Irreparable rotator cuff tears: Current treatment options

Novel methods to diagnose rotator cuff tear and predict post-operative Re-tear: Radiomics models

Objective

To validated a classifier to distinguish the status of rotator cuff tear and predict post-operative re-tear by utilizing magnetic resonance imaging (MRI) markers.

Methods

This retrospective study included patients with healthy rotator cuff and patients diagnosed as rotator cuff tear (RCT) by MRI. Radiomics features were identified from the pre-operative shoulder MRI and selected by using maximum relevance minimum redundancy (MRMR) methods. A radiomics model for diagnosis of RCT was constructed, based on the 3D volume of interest (VOI) of supraspinatus. Another model for the prediction of rotator re-tear after rotator cuff repair (Re-RCT) was constructed based on VOI of humerus, supraspinatus, infraspinatus and other clinical parameters.

Results

The model for diagnosing the status of RCT produced an area under the receiver operating characteristic curve (AUC) of 0.989 in the training cohort and 0.979 for the validation cohort. The radiomics model for predicting Re-RCT produced an AUC of 0.923 ± 0.017 for the training dataset and 0.790 ± 0.082 for the validation dataset. The nomogram combining radiomics features and clinical factors yielded an AUC of 0.961 ± 0.020 for the training dataset and 0.808 ± 0.081 for the validation dataset, which displayed the best performance among all models.

Conclusion

Radiomics models for the diagnosis of rotator cuff tear and prediction of post-operative Re-RCT yielded a decent prediction accuracy.

Biomechanical Comparison Between Superior Capsular Reconstruction and Lower Trapezius Tendon Transfer in Irreparable Posterosuperior Rotator Cuff Tears

BACKGROUND

Superior capsular reconstruction (SCR) and lower trapezius tendon transfer (LTT) have recently been used to manage irreparable posterosuperior rotator cuff tears (PSRCTs). There has been a paucity of comparative biomechanical considerations between the 2 procedures.

PURPOSE

To compare the glenohumeral stability and biomechanical properties between SCR and LTT in PSRCTs involving the entire infraspinatus tendon region.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight fresh-frozen cadaveric shoulders were tested at 0°, 20°, and 40° of shoulder abduction. Maximum internal, external, and total humeral range of motion (ROM), superior translation of the humeral head, and subacromial contact characteristics were compared among 4 conditions: (1) intact rotator cuff, (2) PSRCTs involving the entire infraspinatus tendon region, (3) LTT using Achilles allograft (12 N and 24 N of loading), and (4) SCR using fascia lata allograft.

RESULTS

Although a decrease in total ROM was noted in LTT with 12 N compared with the tear condition, LTT with both 12 N and 24 N as well as SCR did not restrict total rotational ROM compared with the intact condition. LTT had decreased total ROM compared with tear condition at 20° of abduction (P = .042), while no significant decrease was confirmed at all abduction angles after SCR. SCR and LTT with 24 N decreased superior translation compared with the PSRCT condition at 0° and 20° of abduction (P < .037) but not significantly at 40° of abduction, whereas LTT with a 24-N load decreased glenohumeral superior translation at all abduction angles (P < .039). Both SCR and LTT decreased subacromial contact pressure compared with the tear condition (P < .014) at all abduction angles. SCR decreased subacromial contact pressure at 0° and 40° of abduction (P = .019 and P = .048, respectively) compared with LTT with 12 N of loading, while there was no difference between SCR and LTT with 24 N of loading in all abduction angles. SCR increased the contact area compared with the PSRCT condition at all abduction angles (P < .023), whereas LTT did not increase the contact area.

CONCLUSION

SCR and LTT decreased glenohumeral superior translation and contact pressure compared with PSRCT conditions. The LTT was superior to SCR in terms of superior translation of the humeral head at a higher shoulder abduction angle, whereas the SCR showed more advantageous subacromial contact characteristics compared with LTT.

CLINICAL RELEVANCE

These biomechanical findings provide insights into these 2 fundamentally different procedures for the treatment of young and active patients with PSRCTs involving the entire infraspinatus tendon region.

Long head of biceps tendon augmentation for massive rotator cuff tears improves clinical results regardless of the number of tendons involved

PURPOSE

Management of massive rotator cuff tears (MRCTs) remains debated, and various arthroscopic and open techniques have been described for their management. Nevertheless, the optimal strategy remains unclear. The present study evaluated the clinical results in patients managed arthroscopically for MRCTs augmented with the long head biceps tendon (LHBT) at a minimum 1-year follow-up, considering different type of tears, demographic data and number of torn tendons.

