Latissimus dorsi tendon transfer: a comparative analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Top 50 most impactful publications on massive rotator cuff tears

Background

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

Methods

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

Results

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

Conclusion

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

Primary Rotator Cuff Bridging Reconstruction Shows Better Clinical and Radiographic Results Than Revision Bridging Reconstruction

Purpose

To evaluate the outcome of revision rotator cuff bridging reconstruction (BR) as compared to primary BR in a large cohort of patients.

Methods

A retrospective chart review was conducted for patients who underwent BR using dermal allograft for large/massive rotator cuff tears between 2010 and 2018. Patients who completed Western Ontario Rotator Cuff Index (WORC) and Disability of the Arm, Shoulder, and Hand (DASH) scores both pre- and postoperatively were included. Pre- and postoperative magnetic resonance imaging scans were compared to assess for differences in fatty infiltration, muscle atrophy, and graft status.

Results

Eighty patients met the inclusion criteria, including 43 patients who underwent BR as a primary surgery and 37 patients who underwent revision BR. The mean follow-up duration was 5.7 ± 1.9 years in the primary group and 5.8 ± 2.0 years in the revision group. Both WORC and DASH scores significantly improved from pre- to postoperatively for both the primary and revision groups (P < .05). The primary group had significantly better postoperative WORC and DASH scores at 6 months, 1 year, and final follow-up (P < .05). Failure rate of the graft was higher in the revision group compared to primary group (14.3% vs 6.1%, respectively; P = .337), and the amount of fatty infiltration of supraspinatus and infraspinatus muscles significantly improved in patients who received primary BR compared to revision BR (P < .05).

Conclusions

BR using dermal allograft for large/massive irreparable rotator cuff tears showed improvement of functional outcomes, with primary cases resulting in better improvement in patient-reported outcomes compared to revision cases. Primary BR was also associated with better postoperative fatty infiltration of supraspinatus and infraspinatus muscles.

Level of Evidence

Level III, retrospective cohort study.

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

BACKGROUND

The definition of irreparable rotator cuff tear (IRCT) is controversial. This scoping review provides definitions used to describe IRCT in the literature. This scoping review (1) identified criteria used in the definition of IRCT and (2) investigated the current state of those criteria in prospective surgical therapeutic trials.

METHODS

This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. PubMed, Scopus, and Web of Science were searched in March 2023. Studies were screened against predetermined inclusion and exclusion criteria. Criteria regarding clinical symptoms, preoperative images, and intraoperative findings were captured respectively.

RESULTS

A total of 41 prospective studies were eligible for inclusion, and 35 studies (85.4%) defined IRCT. IRCT was defined on the basis of the following main criteria: preoperative image findings (28/35), intraoperative findings (24/35), and symptoms (16/35). With regard to preoperative images, IRCT was mainly defined on the basis of retraction of the tendon in the coronal plane (22/28), the severity of fatty degeneration (19/28), and ruptured tendon number or width of the defect in the sagittal plane (17/28).

CONCLUSION

This scoping review highlights the lack of a standardized definition for IRCT in clinical practice, with common predictive criteria including a duration of over 6 months, retraction beyond 5 cm, Goutallier grade 3 fatty infiltration, and the rupture of two or more tendons. However, surgeons should apply more than one criterion when examining preoperative images and confirm reparability during surgery. A more objective manner of evaluating intraoperative reparability is necessary.

Radiologic and clinical outcomes of an arthroscopic bridging graft for irreparable rotator cuff tears with a modified MasonAllen stitch using a plantaris tendon autograft: a case series with minimum 2-year outcomes

BACKGROUND

Surgical management of a massive rotator cuff tear (RCT) is always challenging. This study describes the clinical and radiological outcomes of patients who underwent bridging grafts using a plantaris tendon for an irreparable RCT.

METHODS

Thirteen patients with a massive RCT were treated with arthroscopic interposition of a folded plantaris tendon autograft between June 2017 and January 2020. For clinical evaluation, a visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, Constant-Murley score, and range of motion values were collected. For radiographic evaluation, standardized magnetic resonance imaging and ultrasonography were performed to check the integrity of the interposed tendon.

RESULTS

A statistically significant improvement at the final follow-up was evident in scores for the VAS (-3.0, P=0.003), ASES (24.9, P=0.002), D ASH (-20.6, P=0.001), and Constant-Murley values (14.2, P=0.010). In addition, significant improvement was shown in postoperative flexion (17.3°, P=0.026) and external rotation (27.7°, P<0.001). In postoperative radiologic evaluations, the interposed tendons were intact at the last examination in 12 of the 13 patients. No complications related to donor sites were reported.

CONCLUSIONS

An arthroscopic bridging graft for irreparable RCTs using a modified Mason-Allen stitch and a plantaris autograft resulted in improved short-term radiological and clinical outcomes. Graft integrity was maintained for up to 2 years in most patients. Level of evidence: IV.

A scoping review of tendon transfer surgeries and postsurgical physical therapy interventions in individuals with massive rotator cuff tears

OBJECTIVE

To identify tendon transfer surgeries and postsurgical physical therapy interventions in people with massive rotator cuff (RC) tears.

METHODS

The literature search was conducted in the MEDLINE, Science Direct, Scopus, Web of Science, and PEDro databases from inception to September 2022. Studies with patients diagnosed with massive RC tears undergoing tendon transfers that reported physical therapy interventions after surgery were included. Two reviewers pooled the data into ad hoc summary tables with the following information: authors, year, study characteristics (sample size, tendon transfer surgical used, approach type, preoperative risk, deficit addressed, additional surgical interventions), and physical therapy interventions (early stage, intermediate stage, and advanced stage).

RESULTS

Forty-four articles (59.0% case series) were included, with a total sample of 1213 participants. The most frequently used surgery was the isolated tendon transfer of the latissimus dorsi (49.1%). Most of the studies reported three main stages of physical therapy interventions after tendon transfer surgery: early stage (lasting 5-6 weeks), intermediate stage (started at 7-12 weeks), and advanced stage (started at 12 weeks). Physical therapy interventions included passive, active-assisted, resisted therapeutic exercise, and hydrotherapy.

CONCLUSIONS

The evidence regarding physical therapy interventions after RC tendon transfer surgery is limited to the number and duration of the stages and general characteristics without specifying the type and dose of the interventions. Future research with high methodological quality should integrate more detailed rehabilitation protocols to better guide therapeutic decisions after RC transfer surgery.

Outcomes After Superior Capsular Reconstruction With an Achilles Tendon-Bone Allograft Using the Modified Keyhole Technique: A 2-Year Follow-up of a Novel Technique for Irreparable Rotator Cuff Tears

Background

Despite improved outcomes, failure or nonhealing of graft materials has been reported after superior capsular reconstruction (SCR) for massive irreparable rotator cuff tears.

Purpose

To evaluate the short-term clinical and radiological outcomes of a novel technique for SCR using an Achilles tendon-bone allograft.

Study Design

Case series; Level of evidence, 4.

Methods

We performed a retrospective review of patients who underwent SCR using an Achilles tendon-bone allograft with the modified keyhole technique and who had a minimum follow-up of 2 years. The visual analog scale score for pain, American Shoulder and Elbow Surgeons score, and Constant score were evaluated as subjective outcomes, while range of motion of the shoulder joint and isokinetic strength were evaluated as objective outcomes. The acromiohumeral interval (AHI), bone-to-bone healing of the allograft and humeral head on computed tomography, and graft integrity on magnetic resonance imaging were evaluated as radiological outcomes.

