forward flexion (d = 0.50, P = .009), external rotation (d = 0.40, P < .001), function (d = 1.04, P < .001), and pain (d = -0.89, P < .001).

CONCLUSION

Patients with irreparable MRCT without presence of osteoarthritis have a high likelihood of achieving a painless shoulder and functional improvements after RSA.

Should massive rotator cuff tears be reconstructed even when only partially repairable?

PURPOSE

(1) To evaluate midterm functional outcomes of arthroscopic repair of massive rotator cuff tears and (2) to determine the prognostic factors that could influence outcome. The hypothesis was that both partial and complete repairs would result in equivalent improvement of clinical score.

METHODS

From a prospective series of 525 rotator cuff repairs, we analysed records of the 73 patients who were treated for massive tears. The median follow-up was 41 months (range 29-55), and functional outcome was evaluated using the Constant score, shoulder strength, and subjective shoulder value.

RESULTS

The median CS improved from 34 points to 81 points (p < 0.001). The scores were better for both types of two-tendon tears, posterosuperior (83, n = 33) and anterosuperior (85, n = 13) (n.s.), than for three-tendon tears (74, n = 27) (p < 0.001). The scores were also better when fatty infiltration was of stage I (84, n = 28) than of stage II (78, n = 34) (p < 0.001) or stage III (74, n = 11) (p = 0.04). The scores were only slightly higher for completely reparable tears (81.5, n = 50) than for partially reparable tears (79, n = 23) (n.s.). Ultrasonic examination revealed incomplete healing, in 10 of the 50 completely repaired tears, and in 11 of the 23 partially repaired tears.

CONCLUSIONS

The results of the present study compare favourably with those in recent literature and confirm the hypothesis that both partial and complete repairs of massive rotator cuff tears produce equivalent improvements of Constant scores. The clinical relevance of these observations is that even if repairs of two-tendon tears result in superior functional outcomes, repairs of three-tendon tears produce equivalent 'relative' improvement that grants sufficient patient satisfaction and autonomy.

LEVEL OF EVIDENCE

Comparative case series, Level IV.

Massive rotator cuff tears: definition and treatment

PURPOSE

The aim of this review is to summarise tear pattern classification and management options for massive rotator cuff tears (MRCT), as well as to propose a treatment paradigm for patients with a MRCT.

METHOD

Data from 70 significant papers were reviewed in order to define the character of reparability and the possibility of alternative techniques in the management of MRCT.

RESULTS

Massive rotator cuff tears (MRCT) include a wide panoply of lesions in terms of tear pattern, functional impairment, and reparability. Pre-operative evaluation is critical to successful treatment. With the advancement of medical technology, arthroscopy has become a frequently used method of treatment, even in cases of pseudoparalytic shoulders. Tendon transfer is limited to young patients with an irreparable MRCT and loss of active rotation. Arthroplasty can be considered for the treatment of a MRCT with associated arthritis.

CONCLUSION

There is insufficient evidence to establish an evidence-based treatment algorithm for MRCTs. Treatment is based on patient factors and associated pathology, and includes personal experience and data from case series.

Isolated subscapularis repair for massive rotator cuff tear

The best surgical treatment for an irreparable rotator cuff tear is controversial. In such cases, partial rotator cuff repair, primarily involving the posterior cuff in most reports, has been shown to be beneficial. The authors retrospectively investigated 41 patients who underwent arthroscopic subscapularis-only repair and greater tuberoplasty between April 2003 and August 2009 for massive 3-tendon cuff tears with irreparable supraspinatus and infraspinatus tendons after 3 months of conservative management was unsuccessful. Twenty-five patients (61%) underwent biceps tenotomy, and the remaining 39% had preexisting biceps tenotomy or rupture. The patients were assessed with American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores. Of the 41 patients, 34 (83%) were available for a follow-up telephone questionnaire after a minimum of 12 months (mean, 35 months; range, 12-84 months). Mean ASES and SANE scores were 76% and 63%, respectively. Mean postoperative passive range of motion was 156° of forward flexion and 39° of external rotation. Of the patients queried, 74% (25 of 34) were able to actively raise their arms above shoulder level. For those with a positive belly-press test result preoperatively, 22 of 27 patients had a negative test result postoperatively. A total of 3 complications (7.3%) occurred. Workers' compensation claim was a strong predictor of lower shoulder scores. Arthroscopic subscapularis-only repair and greater tuberoplasty may offer a promising and safe method for treating massive rotator cuff tears when the supra-spinatus and infraspinatus tendons are irreparable. Workers' compensation claim may predict lower outcome scores.

Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen years

BACKGROUND

The role of reverse shoulder arthroplasty (RTSA) in the relatively young individual is currently unclear. Our study evaluates the midterm to long-term results of RTSA for patients aged younger than 65 years with pseudoparalysis secondary to massive irreparable rotator cuff tears, with or without arthritis.

METHODS

Between 1997 and 2006, 46 RTSAs (41 patients) were performed. Mean age was 60 years (range, 46-64 years). At the latest follow-up, 5 patients had died and 1 was lost, leaving 35 patients (40 shoulders) with a mean follow-up of 93 months (range, 60-171 months).

RESULTS

The mean relative Constant score increased from 34% to 74% (P < .0001) and the subjective shoulder value improved from 23% to 66% (P < .0001). Significant improvements were seen in active forward elevation (72° to 119°), pain scores, and strength (P < .001). One or more complications occurred in 15 shoulders (37.5%), with 6 failures (15%) resulting in removal or conversion to hemiarthroplasty (3 with infection, 3 with glenoid loosening). Ten shoulders (25%) underwent partial or total component exchange, conversion to hemiarthroplasty, or removal. Of the 15 patients who developed complications, 9 did not require prosthesis removal or conversion and functional outcome and subjective shoulder value were similar to those with no complications (P > .4).

