Massive rotator cuff tears in patients younger than 65 years. Epidemiology and characteristics

Lower trapezius tendon transfer for massive irreparable rotator cuff tears improves outcomes in patients with high grade fatty infiltration of teres minor

Background

This study compares postoperative outcomes of lower trapezius tendon transfers (LTTTs) in massive irreparable rotator cuff (RC) tears based on the degree of teres minor (TM) fatty infiltration.

Methods

In this prospective longitudinal observational study, patients with massive RC tears undergoing arthroscopic-assisted LTTT by two surgeons were screened. TM fatty infiltration on preoperative magnetic resonance imaging was graded using the Goutallier classification. Two groups were created as follows: group A included grades 0 and 1 (no or little fatty infiltration), and group B included grades 2 to 4 (moderate-to-severe fatty infiltration). Participants completed the Single Assessment Numeric Evaluation (SANE) score preoperatively, and 12- and/or 24 months postoperatively along with a clinical assessment. Independent t-tests compared groups, and paired t-tests compared pre-vs. postoperative results. Significance was defined as P < .05.

Results

There were 47 patients in group A and 19 in group B. No group differences were found in preoperative SANE score, forward elevation or active external rotation (ER). Both groups showed significant postoperative improvements in SANE score with no differences between the groups. An ER lag sign was observed in 18/47 patients (38.3%) in group A and 11/19 patients (57.9%) in group B (P = .177). Preoperative ER strength was significantly different in group A (2.9 kg) vs. group B (0.7 kg; P = .001), but postoperative ER strength was similar (P = .931).

Conclusion

LTTT is a suitable salvage procedure regardless of the degree of TM fatty infiltration and should be considered an alterative procedure to latissimus dorsi tendon transfer in patients with high-grade TM fatty infiltration.

Characteristics of Traumatic Versus Atraumatic Rotator Cuff Tears in Patients Under 50 Years of Age

BACKGROUND

 The prevalence of rotator cuff tears (RCTs) is known to be lower in younger patients compared to older patients. Recent studies in patients less than 50 years of age who sustain an RCT have focused on etiology, pathogenesis, and clinical outcomes following treatment. There are fewer studies that have focused on the demographics and clinical characteristics that may predispose this patient population to develop a tear. The purpose of this study is to evaluate the difference in risk factors for degenerative tears compared to traumatic tears in patients under 50 years of age.

METHODS

This single-center retrospective study utilized an internal registry of patients who had RCT injuries identified by the International Classification of Diseases (ICD)-10 code M75.1x and confirmed by MRI between 2018 and 2023. Patients 50 years of age or younger were included and then classified into traumatic versus atraumatic RCT etiology groups. Demographics, tear characteristics, and clinical comorbidities were compared between the cohorts. Statistical analyses included a two-sided student's t-test, Wilcoxon rank-sum test, Chi-square test, and Fisher's exact test.

RESULTS

A total of 177 patients under 50 years of age were identified. There was a higher prevalence of traumatic tears (59.9% vs. 40.1%; p = 0.008), the majority of whom identified as male (75.5% vs. 49.3%, p<0.001) when compared to the atraumatic cohort. Full-thickness tears were more likely to be traumatic (p = 0.04) and seen in patients insured by workers' compensation (p = 0.05). There was no significant difference in the age or preoperative comorbidities between the two groups.

CONCLUSIONS

Our study reveals a higher incidence of traumatic RCTs in a younger patient group. Sex, severity of tear, and workers' compensation were found to differ between traumatic and atraumatic cohorts. Further research is required to understand the interplay of these factors in younger patients' tear risk.

Risk Factors for Loss of Active Shoulder Range of Motion in Massive Rotator Cuff Tears

Background:

Patients with massive rotator cuff tears often exhibit loss of active range of shoulder motion, which can interfere with activities of daily living. The risk factors for loss of motion remain largely unknown.