Results

This study included 32 patients with a mean age of 56.8 ± 4.2 years and a mean follow-up of 28.4 ± 6.2 months. A significant improvement from preoperatively to the last follow-up was seen in the mean visual analog scale score for pain (from 6.7 to 1.8), American Shoulder and Elbow Surgeons score (from 42.7 to 83.8), Constant score (from 47.2 to 78.5), and AHI (from 4.8 to 8.2 mm) (P < .001 for all) as well as range of motion in forward elevation and internal rotation (P < .001 for both). Medial-to-lateral graft integrity was good in all patients. Nonunion at the fitting zone of the keyhole on the greater tuberosity was diagnosed in 1 case (3.1%), and failure of incorporation between the allograft and remnant tendon at the site of posterior margin convergence was observed in 4 cases (12.5%).

Conclusion

The outcomes after SCR using an Achilles tendon-bone allograft and the keyhole technique improved, with an increased AHI and excellent integrity in the medial and lateral directions compared with preoperatively. This technique is a reasonable option for the surgical treatment of irreparable rotator cuff tears.

Clinical and Radiological Outcomes of Arthroscopic Superior Capsular Reconstruction Versus Primary Rotator Cuff Repair in Massive Rotator Cuff Tears: A Propensity Score-Matched Study

BACKGROUND

Arthroscopic superior capsular reconstruction (aSCR) has emerged as a treatment option for managing massive rotator cuff tears (MRCTs) given the unpredictable results after an arthroscopic rotator cuff repair (aRCR). Yet, few comparative studies of aSCR and aRCR have been conducted.

PURPOSE

To compare the clinical and radiological outcomes between aRCR and aSCR in patients with MRCT.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 163 cases of MRCT from 2010 to 2020 with follow-up ≥2 years were retrospectively reviewed. Among them, 102 had aRCR and 61 had aSCR using fascia lata autograft. Propensity score matching was used to select controls matched for age, sex, diabetes mellitus, osteoporosis, preoperative American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, Constant score, pain visual analog scale (pVAS) score, range of motion (ROM), tear size, global fatty degeneration index, and acromiohumeral distance (AHD). Last, 33 cases in each group were selected after propensity score matching. Radiological assessment was conducted using serial postoperative magnetic resonance imaging. Pre- and postoperative findings-including American Shoulder and Elbow Surgeons, pVAS, Single Assessment Numeric Evaluation, and Constant scores and ROM-were assessed to compare clinical outcomes. For radiological outcomes, global fatty degeneration index, AHD, and healing rate were evaluated. Healing failure was defined as Sugaya classification IV or V in the aRCR group, as compared with a full-thickness tear of the graft in the aSCR group, which corresponded to Sugaya classification IV or V.

RESULTS

Postoperative clinical outcomes were significantly improved at the final follow-up in both groups. In the aSCR group, postoperative forward flexion, pVAS, and AHD were significantly improved as compared with the aRCR group (mean, 161° vs 148° [P = .02]; 1.03 vs 1.64 [P = .047]; 7.00 vs 5.23 mm [P < .001], respectively). The healing rate was 20 of 33 (60.6%) for aRCR and 29 of 33 (87.9%) for aSCR (P = .022).

CONCLUSION

aSCR and aRCR are effective and reliable treatment options for MRCT. However, when compared with aRCR, aSCR showed improved clinical outcomes, including pVAS score, postoperative ROM, and favorable radiological findings, including AHD and a higher healing rate.

Clinical outcomes in latissimus dorsi transfer single- versus double-incision technique

BACKGROUND/HYPOTHESIS

In patients with irreparable postero-superior rotator cuff lesions, a latissimus dorsi transfer (LDT) is performed. For this surgery, different techniques are used. In this study, we aim to compare the patient's functional outcome after treatment with modified L'Episcopo "single-incision" and modified Gerber "double-incision" technique for LDT.

METHODS

44 patients with irreparable postero-superior rotator cuff ruptures, refractory to physiotherapeutic treatment were included. 21 patients were treated using a modified L'Episcopo "single-incision", 23 patients with modified Gerber "double-incision" surgical approach. All patients had full-thickness tears of at least two complete tendons, and all had fully functioning deltoid and subscapularis muscles. Preoperatively, there were statistically significant differences between the two groups in all preoperative CMS sub-parameters except "power" and "pain". In the postoperative follow-up, a functional assessment using "Constant-Murley Score" (CMS) and "Age- and gender-related CMS" was conducted.

STUDY DESIGN

Retrospective-comparative trial.

LEVEL OF EVIDENCE III

RESULTS

There were no statistically significant differences between age, sex and time of follow-up between the two study groups (p > 0.05). The mean age was 59.2(± 6.3) years, and the mean follow-up time was 45.4(± 9.3) months for both groups taken together. Mean CMS improved for both groups together from 24.2 ± 8.2 points prior to surgery, to 62.8 ± 17.4 points after a mean follow-up time of 45.4 ± 9.3 months post surgery. The patients treated with "single-incision" surgery (n = 21) gained significantly (p < 0.001) more in CMS and all CMS-sub-scoring parameters except power and pain, compared to the patients treated with "double-incision" technique (n = 23).

CONCLUSION

This survey shows appealing post-operative functional outcome in patients with irreparable postero-superior rotator cuff lesions treated with two different techniques for LDT. We believe that the presentation of these methods and their results might encourage shoulder surgeons to implement these techniques. Especially the "single-incision" LDT surgery might be a more accustomed technique for many shoulder surgeons well trained in the deltopectoral approach.

Early postoperative recovery comparisons of superior capsule reconstruction to tendon transfers

BACKGROUND

The management of massive posterosuperior rotator cuff tears is controversial, with no gold standard. Two recently developed techniques that have shown promising initial results include arthroscopic superior capsular reconstruction (SCR) and tendon transfers (latissimus or lower trapezius). However, there remains a scarcity of studies examining each procedure's early postoperative clinical outcomes individually or in comparison to each other. The purpose of this study is to compare the early postoperative recovery outcomes of tendon transfers (TTs) to SCR.

METHODS

Using the surgical outcomes system global database (Arthrex Inc.), we assessed the postoperative recovery outcomes for all patients who had outcomes recorded at least 6 months after SCR or TT. The time points analyzed included preoperative and postoperative (2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years). The outcomes analyzed included pain visual analog scale (VAS) score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, VR-12 physical, and Single Assessment Numeric Evaluation (SANE).

RESULTS

Overall, 163 patients underwent SCR and 24 arthroscopically assisted TT. The mean age for SCR and TT was 60 and 56 years, respectively. Postoperative recovery curves demonstrate that both procedures produced improved outcomes at each postoperative time point compared to preoperative. The pain and functional outcomes measures, including VAS, ASES, SANE, and VR-12 physical, were comparable for TT and SCRs, with similar recovery curves between the 2 techniques. Ultimately at 2 years postoperatively, there were no significant differences between the 2 techniques.

CONCLUSIONS

Analysis of the early outcomes associated with arthroscopic treatment of massive posterosuperior rotator cuff tears demonstrated that the arthroscopically assisted tendon transfers and arthroscopic superior capsular reconstruction had similar pain and functional outcomes throughout the 2-year postoperative recovery period. Overall, the process of recovery appears equivalent between the 2 techniques. Future studies are needed to assess the outcomes of each technique and specific indications in an attempt to delineate an algorithm for the treatment of irreparable rotator cuff tears.

Management of Failed Rotator Cuff Repairs: A Review

Failed rotator cuff repairs present a complex issue for treating surgeons. Many methods of management exist for this pathology including revision repair with biologic augmentation, repairs with allograft, tendon transfers, superior capsular reconstruction, balloon arthroplasty, bursal acromial reconstruction, and reverse total shoulder arthroplasty. This review discusses the current literature associated with these management options.

Partial Rotator Cuff Repair Provides Improved Patient-Reported Outcome Measures Following Superior Capsule Reconstruction (SCR)

Purpose

To evaluate the role of concomitant partial rotator cuff repair (RCR) (i.e., infraspinatus) on patient-reported clinical outcomes following superior capsule reconstruction (SCR).

