Clinical and Structural Outcomes of Nonoperative Management of Massive 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.

Rotator cuff tear patterns: MRI appearance and its surgical relevance

A new perspective on rotator cuff anatomy has allowed a better understanding of the patterns of the different rotator cuff tears. It is essential for radiologists to be aware of these different patterns of tears and to understand how they might influence treatment and surgical approach. Our objective is to review the arthroscopy correlated magnetic resonance imaging appearance of the different types of rotator cuff tears based on current anatomical concepts.Critical relevance statement Knowledge of the characteristics of rotator cuff tears improves our communication with the surgeon and can also make it easier for the radiologist to prepare a report that guides therapeutic conduct and serves as a prognosis for the patient.Key points• There is no universally accepted classification for RC tears.• New patterns such as delamination or myotendinous junction tears have been defined.• The most difficult feature to assess in full thickness tears on MRI is the pattern.• Fatty infiltration of the RC tendons is crucial in the prognosis and outcome.• The radiological report is an effective way of communication with the surgeon.

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.

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

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

Many patients fail to achieve MCID for PROMIS upper extremity and pain interference following nonoperative management of rotator cuff tears

Background

Efficacy of nonoperative treatment for rotator cuff tears has been debated, especially for full-thickness tears. The purpose of this study was to a) define the minimal clinically important difference (MCID) of nonoperative treatment with regard to Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) and upper extremity (UE), and b) determine the proportion of patients with both partial and full-thickness tears (PTRCT, FTRCT) who achieve this improvement following initial nonoperative treatment. We hypothesized that >75% of PTRCT and FTRTC patients would achieve MCID for PROMIS PI and UE.

Methods

We performed a retrospective cohort study evaluating nonoperatively managed patients with image-confirmed PTRCT and FTRCT. Treatment modalities and follow-up PROMIS scores at least 6 months after their initial visit were recorded. Using a distribution technique, MCID was calculated.

Results

A total of 111 FTRCT and 68 PTRCT patients were included with at least 6 months of follow-up. At 6 months from initial presentation, the MCID for PROMIS UE was 3.75 and 3.95 for FTRCT and PTRCT patients, respectively. For PROMIS PI, the MCID was 3.35 and 3.90 for FTRCT and PTRCT, respectively. In total, 41% of FTRCT and 41% of PTRCT achieved MCID for PROMIS UE. Thirty-four percent of FTRCT and 35% of PTRCT achieved MCID for PROMIS PI.

Conclusion

The majority of patients undergoing nonoperative treatment for supraspinatus/infraspinatus rotator cuff tears did not achieve MCID at 6 months for PROMIS PI (34% for FTRCT and 35% for PTRCT) or UE (41% for FTRCT and 41% for PTRCT).

Content reporting and effectiveness of therapeutic exercise in the management of massive rotator cuff tears: A systematic review with 490 patients

Background

Massive rotator cuff tears (MRCT) account for a substantial fraction of tears above the age of 60 years. However, there are no clear criteria for prescription parameters within therapeutic exercise treatments. The aim of this study was to evaluate the effects and characteristics of therapeutic exercise treatments in patients with MRCT.

Methods

A systematic search was conducted in MEDLINE/PubMed, Web of Science, SPORTDiscus, SciELO, Scopus and EMBASE from inception to August 2022. Studies were included if they evaluated the effects of exercise on patients with MRCT. The risk of bias was evaluated and the Consensus on Exercise Reporting Template (CERT) was also used. A narrative synthesis without meta-analysis was performed.

Results

One randomized controlled trial, two non-randomized studies, six non-controlled studies, one case series and four retrospective studies were included. They ranged from serious to moderate risk of bias. The CERT reflected a poor description of the exercise programmes. Studies showed a pattern of improvements in most patient-reported outcome measures (PROM) surpassing the MCID, and active elevation range of motion.

Conclusions

There is limited evidence that exercise and co-interventions are effective in the management of some patients with MRCT, based on a systematic review without meta-analysis. Future research should improve content reporting.

Level of evidence

IV.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, treatment study with retrospective cohort comparison.

Superior Capsular Reconstruction Versus Latissimus Dorsi Tendon Transfer for Irreparable Rotator Cuff Tears: Minimum 5-year Outcomes

Background

Arthroscopic superior capsular reconstruction (SCR) has been introduced as a successful alternative to latissimus dorsi tendon transfer (LDTT) for irreparable posterosuperior rotator cuff tears.

Purpose

To compare minimum 5-year clinical outcomes of SCR and LDTT for the treatment of irreparable posterosuperior rotator cuff tears in patients with minimal evidence of arthritis and intact or reparable subscapularis tears.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who underwent SCR or LDTT and had undergone surgery ≥5 years earlier were included. The SCR technique used a dermal allograft customized to the defect. Surgical, demographic, and subjective data were collected prospectively and reviewed retrospectively. Patient-reported outcome (PRO) scores utilized were the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), the short version of the Disabilities of the Arm, Shoulder and Hand score (QuickDASH), 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS), and patient satisfaction. Further surgical procedures were documented, and treatment that progressed to reverse total shoulder arthroplasty (RTSA) or revision rotator cuff surgery was considered a failure. Kaplan-Meier survivorship analysis was performed.

Results

Thirty patients (n = 20 men; n = 10 women) with a mean follow-up of 6.3 years (range, 5-10.5 years) were included. A total of 13 patients underwent SCR and 17 patients underwent LDTT. The mean age of the SCR group was 56 years (range, 41.2-63.9 years), and the mean age of the LDTT group was 49 years (range, 34.7-57 years) (P = .006). One patient in the SCR group and 2 patients in the LDTT group progressed to RTSA. Two additional (11.8%) patients in the LDTT group had further surgery-1 had arthroscopic cuff repair and 1 had hardware removal with biopsies. The SCR group demonstrated significantly better ASES (94.1 ± 6.3 vs 72.3 ± 16.4; P = .001), SANE (85.6 ± 8 vs 48.7 ± 19.4; P = .001), QuickDASH (8.8 ± 8.7 vs 24.3 ± 16.5; P = .012), and SF-12 PCS (56.1 ± 2.3 vs 46.5 ± 6; P = .001) PROs at the final follow-up. There was no significant difference between groups in median satisfaction (SCR, 9; LDTT, 8 [P = .379]). At 5 years, survivorship rates were 91.7% and 81.3% for the SCR and LDTT groups, respectively (P = .421).

Conclusion

At the final follow-up, SCR yielded superior PROs compared with LDTT for the treatment of massive, irreparable posterosuperior rotator cuff tears despite similar patient satisfaction and survivorship between procedures.

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 Irreparable Posterosuperior Rotator Cuff Tears-A Current Concepts Review and Proposed Treatment Algorithm by the AGA Shoulder Committee

Posterosuperior rotator cuff tears range among the most common causes of shoulder complaints. While non-operative treatment is typically reserved for the elderly patient with low functional demands, surgical treatment is considered the gold standard for active patients. More precisely, an anatomic rotator cuff repair (RCR) is considered the most desirable treatment option and should be generally attempted during surgery. If an anatomic RCR is impossible, the adequate choice of treatment for irreparable rotator cuff tears remains a matter of debate among shoulder surgeons. Following a critical review of the contemporary literature, the authors suggest the following evidence- and experience-based treatment recommendation. In the non-functional, osteoarthritic shoulder, treatment strategies in the management of irreparable posterosuperior RCT include debridement-based procedures and reverse total shoulder arthroplasty as the treatment of choice. Joint-preserving procedures aimed at restoring glenohumeral biomechanics and function should be reserved for the non-osteoarthritic shoulder. Prior to these procedures, however, patients should be counseled about deteriorating results over time. Recent innovations such as the superior capsule reconstruction and the implantation of a subacromial spacer show promising short-term results, yet future studies with long-term follow-up are required to derive stronger recommendations.