Purpose:

To clarify the predictive factors that affect the range of motion in chronic massive rotator cuff tears using multivariate analyses.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

The authors retrospectively reviewed 204 consecutive patients who were evaluated at their institution with chronic massive rotator cuff tears. In this study, the dependent variable was determined to be active anterior elevation limited to ≤90° or external rotation (ER) with the arm at the side limited to ≤0°. Explanatory variables included age; sex; affected side; duration of symptoms; smoking history; existence of diabetes, hypertension, or rheumatoid arthritis; involved tendons; presence of a 3-tendon tear; rupture of the long head of biceps tendon; superior migration of the humeral head; and cuff tear arthropathy. Baseline variables that were observed to be significant in the univariate analyses were included in multivariate models, which used logistic regression to identify independent predictors of loss of motion.

Results:

Overall, 73 patients (35.8%) exhibited limited anterior elevation, and 27 (13.2%) exhibited limited ER. Multivariate analyses showed that inferior subscapularis tear (odds ratio [OR], 14.66; 95% CI, 2.95-72.93; P = .001), smoking (OR, 4.13; 95% CI, 1.94-8.79; P < .001), superior migration of humeral head (OR, 3.92; 95% CI, 1.80-8.53; P = .001), and 3-tendon tear (OR, 3.29; 95% CI, 1.32-8.20; P = .011) were significantly associated with the loss of anterior elevation. Teres minor tear (OR, 73.37; 95% CI, 9.54-564.28; P < .001) and superior migration of the humeral head (OR, 3.55; 95% CI, 1.04-12.19; P = .044) were significantly associated with loss of ER.

Conclusion:

In the current study, a history of smoking, type of torn tendons, and superior migration of the humeral head were associated with loss of active shoulder motion. In particular, the status of inferior subscapularis or teres minor contributed to the onset of pseudoparalysis in massive rotator cuff tears.

Carbon fibre reinforced PEEK versus traditional metallic implants for orthopaedic trauma surgery: A systematic review

INTRODUCTION

There is no literature review comparing outcomes of fixation using carbon-fibre-reinforced polyetheretherketone (CFR PEEK) compared to metal implants used in orthopaedic extremity trauma surgery. A systematic review was performed to compare CFR PEEK to metal implants for clinically-important fracture outcomes.

METHODS

A search of the online databases of PubMed/Medline, EMBASE and Cochrane Database was conducted. A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A meta-analyses was performed for functional outcomes in proximal humerus fractures converting the score differences to standard mean difference units. GRADE approach was used to determine the level of certainty of the estimates.

RESULTS

Two prospective randomised controlled trials and seven comparative observational studies with a total of 431 patients were included. Of the nine studies included, four compared the use of CFR PEEK against metal plates in proximal humerus fractures. Aggregated functional scores across the proximal humerus studies, there was a small signal of better improvement with CFR PEEK (SMD 0.22, 95% CI -0.03 to 0.47, p = 0.08, low certainty). Greater odds of adverse events occurred in the metal group (OR 2.34, 95% CI 0.73 to 7.55, p = 0.15, low certainty).

CONCLUSIONS

Low to very low certainty evidence suggests a small improvement in functional recovery with CFR PEEK in proximal humerus fractures. This may be mediated through a small reduction in major adverse events related to fracture healing and stability. There is currently insufficient evidence to support the widespread use of CFR PEEK implants in fracture fixation.

LEVEL OF EVIDENCE

Level IV.

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.

Can a simple fall cause a rotator cuff tear? Literature review and biomechanical considerations

PURPOSE

A simple fall on the shoulder is often referred to as minor trauma that cannot cause a tendon tear but at best reveal a pre-existing rotator cuff pathology. We wanted to know whether this statement was true. The purpose of our study was therefore to summarize the causes of acute rotator cuff tears reported in the literature and provide a biomechanical explanation for tendon tears diagnosed after a fall.