METHODS

Patients treated in a secondary referral centre from January 2021 to April 2022 were enroled prospectively. Inclusion criteria were pain, inability to fully elevate the affected shoulder, irreparable tears and active and motivated patients. All patients were managed within 2 months from diagnosis in a single centre by the same surgeons. Preoperative shoulder radiographs and magnetic resonance imaging (MRI) were collected, and clinical assessment was also performed using the Numerical analogue scale (NAS), Constant score (CS) American Shoulder and Elbow Surgeons Shoulder Score (ASES). Tissue retraction and tendon fatty infiltration were evaluated using Patte and Fuchs scale, respectively. Clinical assessment was performed using the same scales at 3-6 months and 1-year follow-up.

RESULTS

A total of 55 patients (31 female and 24 male) with a mean age of 60 ± 7.1 years were enroled for a mean follow-up of 18.2 ± 4.3 months. The mean preoperative NAS was 7.8 ± 0.6, CS was 20.5 ± 7.6 and ASES was 22.6 ± 9.2, increasing, respectively, to 0.3 ± 0.6, 91.5 ± 6.9 and 94.2 ± 6.7. No adverse side effects (infection, rejection, allergy) were reported during the study period. All patients were evaluated after surgery at 3 and 6 months and 1 year with statistically significant improvement for each score at the first and last follow-up (p < 0.05).

CONCLUSIONS

The use of LHBT augmentation in patients with MRCTs in appropriately selected patients is safe and effective and can lead to pain relief and acceptable clinical outcomes. Furthermore, its use carries low donor site morbidity and is cost effective. Comparative studies, including randomised controlled trials, with other proposed techniques are needed to confirm these findings.

LEVEL OF EVIDENCE

Level IV.

Patients With Intact Shoulder Superior Capsular Reconstruction Grafts on Ultrasound Show Significant Improvement in Functional Outcomes at Minimum 2-Year Follow-up

Purpose

To assess the utility of using dynamic ultrasound for postoperative evaluation after superior capsular reconstruction (SCR) by evaluating graft integrity and its correlation with clinical outcomes at a minimum 2-year follow-up.

Methods

A retrospective chart review was conducted to identify patients who underwent SCR between July 2015 and July 2020 with a minimum 2-year clinical and ultrasound follow-up. Clinical outcome measures included Simple Shoulder (SS) and American Shoulder and Elbow Surgeon (ASES) scores. Integrity of the SCR graft was evaluated by dynamic ultrasound.

Results

We evaluated 22 shoulders in 21 patients with a mean follow-up of 44.8 months (range, 24-71 months). The graft was found to be intact by ultrasound evaluation in 82% (18/22). Patients with intact grafts had higher mean SS (11.6 vs 7.8, P = .00079) and ASES (91.2 vs 64.1, P = .0296) scores at latest follow-up compared to those with failed grafts. Those with intact grafts also had significant improvement in SS (3.7 vs 11.6, P < .00001) and ASES (23.2 vs 91.2, P < .00001) scores at latest follow-up compared to their preoperative scores. In contrast, patients with graft failure had no significant improvement in SS (6.3 vs 9.0, P = .123) and ASES (40.4 vs 58.3, P = .05469) scores at latest follow-up compared to their preoperative scores. There was no difference between clinical outcomes at 6 to 12 months vs latest follow-up for both SS (P = .11, P = .5) and ASES (P = .27, P = .21) scores.

Conclusions

SCR grafts were found by ultrasound to be intact in 82% of cases. Patients with intact grafts on ultrasound had significant improvement in functional outcome scores while those with graft failure did not. Functional outcome scores suggest that maximal recovery from this procedure occurs by 6 to 12 months.

Level of Evidence

Level IV, therapeutic case series.

Evaluation of spin in reviews of biodegradable balloon spacers for massive irreparable rotator cuff tears

HYPOTHESIS

Clinical studies are often at risk of spin, a form of bias where beneficial claims are overstated while negative findings are minimized or dismissed. Spin is often more problematic in abstracts given their brevity and can result in the misrepresentation of a study's actual findings. The goal of this study is to aggregate primary and secondary studies reporting the clinical outcomes of the use of subacromial balloon spacers in the treatment of massive irreparable rotator cuff tears to identify the incidence of spin and find any significant association with study design parameters.

MATERIALS AND METHODS

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Independent searches were completed on 2 databases (PubMed and Embase) for primary studies, systematic and current concepts reviews, and meta-analyses and the results were compiled. Two authors independently screened the studies using a predetermined inclusion criteria and aggregated data including titles, publication journals and years, authors, study design, etc. Each study was independently assessed for the presence of 15 different types of spin. Statistical analysis was conducted to identify associations between study characteristics and spin.