Arthroscopic Repair Benefits Reparable Rotator Cuff Tear Patients Aged 65 Years or Older With a History of Traumatic Events

PURPOSE

To evaluate the clinical outcomes of arthroscopic rotator cuff repair at 2-year follow-up in patients aged 65 years or older with a history of traumatic events divided into groups based on symptom duration (<3 months, 3-6 months, and >6 months from injury to surgery) and to compared patient-reported outcomes among the 3 groups.

METHODS

Between 2015 and 2020, 110 patients who met the inclusion criteria were enrolled in this study; these patients were divided into 3 groups according to symptom duration: less than 3 months (group A), 3 to 6 months (group B) and more than 6 months (group C). Preoperative and 2-year postoperative clinical outcomes were compared, including American Shoulder and Elbow Surgeons, Constant-Murley, University of California, Los Angeles, Simple Shoulder Test, and visual analog scale scores; forward elevation; external rotation; and internal rotation. The minimal clinically important difference (MCID), patient acceptable symptom state, substantial clinical benefit, and maximum outcome improvement were also compared among the groups.

RESULTS

The American Shoulder and Elbow Surgeons score, as the primary outcome, improved significantly from 41.0 ± 18.5 to 85.4 ± 8.1 in group A, from 53.7 ± 14.3 to 86.3 ± 11.7 in group B, and from 49.7 ± 18.5 to 83.9 ± 11.9 in group C. All the other parameters showed statistically significant improvements at 2-year follow-up in each group (all P < .05). There was no significant difference in each parameter among the 3 groups except the visual analog scale score, which did not achieve the MCID. Overall, 86 patients (78.2%) exceeded the MCID, 87 patients (79.1%) achieved the patient acceptable symptom state, 77 patients (70.0%) achieved substantial clinical benefit, and 62 patients (56.4%) achieved maximum outcome improvement without significant differences among the 3 groups.

CONCLUSIONS

In rotator cuff tear patients aged 65 years or older with a history of traumatic events, arthroscopic rotator cuff repair significantly improves clinical outcomes at 2-year follow-up regardless of symptom duration if the tear is fully reparable.

LEVEL OF EVIDENCE

Level III, prognostic retrospective study.

Movement compensation is driven by the deltoid and teres minor muscles following severe rotator cuff tear

BACKGROUND

Rotator cuff tears are common in older adults, negatively affecting function. Previous simulation-based studies reported more posterior and superior oriented glenohumeral loading with increased cuff tear severity and task performance, although corresponding muscle compensation strategies are unclear. Our objective is to determine how shoulder muscle forces change with increased rotator cuff tear severity during functional task performance.

METHODS

Eight musculoskeletal models of increasing tear severity were developed to represent no rotator cuff tear to massive three-tendon tears. Simulations were performed using each combination of model and kinematics for five functional tasks. Individual muscle forces were averaged for each task and tear severity, then normalized by the sum of the muscle forces across the shoulder. Forces were compared across tear severity and muscle.

FINDINGS

For muscle force contribution, interactions between tear severity and muscle and a main effect of muscle were seen for all tasks (P < 0.0001). Middle deltoid increased force contribution by >10% in the greatest tear severity model compared to no cuff tear model for all tasks (all P < 0.0001). Teres minor contribution increased by 7.7%, 5.6%, and 11% in the greatest tear severity model compared to the no cuff tear model for forward reach, axilla wash, and upward reach 105° tasks, respectively (all P < 0.0001).

INTERPRETATION

Functional tasks elicit compensatory responses from uninjured muscles following severe cuff tears, notably in middle deltoid and teres minor, leading to posterior-superior glenohumeral loading. The muscles are potential targets for strengthening to avoid injury from sustained increased muscle force.

Evaluation of Radiographic Changes 5 Years After Arthroscopic Rotator Cuff Repair

Background:

Radiographic changes in the glenohumeral joint often occur after rotator cuff repair; however, the details of the progression and underlying causes remain unknown.

Purpose:

To retrospectively evaluate the timing and frequency of radiographic changes after arthroscopic rotator cuff repair and to clarify the predictive factors that affect the onset of such changes using multivariate analysis.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

We retrospectively reviewed 100 patients with 5 years of follow-up after arthroscopic rotator cuff repair and evaluated the postoperative shift in radiographic findings on plain radiographs every year during follow-up. Factors related to osteoarthritis, acromial spur re-formation, and greater tuberosity resorption at 5 years after surgery were evaluated using logistic regression analyses. Explanatory variables included preoperative factors, intraoperative factors, and postoperative retear. Baseline variables significant in the univariate analyses were included in the multivariate models.

Results:

Of the 100 patients, 12 developed osteoarthritis, 26 developed acromial spur formation, and 16 developed greater tuberosity resorption at 5 years after surgery. The incidence and grade of osteoarthritis and acromial spur gradually increased over time postoperatively. On the other hand, greater tuberosity resorption developed within 2 years after surgery but did not progress later. Multivariate analysis showed that a larger anteroposterior tear size (odds ratio [OR], 1.09; 95% CI, 1.01-1.17; P = .037) was a risk factor for postoperative osteoarthritis. Early retear (OR, 10.26; 95% CI, 1.03-102.40; P = .047) was a risk factor for acromial spur re-formation. Roughness of the greater tuberosity (OR, 9.07; 95% CI, 1.13-72.82; P = .038) and larger number of suture anchors (OR, 3.34; 95% CI, 1.66-6.74; P = .001) were risk factors for greater tuberosity resorption.

Conclusion:

Our study showed that radiographic changes occurred in 40% of patients within 5 years after arthroscopic rotator cuff repair. While the osteoarthritic changes and acromial spur re-formation gradually progressed postoperatively, the greater tuberosity resorption stopped within 2 years after surgery. Tear size, morphology of the greater tuberosity, and the number of suture anchors can affect radiographic changes. Furthermore, this study suggested that acromial spur re-formation may be an indicator of early retears.

Zimmer Z, Gilotra MN. Reliability, validity, and responsiveness of a novel subscapularis outcome score: The Baltimore Orthopedic Subscapularis Score

Background

Available surveys that evaluate shoulder strength and pain often combine rotator cuff muscles making the test unable to differentiate subscapularis tears from other pathology including concomitant supraspinatus, infraspinatus tears. The purpose of this study was to validate a subscapularis-specific shoulder survey (Baltimore Orthopedic Subscapularis Score) as a viable clinical outcome assessment through analysis of psychometric properties.

Methods

A 5-question survey was given to a study population of 390 patients, 136 of whom had full thickness rotator cuff tears with a minimum score of 5 (better) and a maximum score of 25 (worse). Surveys were given during the initial consultation, preoperative visit, and postoperative visit. Content validity, construct validity, test-retest reliability, responsiveness to change, internal consistency, and minimal clinically important difference using distribution and anchor-based methods were determined for our subscapularis function survey.

Results

A high correlation was reported on test-retest reliability (intraclass correlation coefficient = 0.89). An acceptable internal consistency was reported for all patients surveyed (Cronbach alpha = 0.91). Floor and ceiling effects for patients with rotator cuff pathology were minimized (1% for both). Patients with an isolated subscapularis tear scored worse than supraspinatus/infraspinatus tears and exhibited similar dysfunction as patients with a supraspinatus/infraspinatus/subscapularis tear. An acceptable construct validity was reported with subscapularis-involved tears demonstrating higher scores with significance (P < .05). There was excellent responsiveness to change with a standardized response mean of 1.51 and effect size of 1.27 (large > 0.8). The minimal clinically important difference using a distribution and anchor-based method was 4.1 and 4.6, respectively. Among patients with rotator cuff tears in this population, a score of 22 or higher predicts a subscapularis tear 75% of the time, in spite of its low overall prevalence.

Conclusion

The subscapularis shoulder score demonstrated acceptable psychometric performance for outcomes assessment in patients with rotator cuff disease. This survey can be used as an effective clinical tool to assess subscapularis function.