Methods

Postoperative recovery outcomes of SCR alone were compared with SCR with concomitant infraspinatus rotator cuff repair (SCR+RCR) at 3, 6, 12, and 24 months. Patients were included if they had an SCR surgery with or without a concomitant infraspinatus repair. Patients were excluded if they did not have a minimum of 6 months’ follow-up or if a preoperative baseline questionnaire was not performed. Outcome measures included pain visual analog scale, American Shoulder and Elbow Surgeons (ASES) Shoulder Function, ASES Shoulder Index, and Single Assessment Numeric Evaluation (SANE) score.

Results

Overall, 180 patients were evaluated, including 163 patients who underwent SCR alone and 17 patients who underwent concomitant infraspinatus repair (SCR+RCR). There was no difference in demographic data including age, sex, and body mass index. The postoperative recovery curves demonstrated SCR alone and SCR+RCR both provide significantly improved pain and functional scores at 2 years postoperatively (P < .001). When we compared the 2 groups, SCR+RCR provided significantly improved ASES Index (87.6 vs 78.2, P = .048) and ASES Function (25.5 vs 21.7, P = .02). There was no statistically significant difference in SANE scores (75.5 vs 64.2, P = .07) at 24 months’ follow-up.

Conclusions

SCR provides modest improvements in pain and function at 2 years postoperatively in patients with irreparable rotator cuff tears. Patients who underwent SCR and concomitant infraspinatus repair demonstrated significantly improved ASES Index and ASES Function scores and statistically nonsignificant improvement in SANE scores at 24 months postoperatively when compared with SCR alone.

Level of Evidence

III, retrospective cohort study.

Shoulder kinematics and muscle activity following latissimus dorsi transfer for massive irreparable posterosuperior rotator cuff tears in shoulders with pseudoparalysis

BACKGROUND

The aim of this study was to evaluate the thoracohumeral (TH) and glenohumeral (GH) motion with muscle activity after latissimus dorsi transfer (LDT) in a shoulder with a massive irreparable posterosuperior rotator cuff tear (MIRT) and pseudoparalysis compared with the asymptomatic contralateral shoulder (ACS).

METHODS

We recruited and evaluated 13 patients after LDT in a shoulder with preoperative clinical pseudoparalysis and an MIRT on magnetic resonance imaging, with a minimum follow-up period of 1 year, and with a Hamada stage of 3 or less. Three-dimensional electromagnetic tracking was used to assess shoulder active range of motion in both the LDT shoulder and the ACS. The maximal active elevation of the shoulder (MAES) was assessed and consisted of forward flexion, scapular abduction, and abduction in the coronal plane. Maximal active internal rotation and external rotation were assessed separately. Surface electromyography (EMG) was performed to track activation of the latissimus dorsi (LD) and deltoid muscles during shoulder motion. EMG was scaled to its maximal isometric voluntary contraction recorded in specified strength tests.

RESULTS

In MAES, TH motion of the LDT shoulder was not significantly different from that of the ACS (F_1,12 = 1.174, P = .300) but the GH contribution was significantly lower in the LDT shoulder for all motions (F_1,12 = 11.230, P = .006). External rotation was significantly greater in the ACS (26° ± 10° in LDT shoulder vs. 42° ± 11° in ACS, P < .001). The LD percentage EMG maximum showed no significant difference between the LDT shoulder and ACS during MAES (F_1,11 = 0.005, P = .946). During maximal active external rotation of the shoulder, the LDT shoulder showed a higher percentage EMG maximum than the ACS (3.0% ± 2.9% for LDT shoulder vs. 1.2% ± 2.0% for ACS, P = .006).

CONCLUSIONS

TH motion improved after LDT in an MIRT with pseudoparalysis and was not different from the ACS except for external rotation. However, GH motion was significantly lower after LDT than in the ACS in active-elevation range of motion. The LD was active after LDT but not more than in the ACS except for active external rotation, which we did not consider relevant as the activity did not rise above 3% EMG maximum. The favorable clinical results of LDT do not seem to be related to a change in LD activation and might be explained by its effect in preventing proximal migration of the humeral head in active elevation.

Tendon transfers for massive rotator cuff tears

Massive rotator cuff tears (MRCTs) present a particular challenge due to high rates of retear that can range from 18 to 94%, failure of healing after repair, and potential for irreparability.

Management of MRCTs must take into consideration the patient's characteristics, clinical examamination and expectation, number and quality of muscle tendons units involved.

Conservative treatment, arthroscopic long head of the biceps tenotomy, cuff debridement, partial repair, and superior capsule reconstruction are viable solutions to treat selected patients.

The goal of tendon transfers is to achieve stable kinematic by restoring rotational strength and force coupling of the shoulder joint.

The ideal candidate is a young, motivated patient with small degenerative changes of the glenohumeral joint, a massive irreparable cuff tear, significant atrophy, fatty infiltration, and functional deficit.

Patients with posterosuperior massive tears have impaired shoulder function with external rotation weakness and eventually lag sign If the teres minor is affected.

Latissimus dorsi transfer is the most used with results lasting for long follow-up and lower Trapezius transfer is becoming a surgical option. For anterosuperior tears, there is still controversial if pectoralis major is the best option when compared to latissimus dorsi although this last has a similar vector force with the supraspinatus tendon.

Complications associated with tendon transfers include neurovascular injury, infection, and rupture of the transferred tendon.

Use of an Arthroscopic Bridging Graft for Irreparable Rotator Cuff Tears With the Modified Mason-Allen Stitch Using a Tendon Autograft

We describe a technique for treating irreparable rotator cuff tears (RCTs) by bridging grafts with a long tendon autograft. In this technique, the plantaris tendon is harvested and prepared in a Y-shaped graft. The folded end of the graft is anchored to the greater tubercle and the other 2 limbs are fixed to rotator cuff tissue using modified Mason-Allen stitches. The autograft can decrease the tension on the repair of irreparable RCTs and has biological superiority. Our clinical experience indicates this technique will bring superior integrity to irreparable RCT repairs.

Superior Capsule Reconstruction and Lower Trapezius Transfer for Irreparable Posterior-Superior Rotator Cuff Tear: A Case Report

CASE

A 49-year-old right-hand-dominant male weightlifter was referred with persistent left shoulder pain, weakness, and range of motion limitations after failed arthroscopic rotator cuff repair and subsequent arthroscopic debridement for a massive posterior-superior supraspinatus and infraspinatus tear. The patient underwent a superior capsular reconstruction (SCR) with lower trapezius (LT) transfer to re-establish rotator cuff function.

CONCLUSION

LT transfer in addition to SCR may be a promising modality to treat massive, irreparable posterior-superior rotator cuff tears in young adults. LT transfer can optimize external rotation, whereas SCR may more adequately address pain and forward elevation.

Biomechanical analysis of latissimus dorsi, pectoralis major, and pectoralis minor transfers in subscapularis-deficient shoulders

BACKGROUND

Irreparable subscapularis (SSc) tears alter the dynamic force coupling of the shoulder, resulting in pain, weakness, and impaired shoulder function. Pectoralis major (Pma), pectoralis minor (Pmi), and latissimus dorsi (LD) transfers are treatment options for irreparable SSc tears, but clinical outcomes vary. The purpose of this study was to compare the biomechanical properties of Pma, Pmi, and LD transfers in an SSc-deficient shoulder using a computational model.

METHODS

A computer shoulder model was used to investigate the moment arms of Pma, Pmi, and LD tendon transfers compared with an intact SSc. Nine computed tomography scans from subjects without osteoarthritis were used. Virtual Pma, Pmi, and LD transfers were performed to the upper border of the SSc insertion site on the lesser tuberosity of the humerus. Muscle moment arms were computed for functional motions of 0°-80° of internal rotation with the arm in 20° and 90° of shoulder abduction and 0°-150° of shoulder abduction. The results were compared with those of the native SSc moment arms. A repeated-measures analysis of variance was then performed to determine significant differences.