RESULTS

Twenty-nine studies met the inclusion criteria for our analysis, of which 10 were reviews or meta-analyses and 19 were primary studies. Spin was identified in every study except for 2 (27/29, 93.1%). Type 3 spin, "Selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention" and type 9 spin, "Conclusion claims the beneficial effect of the experimental treatment despite reporting bias" were most frequently noted in our study, both observed in 12/29 studies (41.4%). Date of publication, and adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses or "The International Prospective Register of Systematic Reviews" were study characteristics associated with a higher rate of certain types of spin. There was a statistically significant association between disclosure of external study funding source and the presence of spin type 4, but none of the other forms of spin.

CONCLUSION

Spin is highly prevalent in the abstracts of primary studies, systematic reviews, and meta-analyses discussing the use of subacromial balloon spacer technology in the treatment of massive irreparable rotator cuff tears. Our findings revealed that spin in the abstract tended to favor the balloon spacer intervention. Further efforts are required in the future to mitigate spin within the abstracts of published manuscripts.

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.

Emerging Role of Quantitative Ultrasound-Based Imaging Techniques for Characterizing Rotator Cuff Tears: A Scoping Review

Rotator cuff myosteatosis following cuff tears is very common and one of the most important prognostic factors in clinical management. Quantitative ultrasound-based imaging techniques (QUBIT) are frequently used along with magnetic resonance imaging (MRI) to evaluate rotator cuff fatty degeneration. However, the examination of rotator cuff tissue integrity by QUBIT is lacking a standardized imaging protocol and procedural methodologies. In this scoping review, we synthesized the current state of QUBIT against the reference imaging modalities in patients with rotator cuff tears. The literature search was extracted from 963 studies, with 22 studies included in the final review in accordance with the preferred reporting items for systematic reviews and meta-analyses extensions for scoping reviews. The selected studies included human participants and focused on measuring at least one prognostic or diagnostic factor using ultrasonography-based imaging with reference to MRI. The findings suggest both conventional B-mode ultrasound and shear wave elastography imaging were comparable to MRI-based imaging techniques for the evaluation of fatty infiltration and rotator cuff tear characterization. This review establishes guidelines for reporting shoulder-specific QUBIT aimed at developing a standardized imaging protocol. The objective was to enhance the diagnostic and prognostic capabilities of QUBIT in the clinical setting.

Massive Irreparable Rotator Cuff Tears: Which Patients Will Benefit from Physiotherapy Exercise Programs? A Narrative Review

Massive irreparable rotator cuff tears can cause significant shoulder pain, disability and reduction in quality of life. Treatment approaches can be operative or non-operative. Operative approaches include reverse total shoulder arthroplasty, arthroscopic debridement, partial rotator cuff repair, subacromial balloon spacers, superior capsule reconstruction, and tendon transfer procedures. Non-operative approaches include physiotherapy exercise programs and corticosteroid injections. There are no randomized controlled trials comparing the different treatment approaches. It is therefore challenging for clinicians to advise patients on what is their best treatment pathway. Physiotherapy exercise programs are less expensive and have lower risks for patients than surgical approaches. However, the success of physiotherapy in patients with massive irreparable rotator cuff tears is highly variable with published success rates of 32-96%. Several cohort studies have sought to identify if certain factors are predictive of success with physiotherapy. Several biomechanical factors were identified as possibly being related to a successful or unsuccessful outcome following physiotherapy, with complete tear of subscapularis demonstrating the strongest evidence. However, there were no appropriately designed prognostic studies. There has been a strong emphasis on biomechanical factors. Other domains such as psychosocial factors, which are important in similar patient populations, have not been explored. We recommend that further research is needed in this area and should include randomized controlled trials comparing treatment approaches and longitudinal prospective prognostic studies to identify predictors of treatment success.

Arthroscopic Superior Capsular Reconstruction (ASCR): All Soft Anchors Technique

Rotator cuff tears are among the most common orthopaedic injuries. If not treated, they can result in a massive irreparable tear because of tendon retraction and muscle atrophy. Mihata et al. in 2012 described the technique of superior capsular reconstruction (SCR) using fascia lata autograft. This has been considered an acceptable and effective method for treating irreparable massive rotator cuff tears. We describe an arthroscopically assisted superior capsular reconstruction (ASCR) technique using all soft anchors to preserve the bone stock and reduce possible hardware complications. Moreover, knotless anchors for the lateral fixation make the technique easier to reproduce.

Poor Results After Arthroscopic Treatment of Irreparable Rotator Cuff Tears Using a Subacromial Balloon Spacer

INTRODUCTION

Arthroscopic balloon spacer arthroplasty (BSA) is a relatively recent procedure for patients with irreparable rotator cuff tears, conceived to prevent degenerative joint changes and relieve subacromial pain.