Arthroscopic Superior Capsular Reconstruction for Massive Irreparable Rotator Cuff Tears Results in Significant Improvements in Patient Reported Outcomes and Range of Motion: A Systematic Review

Purpose

The purposes of this study were to evaluate the clinical outcomes (with the minimum mean follow-up period of 2 years) of arthroscopic superior capsular reconstruction (ASCR) using different grafts for massive irreparable rotator cuff tears (MIRCTs) and to explore whether margin convergence in ASCR affects range of motion (ROM) outcomes.

Methods

This systematic review was registered in PROSPERO and was then conducted following PRISMA guidelines by searching the databases: MEDLINE, EMBASE, Web of Science, and Cochrane Library database before April 2021. These literature searches investigating the clinical outcomes of ASCR were included. The methodological quality of included studies was assessed using the MINORS criteria. The data, including margin convergence, patient-reported outcome scores, range of motion, and complications, were extracted and analyzed. The minimal clinically important differences (MCID) criteria was used to define clinical significance.

Results

15 studies met the inclusion criteria. All studies reported statistically significant improvements in visual analog scale scores (range: 2.07 to 7.1) and American Shoulder and Elbow Surgeons scores (range: 18.1 to 58). Significant improvements of Constant scores were noted in 4 of 5 reporting studies (mean improvement ranged from 14.64 to 50.79). Active forward flexion/elevation (11 studies), active abduction (4 studies), and active external rotation (8 studies) displayed improvements in all reporting studies, with mean changes ranging from 12 to 73.68, 19 to 89.21, and 1 to 24.74, respectively. The mean change of postoperative acromiohumeral distance ranged from −0.86 mm to 3.2 mm in 9 studies. The postoperative complication rate of ASCR ranged from 4.5% to 47.6%. The anterior margin convergence in SCR was associated with a relatively poor improvement in active external rotation.

Conclusions

ASCR contributes to significant improvements in patient-reported clinical outcomes and ROM at follow-up after a mean of more than two years, emerging as a viable option for patients with MIRCTs. The anterior margin convergence should be prudently chosen, especially in ASCR using fascia lata autograft, on account of the probable restriction on postoperative active external rotation.

Level of Evidence

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

Long-term Results of Arthroscopic Repair of Full-Thickness Traumatic Rotator Cuff Tears in Active Duty Military Patients Under the Age of 40 Years

BACKGROUND

Arthroscopic rotator cuff repair is an effective procedure through which to decrease pain and increase strength, with favorable long-term outcomes demonstrated in older patient populations with full-thickness rotator cuff tears. The long-term outcomes after this procedure in younger, higher-demand patients, however, is not as clearly defined.

PURPOSE

To report on the long-term outcomes after arthroscopic rotator cuff repair of traumatic full-thickness rotator cuff tears in active duty military patients under the age of 40 years at the time of surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Preoperative, midterm, and final evaluations were collected, including scores on the visual analog scale for pain, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons shoulder form. A total of 42 patients were screened for inclusion: 3 underwent additional surgical procedures on the operative shoulder and 2 were lost to follow-up, leaving 37 patients with mean follow-up of 104.51 months available for analysis. A subgroup analysis was performed comparing outcomes between patients with Southern California Orthopaedic Institute grade 1 or 2 tears and those with grade 3 or 4 tears.

RESULTS

At final follow-up, pain per the visual analog scale decreased to 1.16 from 8.03 (P < .0001); the Single Assessment Numeric Evaluation score increased to 87.32 from 48.24 (P < .0001); and the American Shoulder and Elbow Surgeons score increased to 88.68 from 41.00 (P < .0001). There was no statistically significant difference in outcome scores or range of motion between midterm and final follow-up. Improvement in outcome scores and range of motion at final follow-up did not vary between patients with small and large tears. Of 42 patients, 37 (88.1%) were able to return to full unrestricted active duty and sporting activity, while 5 (11.9%) were medically separated from the military.

CONCLUSION

Active duty military patients under the age of 40 years with traumatic full-thickness rotator cuff tears had statistically and clinically significant increases in outcome scores and decreases in pain after arthroscopic rotator cuff repair at long-term follow-up.

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.

Preoperative Single Assessment Numeric Evaluation Score Predicts Poor Outcomes After Reverse Shoulder Arthroplasty for Massive Rotator Cuff Tears Without Arthritis

Limited clinical evidence is available to help to predict poor outcomes after reverse shoulder arthroplasty (RSA) among patients with massive rotator cuff tears without glenohumeral arthritis. A retrospective case-control study was performed for patients who underwent RSA for massive rotator cuff tear without glenohumeral arthritis (Hamada score ≤3) and had a minimum of 2 years of follow-up. Preoperative risk factors for poor outcomes were subsequently analyzed. Sixty patients (mean age, 71.4±7.4 years) met the inclusion criteria. Of these, 18 (30%) patients had poor outcomes (case group). The case group had significantly worse postoperative Single Assessment Numeric Evaluation (SANE) (61.6±29.5 vs 84.9±14.1, respectively; P=.002), American Shoulder and Elbow Surgeons (58.9±22.5 vs 82.2±14.2, respectively; P<.001), and Simple Shoulder Test (5.4±3.6 vs 8.5±2.4, respectively; P=.002) scores compared with the control group. Patients with poor outcomes had significantly higher preoperative SANE scores compared with control subjects (40.4±28.4 vs 18.8±15.7, respectively; P=.021). The results of this study suggest that patients with better overall preoperative function, as represented by higher SANE scores, have a greater likelihood of poor functional outcomes after RSA for massive rotator cuff tears without glenohumeral arthritis. For these patients, alternative treatment options should be considered. [Orthopedics. 2022;45(4):215-220.].

Functional outcome following arthroscopic repair of massive rotator cuff tears is equal to smaller rotator cuff tears: a retrospective case-control study

BACKGROUND

There is a paucity of studies comparing patient-reported outcomes of arthroscopic massive rotator cuff repairs against non-massive rotator cuff repairs. The aim of this study is to assess the Quick Disabilities of the Arm, Shoulder and Hand questionnaire and Oxford Shoulder Score at a minimum of one-year follow-up according to the size of the rotator cuff tear.

METHODS

A retrospective case-control study was undertaken. All patients underwent rotator cuff repairs using the same technique by a single surgeon. Quick Disabilities of the Arm, Shoulder and Hand questionnaire and Oxford Shoulder Score were collected pre-operatively and at final review with a minimum follow-up of one year. Patients with massive rotator cuff repairs were compared to patients who had non-massive rotator cuff repairs.

RESULTS

Eighty-two patients were included in the study of which 42 (51%) underwent massive rotator cuff repair. The mean follow-up period was 17.5 months. Quick Disabilities of the Arm, Shoulder and Hand questionnaire improved significantly (p < 0.001) from 46.1 pre-operatively to 15.6 at final follow-up for massive rotator cuff repairs. Oxford Shoulder Score improved significantly (p < 0.001) from 26.9 pre-operatively to 41.4 at final follow-up for massive rotator cuff repairs. There was no significant difference in the final Quick Disabilities of the Arm, Shoulder and Hand questionnaire (p = 0.35) or Oxford Shoulder Score (p = 0.45) between the groups. No revision surgery was required within the follow-up period.

CONCLUSION

Arthroscopic massive rotator cuff repairs have comparable functional outcome to smaller rotator cuff repair in the short-term and should be considered in a selected group of patients.

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.

Interposition Graft Bridging Reconstruction of Irreparable Rotator Cuff Tears Using Acellular Dermal Matrix: Medium-Term Results

PURPOSE

In this study, we aimed to evaluate the medium-term clinical outcomes for patients who underwent bridging reconstruction.