CONCLUSION

RTSA in younger patients provides significant subjective improvement and substantial gain in overall function, which is maintained up to 10 years. Although the complication rate is high, most can be treated successfully without compromise to clinical outcome. However, it is imperative that the high complication rate is explained to patients, with the risks and benefits carefully considered.

[Influence of chronic, structural changes of the muscle-tendon unit on the indication and technique of rotator cuff reconstruction]

Rotator cuff lesions are common and the incidence increases with age. After tendon rupture of the rotator cuff, the muscle-tendon unit retracts, which is accompanied by muscle fatty infiltration, atrophy, and interstitial fibrosis of the musculature, thus, fundamentally changing the muscle architecture. These changes are important prognostic factors for the operative rotator cuff reconstruction outcome. Selection of the correct time point for reconstruction as well as the optimal mechanical fixation technique are decisive for successful attachment at the tendon-to-bone insertion site. Thus, knowledge of the pathophysiological processes plays an important role. The goal of this article is to establish a relationship between currently existing evidence with respect to the preoperatively existing changes of the muscle-tendon unit and the choice of the time for the operation and the operative technique.

Clinical and radiographic outcomes after arthroscopic repair of massive rotator cuff tears using a suture bridge technique: assessment of repair integrity on magnetic resonance imaging

BACKGROUND

High retear rates of arthroscopic massive rotator cuff repair have been reported with relatively satisfactory functional outcomes.

PURPOSE

To assess the clinical and radiological outcomes of an arthroscopic repair of massive rotator cuff tears using a suture bridge technique. We also aimed to explore the various factors that may affect retears.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Sixty-six patients included in the study were divided into 2 groups according to the presence of retears on magnetic resonance imaging (MRI) evaluation at a minimum of 1 year after surgery. We evaluated the visual analog scale (VAS) for pain during motions, the University of California, Los Angeles (UCLA) score, and the absolute and relative Constant scores (mean follow-up, 25.4 months).

RESULTS

Twenty-eight of the 66 patients (42.4%) in this study had a retear. At the final follow-up visit, pain VAS, UCLA score, and absolute and relative Constant scores in the completely healed group were significantly superior to those in the retear group, with 2, 29.5, 76.0, and 95.2 points and 4, 26.0, 70.6, and 87.3 points, respectively (P < .05). From univariate analysis, the preoperative mean acromiohumeral distance, extent of retraction, and degree of fatty infiltration of the supraspinatus and infraspinatus were significantly different between the completely healed (7.83 mm, 2.97 cm, 1.74, and 0.71, respectively) and the retear group (6.36 mm, 3.97 cm, 2.54, and 2.07, respectively; P < .05). From multivariate logistic regression analysis, the preoperative degree of fatty infiltration of the infraspinatus and extent of retraction were the 2 most important factors associated with retears.

CONCLUSION

Arthroscopic repair of massive rotator cuff tears using a suture bridge technique has a relatively high retear rate, and these structural failures appear to have a significant difference in clinical outcomes compared with the healed group. Degree of fatty infiltration of the infraspinatus and extent of retraction are the 2 most important factors associated with a retear. Orthopaedic surgeons should predict the possibility of retear before surgery and counsel patients about their expected functional results.

Outcome of rotator cuff repair in large-to-massive tear with pseudoparalysis: a comparative study with propensity score matching

BACKGROUND

Active range of motion deficit is one of the alleged negative influencing factors of rotator cuff repair. Recently, with the popularity of reverse total shoulder arthroplasty (RTSA), there is a tendency toward performing RTSA in cases of nonarthritic large-to-massive tears with pseudoparalysis.

HYPOTHESIS

Rotator cuff repair in patients with active motion deficit may yield inferior outcome.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Among 195 complete repairs of large-to-massive rotator cuff tears, 35 patients experienced painful pseudoparalysis preoperatively. Propensity score matching (1-to-1) was performed between pseudoparalytic and nonpseudoparalytic groups. Finally, 29 patients in each group were matched using the following variables: age, gender, dominance, onset period, aggravation period, number of tendons involved, retraction, operation method (arthroscopic or mini-open), rows of repair (single or double), number of anchors, and fatty degeneration of the supraspinatus, infraspinatus, and subscapularis. At least 1 year after surgery (mean, 30.5 months), range of motion, visual analog scale for pain and satisfaction, Constant score, Simple Shoulder Test, American Shoulder and Elbow Surgeons (ASES) score, and University of California, Los Angeles shoulder rating scale (UCLA score) were evaluated. Healing of repaired cuffs was evaluated by computed tomography arthrography.

RESULTS

Range of motion was improved in both groups after rotator cuff repair. Active forward elevation had significantly improved postoperatively in the pseudoparalytic group (P < .001). All functional outcome scores improved at the final follow-up visit compared with preoperative values (all P < .05). Preoperative Constant, ASES, and UCLA scores were significantly inferior in the pseudoparalytic group, but all except the Constant score showed no differences between the 2 groups at the final follow-up (P = .04). Postoperatively, 7 patients (24.1%) in the pseudoparalytic and 1 (3.4%) in the nonpseudoparalytic group showed pseudoparalysis (P = .03). Among 37 patients who underwent postoperative computed tomography arthrography, cuff healing was achieved in 6 of 18 (33.3%) in the pseudoparalytic and 9 of 19 (47.4%) in the nonpseudoparalytic group (P = .385).

CONCLUSION

Recovery from pseudoparalysis after rotator cuff repair was evident in a large portion of the study group, and postoperative function and cuff healing were not different according to the presence of pseudoparalysis. Considering possible complications and longevity of RTSA, rotator cuff repair should be the first-line treatment option for large-to-massive tears.