METHODS

This is a retrospective case series of 16 consecutive patients treated with BSA and followed up for a minimum 12 months. Besides BSA, partial tendon repair was done whenever possible. Radiographical parameters such as acromiohumeral distance and Hamada stage were measured preoperatively and postoperatively. Range of motion, functional results (Constant score; Simple Shoulder Test; American Shoulder and Elbow Surgeons score; and Disabilities of the Arm, Shoulder, and Hand score), health-related quality of life results with the EuroQol Five Dimensions tool, complications, and patient satisfaction were also analyzed.

RESULTS

The mean age was 64 ± 10.3 years, and the male/female ratio was 6/10. Partial repair was achieved in five patients (31.2%) and did not influence functional or health-related quality of life results ( P = 0.11). The mean acromiohumeral distance and Hamada stage worsened from preoperative measures (3.7 ± 2.0 mm and 2.3 ± 1.1) to final follow-up measures (3.1 ± 2.4 mm and 3.1 ± 1.3). Shoulder abduction increased by 7.8° ± 26.8° and forward flexion decreased by 25.5° ± 32.4° after surgery. The functional results at the final follow-up were Constant 49.5 ± 18.0; American Shoulder and Elbow Surgeons 60.2 ± 27.2; Simple Shoulder Test 8.5 ± 4.6; and Disabilities of the Arm, Shoulder, and Hand 32.7 ± 12.1. The mean index value for the EuroQol Five Dimensions was 0.79, and perceived quality of life was 85.6 ± 15.4 of 100 points. 62.5% of the patients (10) were satisfied with surgery. The complication rate was 13% (2), accounting for one deep infection and one balloon migration.

CONCLUSION

Theoretical benefits of BSA for delaying superior humeral head translation and arthropathic changes could not be demonstrated in our series. Its functional results and satisfaction rates are low, but self-reported quality of life after surgery does not seem impaired. Complications do not occur frequently but require reintervention and endanger joint viability.

LEVEL OF EVIDENCE

Level IV (case series).

Nonarthroplasty options for massive, irreparable rotator cuff tears have improvement in range of motion and patient-reported outcomes at short-term follow-up: a systematic review

PURPOSE

To compare various nonarthroplasty treatment options for massive, irreparable rotator cuff tears, including allograft bridging/augmentation, debridement, partial repair, superior capsule reconstruction (SCR), subacromial balloon spacer, and tendon transfer.

METHODS

A comprehensive search was conducted through the PubMed, MEDLINE, and EMBASE databases for all articles pertaining to nonarthroplasty treatment options for irreparable rotator cuff tears. Inclusion criteria included manuscripts published between 2009 and 2020 with at least 1 year follow-up and Level I-IV evidence. Articles were separated into six groups: debridement, arthroscopic and open repair, allograft bridging/augmentation, SCR, subacromial balloon spacer, and tendon transfer. Data points included range of motion (external rotation, abduction, forward flexion, and internal rotation), visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Constant score, rate of revision surgery, and rate of conversion to arthroplasty.

RESULTS

A total of 83 studies and 3363 patients were included. All treatment options had statistically significant improvements in postoperative range of motion and patient-reported outcomes. Debridement had statistically significantly greater postoperative abduction and forward flexion range of motion, as well as better VAS pain scores, compared to the other treatment options. The SCR subgroup had the greatest improvement in ASES scores postoperatively. The overall revision rate was 7.2% among all surgical options, with the allograft bridging/augmentation group having the lowest rate of revision at 0-8.3%. The overall rate of conversion to arthroplasty was 7.2%, with debridement having the greatest rate of conversion at 15.4%.

CONCLUSION

All six nonarthroplasty treatment options for irreparable rotator cuff tears resulted in statistically significant improvements in range of motion and patient-reported outcomes at 1 year follow-up or more, with low rates of revision and conversion to arthroplasty. Debridement had statistically significantly greater postoperative abduction and forward flexion range of motion, as well as better VAS pain scores, compared to the other treatment options. However, these conclusions should be interpreted with caution due to the heterogeneous nature of the data, lack of prospective randomized control trials, and short-term follow-up. The findings of this study highlight the complexity of irreparable, massive rotator cuff tears, and the need for an individualized approach when treating these patients.

LEVEL OF EVIDENCE

Level IV.

Outcomes of arthroscopic-assisted middle trapezius tendon transfer for isolated irreparable supraspinatus tendon tears: minimum 2-year follow-up

INTRODUCTION

Middle trapezius tendon (MTT) transfer has been proposed as a feasible option for managing isolated irreparable supraspinatus tears (IISTTs). However, no clinical study has been attempted. This study aimed to evaluate clinical and radiologic outcomes of arthroscopic-assisted MTT transfer in patients with IISTTs.