METHODS

A retrospective chart review was conducted for all patients who underwent bridging reconstruction between 2010 and 2018. Patients who were missing either pre- or postoperative outcome scores were excluded. All included patients completed self-reported questionnaires (Western Ontario Rotator Cuff [WORC] and Disabilities of the Arm, Shoulder and Hand [DASH]) pre- and postoperatively at 6 months, 1 year, and annually thereafter. All scores were reported out of 100.

RESULTS

Ninety-one patients initially met our inclusion criteria, and 33 were excluded owing to lack of either pre- or postoperative outcome scores. Nine patients were lost to follow-up; therefore, 49 patients were finally evaluated, including 30 males (61.2%) and 19 females (38.8%) with an age of 59.6 ± 10.4 years (mean ± standard deviation) and mean follow-up of 5.3 years (range 2 to 9). Both WORC and DASH scores significantly improved from pre- to postoperatively (WORC: 69.6 ± 12.2 to 27.9 ± 23.7, P < .001; DASH: 51.5 ± 17.5 to 24.5 ± 23.0, P = .001). For WORC and DASH, 92% and 74% of patients, respectively, met the minimal clinical importance difference.

CONCLUSION

Our results showed that patients' clinical outcome scores significantly improved with an average of 5-year follow-up, which demonstrates that bridging reconstruction is a safe procedure with promising midterm clinical outcomes.

LEVEL OF EVIDENCE

IV, retrospective case series.

A unique sarcopenic progression in the mouse rotator cuff

BACKGROUND

In response to chronic injury, the muscles of the rotator cuff (RC) experience a unique degeneration characterized by extensive fatty infiltration and loss of contractile function. Human studies suggest this degeneration is also a feature of RC sarcopenia and may precede RC injury. In this study, we investigated whether RC muscles exhibit a similar unique sarcopenia in the mouse.

METHODS

Male and female mice were subdivided into four age groups: 3, 9, 18, and 24 months. The supraspinatus (SS) and infraspinatus muscles of the RC and the tibialis anterior (TA) muscle of the hindlimb were assessed. Muscle mass, contractile function, fibre cross-sectional areas and numbers, fatty infiltration, and fibrosis were assessed at each time point. Targeted transcriptional analyses were performed to assess the role of metabolic and inflammatory derangement in the pathology.

RESULTS

The 24-month-aged female mice exhibited decreased mass (25% lower than at 9 and 18 months, P < 0.01) in all muscles tested. However, only RC muscles also exhibited decreased contractile tension at this time point (20% lower than at 18 months, P < 0.005). Similarly, only female RC muscles exhibited increased fatty infiltration at 24 months (20% higher than 9 months, P < 0.05) and had elevated transcriptional markers of adipogenesis (2.4-fold higher Pparg and 3.8-fold higher Adipoq expression compared with 9 months, P < 0.001). Unbiased metabolic transcriptional profiling identified up-regulation of the antigen presentation (Z scores of 2.3 and 1.9 for SS and TA, respectively) and cytokine and chemokine signalling (Z scores of 3.1 and 2.4 for SS and TA, respectively) pathways in 24 month female muscle compared with 9. Further transcriptional analysis supported increased expression of pro-adipogenic inflammatory signals (6.3-fold increase in Il6 and 5.0-fold increase in Anxa2, P < 0.01) and increased presence of fibro-adipogenic progenitors (2.5-fold) in the 24-month-aged female RC compared with 9 months that together exacerbate fatty infiltration.

CONCLUSIONS

These data indicate that female mice replicate the unique sarcopenic pathology in the ageing human RC. Furthermore, they suggest that the exacerbated fatty infiltration is due to an interaction between higher resident fibro-adipogenic progenitor numbers and an elevated systemic inflammation in aged female mice. We conclude that female mouse RC muscle is a novel system to study both human RC degeneration and the signals that regulate sarcopenic fatty infiltration in general, which is prevalent in humans but largely absent from the rodent hindlimb.

Glenohumeral joint loading is impacted by rotator cuff tear severity during functional task performance

BACKGROUND

Rotator cuff tear is a common musculoskeletal injury, negatively affecting shoulder function. Rotator cuff tear severity ranges from small to massive tears, but it is unclear how tear severity affects glenohumeral joint loading and how changes contribute to secondary injury. This study's objective was to determine how glenohumeral joint contact force changes with tear severity during functional task performance using computational models.

METHODS

Eight models of increasing tear severity were developed, ranging from no rotator cuff tear to massive three-tendon tears. Simulations were performed using models representing increasing tear severity and kinematics for five functional tasks (n = 720 simulations). For each task, magnitude and orientation of peak resultant joint contact force for each tear severity was identified, then compared to the no rotator cuff tear model.

FINDINGS

For all tasks, compared to the no rotator cuff tear model, joint contact force magnitude decreased 9.5% on average with infraspinatus involvement, then plateaued at 20.8% average decrease with subscapularis involvement. Projected orientation of peak joint contact force vector was located more superior in the glenoid with increased tear severity, with significant changes (p < 0.0003) for all tasks with infraspinatus involvement.

INTERPRETATION

Decreased magnitude and superior orientation of joint contact force suggest fewer intact muscles contribute to force distribution across the joint, although more work is needed characterizing associated compensation strategies. All force vectors remained oriented within the glenoid rim for all tasks and models, suggesting the system prioritizes joint stability. This work identifies how joint contact force changes with rotator cuff tear severity.

Fatty degeneration of the rotator cuff: pathogenesis, clinical implications, and future treatment

Chronic rotator cuff pathology is often complicated by fatty degeneration of the rotator cuff (FDRC) muscles, an insidious process associated with poor prognosis with or without surgical intervention. Currently there is no treatment for FDRC, and many studies have described a natural course for this disease almost always resulting in further degeneration and morbidity. Recapitulating FDRC using animal injury models, and using imaging-based studies of human FDRC, the pathophysiology of this disease continues to be further characterized. Researchers studying mesenchymal stem cell-derived progenitor cells and known fibrogenic and adipogenic signaling pathways implicated in FDRC seek to clarify the underlying processes driving these changes. While new cell- and molecular-based therapies are being developed, currently the strongest available avenue for improved management of FDRC is the use of novel imaging techniques which allow for more accurate and personalized staging of fatty degeneration. This narrative review summarizes the evidence on the molecular and pathophysiologic mechanisms of FDRC and provides a clinical update on the diagnosis and management of this condition based on the existing knowledge. We also sought to examine the role of newer biologic therapies in the management of RC fatty degeneration and to identify areas of future research.

Early repair of traumatic rotator cuff tears improves functional outcomes

BACKGROUND

The impact of surgical timing on outcomes involving traumatic rotator cuff tears (RCTs) remains uncertain. The purpose of this study was to determine how functional outcomes are affected by surgical timing in traumatic RCTs.

METHODS

We performed a retrospective review of patients with repair of traumatic full-thickness RCTs. Preoperative magnetic resonance imaging scans were evaluated by 2 blinded reviewers to measure RCT area and muscular atrophy. Functional outcomes were assessed via the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, Simple Shoulder Test score, and visual analog scale (VAS) pain score. Patients were divided into 4 groups based on the time from injury to surgery: 0-2 months (group 1), 2-4 months (group 2), 4-6 months (group 3), and 6-12 months (group 4). Multivariate analysis was performed to assess the impact of surgical timing on functional outcomes. A subanalysis was performed to assess outcomes in patients who underwent surgery within 3 weeks of injury.