METHOD

We searched PubMed and included studies reporting rotator cuff tears occurring due to a trauma. The number of cases, the tendons involved, the age of the patients, and the nature of trauma were summarized. In addition, we noted any information provided by the authors on the pathogenesis of acute tendon ruptures.

RESULTS

Sixty-seven articles with a total of 4061 traumatic rotator cuff tears met the inclusion criteria. A simple fall was the most common cause (725 cases) and the supraspinatus tendon was most frequently affected. The postulated pathomechanism is a sudden stretch of the tendon-muscle unit while contracting (eccentric loading).

CONCLUSION

A simple fall can cause an acute rotator cuff tear and fall-related tears are not restricted to young individuals. They can affect patients of any age. The stresses occurring within the rotator cuff during an attempt to cushion a fall may locally exceed the tensile strength of the tendon fibers and cause a partial or full-thickness tear.

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.

Clinical and structural outcome 20 years after repair of massive rotator cuff tears

BACKGROUND

Short- and mid-term outcomes after massive cuff tear repair are well reported, but there is no documentation of the clinical and structural outcomes at 20 years of follow-up. The hypothesis of the present study was that at 20 years, deterioration of the shoulder would have occurred and led to a substantial number of reoperations.

METHODS

The authors retrospectively recalled all 127 patients operated for massive rotator cuff tears in 1994 at 6 different centers. At the 20-year follow-up, 26 patients died and 35 were lost to follow-up. Thirteen (10.2%) had been reoperated. This left 53 patients for personal clinical assessment. Forty-nine consented to standardized radiographic evaluation for assessment of osteoarthritis, 36 patients underwent magnetic resonance imaging, allowing assessment of tendon healing, atrophy, and fatty infiltration (FI) of the cuff muscles.

RESULTS

The final Constant-Murley score (CS) was 68 ± 17.7 (range, 8-91) vs. 44 ± 15.3 (range, 13-74) preoperatively (P < .05). The final Subjective Shoulder Value (SSV) was 73% ± 23% (range, 0-100). Retears (Sugaya IV and V) were found in 17 cases (47%). Nine patients (17%) had cuff tear arthropathy (Hamada stage 4). The CS and SSV for the shoulders with FI stages III or IV were significantly inferior (53 ± 19 points and 65% ± 14% respectively) than for those with FI stages 0-II (respectively, 71.6 ± 6 points and 73% ± 4%) (P < .05).

CONCLUSIONS

Twenty years after surgical repair of massive rotator cuff tears, the functional scores remain satisfactory, and the rate of revision is low.

Preoperative Rotator Muscle Strength Ratio Predicts Shoulder Function in Patients After Rotator Cuff Repair

Background

Shoulder function after rotator cuff repair is associated with patient satisfaction after surgery. Several studies have demonstrated that the muscle strength ratio (external rotators/internal rotators) is an important factor to evaluate shoulder function, but little is known about the relationship between the preoperative muscle strength ratio and postoperative shoulder function.

Purpose

To evaluate the effect of the preoperative muscle strength ratio of the shoulder rotators on function after rotator cuff repair.

Study Design

Cohort study; Level of evidence, 3.

Methods

The study participants were patients with small- to medium-sized rotator cuff tears diagnosed by magnetic resonance imaging; 77 patients were included in the analysis. Preoperative muscle strength was assessed through use of isokinetic equipment. Patients were classified into 2 groups (normal and abnormal) according to a normal strength ratio range of 55% to 75%, with "abnormal" meaning a deviation of more than 15% from the normal range. The American Shoulder and Elbow Surgeons (ASES) score and the Constant score were used to evaluate shoulder function preoperatively and postoperatively at 6 months, 1 year, and 2 years.

Results

There were 30 patients in the normal group and 47 in the abnormal group, with a preoperative muscle strength ratio of 63.5% ± 5.5% and 42.6% ± 6.1%, respectively. The ASES score was 88.6 ± 9.1 in the normal group and 77.5 ± 13.6 in the abnormal group at 2 years postoperatively, and the Constant score was 82.7 ± 8.4 in the normal group and 69.5 ± 13.4 in the abnormal group at 2 years postoperatively. A significant difference was found in postoperative shoulder function between the normal and abnormal groups.