METHODS

This retrospective study included patients who underwent arthroscopic-assisted MTT transfer using fascia lata autograft for IISTTs. Clinical outcomes, including pain visual analog scale (VAS), Constant, American Shoulder and Elbow Society (ASES), University of California Los Angeles (UCLA) shoulder scores and active range of motion (aROM), were assessed. Radiographic analyses included the acromiohumeral distance (AHD), Hamada grade, and transferred tendon integrity at the final follow-up.

RESULTS

Twenty-two patients (mean age: 63.3 ± 6.8 [51‒74] years; mean follow-up period: 28.9 ± 4.9 [24‒44] months) met the study criteria. The mean VAS, Constant, ASES, and UCLA scores improved postoperatively at the final follow-up (p < 0.001). The mean aROMs for forward flexion and abduction were significantly increased postoperatively. No significant changes of AHD (p = 0.105) and Hamada grade (p = 0.815) were observed postoperatively. One patient had a re-tear of the transferred tendon at the footprint site at the final follow-up.

CONCLUSION

In this minimum 2-year follow-up study of the novel aMTT transfer using fascia lata autograft, we found significant improvement in pain relief, clinical scores, and active forward flexion and abduction. Additionally, no significant progression of cuff tear arthropathy was observed at the final follow-up. Therefore, aMTT transfer could be a promising treatment option for patients with IISTTs. However, further multicenter and long-term trials are needed to verify its effectiveness.

LEVEL OF EVIDENCE

Retrospective case series, level IV.

Posttreatment Imaging of the Shoulder

The shoulder joint is vulnerable for injuries following trauma and in the context of sporting activities. Degenerative rotator cuff disease is also a common entity. Conservative therapy is often not indicated or does not lead to the desired success, so surgical intervention is necessary. Routine follow-ups, but also persistent complaints, delayed healing, or recurrent trauma, usually need postoperative imaging of the shoulder. The choice of the adequate imaging modality and technique is important to reach the correct diagnosis. Additionally, knowledge of the most common surgical procedures, as well as typical normal findings and expected pathologies on different imaging modalities, is crucial for the radiologist to play a relevant role in the postoperative diagnostic process. This article addresses postoperative imaging after rotator cuff repair, shoulder arthroplasty, and surgery for shoulder stabilization with an emphasis on computed tomography and magnetic resonance imaging.

Clinical effect of arthroscopic long head of biceps transfer and tenodesis on irreparable rotator cuff tear

Objective

To explore the clinical effect of arthroscopic long head of biceps transfer and tenodesis for on irreparable rotator cuff tear.

Methods

A total of 18 patients with irreparable rotator cuff tear who were treated in the Dongfang Hospital Affiliated to Tongji University School of Medicine from April 2018 to March 2020 were included in this study. They all underwent arthroscopic long head of biceps transfer and tenodesis. Shoulder joint motions (forward flexion, abduction, and external rotation angle) and magnetic resonance imaging (MRI) were performed. Moreover, visual analogue scale (VAS) and university of California Los Angeles (UCLA) score were conducted during follow-up.

Results

Preoperative symptoms lasted from 3 to 16 months, with an average duration of 10 months. All patients healed in the first stage without obvious complications were included. All patients were followed up for 4 to 14 months after the surgery, with an average duration of 11.1 months. The range of shoulder joint motions, including forward flexion (80.52° ± 31.19° vs. 149.47° ± 28.36°), abduction (65.13° ± 37.59° vs. 152.46° ± 28.64°) and lateral rotation (30.17° ± 15.15° vs. 71.49° ± 11.42°) was significantly improved after operation (P < 0.05). The VAS score was notably decreased after operation (8.46 ± 0.80 vs. 1.55 ± 0.70), but the UCLA score was markedly increased (15.27 ± 2.89 vs. 31.17 ± 2.36). MRI imaging showed that 15 patients had good tissue healing, with a healing rate of 83.3% (15/18).

Conclusion

Arthroscopy of the biceps long head tendon transposition can significantly relieve pain in patients with large rotator cuff tears, improve joint mobility, and restore joint function.

Editorial Commentary: Interposition Graft Bridging Reconstruction: Good Mid-Term Outcomes for Massive Irreparable Rotator Cuff Tears

Massive irreparable rotator cuff tears without glenohumeral arthritis are a common cause of shoulder pain and disability. Many surgical treatment options have been proposed, including debridement, partial repair, tendon transfer, superior capsule reconstruction, balloon spacer placement, bursal acromial reconstruction, and reverse shoulder arthroplasty. Interposition graft bridging reconstruction, as evidenced by the mid-term results of the current study, may also be considered, at least for now. However, let's see if this procedure will truly stand the test of time because all orthopaedic surgeons know that the one thing that ruins good results is long-term follow-up!