RESULTS

Internal rotation moment arms of the transferred Pma and Pmi decreased significantly after 30° and 40° of internal rotation compared with the SSc moment arm of the intact shoulder, whereas the moment arm of LD transfer more closely mimicked that of the native SSc through 0°-80° of internal rotation. All 3 tendon transfer configurations demonstrated weak abductive moment arms (7.6-8.0 mm), comparable to the intact SSc (7.8 mm) but significantly lower than the intact adductive moment arms of the native Pma and LD (26.8 mm and 28.2 mm, respectively).

CONCLUSION

LD transfer most closely approximates the native SS regarding internal rotation moment arms. However, LD transfer also showed a reduction in adductive moment arms.

Classification system of graft tears following superior capsule reconstruction

OBJECTIVE

Superior capsule reconstruction (SCR) is a treatment option for irreparable massive rotator cuff tears (MRCT). The purpose of this study is to describe a classification system for graft integrity and tear location.

METHODS

Patients who underwent SCR at a single institution were included. Pre-operative age, gender, prior surgery, Hamada grade, and Goutallier stage were recorded. An MRI was performed postoperatively to assess graft integrity and tear location.

RESULTS

53 patients met inclusion criteria. Mean age was 60.1 ± 7.9 years. A post-operative MRI was performed in 42 (80%) patients at a mean of 14 ± 7 months (range, 6-40 months). MRIs demonstrated an intact graft in 16 (38%) shoulders. Of the 26 graft tears, 14 (54%) were from the glenoid, 5 (19%) mid-substance, 6 (23%) from the tuberosity, and 1 (3.8%) had complete graft absence.

CONCLUSION

Graft tears are common following SCR. We describe four different graft tear locations and submit a classification system that can be used in future studies to better compare outcomes based on graft integrity and tear location. Clinical correlation with graft integrity and graft tear location needs to be further investigated.

Mid-term results of arthroscopically assisted latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears

BACKGROUND

With progress in arthroscopic surgery, latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears (RCTs) has become a reliable all-arthroscopic or arthroscopically assisted procedure. The mid-term results of arthroscopically assisted latissimus dorsi transfer (aLDT) are scarce in the literature. The purpose of this study was to report our clinical and radiographic mid-term results of aLDT for irreparable posterosuperior RCTs.

METHODS

Thirty-one consecutive patients with a mean age of 55.5 years (range, 38-73 years) at the time of aLDT were evaluated after a mean of 3.5 years (range, 2-5 years). All patients had irreparable, full-thickness tears of at least the complete supraspinatus, with or without infraspinatus tendons, and 12 patients (39%) had undergone previous rotator cuff repair (RCR). A concomitant upper-third subscapularis repair was needed at the time of aLDT in 7 patients (23%). Mid-term results were assessed clinically and radiographically (including magnetic resonance imaging).

RESULTS

At final follow-up, 4 patients with failure (13%) had undergone revision to reverse total shoulder arthroplasty (RTSA) essentially for untreatable pain. Patients with revision to RTSA had significantly higher preoperative pain levels (Constant pain score, 6 points vs. 11 points; P = .032) and lower Constant activity scores (2 points vs. 5 points, P = .017) than the remaining 27 patients. Patients with failed previous RCRs had significantly inferior results compared with patients without previous repair (mean Subjective Shoulder Value, 67% vs. 88%; P = .035). For the 27 patients without revision, the mean relative Constant score improved from 63% to 76% (P = .032), the Constant pain score, from 10.5 to 12.7 points (P = .012), and the Subjective Shoulder Value, from 43% to 77% (P < .001). Significant progression of glenohumeral arthropathy by 2 or more grades according to the Hamada classification was observed in 13 of the 27 patients (48%), but there was no significant difference in clinical outcomes between the patients with arthropathy (n = 13) and those without it (n = 14, P = .923).

CONCLUSIONS

The mid-term results of aLDT for irreparable posterosuperior RCTs were associated with significant improvements in objective and subjective outcome measures. The failure rate leading to conversion to RTSA was relatively high in this cohort. The failures were associated with unusually intense pain in low-demand individuals and/or revision of failed RCR. Long-term results of aLDT are needed to evaluate the effect of this procedure on the progression of osteoarthritis.

Complications of Superior Capsule Reconstruction for the Treatment of Functionally Irreparable Rotator Cuff Tears: A Systematic Review

PURPOSE

The purpose of this systematic review is to characterize the complications associated with superior capsule reconstruction (SCR) for the treatment of functionally irreparable rotator cuff tears (FIRCTs).

METHODS

This systematic review was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Two independent reviewers completed a search of PubMed, Embase, and Medline databases. Studies were deemed eligible for inclusion if they reported postoperative outcomes of arthroscopic SCR for FIRCTs and considered at least 1 postoperative complication. Statistical heterogeneity was quantified via the I² statistic. Due to marked heterogeneity, pooled proportions were not reported. All complications and patient-reported outcomes were described qualitatively.

RESULTS

Fourteen studies met the inclusion/exclusion criteria. The overall complication rate post-SCR ranged from 5.0% to 70.0% (I² = 84.9%). Image-verified graft retear ranged from 8% to 70%, I² = 79.4%), with higher rates reported when SCR was performed using allograft (19%-70%, I² 76.6%) compared to autograft (8%-29%, I² = 66.1%). Reoperation (0%-36%, I² = 73.4%), revision surgeries (0%-21%, I² = 81.2%), medical complications (0%-5%, I² = 0.0%), and infections (0%-5%, I² = 0.0%) were also calculated.

CONCLUSIONS

SCR carries a distinct complication profile when used for the treatment of FIRCTs. The overall rate of complications ranged from 5.0% to 70.0%. The most common complication is graft retear with higher ranges in allografts (19%-70%) compared to autografts (8%-29%). The majority of studies reported at least 1 reoperation (range, 0%-36%), most commonly for revision to reverse shoulder arthroplasty.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV or better investigations.

Clinical outcomes of latissimus dorsi tendon transfer and superior capsular reconstruction for irreparable rotator cuff tears: a systematic review

BACKGROUND

Functionally irreparable rotator cuff tears (FIRCTs) present an ongoing challenge to the orthopedic surgeon. The aim of this systematic review was to critically compare the outcomes of three latissimus dorsi tendon transfer (LDT) techniques and two superior capsular reconstruction (SCR) techniques in treatment of FIRCTs.

METHODS

A systematic review of studies evaluating the outcome of FIRCT treatment was performed via a search of four databases in April 2020. Each included study was reviewed in duplicate by two reviewers for evaluation of methodological quality. The treatments analyzed were arthroscopic LDT (aLDT), open LDT Gerber technique (oLDTG), open LDT L'Episcopo technique (oLDTL), SCR with allograft (SCR-Allo), and SCR with autograft (SCR-TFL). Demographics, range of motion, patient-reported outcome measures, radiographic acromiohumeral distance (AHD), treatment failures, and revisions were recorded.

RESULTS

Forty-six studies (1287 shoulders) met criteria for inclusion. Twenty-three studies involved open latissimus transfer, with 445 shoulders undergoing oLDTG with mean follow-up of 63.2 months and 60 patients undergoing oLDTL with mean follow-up of 51.8 months. Ten studies (n = 369, F/U 29.2mo) reported on aLDT. Seven studies (n = 253, F/U 16.9mo) concerned SCR-Allo, and six studies (n = 160, F/U 32.mo) reported on SCR-TFL. Range of motion and subjective outcome scores improved in all techniques with no differences across treatments. Both SCR methods provided greater improvement in AHD than open LDT methods (p < 0.01). The re-tear rates were lower in both oLDT groups compared to the SCR groups (p = 0.03). Clinical failure rates were higher in the SCR-Allo and oLDTG groups, while overall treatment failures were lowest in oLDTL compared to all four other groups.