RESULTS

The study included 206 patients (150 men and 56 women) with a mean age of 60.0 ± 9.7 years and a minimum of 24 months' clinical follow-up (mean, 35.5 months; range, 24-54.4 months). The average tear area was 8.4 ± 6.3 cm² in group 1 (66 patients), 5.8 ± 5.1 cm² in group 2 (76 patients), 5.1 ± 4.6 cm² in group 3 (29 patients), and 3.7 ± 3.1 cm² in group 4 (35 patients) (P < .001). There were significant differences between the 4 cohorts in the final postoperative ASES score (P = .030) and VAS pain score (P = .032). The multivariate regression demonstrated that patients who underwent surgery within 4 months of injury had estimated improvements of 10.3 points in the ASES score (P = .008), 1.8 points in the Simple Shoulder Test score (P = .001), 8.6 points in the SANE score (P = .033), and 0.93 points in the VAS pain score (P = .028) compared with patients who underwent surgery later. The subanalysis demonstrated that patients who underwent surgery within 3 weeks of injury (n = 13) had significantly better VAS (P = .003), ASES (P = .008), and SANE (P = .019) scores than patients who underwent surgery at between 3 weeks and 4 months after injury (n = 129).

CONCLUSIONS

This study demonstrates that surgical repair of traumatic RCTs results in significant improvements in functional outcomes for all patients; however, patients who undergo surgery within 3 weeks can expect the best functional outcomes, with a drop in function in patients who undergo surgery >4 months after injury.

Muscle stem cells and rotator cuff injury

The incidence of reinjury after treatment of rotator cuff tears (RCTs) remains very high despite the variety of nonoperative treatments and the high volume of surgical interventions performed. Muscle stem cells (MuSCs), also known as satellite cells, have risen to the forefront of rotator cuff tear research as a potential adjuvant therapy to aid unsatisfactory surgical outcomes. MuSCs are adult stem cells exhibiting the capacity to proliferate and self-renew, both symmetrically and asymmetrically. As part of this niche, they have been shown to adopt an activated phenotype in response to musculoskeletal injury and decrease their cellular populations during aging, implicating them as key players in both pathologic and normal physiological processes. While commonly connected to the regenerative phase of muscle healing, MuSCs also have the potential to differentiate into adverse morphologies. For instance, if MuSCs differentiate into adipocytes, the ensuing fatty infiltration serves as an obstacle to proper muscle healing and has been associated with the failure of surgical management of RCTs. With the potential to both harm and heal, we have identified MuSCs as a key player in RCT repair. To better understand this dichotomy, the following review will identify key studies regarding the morphology, function, and behavior of MuSCs with respect to RCTs and healing.

Prospective, randomized evaluation of latissimus dorsi transfer and superior capsular reconstruction in massive, irreparable rotator cuff tears

BACKGROUND

The treatment of massive, irreparable rotator cuff tears remains controversial today because there is no consensus on the ideal treatment option. This investigation aimed to prospectively evaluate and compare the outcomes of arthroscopy-assisted latissimus dorsi transfer and superior capsular reconstruction in the treatment of massive, irreparable rotator cuff tears.

METHODS

Forty-two patients at an average age of 62.8 years with massive, irreparable rotator cuff tears were randomized into 2 treatment groups. Twenty-one patients underwent arthroscopy-assisted latissimus dorsi tendon transfer (LDT), and 21 patients underwent arthroscopy-assisted superior capsular reconstruction (SCR). The patients were followed up prospectively for 31 months on average. One patient in the SCR group was lost to follow-up. The outcomes were evaluated with American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Western Ontario Rotator Cuff Index (WORC), visual analog scale (VAS), and Constant scores clinically and with acromiohumeral distance (AHD) measurements radiologically.

RESULTS

Both groups displayed improved results in ASES, WORC, Constant, and VAS scores in the final follow-up (P < .001). The LDT group had significantly better results in AHD (P = .006), whereas the SCR group yielded significantly higher improvements in ASES (P = .007) and Constant (P = .008) scores. The rate of successful pseudoparalysis treatment was 45% (5/11) in the LDT group and 92% (12/13) in the SCR group (P = .011). The graft failure rate was 5% (1 patient) in each group postoperatively; 1 patient in the SCR group had a traumatic graft rupture and 1 patient in the LDT group was complicated with septic arthritis, which required graft removal.

CONCLUSION

Both SCR and LDT yielded promising short-term results in treatment of massive, irreparable rotator cuff tears in this study. The SCR group displayed better overall outcomes clinically, particularly in the pseudoparalytic shoulders, whereas the LDT group displayed better radiologic results.

Nonoperative treatment of chronic, massive irreparable rotator cuff tears: a systematic review with synthesis of a standardized rehabilitation protocol

PURPOSE

A massive, irreparable rotator cuff tear may cause significant pain and dysfunction. However, the efficacy of nonoperative treatment modalities in this subset of patients is not currently well known. Also, there is currently no gold standard nonoperative protocol to guide treatment. The goal of the present systematic review is to determine if there is any evidence to support the use of various nonoperative treatment modalities and synthesize a standardized nonoperative treatment protocol for the patient with a massive irreparable rotator cuff tear.

METHODS

A comprehensive review of the literature utilizing PRISMA guidelines was performed. Studies involving clinical outcomes of nonoperative treatment of massive, irreparable rotator cuff tears were included. Articles were reviewed by 2 reviewers to determine inclusion or exclusion based on established criteria. Selected articles were reviewed for results of clinical and functional outcomes. The studies were also reviewed to determine their level of evidence and potential sources of bias. A standardized nonoperative treatment protocol was developed by taking described elements of the protocols used in studies that demonstrated clinical improvement beyond the MCID for the outcome scores used by the authors.

RESULTS

A total of 10 studies met inclusion criteria for our studies. Of the included studies, 1 was Level III evidence and the remaining 9 were Level IV evidence. Multiple studies showed significant improvement exceeding the MCID for functional outcome scores following treatment. Also, several studies demonstrated significant improvements in strength and range of motion. The overall success of nonoperative treatment ranged from 32%-96%. The synthesized nonoperative treatment protocol is characterized by requiring some supervised physical therapy, often requiring 12 weeks or more, focusing on supine exercises with gradual progression to upright. Corticosteroid injections and nonsteroidal anti-inflammatory drugs may also be of benefit.

CONCLUSION

Despite low-quality evidence, nonoperative treatment has been shown to be efficacious for patients with chronic, massive, irreparable rotator cuff tears. Using these results, a synthesized rehabilitation program was developed to guide clinicians when treating patients with massive irreparable rotator cuff tears.

"Current concepts and expert practice report: Augmentation of rotator cuff repairs"

Rotator cuff tears are common shoulder injuries expected to increase with the growth of the aging population. Although a small subset of patients with low functional demands can be treated nonoperatively, surgical intervention is a cost-effective solution, which can restore shoulder function and help patients return to activity sooner. While multiple surgical options are available, rotator cuff repair is a highly utilized procedure with varying success. Due to a large proportion of rotator cuff repairs still failing to completely heal, this procedure requires careful planning to achieve anatomical and biomechanically stability. New technology and techniques are being explored to help increase the success of rotator cuff repairs with an increasing focus on augmentation. The current article gives a brief overview of pertinent anatomy, treatment options, and challenges in healing of rotator cuff repairs. Thereafter, the merits of different types of rotator cuff repair augmentation available will be discussed as well as the authors' experience in utilizing biologic augmentation and surgical technique.

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.

Consider Long Head of Biceps Tendon for Reconstruction of Massive, Irreparable Rotator Cuff Tear

Despite the different treatment options for irreparable and massive rotator cuff tears (RCTs), there is no optimal treatment. Thirty percent of total RCTs can be classified as irreparable because of the massive tear size and severe muscle atrophy. The reported treatment failure rate is approximately 40% for massive RCTs. RCTs may be treated conservatively or surgically depending on pain, disability, and functional demands. The surgical treatment options are many, but decision making is a challenge; the real challenge is to apply the correct procedure for the correct indication in each patient. The long head of the biceps tendon (LHBT) was used for augmentation to bridge the gap in immobile, massive RCTs. An arthroscopic biceps-incorporating technique was used for repair of large and massive RCTs, avoiding undue tension on the rotator cuff (RC). Recently, the LHBT was used for superior capsular reconstruction. This article describes the use of the LHBT for reconstruction of massive and irreparable RCTs through the following steps: (1) open exposure of the RCT, (2) debridement and subacromial decompression, (3) biceps tenotomy at the LHBT's origin on the glenoid, (4) LHBT and RC cuff mobilization, (5) passage of the LHBT through the mobilized RC and reflection onto itself, (6) tuberoplasty, and (7) fixation of the RC complex at the RC footprint.