Conclusion

This study demonstrated that the preoperative muscle strength ratio was associated with postoperative shoulder function. The preoperative muscle strength ratio should be considered an important predictor of shoulder function after rotator cuff repair.

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.

Identify differential gene expressions in fatty infiltration process in rotator cuff

Background

Rotator cuff tears are one of the most frequent upper extremity injuries and lead to pain and disability. Recent studies have implicated fatty infiltration in rotator cuff is a key failure element with the higher re-tear rates and poorer functional prognosis. Therefore, we investigated the differential expression of key genes in each stage of rotator cuff tear.

Methods

A published expression profile was downloaded from the Gene Expression Omnibus database and analyzed using the Linear Models for Microarray Data (LIMMA) package in R language to identify differentially expressed genes (DEGs) in different stages of injured rotator cuff muscles. Gene ontology (GO) functional and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses were performed to annotate the function of the DEGs. Finally, PPI network and module analysis were used to identify hub genes.

Results

A total of 1089 fatty infiltration-related DEGs were identified, including 733 upregulated and 356 downregulated genes, and GO analyses confirmed that fatty infiltration was strongly associated with inflammatory response, aging, response to lipopolysaccharide, and immune response. Significantly enriched KEGG pathways associated with these DEGs included the phagosome, cell adhesion molecules, tuberculosis, and osteoclast differentiation. Further analyses via a PPI network and module analysis identified a total of 259 hub genes. Among these, Tmprss11d, Ptprc, Itgam, Mmp9, Tlr2, Il1b, Il18, Ccl5, Cxcl10, and Ccr7 were the top ten hub genes.

Conclusions

Our findings indicated the potential key genes and pathways involved in fatty degeneration in the development of fatty infiltration and supplied underlying therapeutic targets in the future.

Electronic supplementary material

The online version of this article (10.1186/s13018-019-1182-1) contains supplementary material, which is available to authorized users.

Arthroscopic Superior Capsule Reconstruction Can Eliminate Pseudoparalysis in Patients With Irreparable Rotator Cuff Tears

BACKGROUND

Patients with pseudoparalysis and irreparable rotator cuff tears have very poor function. The authors developed a superior capsule reconstruction (SCR) technique for irreparable rotator cuff tears that restores shoulder stability and muscle balance, improving shoulder function and relieving pain.

PURPOSE

To evaluate whether arthroscopic SCR reversed preoperative pseudoparalysis in patients with irreparable rotator cuff tears.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

One hundred consecutive patients with irreparable rotator cuff tears underwent arthroscopic SCR with fascia lata autografts; 7 patients with deltoid weakness from cervical or axillary nerve palsy and 5 with severe presurgical shoulder stiffness were excluded. The remaining 88 were allocated to 3 groups according to their preoperative active shoulder elevation: no pseudoparalysis (45 patients; mean age, 66.2 years; mean tear size, 3.5 cm), moderate pseudoparalysis (28 patients, 68.3 years, 3.5 cm), and severe pseudoparalysis (15 patients, 62.3 years, 4.9 cm). Clinical outcome, active shoulder range of motion, acromiohumeral distance, and healing rate were compared between patients with and without pseudoparalysis, as well as before surgery and at final follow-up (35-110 months).

RESULTS

American Shoulder and Elbow Surgeons score, active elevation, active external rotation, and acromiohumeral distance increased significantly after arthroscopic SCR among all patients. Graft healing rates did not differ among the groups ( P = .73): 98% (44 of 45) for no pseudoparalysis, 96% (27 of 28) for moderate pseudoparalysis, and 87% (13 of 15) for severe pseudoparalysis. Pseudoparalysis was reversed in 96% (27 of 28) of patients with preoperative moderate pseudoparalysis and 93% (14 of 15) with preoperative severe pseudoparalysis. Both patients with residual pseudoparalysis postoperatively (1 of 28 with preoperative moderate pseudoparalysis, 1 of 15 with preoperative severe pseudoparalysis) had graft tears.