CONCLUSION

SCR techniques were associated with improved short-term radiographic acromiohumeral distance, while the open LDT techniques had lower tendon re-tear and treatment failure rates. All techniques resulted in improved clinical outcomes and pain relief compared to preoperative levels with no differences across techniques.

LEVEL OF EVIDENCE IV

Systematic review of case series and cohort studies.

Bilateral total shoulder arthroplasty: A systematic review of clinical outcomes

BACKGROUND

The purpose of this study was to describe the clinical outcomes following bilateral total shoulder arthroplasty (TSA).

METHODS

A systematic search of the PubMed, Embase, and Cochrane Library databases following PRISMA guidelines was performed. English-language literature published from 2010 to 2018 analyzing bilateral TSA (anatomic and/or reverse) with a minimum one-year follow-up was reviewed by two independent reviewers. Study quality was evaluated with the Modified Coleman Methodology Score and the methodological index for non-randomized studies score.

RESULTS

Eleven studies (1 Level II, 3 Level III, 7 Level IV) with 292 patients were included. Two studies reported on bilateral anatomic TSA (n = 54), six reported on bilateral reverse TSA (RTSA; n = 168), two reported on anatomic TSA with contralateral RTSA (TSA/RTSA; n = 31), and one compared bilateral anatomic TSA (n = 26) and bilateral RTSA (n = 13). Among studies, mean revision rate ranged from 0% to 10.53% and mean complication rate ranged from 4.9% to 31.3%. At final follow-up, patients experienced significant overall improvements in range of motion and patient-reported outcome score measurements. However, bilateral anatomic TSA resulted in greater improvements in external rotation compared to bilateral RTSA. Overall patient satisfaction was 91.0%.

CONCLUSION

The available data indicate that bilateral TSA allows for functional and pain improvements and result in high patient satisfaction.

LEVEL OF EVIDENCE

IV.

Current Options in Tendon Transfers for Irreparable Posterosuperior Rotator Cuff Tears

Massive irreparable posterosuperior rotator-cuff tears are debilitating lesions that usually require surgical treatment. Even though there is no consensus regarding the best surgical technique, tendinous transfers around the shoulder are the most commonly performed procedures. The latissimus dorsi tendon remains the most commonly used, but different modifications to the original technique have been shown to minimize complications and to improve functional results and satisfaction. Other techniques, such as the transfer of the lower trapezius tendon, are promising and should be considered, especially for patients with isolated loss of external rotation. The present paper is a literary review regarding tendon transfers for irreparable posterosuperior rotator-cuff tears.

Tendon transfers for irreparable rotator cuff tears

Symptomatic irreparable rotator cuff tears pose a challenge for shoulder surgeons. Whilst reverse polarity shoulder arthroplasty is an effective option for older symptomatic patients who have exhausted conservative management, the optimal treatment for younger patients remains controversial. In this article we outline the main tendon transfer options, including anatomical considerations, indications, contraindications, surgical technique, complications and a review of the evidence. Tendon transfers provide an alternative joint-preserving surgical option, but the evidence so far is limited, with a clear need for well-designed comparative studies to confirm their effectiveness.

Early versus delayed repair of traumatic rotator cuff tears. Does timing matter on outcomes?

INTRODUCTION

The purpose of this study was to determine if delay (before or after 4 months) in repairing a symptomatic traumatic rotator cuff tear affected clinical outcome, re-rupture rates and use of interpositional dermal grafts.

METHODS

This was a case matched (age + tear size) series of patients who underwent an early (≤ 4 months) or delayed (> 4 months) rotator cuff repair following a traumatic tear. If a direct repair could not be achieved a dermal interposition graft was used. Outcomes were collected at a median time of 30 months post-operatively using the Oxford, Constant and EQ5D scores.

RESULTS

Twenty patients underwent rotator cuff repair within 4 months (1-4) of injury. Twenty age and cuff tear size-matched patients were identified who had undergone a delayed repair (4.1-24 months) after injury. We found no significant difference (p > 0.05) in patient reported outcomes scores between the early and delayed repair. [Oxford scores; Early 43(13-48), Delayed 45 (31-48); Constant scores; Early 73 (21-94), Delayed 73.5 (44-87); EQ5D; Early 0.75 (0.25-1), Delayed 0.77 (0.4-1)]. Time to full recovery was significantly longer (14 vs 33.8 months) for the delayed repair group (P > 0.05). When cuff tears were subdivided into < 3 cm tears or ≥ 3 cm tears, no significant difference outcome scores were founds. However, use of dermal interposition graft was 44% in delayed group for tears ≥ 3 cm. No grafts were used in early repair group. There was one symptomatic re-tear in our series which was in the early repair group.

CONCLUSION

When compared to the delayed repair group, patients that underwent early repair of traumatic rotator cuff tears had shorter time of recovery, and less need for allograft augmentation for tears 3 cm or greater. However, at mid-term follow-up, this study found no difference in patient reported outcomes following early versus delayed repair of traumatic rotator cuff tears.

LEVEL OF EVIDENCE

3.

Latissimus dorsi tendon transfers: a historical journey

Several latissimus dorsi tendon transfer techniques for shoulder problems have been previously described and developed. These techniques involve the transfer in obstetric palsy, transfer in irreparable posterosuperior rotator cuff tears and subscapularis tears, and transfer in reverse shoulder arthroplasty. We detail the differences in planning and surgery and the need for different approaches. This historical and technical description provided in this study will benefit surgeons wishing to use the procedure.

Posterior latissimus dorsi transfer for massive irreparable posterosuperior rotator cuff tears: does it work in the elderly population? A comparative study between 2 age groups (≤55 vs. ≥75 years old)

HYPOTHESIS AND/OR BACKGROUND

Management of irreparable posterosuperior rotator cuff tears (RCTs) presents a significant challenge to shoulder surgeons. Previous studies on latissimus dorsi transfer (LDT) have demonstrated good to excellent outcomes in younger patients, but this indication is debatable in the elderly. The main objective of this study was to compare the results of LDT in a group of patients aged ≤55 years vs. one of patients aged ≥75 years. We hypothesized that LDT could give equally good results in the elderly as in the younger population.

METHODS

Between 2014 and 2017, a total of 153 patients who underwent LDT either for irreparable posterosuperior RCT or for failed prior repair were enrolled. All LDTs were performed by a single surgeon, were arthroscopically assisted, and fixed onto the humeral head with 2 anchors. A retrospective comparative clinical study was conducted. Patients with a minimum of 24 months of follow-up were divided into 2 groups: group A (≤55 years old at surgery) and group B (≥75 years old at surgery). The age-adjusted Constant-Murley score (aCMS), Subjective Score Value (SSV), Simple Shoulder Test (SST), Activities of Daily Living requiring active External Rotation (ADLER) score, visual analog scale for pain (VAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, patient's satisfaction, and rate of LD tendon rupture at last follow-up were compared.

RESULTS

A total of 66 patients met inclusion criteria. Four in 66 patients (6%) were lost to follow-up. There were 31 patients in group A and 31 patients in group B. The mean age was 52 and 77 years for the respective groups. Preoperatively, the 2 groups were comparable with respect to other characteristics like the mean number of ruptured tendons, mean preoperative Hamada stage, mean SST, and mean aCMS. The mean follow-up was 33 and 31 months, respectively. At last follow-up, there was no significant difference in the scores evaluated between groups A and B with SSV (61 vs. 66.7 points), ADLER (23 vs. 26.4 points), VAS (2.8 vs. 2.2 points), and ASES (64.4 vs. 72.4 points), respectively, except for the aCMS (75 vs. 96.3; ±001) and the SST (6.2 vs. 8.3; P < .001). Patient's satisfaction was not significantly different in both groups (81% of either satisfied or very satisfied patients in both groups). The rate of LD tendon rupture was higher in group A: 10 (33%) vs. 8 (26%).