Posterior decentering of the humeral head in patients with arthroscopic rotator cuff repair

Background: In some patients with rotator cuff tear (RCT), the axial view of magnetic resonance imaging (MRI) shows subtle posterior decentering (PD) of the humeral head from the glenoid fossa. This is considered to result from a loss of centralization that is typically produced by rotator cuff function. There are few reports on PD in RCT despite the common occurrence of posterior subluxation in degenerative joint disease. In this study, we investigated the effect of PD in arthroscopic rotator cuff repair (ARCR). Methods: We conducted a retrospective study of consecutive patients who underwent ARCR at our institute and were followed-up for at least 1 year. PD was identified as a 2 mm posterior shift of the humeral head relative to the glenoid fossa in the axial MRI view preoperatively. The tear size and fatty degeneration (FD, Goutallier classification) were also evaluated using preoperative MRI. Retears were evaluated through MRI at 1 year postoperatively. Results: We included 135 shoulders in this study. Ten instances of PD (including seven retears) were observed preoperatively. Fifteen retears (three and 12 retears in the small/medium and large/massive tear groups, respectively) were observed postoperatively. PD was significantly correlated with tear size, FD, and retear occurrence (p<0.01 each). The odds ratio for PD in retears was 33.8, which was greater than that for tear size ≥3 cm and FD grade ≥3. Conclusions: We concluded that large tear size and FD contribute to the occurrence of PD. Furthermore, PD could be a predictor of retear after ARCR.

Editorial Commentary: Clinical Improvements of Superior Capsular Reconstruction Are Not Due to Maintained Dynamic Acromiohumeral Distance

Biomechanical data often help inform clinical decision-making in orthopaedic surgery. However, there are times when the biomechanical data and clinical data do not align. This is seen in cases of statistical but clinically irrelevant differences. This is also seen at times in cases of demonstrated clinical improvements with a poorly understood mechanism. Superior capsular reconstruction has gained significant traction since the original description in 2012. It has taken a central role in the armamentarium of treatment options of irreparable rotator cuff tears. There is robust published literature on the time zero biomechanics of superior capsular reconstruction and its stabilizing effects on the glenohumeral joint, especially with regards to superior migration of the humeral head. There also is demonstrated good early patient-reported outcomes with superior capsular reconstruction. However, the cause and effect may not be as simple as the biomechanical studies may suggest, and the underlying mechanism of why the superior capsular reconstruction appears to improve early outcomes remains poorly understood. These mechanisms are important to understand in order to inform technique changes and improvements and help us optimize treatment of the patient with an irreparable rotator cuff tear.

«Terrible triad» of the shoulder. Biomechanicalsemi-natural modeling andjustificationto rotator cuff restoration

The aim of this study: was determine the force of tension and deformation of axillary nerve in rupture rotator cuff and paresis of deltoid muscle of the shoulder joint. Material and methods: Semi-natural modelling based on the axial scans spiral computed tomography of the intact shoulder joint was performed to determine the degree of traction load on the axillary nerve with distal displacement shoulder head and tendon rupture which paresis of the deltoid muscle. Result: The values of deformations for axillary nerve being at the limit of tissue strength at distal displacement of humeral head of the model by 50 %, progressively increased with increasing distal displacement of humeral head to 100 % of its diameter, reaching values 1.7 times higher than the strength nervous tissue. Conclusion: The progressive changes occurring in the axillary nerve under the action of traction loads, and as a consequence of its ischemia, over time can lead not only to demyelination, but also to the defeat of the axons themselves atrophy of its fibers. In turn, deltoid muscle atrophy increases the traction load on the affected axillary nerve, which forms a vicious circle. The only possible option to "break" the vicious circle is restore the stabilizing structures damaged during the injury, among which one of the most important is the tendons of the rotator cuff of the shoulder. Surgical restoration of the integrity rotator cuff of the shoulder reduces the traction load acting on the axillary nerve, which in turn significantly improves the conditions for reinnervation of the deltoid muscle.