CONCLUSION

Arthroscopic SCR restored superior glenohumeral stability and improved shoulder function among patients with or without pseudoparalysis who had previously irreparable rotator cuff tears. In the absence of postoperative graft tear, arthroscopic SCR reversed preoperative pseudoparalysis. Graft healing rates after arthroscopic SCR did not differ between patients with and without pseudoparalysis.

Influence of rotator cuff tears on glenohumeral stability during abduction tasks

One of the main goals in reconstructing rotator cuff tears is the restoration of glenohumeral joint stability, which is subsequently of utmost importance in order to prevent degenerative damage such as superior labral anterior posterior (SLAP) lesion, arthrosis, and malfunction. The goal of the current study was to facilitate musculoskeletal models in order to estimate glenohumeral instability introduced by muscle weakness due to cuff lesions. Inverse dynamics simulations were used to compute joint reaction forces for several static abduction tasks with different muscle weakness. Results were compared with the existing literature in order to ensure the model validity. Further arm positions taken from activities of daily living, requiring the rotator cuff muscles were modeled and their contribution to joint kinetics computed. Weakness of the superior rotator cuff muscles (supraspinatus; infraspinatus) leads to a deviation of the joint reaction force to the cranial dorsal rim of the glenoid. Massive rotator cuff defects showed higher potential for glenohumeral instability in contrast to single muscle ruptures. The teres minor muscle seems to substitute lost joint torque during several simulated muscle tears to maintain joint stability. Joint instability increases with cuff tear size. Weakness of the upper part of the rotator cuff leads to a joint reaction force closer to the upper glenoid rim. This indicates the comorbidity of cuff tears with SLAP lesions. The teres minor is crucial for maintaining joint stability in case of massive cuff defects and should be uprated in clinical decision-making. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1628-1635, 2016.

Combined Subscapularis Tears in Massive Posterosuperior Rotator Cuff Tears: Do They Affect Postoperative Shoulder Function and Rotator Cuff Integrity?

BACKGROUND

Previous studies on massive rotator cuff tears have not addressed the outcomes of tears extending to the subscapularis tendon.

HYPOTHESIS

The retear rate in patients with a massive posterosuperior rotator cuff tear combined with a subscapularis tear is higher than that in patients with a massive posterosuperior rotator cuff tear with an intact subscapularis tendon.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were collected and analyzed from 92 consecutive patients who underwent arthroscopic repair of a massive posterosuperior rotator cuff tear. Patients were divided into 3 groups according to the status of the subscapularis tendon: intact subscapularis tendon (I-massive tear; n = 42), tear involving half or less than half of the subscapularis tendon (S-massive tear; n = 22), and tear involving more than half of the subscapularis tendon (L-massive tear; n = 28). The integrity of the rotator cuff was determined by ultrasonography at 4.5 and 12 months or later after surgery. Clinical evaluations were performed using the visual analog scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, the Constant score, and active shoulder range of motion. Data were collected on the day before surgery and at final follow-up (at least 24 months postoperatively).

RESULTS

A total of 25 retears (27%) were identified based on an ultrasonographic evaluation. Although statistical significance was not found, there was a trend toward a higher retear rate in patients with an L-massive tear (43%) compared with those with an S-massive tear (18%; P = .050) or I-massive tear (21%; P = .059) at final follow-up. The subclassification of retears according to the involved tendons revealed that subsequent retears of the subscapularis tendon were noted only in patients with an L-massive tear. In patients with an L-massive tear, postoperative data comparison between patients with intact subscapularis tendons and those with failed subscapularis tendons revealed that a significant difference was noted in the VAS (1.1 vs 3.8, respectively) and ASES (90.6 vs 58.5, respectively) scores. The improvement in clinical scores after repair was statistically significant in all groups but not different between the groups.