CONCLUSION

Posterior transfer of latissimus dorsi tendon could be an effective surgical option for the treatment of massive irreparable posterosuperior cuff tears in patients ≥75 years of age.

An OrthoRadiological review of superior capsularreconstruction in the shoulder

Superior capsular reconstruction (SCR) is an emerging surgical technique used to treat patients with irreparable rotator cuff tears. In this procedure, a graft is attached between the superior glenoid and the greater tuberosity, with the aim of optimising glenohumeral joint function and stability. Pre-operative radiological evaluation of patients having such cuff tears is crucial for appropriate patient selection. Such imaging is particularly useful for the assessment of the cuff tear size and location, muscle wasting, fatty infiltration and the presence of any glenohumeral joint arthritis. In addition, post-operative imaging is useful in assessing graft integrity, with specific patterns of graft failure now being recognised on imaging. This article will discuss the indications and contraindications for this procedure, and review the biomechanical concepts of SCR in improving glenohumeral joint stability and restoring the force couples around the joint. The radiological appearances of the intact graft and the various patterns of graft failure will be illustrated, along with various radiological examples.

Modified L'Episcopo tendon transfer for isolated loss of active external rotation

BACKGROUND

Patients with isolated loss of active external rotation (ILER) but preserved active forward elevation have recently been identified as a rare and distinct clinical entity. The modified L'Episcopo procedure attempts to restore horizontal muscle balance and restore active external rotation.

METHODS

A retrospective study was performed for all patients with ILER and preserved forward elevation with Hamada stage ≤2 changes undergoing the modified L'Episcopo tendon transfer. Preoperative rotator cuff fatty infiltration and morphology was reported. Clinical, radiographic, and functional outcomes were recorded preoperatively and compared to postoperative outcomes at a minimum of 24 months' follow-up.

RESULTS

Nine patients (8 male, 1 female) with a mean age of 58.4 years (range, 51-67 years) were evaluated at a mean follow-up of 64.3 months (range, 24-126 months). Significant improvement was demonstrated in active external rotation with the arm at the side (mean increase of 47°; range, 30°-60°, P = .004) and at 90° abduction (mean increase of 41°; range, 20°-70°, P = .004). The mean Constant score and pain score significantly improved at final follow-up (P = .004). All patients were either very satisfied or satisfied, with a mean subjective shoulder value of 74% (range, 60%-99%).

CONCLUSION

In appropriately selected patients with ILER and preserved active forward elevation, the modified L'Episcopo procedure can restore horizontal muscle balance and produce significant improvements in active external rotation, Constant score, and pain.

Outcome of arthroscopically assisted lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tears

BACKGROUND

The purpose of this study is to report the outcome of arthroscopically assisted lower trapezius transfer to reconstruct irreparable posterior-superior rotator cuff tear.

METHODS

Forty-one consecutive patients with irreparable posterior-superior rotator cuff tears who underwent an arthroscopically assisted transfer of the lower trapezius transfer were included in this study. The patients' average age was 52 years (range 37-71), and average follow-up was 14 months (range 6-19 months). Nineteen patients had true pseudoparalysis preoperatively, whereas 66% had a prior failed rotator cuff repair. Outcome measures included visual analog scale (VAS) pain score, range of motion, Subjective Shoulder Value (SSV), and Disabilities of the Arm, Shoulder, and Hand (DASH) score.

RESULTS

Thirty-seven (90%) patients had significant improvement of all outcome scores: VAS, SSV, and DASH. The presence of a subscapularis tear did not affect the outcome. However, 3 patients who had preoperative rotator cuff arthropathy changes of the shoulder had persistent pain and limited range of motion of the shoulder after surgery, and 2 of them underwent reverse shoulder arthroplasty. Two additional patients had a traumatic rupture of the transfer as a result of fall (at 5 and 8 months postop). One underwent revision arthroscopic repair and did well after surgery, and the other had good pain relief but recurrent weakness and limited range of motion, and elected not to have a revision surgery.

CONCLUSIONS

Arthroscopic-assisted lower trapezius transfer may lead to a good outcome in patients with massive irreparable posterior-superior rotator cuff tears, including patients with pseudoparalysis. The presence of an associated reparable subscapularis tear did not affect the outcome.

Latissimus dorsi transfer for irreparable subscapularis tear

There is a paucity of information on latissimus dorsi transfer (LDT) for subscapularis insufficiency. The purpose of this study is to report the outcome of LDT to reconstruct an irreparable subscapularis tear.

METHODS

Excluding patients with prior failed Latarjet procedures, we examined 56 consecutive patients who underwent open (n = 14) or arthroscopic (n = 42) LDT. The average age was 53 years (range, 23-79), and 46 patients had a prior surgery. Outcome measures included visual analog scale score for pain, range of motion (ROM), subjective shoulder value (SSV), and Constant shoulder score (CSS).

RESULTS

At a mean 13-month follow-up (7-51 months), patients had significant improvements in their pain, ROM, SSV, and CSS when compared to preoperatively. At final follow-up, 26% of patients continued to have proximal migration, and 11% of patients had anterior subluxation. The patients with frank anterior escape had a higher likelihood of having proximal migration and anterior subluxation, but this was not statistically significant. Stages of arthritis did not progress. Revision surgeries included 2 patients who revised to a reverse shoulder arthroplasty for rupture of the tendon transfer. Furthermore, 3 patients had LDT ruptures but did not elect to undergo further surgery.

CONCLUSIONS

LDT for irreparable subscapularis tears has the potential to lead to significant clinical improvements. Most patients improve in many of the signs of subscapularis insufficiency, including anterior and/or proximal subluxation, clinical examination maneuvers, and shoulder function. Overall, this transfer represents a reasonable option for this difficult pathology.

Superior capsular reconstruction: 2-year follow-up results

Introduction

A prerequisite for a satisfying functional result in the treatment of an irreparable rotator cuff rupture is a significant reduction of shoulder pain and better range of motion with an increase in anatomic glenohumeral joint stability.

Purpose

Prospective study to examine the outcome after superior capsular reconstruction using a porcine extracellular matrix dermal graft. A special emphasis was primarily on the functional outcome, secondarily on radiographic shoulder changes, that superior capsular reconstruction might yield.

Methods

Clinical results were evaluated using the Constant score and Western Ontario Rotator Cuff (WORC) index over a 2-year period. All patients had magnetic resonance imaging (MRI) of the injured shoulder after 1 year. Graft integration and durability were qualitatively estimated as well as any graft deterioration or resorption.

Results

Thirteen patients with 13 superior capsular reconstructions were included over a 3-year period. Mean age was 61 years (range 50-70) at the time of surgery. At final follow-up (mean 24 months, range 23-32), the mean Constant score had improved from an average of 24.9-55.7 points. The mean WORC index had increased from a percentage average of 32.3%-61.9%. Eleven of 13 grafts were intact on follow-up MRI.

Conclusion

Our hypothesis was that successful implantation of a dermal xenograft would correlate with both better functional outcome and stabilized glenohumeral radiographic features. We saw a group of patients with variable but significant increases in functional results and in general with limited pain and with an intact xenograft on an MRI scan. We did not find a positive correlation between functional outcome scores and graft durability nor with single cuff tendon defects vs. larger rotator cuff defects.This study suggests that a superior capsular reconstruction can yield results that are comparable or superior to other known salvage treatment options in patients with large to massive rotator cuff defects without significant cuff tear arthropathy. The hypothesis that superior capsular reconstruction can be a relevant treatment method for irreparable rotator cuff tears could not be refuted despite a fairly low patient inclusion number. With these results, selected patients can be considered for a different treatment than reverse shoulder arthroplasty, débridement, or tendon transfer.