Advancement in Arthroscopic Superior Capsular Reconstruction for Irreparable Massive Rotator Cuff Tear

Irreparable massive rotator cuff tear (IMRCT) was one of the causes of shoulder dysfunction, despite technical improvement, the failure rate of IMRCT was still demonstrated to be high. Traditional treatments like non-surgical treatments, partial rotator cuff repair, and tendon transfers could only achieve a slight improvement. A potential cause for high failure rate was the fact that traditional treatments cannot restore the superior stability of glenohumeral joint, and thus restricted the movement of shoulder joint severely. Superior capsular reconstruction (SCR) using a variety of grafts (autograft, allograft, xenograft, or synthetic grafts) provided a promising option for IMRCT. In surgery, graft was fixed medially to superior glenoid and laterally to the footprint of humeral greater tuberosity. SCR could increase the stability of the superior glenohumeral joint, decrease the subacromial pressure and acromiohumeral distance. This review summarized the relevant literature regarding the alternative grafts, surgery indications, operative techniques and clinical outcomes of SCR. we compared the different grafts, key surgical steps, the advantages and disadvantages of different surgical methods to provide clinicians with new surgical insights into the treatments of IMRCT. In conclusion, IMRCT without severe glenohumeral arthritis was the best suitable indication for SCR. The clinical outcomes were positive in the short-term and middle-term following-up. More studies were necessary to determine long-term results of this surgical procedure.

Good long-term patient-reported outcome after shoulder arthroplasty for cuff tear arthropathy

Background

The use of the reverse shoulder arthroplasty (RSA) for cuff tear arthropathy (CTA) has increased within the last decades, but there is still limited information about the long-term outcome and how it performs in comparison with hemiarthroplasty (HA). The aim of this study was to compare the long-term patient-reported outcomes of RSA and HA for CTA.

Methods

We included all patients with CTA, who according to the Danish Shoulder Arthroplasty Registry, underwent either HA or RSA between 2006 and 2010. Patients who were alive were sent the Western Ontario Osteoarthritis of the Shoulder (WOOS) questionnaire in 2020. One hundred twenty (65%) patients returned a complete questionnaire. The linear regression model was used to compare RSA and HA. Sex, age, and previous surgery were included in the multivariable model.

Results

Forty-two HAs and 78 RSAs were evaluated with a mean follow-up time of 11.5 and 10.6 years, respectively. The mean WOOS score was 66.7 for HA and 71.7 for RSA. The difference of 5.0 was neither statistically significant nor clinically important (95% confidence interval: -4.3 to 14.2, P = .17), nor were there any significant risk of a worse WOOS score for sex, age, or previous surgery.

Conclusion

To our knowledge, this is the first study to compare the long-term patient-reported outcomes of HA and RSA for CTA. Our results indicate that RSA is a reliable and durable treatment option for CTA with good long-term results. Based on this observational study, it is not possible to make safe estimates about the effect of RSA compared with HA, but similar to RSA, HA was associated with relatively good long-term results.

Association between type of rotator cuff tear and functional outcomes in patients with massive and irreparable rotator cuff tear: A pre-post intervention study

BACKGROUND

The aim of this study was to analyze: (1) the differences in the pre-post change in functional outcomes after a physical therapy program by the type of massive and irreparable rotator cuff tear (MIRCT) controlling for potential confounders, and (2) the influence of lifestyle behaviors and demographic and tear tendon characteristics on function in patients over 60 years of age with conservatively treated MIRCT.

MATERIALS AND METHODS

In this pre-post intervention study, 92 patients were prospectively recruited at the Clinical Hospital San Borja Arriaran, with atraumatic MIRCT, between 60 and 75 years of age (mean: 67.9 ± 4.5 years), and the mean of length of symptoms was 16.5 months (±5.7 months). Patients received a physical therapy program consisting of manual therapy and a specific exercise program of 2 sessions per week for 12 weeks. The imaging findings were performed by 2 medical radiologists who classified the rotator cuff tear according to the criteria proposed by Collins. Shoulder function, upper limb function, and pain intensity were assessed with the Constant-Murley; Disabilities of the Arm, Shoulder, and Hand; and visual analog scale (VAS), respectively. Analysis of covariance models were estimated to assess differences in MIRCT categories between functional outcomes. Multiple regression model analysis was used for the association between the change in functional outcomes and lifestyle behaviors, and demographic and tear tendon characteristics.

RESULTS

The results showed no pre-post change in functional outcomes by type of MIRCT in all models (P > .05). There is an association between length of symptoms (P = .000), and the baseline values of the 3 functional measures (P = .000) are associated with changes in Constant-Murley; Disabilities of the Arm, Shoulder, and Hand; and VAS. In addition, changes in VAS are associated with body mass index (BMI) (P = .000), and changes in Constant-Murley are associated with gender (P = .023), BMI (P = .000), and tobacco consumption (P = .000).