Treatment of non-arthritic pseudoparetic shoulders with irreparable massive rotator cuff tears: arthroscopic procedures yield comparable midterm results to reverse arthroplasty

Background

Irreparable massive rotator cuff tears (IMRCTs) are a well-known cause for functional limitation and difficult to treat. Although several joint-preserving as well as joint-replacing procedures were found to provide pain relief and gain of function, midterm results are scarce, particularly in pseudoparetic shoulder joints unaccompanied by severe osteoarthritis. The purpose of this study was to compare the midterm functional outcomes of arthroscopic procedures to those of reverse total shoulder arthroplasty (RTSA) in pseudoparetic shoulders with IMRCTs unaccompanied by severe osteoarthritis.

Methods

All patients who underwent either joint-preserving (group A) or joint-replacing (group B) procedures for IMRCT unaccompanied by severe osteoarthritis with a pseudoparetic shoulder function were retrospectively included. Clinical assessment included the Constant Score (CS), the Subjective Shoulder Value (SSV) and the Visual Analog Score (VAS) at baseline and at latest follow-up. Furthermore, the complication and revision rates were assessed.

Results

Overall, a total 56 patients were included of whom each 28 patients formed group A (male, 36%) and B (male, 53%) with a mean patient age at time of surgery of 70 ± 7 years and 72 ± 7 years, respectively. The mean follow-up period was 56 ± 17 months. At final follow-up, the total CS (group A: 66 ± 14 points; group B 54 ± 15 points) was significantly increased after arthroscopic treatment when compared to RTSA (p=0.011). However, no significant differences were detected with SSV (p=0.583) and VAS (p=0.536). Although complication rate (11% versus 18%) was not significantly different (p=0.705), number of revision surgeries was significantly higher in group B when compared to group A (p=0.041).

Conclusions

In non-arthritic pseudoparetic shoulders, both joint-preserving and joint-replacing procedures yielded good clinical midterm outcomes for the treatment of degenerative IMRCTs. Despite of comparable functional and satisfactory functional improvement, increased complication rates and surgical invasiveness outweigh the benefits of primary RTSA and therefore reserve this procedure to a second-line treatment in pseudoparetic patients without any signs of severe cuff arthropathy.

Superior Capsular Reconstruction: A Systematic Review of Surgical Techniques and Clinical Outcomes

PURPOSE

To evaluate surgical techniques and clinical outcomes of arthroscopic superior capsular reconstruction (SCR) for the treatment of massive irreparable rotator cuff tears.

METHODS

A systematic review was registered with PROSPERO and performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The PubMed, Scopus, and Cochrane databases were searched. Studies investigating SCR with reported surgical techniques were included. Animal studies, cadaveric studies, review studies, and letters to the editor were excluded. The technical aspects of the surgical techniques for SCR were analyzed in each article, which included graft type, glenoid fixation method, greater tuberosity fixation method, graft passage technique, suture management, margin convergence, concomitant procedures, and postoperative rehabilitation protocol. Clinical outcomes, when available, were also analyzed.

RESULTS

We screened 365 articles, of which 29 described surgical techniques for SCR. According to the Modified Coleman Methodology Score, 24 articles were rated as poor (score < 55), 4 were rated as fair (score between 55 and 69), and 1 was rated as good (score between 70 and 84), with an average score of 25.8 ± 20.9. The most commonly performed technique for SCR used the following: an acellular dermal allograft, 2 biocomposite suture anchors for glenoid fixation, transosseous-equivalent double-row suture anchor fixation for greater tuberosity fixation with 2 biocomposite medial-row anchors and 2 biocomposite lateral-row anchors, the double-pulley technique combined with an arthroscopic grasper and/or pull suture to pass the graft into the shoulder, the performance of both anterior and posterior margin convergence, and a native rotator cuff repair when possible. Only 8 studies reported clinical outcomes, and they showed that SCR provides significant improvement in patient-reported outcomes, significant improvement in shoulder range of motion, variable graft failure rates, low complication rates, and variable reoperation rates. There were no studies comparing outcomes among the various surgical techniques.

CONCLUSIONS

Many surgical techniques exist for arthroscopic SCR. However, no superior technique was shown because there were no studies comparing clinical outcomes among these various techniques.

LEVEL OF EVIDENCE

Level V, systematic review of Level III, IV, and V studies.

Conservative versus surgical management for patients with rotator cuff tears: a systematic review and META-analysis

BACKGROUND

This study aims to compare conservative versus surgical management for patients with full-thickness RC tear in terms of clinical and structural outcomes at 1 and 2 years of follow-up.

METHODS

A comprehensive search of CENTRAL, MEDLINE, EMBASE, CINAHL, Google Scholar and reference lists of retrieved articles was performed since the inception of each database until August 2020. According to the Cochrane Handbook for Systematic Reviews of Interventions, two independent authors screened all suitable studies for the inclusion, extracted data and assessed risk of bias. Only randomised controlled trials comparing conservative and surgical management of full-thickness RC tear in adults were included. The primary outcome measure was the effectiveness of each treatment in terms of Constant-Murley score (CMS) and VAS pain score at different time points. The secondary outcome was the integrity of the repaired tendon evaluated on postoperative MRI at different time points. The GRADE guidelines were used to assess the critical appraisal status and quality of evidence.

RESULTS

A total of six articles met the inclusion criteria. The average value of CMS score at 12 months of follow-up was 77.6 ± 14.4 in the surgery group and 72.8 ± 16.5 in the conservative group, without statistically significant differences between the groups. Similar results were demonstrated at 24 months of follow-up. The mean of VAS pain score at 12 months of follow-up was 1.4 ± 1.6 in the surgery group and 2.4 ± 1.9 in the conservative group. Quantitative synthesis showed better results in favour of the surgical group in terms of VAS pain score one year after surgery (- 1.08, 95% CI - 1.58 to - 0.58; P < 0.001).

CONCLUSIONS

At a 2-year follow-up, shoulder function evaluated in terms of CMS was not significantly improved. Further high-quality level-I randomised controlled trials at longer term follow-up are needed to evaluate whether surgical and conservative treatment provide comparable long-term results.

[Principles of tendon healing at the shoulder and consequences for their treatment : Importance of platelet-rich plasma and regenerative medicine]

Tendon pathologies are a frequent cause of shoulder pain and can lead to significant decline in the quality of life. Conservative treatment is suitable for most tendon pathologies. In addition to classical conservative treatment options, such as physiotherapy, oral analgesia and infiltrations, there are a number of additive treatment options to promote structural tendon healing and clinical outcome. Furthermore, there are approaches to improve the results of the surgical treatment of tendon injuries by biological augmentation. The objective of this article is to give an overview of biological and regenerative therapeutic options in the treatment of tendon injuries of the shoulder. Therefore, the anatomical and molecular biological principles of the tendon structure and their importance for tendon healing are explained in order to highlight the various therapeutic options for daily practice. Biological augmentation procedures and regenerative medicine represent a promising therapeutic option for tendon injuries of the shoulder, however, the benefits are so far supported by little or no evidence at all.

Differences in scapular motion and parascapular muscle activities among patients with symptomatic and asymptomatic rotator cuff tears, and healthy individuals

Background

Altered scapular motion is thought to be one of the factors associated with the development of symptomatic rotator cuff tears. However, the differences in kinematics and muscle activities of scapular upward/downward rotation between patients with symptomatic and asymptomatic tears are unclear. The purpose of this study was to compare the differences in kinematics and muscle activities of scapular rotation among patients with symptomatic and asymptomatic tears, and healthy individuals.