Surgical Management of Massive Irreparable Cuff Tears: Latissimus Dorsi Transfer for Posterosuperior Tears

PURPOSE OF REVIEW

This review aims to describe the role of the latissimus dorsi transfer (LDT) for patients with irreparable posterosuperior rotator cuff tears (RCTs).

RECENT FINDINGS

Historically, the LDT has been performed as an open (double-incision) procedure for neurologically intact, relatively young patients with irreparable posterosuperior RCTs with disabling loss of active external rotation with or without impaired active elevation. The transferred tendon reconstitutes the posterior rotator cuff and force couple, respectively and thus has the potential to function effectively as an external rotator and humeral head depressor. Long-term results of the open technique have demonstrated in the majority of patients substantial and durable improvements in shoulder function and pain relief at the 10-year benchmark. With the advancements of arthroscopic surgery, the LDT was expanded to an arthroscopically assisted procedure with promising short-term results. In addition to adequate technical performance, the success of the procedure depends on preoperative factors, such as exclusion of glenohumeral osteoarthritis and acromial acetabularization; intact or reparable subscapularis tendon; intact (or hypertrophic) teres minor muscle; adequate preoperative activity of the latissimus dorsi; and normal or mild impairment of overhead function. The LDT (open or arthroscopically assisted) is a reliable treatment option for patients with massive, irreparable posterosuperior RCTs with disabling loss of active external rotation, with or without diminished overhead function and without advanced glenohumeral osteoarthritis. Precise patient selection is of tremendous importance in the success of the LDT.

Surgical Management of Massive Irreparable Posterosuperior Rotator Cuff Tears: Arthroscopic-Assisted Lower Trapezius Transfer

PURPOSE OF THE REVIEW

Functionally irreparable rotator cuff tears (FIRCTs) remain one of the most challenging pathologies treated in the shoulder. The lower trapezius transfer represents a very promising treatment option for posterosuperior FIRCT. This article reviews the role for the lower trapezius transfer in the treatment of patient with FIRCTs and highlights the tips and tricks to performing this arthroscopic-assisted procedure.

RECENT FINDINGS

The treatment of posterosuperior FIRCTs contemplates a wide array of surgical options, including partial repair, biceps tenodesis/tenotomy, superior capsule reconstruction, subacromial balloon, reverse shoulder arthroplasty, and open-/arthroscopic-assisted tendon transfers. Tendon transfers have emerged as very promising reconstructive options to rebalance the anterior-posterior force couple. Controversy remains regarding the relative indications of latissimus dorsi transfer (LDT) and lower trapezius transfer (LTT). Initially used with very good success in patients with brachial plexus injuries, the open LTT has shown excellent clinical and radiographic outcomes in a recent series of patients with FIRCTs. However, this technique should be reserved for patients with an intact or reparable subscapularis tendon and no advanced glenohumeral arthritis or humeral head femoralization. With advancements in surgical technique, the arthroscopic-assisted LTT has shown similar promising results. However, studies on arthroscopically assisted LTT are limited to short-term follow-up, and future comparative trials with large patient numbers and longer follow-up are needed to better understand the indications for this novel tendon transfer in the treatment of FIRCT. The arthroscopic-assisted LTT is a novel, promising option for the treatment of patients with functional irreparable posterosuperior rotator cuff tears. Careful attention to indications and technical pearls are paramount when performing this procedure to optimize postoperative clinical outcomes.

The latissimus dorsi tendon functions as an external rotator after arthroscopic-assisted transfer for massive irreparable posterosuperior rotator cuff tears

PURPOSE

Latissimus dorsi tendon transfer is a surgical option for the treatment of massive irreparable posterosuperior rotator cuff tear. Whether a favourable clinical outcome is due to the latissimus dorsi muscle contraction rather than the passive tenodesis effect remains to be confirmed. The purpose of the current case-control study was to evaluate the shoulder kinematics and latissimus dorsi activation after latissimus dorsi tendon transfer.

METHODS

Eighteen patients suffering from irreparable rotator cuff tear that underwent latissimus dorsi tendon transfer and 18 healthy individuals were examined using a 3D kinematic tracking system and electromyography. Active maximal flexion-extension and abduction-adduction of the humerus were measured for the operated and the contralateral shoulder of the patients and the shoulder of healthy individuals to evaluate the range of motion (ROM) and scapulohumeral rhythm. Electromyographic comparison of isometric contraction between the latissimus dorsi of the operated and contralateral shoulder was carried out.

RESULTS

After arthroscopic-assisted latissimus dorsi tendon transfer, patients showed comparable flexion and abduction ROM to their asymptomatic contralateral shoulders and to the shoulders of healthy individuals. Significantly higher scapular ROM values were found between the latissimus dorsi tendon transfer side and the shoulders of healthy individuals. While performing external rotation with 0° shoulder abduction, a greater percentage of the electromyographic peak value (p = 0.047) and a higher latissimus dorsi internal/external rotation ratio (p = 0.004) were noted for the transferred muscle in comparison to the contralateral shoulder.

CONCLUSION

Although the arthroscopic-assisted latissimus dorsi tendon transfer failed to normalize scapulothoracic joint movements of patients, a functional latissimus flap and a shoulder ROM similar to the contralateral side or the shoulder of healthy individuals can be expected after this procedure in patients with massive irreparable posterosuperior rotator cuff tear.

LEVEL OF EVIDENCE

III.

Long-term outcomes of latissimus dorsi transfer for irreparable rotator cuff tears

PURPOSE

The primary objective of this retrospective study was to validate electrophysiological results of latissimus dorsi tendon transfer (LDTT) to determine if this transfer is active for different daily living tasks, and the secondary objective was to correlate these clinical results.

METHODS

With a mean follow-up of 4.7 years, 14 latissimus dorsi tendon transfers were retrospectively reviewed. Patients were clinically evaluated with the constant score and the SSV. Healing of the tendon on the greater tuberosity and atrophy of the LDTT muscle was determined by ultrasound and compared with the contralateral side. Electrical activity was analyzed by electromyography in active elevation, abduction, and external rotation.

RESULTS

Twelve patients are satisfied (SSV). At the last follow-up, the EMG found a significant electrical activity in the abduction and external rotation and a lower activity in adduction and internal rotation. The mean constant score increased from 29 to 51, the mean forward elevation increased from 89° to 135°, the mean abduction from 92° to 105°, and the external rotation from 12° to 24°. The ultrasound found 12 healed tendons and two ruptures at the myotendinous junction.

CONCLUSION

Electrical activity in abduction and external rotation testifies that the LDT transfer acts as an active muscle transfer and acts not only a muscle tenodesis that covers the humeral head.

Editorial Commentary: Is It Time to Abandon the Latissimus Dorsi Tendon Transfer as a Salvage Procedure for Patients With Large Irreparable Rotator Cuff Tears That Failed Primary Repair?