CONCLUSION

The arthroscopic repair of massive tears results in substantial improvements in shoulder function, regardless of the presence of combined subscapularis tears. However, this study showed a trend toward a high failure rate for the repair of massive posterosuperior rotator cuff tears extending over half of the subscapularis tendon. Therefore, other treatment options should also be considered for this type of rotator cuff tear.

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.

Trapezius muscle transfer for external shoulder rotation: anatomical study

OBJECTIVE:

To compare the viability of transferring the lower and transverse trapezius to the greater tuberosity using three different techniques.

METHODS:

Twelve shoulders from six cadavers were used. The primary outcome was to assess the suture viability of the trapezius muscle transfer to the greater tuberosity in the insertion topography of the infraspinatus, with the arm adducted during internal rotation (hand on the abdomen) and maximum scapular retraction. Three transfers were applied to each shoulder: the lower and transverse trapezius distal insertion (Group 1); lower trapezius alone (Group 2); and lower trapezius insertion and origin (Group 3). Accessory nerve integrity was assessed before and after transfers.

RESULTS:

Sutures were viable in 42% (5/12) and 58% (7/12) on Groups 1 and 3, respectively, with no statistically significant difference (Fisher's test, p=0.558); Group 3 exhibited frequent neurologic injury (11/12). Group 2 was the least successful; the tendon did not reach the greater tuberosity, and no sutures were viable.

CONCLUSION:

Groups 1 and 3 exhibited the best nongrafting suture viability to the greater tuberosity; however, Group 3 was associated to frequent spinal accessory nerve injury. Level of Evidence IV, Anatomical Study

Subacromial Injection Results in Further Scapular Dyskinesis

Background:

Scapular kinematic movement patterns between patients with subacromial impingement and healthy controls have been extensively investigated. However, a high degree of variability has been reported in the literature pertaining to differences between these 2 groups.

Purpose:

To investigate the influence of subacromial pain on scapular kinematics.

Study Design:

Controlled laboratory study.

Methods:

A total of 21 patients with stage 2 subacromial impingement who received local anesthetic injections as part of their normal treatment were recruited for this study. The postinjection kinematic data from these patients were compared with those of healthy age-, sex-, and arm dominance–matched controls.

Results:

Subacromial injections of anesthetics resulted in increased scapular anterior tilting; however, no changes were noted in upward or internal rotation. When compared with healthy controls, patients had greater anterior tilting and upward rotation of the scapula.

Conclusion:

The study findings indicate that the removal of pain in patients with impingement results in further dyskinesis of the scapula.

Clinical Relevance:

Pain may be causing patients with subacromial impingement to limit scapular tilt and upward rotation, and movement limitations may continue after an anesthetic injection.

Functional evaluation of arthroscopic repair of rotator cuff injuries in patients with pseudoparalysis

Objective

to evaluate the functional result from arthroscopic repair of rotator cuff injuries in patients with pseudoparalysis, defined as incapacity to actively raise the arm above 90°, while complete passive elevation was possible.

Methods

we reevaluated 38 patients with a mean follow-up of 51 months (minimum of 24). We analyzed the pseudoparalysis reversion rate and the functional result obtained.

Results

according to the assessment criteria of the University of California in Los Angeles (UCLA), 31 (82%) patients had good and excellent results, two (5%) had fair results and five (13%) had poor results. The mean active elevation went from 39° before the operation to 139° after the operation (p < 0.05); the mean active lateral rotation went from 30° to 48° (p < 0.05) and the mean active medial rotation went from level L3 to T12 (p < 0.05).

Conclusion

arthroscopic repair of rotator cuff injuries produced good and excellent results in 82% of the cases and a statistically significant improvement of active range of motion, with reversion of the pseudoparalysis in 97.4% of the cases. It is therefore a good treatment option.

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.