Methods

Twenty-three patients with rotator cuff tears and 9 healthy individuals (healthy group) participated in this study. Based on a visual analog scale (VAS, 0-100 mm), the patients were divided into symptomatic (13 patients; VAS ≥20 mm) and asymptomatic (10 patients; VAS <20 mm) groups. Scapular upward rotation was measured with a digital inclinometer. Elasticities of the upper trapezius, levator scapulae, and rhomboid major were assessed by using ultrasound real-time tissue elastography to quantify their muscle activities. All measurements were performed at 0°, 60°, 90°, and 120° of active arm elevation in the scapular plane.

Results

Scapular upward rotation was significantly less in the symptomatic group (9.4° ± 5.6°) compared with the asymptomatic group (15.7° ± 6.0°; P = .022) at 90° of arm elevation. The activity of the levator scapulae was significantly higher in the symptomatic group compared with the asymptomatic and healthy groups (P = .013 and P = .005, respectively) at 90° of arm elevation. The activity of the upper trapezius was significantly higher in the symptomatic group compared with the healthy group (P = .015) at 120° of arm elevation.

Conclusion

Patients with symptomatic rotator cuff tears showed less scapular upward rotation and higher activity of the levator scapulae at 90° of arm elevation compared to patients with asymptomatic rotator cuff tears.

Clinical Outcomes of Nonoperative Treatment for Rotator Cuff Retears and Analysis of Factors That Affect Outcomes

Background

Patients who sustain a rotator cuff retear after arthroscopic rotator cuff repair are generally considered to have worse clinical outcomes compared with patients with an intact rotator cuff. However, some patients have good clinical outcomes, even with a retorn rotator cuff.

Purpose

To report the clinical outcomes of nonoperative treatment for rotator cuff retears and analyze the factors affecting clinical outcomes after a retear.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who underwent arthroscopic rotator cuff repair between 2011 and 2017 were reviewed, and those with a full-thickness retear on postoperative magnetic resonance imaging (MRI) were included in this study. According to their pre- and postoperative scores on the pain visual analog scale (pVAS) and functional visual analog scale (fVAS), the patients were divided into 3 groups: (1) mild group (pVAS ≤ 1 and fVAS ≥ 8), (2) moderate group (pVAS ≤ 1 and fVAS ≤ 7 or pVAS 2-3 and fVAS ≥ 8), and (3) severe group (pVAS ≥ 3 and fVAS ≤ 7). Preoperative data (dominant hand involvement, heavy labor) and tear size on 6-month postoperative MRI were analyzed as factors affecting clinical outcomes.

Results

A total of 712 patients were reviewed, and a retear was observed in 62 patients (8.7%). Of the patients with retears, 52 were included in this study: 25 men and 27 women with a mean age of 62.6 years (range, 49-80 years) and mean follow-up period of 40 months (range, 24-88 months). According to the pVAS and fVAS scores, 25 patients (48.1%) were classified into the mild group, 9 (17.3%) into the moderate group, and 18 (34.6%) into the severe group. There were no significant differences in preoperative data among the 3 groups. The tear size in the coronal and sagittal planes decreased by 5.1 and 6.6 mm, respectively, in the mild group but increased by 2.8 and 1.4 mm, respectively, in the severe group.

Conclusion

In patients with retears, 48.1% had only mild symptoms at a mean of 40 months postoperatively. Patients with severe symptoms tended to have an increased tear size on postoperative MRI.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Long-term outcome of arthroscopic debridement of massive irreparable rotator cuff tears

Objectives

To evaluate the clinical and radiographic outcome of low-demand patients with massive rotator cuff tears undergoing arthroscopic debridement in mid- and long-term follow-up, as well as the rate of conversion to reverse shoulder arthroplasty.

Methods

We performed a retrospective analysis of 19 patients with a mean age at surgery of 68 years (range, 55–80 years) from a previously described consecutive cohort and after a mean follow up of 47 month (FU1) and 145 month (FU2). The functional outcome was evaluated with the VAS score, the American Shoulder and Elbow Surgeons (ASES) score, and the age- and gender-adjusted Constant (aCS) score. The radiographic outcome was classified according to the Hamada classification. Non-parametric analyses were carried out with the Mann-Whitney U for independent samples and the Wilcoxon signed-rank test for related samples.

Results

Five patients (26%) developed symptomatic cuff tear arthropathy and underwent reverse shoulder arthroplasty after a mean time of 63 months (range, 45–97 months). These patients were excluded from further analyses. The mean VAS score of the remaining 14 patients at FU1 was significantly lower compared to preoperatively (P = .041), while there were no significant differences between the VAS score at FU1 and FU2 (P = 1.0). The ASES score of the affected shoulder at FU1 was significantly higher compared to prior to surgery (P = .028), while there were no significant differences between the scores of the affected shoulder between FU1 and FU2 (P = .878). While the ASES score of the contralateral shoulder at FU1 was significantly higher than the score of the affected shoulder (P = .038), there were no significant differences in the ASES scores of the affected and the healthy shoulder at FU2 (P = .575). The evaluation of the aCS produced similar results. A progression of the Hamada grade was documented in 6 patients.

Conclusions

Arthroscopic debridement is a safe and valid option for low-demand middle-age or elderly patients with symptomatic massive rotator cuff tears, leading to a significant pain relief and significantly improved functional outcome at mid- and long-term follow up. However, about a quarter of the patients in our cohort had to undergo reverse shoulder arthroplasty due to symptomatic cuff tear arthropathy. Furthermore, some of the remaining patients continued to undergo radiographic progression. This might be due to the natural history of their disease and/or the surgical procedure, and the clinical relevance of this finding should be evaluated in further studies.

Superior Capsule Reconstruction for Irreparable Massive Rotator Cuff Tears: Does It Make Sense? A Systematic Review of Early Clinical Evidence

BACKGROUND

Treatment of irreparable massive rotator cuff tears (MRCTs) in patients without advanced glenohumeral osteoarthritis remains a challenge. Arthroscopic superior capsule reconstruction (SCR) represents a newer method for treatment with increasing popularity and acceptance.

PURPOSE

To analyze the clinical evidence surrounding SCR and determine the current clinical outcomes postoperatively.

STUDY DESIGN

Systematic review.

METHODS

A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Electronic databases of PubMed, MEDLINE, Cochrane, and Google Scholar were used for the literature search. The study quality was evaluated according to the Modified Coleman Methodology Score. Studies in English evaluating SCR outcomes were included.

RESULTS

Seven studies were reviewed, including 352 patients (358 shoulders) treated with arthroscopic SCR with the mean duration of follow-up ranging from 15 to 48 months (range, 12-88 months). Fourteen patients were lost to follow-up, leaving 338 patients (344 shoulders) with clinical outcome data. Graft types included dermal allografts (n = 3 studies), fascia lata autografts (n = 3), or both (n = 1). Most commonly, a double-row technique was utilized for humeral graft fixation. The most common complication included graft tears in 13% of patients, resulting in 15 SCR revisions and 7 reverse shoulder arthroplasties. Postoperatively, improvements in visual analog scale (2.5 to 5.9), American Shoulder and Elbow Surgeons (20 to 56), Japanese Orthopaedic Association (38.0), Subjective Shoulder Value (37.0 to 41.3), and Constant (11.6 to 47.4) scores were observed. Three studies reported respective satisfaction rates of 72.9%, 85.7% and 90%. Increases in external rotation, internal rotation, and abduction with improved strength in external rotation were observed postoperatively. Improvement of pseudoparalysis was also observed in 3 studies. One study reported return to sports in 100% of patients (2 competitively, 24 recreationally) with no adverse outcomes.

CONCLUSION

SCR showed good to excellent short-term clinical outcomes with adequate pain relief and functional improvement. The current evidence suggests that the procedure is an alternative for symptomatic patients with irreparable MRCT; however, the included studies were fair to poor in quality, and there were some notable complications. Long-term follow-up will determine the longevity and ultimate role of this new method in the treatment of irreparable MRCT.