The management of large irreparable rotator cuff tears in the young and active patient population without arthritis presents a challenge for shoulder surgeons due to the limited number of treatment options available that provide predictable outcomes. Latissimus dorsi tendon transfer (LDTT) for the treatment of large, irreparable posterosuperior rotator cuff tears or as a salvage procedure for failed surgical (arthroscopic or open) repair was originally introduced in 1988. Multiple studies have reported both the short- and long-term outcomes after LDTT; however, the majority of these studies included patients without history of previous surgery or a mixed patient population. However, LDTT as a salvage procedure is not as predictable as a primary procedure in terms of pain relief and functional improvement. This is especially true in patients with severe fatty infiltration of the posterior cuff musculature and preoperative acromiohumeral distance <7 mm on static anteroposterior radiography. Conversely, we should not abandon the LDTT in young and active patients with large irreparable rotator cuff tear and intact or repairable subscapularis without arthritis as a primary procedure for treatment. There is plenty of clinical evidence that demonstrates good-to-excellent outcomes in this subset of patients. However, in the setting of one or multiple failed arthroscopic or open cuff repairs, limited range of motion, acromiohumeral distance <7 mm on static anteroposterior radiograph, and severe fatty infiltration of the posterior cuff musculature, I would caution against the use of LDTT as a salvage procedure due to the high failure rate and unreliable clinical results. Currently, there is no role in my own practice for LDTT as a salvage procedure in this patient population.

High Clinical Failure Rate After Latissimus Dorsi Transfer for Revision Massive Rotator Cuff Tears

PURPOSE

To evaluate the clinical success rate, along with risk factors for failure, in patients undergoing latissimus dorsi transfer for the treatment of massive, irreparable, previously failed rotator cuff tears.

METHODS

We performed a retrospective chart review of prospectively collected data from an institutional shoulder outcome registry. All patients who underwent latissimus dorsi transfer for previously failed rotator cuff repair between 2006 and 2013 with a minimum follow-up period of 1 year were included in the study. The indications for inclusion were large (≥2 tendons), retracted, chronic rotator cuff tears with fatty infiltration or atrophy for which prior surgical repair had failed. Preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test scores were collected, along with postoperative Single Assessment Numerical Evaluation scores. Complications and clinical failures (Δ in ASES score <17) were recorded. Patient demographic and tear characteristics were evaluated as potential risk factors for failure.

RESULTS

A total of 22 patients (mean age, 53 ± 6 years) were included in the study, with a mean follow-up time of 3.4 ± 1.1 years. Over 63% of patients (n = 14) reported undergoing 2 or more prior failed rotator cuff repairs. Patients undergoing latissimus dorsi transfer showed significant improvements in ASES scores (from 35.2 ± 21.9 preoperatively to 55.8 ± 22.9 postoperatively, P = .001), Simple Shoulder Test scores (from 3.5 ± 3.1 preoperatively to 5.2 ± 3.4 postoperatively, P = .002), and pain scores (from 5.9 ± 2.8 preoperatively to 4.6 ± 4.3 postoperatively, P = .002) at final follow-up. The complication rate after latissimus transfer was 27%. The rate of revision to reverse total shoulder arthroplasty was 13.6% (n = 3) after a mean of 2.7 years, and the clinical failure rate was 41% (n = 9) at final follow-up. An acromiohumeral interval of less than 7 mm (P = .04) and high-grade fatty infiltration (grade 3 or greater, P = .004) were significant preoperative risk factors for clinical failure.

CONCLUSIONS

Latissimus dorsi tendon transfer resulted in a clinical failure rate of 41% and complication rate of 27%, with an acromiohumeral interval of less than 7 mm and high-grade fatty infiltration being associated with postoperative failure.

LEVEL OF EVIDENCE

Level IV.

Effect of affective temperament on outcome of rotator cuff surgery

INTRODUCTION

Although numerous risk factors have been described, the effects of temperament, which is defined as a risk factor for certain disorders, on the outcome of patients undergoing rotator cuff surgery have not been investigated.

HYPOTHESIS

We investigated whether a relationship exists between affective temperament and the outcome of patients undergoing rotator cuff surgery.

MATERIAL AND METHODS

The outcomes of 176 patients undergoing rotator cuff surgery were examined using the Oxford and Constant questionnaires as well as visual analog scale values preoperatively and postoperatively. Inclusion criteria were defined as 1) dissatisfaction with pain despite 6 months of nonoperative treatment; 2) rotator cuff defects with full-thickness, small- to large-sized defects; 3) presence of a single dominant temperament or nondominant temperament; 4) no history of a diagnosed psychiatric disorder; and 5) a minimum of greater than 1 year of follow-up after surgery. Exclusion criteria were 1) other comorbid shoulder pathology; 2) irreparable or partial rotator cuff rupture; 3) grade 3 retractions; 4) grade 3-4 fatty infiltration; 5) other comorbid diseases such as diabetes, thyroid disorders, or inflammatory diseases; 6) history of shoulder surgery; 7) infection of the shoulder joint; 8) neurologic deficit in muscles around the shoulder; 9) two or more dominant temperaments; and 10) history of acromioclavicular joint resection and/or biceps tenodesis with cuff repair. All patient temperaments were evaluated according to the Temperament Evaluation of Memphis, Pisa, Paris and San Diego auto questionnaire version.

RESULTS

The mean follow-up time was 45.5 months. The outcomes of patients with depressive temperament were worse than of patients with a nondominant temperament. This situation was observed both preoperatively and postoperatively. However, a similar relationship between nondominant and anxious temperament groups was observed only postoperatively.

CONCLUSION

We noticed that depressive and anxious temperaments had a negative effect on patient outcomes after rotator cuff surgery; however, nondominant temperaments had a positive effect on patient outcomes.

LEVEL OF EVIDENCE

Level III; Retrospective Comparative Study.

Superior capsule reconstruction using dermal allograft: early outcomes and survival

BACKGROUND

Superior capsule reconstruction (SCR) has shown promising outcomes in its initial description, but lacks additional reports analyzing outcomes. This study analyzes early outcomes of SCRs in patients with massive irreparable rotator cuff tears.

METHODS

A retrospective analysis of all SCRs at our institution from January 1, 2015, to August 31, 2017, was performed with a minimum 6-months follow-up. A total of 34 patients were included with a mean age of 60 years. SCR was performed by 1 of 6 fellowship trained surgeons.

RESULTS

At an average follow-up of 12 months, 22 patients were identified as failures after modified Neer classification. Furthermore, 8 of these patients have undergone a reoperation, whereas an additional 14 patients were considered clinical failures experiencing continued pain and a lack of shoulder function. Of note, 2 of the 3 patients with a subscapularis tear had a failure. In addition, revision cases, female gender, increased fatty infiltration in the infraspinatus and low surgeon volume were associated with a higher rate of failure. There was no significant improvement in range of motion or functional scores.

CONCLUSION

SCR performed for large-to-massive irreparable rotator cuff tears has a high rate of persistent pain and poor function leading to clinical failure in 65% of patients. Risk factors predicting clinical failure included revision cases, female gender, increased Goutallier fatty infiltration of the infraspinatus, and low surgeon volume (n ≤ 10).

Augmented latissimus dorsi transfer: initial results in patients with massive irreparable posterosuperior rotator cuff tears

BACKGROUND

The surgical treatment of irreparable massive rotator cuff tears is challenging. The purpose of the present study was to report the initial outcomes after a modified latissimus dorsi transfer (LDT) augmented by acellular dermal allograft (ADA).

METHODS

This retrospective study includes 24 patients managed with LDT using ADA augmentation as a bursal-sided onlay between March 2009 and December 2015.

RESULTS

All patients were men with a mean age of 57 years (range 48 years to 70 years). Seven patients had a previously failed rotator cuff repair and ten patients presented with a deficient subscapularis tendon. At last follow-up (mean 27 months), there was a significant improvement in active forward flexion (mean increase 31°; p = 0.016), and abduction by 25° (p = 0.059). The acromiohumeral distance remained stable and the failure rate was low (4%). Neither a history of previous rotator cuff surgery, nor the presence of a subscapularis tear had a negative impact on functional outcome.

CONCLUSIONS

In our cohort of patients, LDT augmented with ADA was a reasonable option for patients with previously failed rotator cuff repair, as well as in the subgroup of patients with a deficient subscapularis tendon.

LEVEL OF EVIDENCE

Level IV: Therapeutic study (case series).