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.

Clinical midterm results of arthroscopic rotator cuff repair in patients older than 75 years

BACKGROUND

The effect of patient age on functional improvement after arthroscopic rotator cuff repair (ARCR) is still a matter of debate. The purpose of this study was to evaluate the clinical midterm results after ARCR in patients who were 75 years or older at the time of surgery.

METHODS

A total of 31 shoulders in 30 patients older than 75 years at the time of surgery underwent ARCR for a degenerative full-thickness rotator cuff tear (RCT) between 2010 and 2016. Among those, 23 shoulders in 22 patients (74%) with a mean age at time of surgery of 77 ± 2 years (range, 75-82 years) were followed up after a mean of 7 ± 2 years (range, 3-9 years). Clinical assessment included the Western Ontario Rotator Cuff (WORC) index as well as patient satisfaction, the Subjective Shoulder Value (SSV), Simple Shoulder Test (SST), and the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score.

RESULTS

Overall, patient satisfaction was excellent, as everybody stated to be very satisfied with the surgery. Neither any complication nor revision surgery occurred during the study period. At final follow-up, the mean WORC index was 88% ± 15%. The mean SSV was comparable between the affected shoulder (90% ± 15%) and the contralateral side (87% ± 15%) (P = .235). The mean SST score was 10 ± 2 points and the mean ASES score was 89 ± 17 points.

CONCLUSION

ARCR for symptomatic RCTs without advanced muscle degeneration in patients older than 75 years at the time of surgery provided good clinical results and high patient satisfaction at midterm follow-up.

Superior Capsular Reconstruction Using 3-layered Fascia Lata Autograft Reinforced with a Nonresorbable Suture Mesh

Purpose

The purpose of this study was to evaluate the short-term clinical outcomes and the complications related to arthroscopic superior capsular reconstruction (SCR) using a 3-layered fascia lata autograft (FLA) reinforced with a nonresorbable suture mesh, in the treatment of irreparable massive rotator cuff tears (MRCTs).

Methods

Consecutive patients with irreparable MRCTs (Goutallier 4, Hamada grade 1-2, Bateman 3-4) who were treated with arthroscopic SCR using reinforced FLA in 2018 were included. Patients with an irreparable subscapularis/infraspinatus, serious cardiovascular condition, systemic infection, rheumatic disease, and known alcohol/drug abuse were excluded from the study. Range of motion and Shoulder Pain and Disability Index (SPADI) scores were assessed preoperatively, at 6 months, and at 12 months postoperatively. A simple t test was used to compare the outcomes. P values <.05 were considered significant. Complications and revision surgeries were registered.

Results

A total of 24 consecutive patients (15 males, 9 females) with a mean age of 61 years (range, 41-76) were enrolled. Twenty (83%) patients achieved minimal clinically important difference in the SPADI score (>18) and 14 (58%) experienced substantial clinical benefit in SPADI (>45). The mean SPADI score improved from 59.0 to 9.7 (P < .0001) at 1-year follow-up. Active abduction improved from 59.5° to 154.3° (P < .0001) and active forward flexion improved from 67.0° to 160.3° (P < .0001) at 1-year follow-up. Eighteen (75%) patients achieved substantial clinical benefit in active abduction (>28.5°) and active forward flexion (>35.4°). Complications included progression of osteoarthritis in 2 cases, tear of the graft in 1 case, and pullout of the anchor in another. Two patients experienced donor site morbidity after harvesting the fascia lata autograft.

Conclusions

Eighty-three percent of the patients achieved minimal clinically important difference and were successfully treated with arthroscopic SCR using a FLA reinforced with a suture mesh. The procedure had a complication rate of 17% and 8.5% of the patients experienced donor site morbidity. All complications occurred in patients who were previously treated with an attempted rotator cuff repair.

Level of Evidence

Level IV, therapeutic case series.

Health Care Utilization and Costs in the Year Prior to Arthroscopic Rotator Cuff Repair

Background:

A majority of cost-control strategies in arthroscopic rotator cuff repair (RCR) have been concentrated on the perioperative and post–acute care periods, with the preoperative health care period being largely overlooked.

Purpose:

To report the distribution of costs associated with health care utilization within the year prior to arthroscopic RCR.

Study Design:

Economic and decision analysis; Level of evidence, 3.

Methods:

The 2007 through 2015 (third quarter) Humana Administrative Claims database was queried using Current Procedural Terminology code 29827 to identify patients undergoing arthroscopic RCR for only degenerative rotator cuff tears. The study cohort was divided into 2 distinct groups based on insurance plan: commercial or Medicare Advantage (MA). Total 1-year costs, per-patient average reimbursements (PPARs), and trends in utilization for the following preoperative health care resource categories were studied: office visits, radiographs, magnetic resonance imaging (MRI) scans, computed tomography (CT) scans, steroid injections, hyaluronic acid (HA) injections, physical therapy, and pain medications (opioids + nonopioids).

Results:

A total of 18,457 MA and 6530 commercial beneficiaries undergoing arthroscopic RCR over the study period were included. Total 1-year preoperative costs (in US$) amounted to $16,923,595 ($916/patient) and $8,397,291 ($1285/patient) for MA and commercial beneficiaries, respectively. The largest proportion of total 1-year costs for both MA and commercial beneficiaries was accounted for by MRI scans (36% and 56%, respectively). PPARs for each health care resource category were as follows: office visits (MA, $240; commercial, $249), radiographs (MA, $60; commercial, $93), MRI scans (MA, $385; commercial, $813), CT scans (MA, $223; commercial, $562), steroid injections (MA, $97; commercial, $137), HA injections (MA, $422; commercial, $602), physical therapy (MA, $473; commercial, $551), and pain medications (MA, $208; commercial, $136). High health care utilization within the past 3 months before surgery was noted for radiographs, physical therapy, opioids, steroid injections, and office visits, with up to 40% to 90% of 1-year PPARs being accounted for within this time period alone.

Conclusion:

Approximately $900 to $1300 per patient was spent in rotator cuff–related health care resource use in the year prior to undergoing arthroscopic RCR. As we begin to implement value in shoulder surgery, judicious use of nonoperative treatment modalities among patients who would not benefit from nonoperative care will be an effective way of reducing costs.

Effect of localized tendon remodeling on supraspinatus tear propagation

Rotator cuff tear propagation is multifactorial and may be due to localized changes in mechanical properties from tendon remodeling based on the inhomogeneous stresses experienced by a tendon with a tear. The objective of this study was to investigate the effect of localized tendon remodeling on tear propagation for simulated supraspinatus tendon tears. A validated computational model of a supraspinatus tendon using subject-specific geometry and material properties with a 1 cm wide anterior tear was used. The medial edge of the supraspinatus tendon was displaced 5 mm to induce tear propagation and cohesive elements were used to model tear propagation. Four remodeling scenarios were investigated: (1) Baseline (no remodeling), (2) Positive remodeling (increased fiber stiffness) and (3) Negative remodeling (decreased fiber stiffness) at tear tips, and (4) Negative remodeling along the medial-lateral tear edge. Output parameters included the amount of tear propagation, critical load to propagate the tear, and maximum principal stress at the tear tips. Positive remodeling at the tear tips resulted in the largest amount of tear propagation (18.4 mm), highest peak maximum principal stress (25.2 MPa), and lowest critical load to propagate the tear (249N). Conversely, negative remodeling at the tear tips resulted in the least amount of tear propagation (16 mm), lowest peak maximum principal stress (17.6 MPa) and highest critical load to propagate the tear (278N). Overall, remodeling at the tear tips has the greatest effect on tear propagation. Therefore, a better method for clinicians to measure tendon stiffness at the tear tips would be helpful to improve outcome of patients.

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.