CONCLUSION

There is no difference in functional outcomes by type of MIRCT after a physical therapy program controlling for potential confounders. In addition, there is an association of length of symptoms with all functional outcomes, an association of BMI with VAS and Constant-Murley questionnaire, and an association between tobacco consumption and Constant-Murley questionnaire. Our results could influence the orthopedic surgeon's decisions; thus, not predicting the functional outcome through imaging findings could lead clinicians to reconsider the need for surgery in the treatment algorithm in patients over 60 years with MIRCT. In addition, demographic characteristics and lifestyle behaviors might be considered within the patient's evaluation and follow-up to decide on surgical interventions and evaluate the clinical course of the disease. Further studies measuring additional variables and longer follow-up are needed to confirm these results.

Chronic musculoskeletal impairment is associated with alterations in brain regions responsible for the production and perception of movement

KEY POINTS

Massive irreparable rotator cuff tear was used as a model to study the impact of chronic pain and motor impairment on the motor systems of the human brain using magnetic resonance imaging. Patients show markers of lower grey/white matter integrity and lower functional connectivity compared with control participants in regions responsible for movement and the perception of visual movement and body shape. An independent cohort of patients showed relative deficits in the perception of visual motion and hand laterality compared with an age-matched control group. These data support the hypothesis that the structure and function of the motor control system differs in patients who have experienced chronic motor impairment. This work also raises a new hypothesis, supported by neuroimaging and behaviour, that a loss of motor function could also be associated with off-target effects, namely a reduced ability to perceive motion and body form.

ABSTRACT

Changes in the way we move can induce changes in the brain, yet we know little of such plasticity in relation to musculoskeletal diseases. Here we use massive irreparable rotator cuff tear as a model to study the impact of chronic motor impairment and pain on the human brain. Cuff tear destabilises the shoulder, impairing upper-limb function in overhead and load-bearing tasks. We used neuroimaging and behavioural testing to investigate how brain structure and function differed in cuff tear patients and controls (imaging: 21 patients, age 76.3 ± 7.68; 18 controls, age 74.9 ± 6.59; behaviour: 13 patients, age 75.5 ± 10.2; 11 controls, age 73.4 ± 5.01). We observed lower grey matter density and cortical thickness in cuff tear patients in the postcentral gyrus, inferior parietal lobule, temporal-parietal junction and the pulvinar - areas implicated in somatosensation, reach/grasp and body form perception. In patients we also observed lower functional connectivity between the motor network and the middle temporal visual cortex (MT), a region involved in visual motion perception. Lower white matter integrity was observed in patients in the inferior fronto-occipital/longitudinal fasciculi. We investigated the cognitive domains associated with the brain regions identified. Patients exhibited relative impairment in visual body judgements and the perception of biological/global motion. These data support our initial hypothesis that cuff tear is associated with differences in the brain's motor control regions in comparison with unaffected individuals. Moreover, our combination of neuroimaging and behavioural data raises a new hypothesis that chronic motor impairment is associated with an altered perception of visual motion and body form.

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.

The experience with the use of a subacromial balloon in the treatment of patients with large, massive, irreparable rotator cuff tears

Background. Large, massive irreparable rotator cuff tears lead to a significant decrease in the function of the shoulder joint together with the development of a pronounced pain syndrome. Such injuries are difficult to treat, and the number of relapses, when trying to restore them, is quite high. The installation of a subacromial balloon is the method of choice for this group of patients and allows restoring the function of the shoulder joint fairly successfully. Aim: to evaluate the results of the treatment of patients with massive irreparable rotator cuff tears injuries in a prospective study from 2016 to 2018. Methods. The results of the arthroscopic treatment of large, irreparable rotator cuff injuries in 25 patients (with the average age of 67 5 years) with the installation of a subacromial balloon are presented. In all the clinical cases, there was a pronounced (grades 34, according to the Goutallier classification) fatty dystrophy of the rotator cuff muscles (supraspinatus or in combination with subaspinatus). All the patients underwent the subacromial space release with a thorough bursectomy and subsequent installation of a subacromial balloon. Results. The average score on the UCLA scale was 14 3 points (1117) before the operation and 312 points (2933) 12 months after the operation, the results were considered good and excellent. Conclusion. The results obtained allow us to evaluate the described technique as low-traumatic, simple and fast in its accomplishment, aimed at the reduction of the pain syndrome and restoration of the upper extremity function.

Staged arthroscopic procedure for treating simultaneous shoulder and elbow synovial chondromatosis: A case report and literature review

It is extremely rare for ipsilateral shoulder and elbow synovial chondromatosis to occur simultaneously. We report a very rare case of simultaneous shoulder and elbow synovial chondromatosis in a 53-year-old woman who was treated through staged surgeries. Shoulder arthroscopic synovectomy, debridement, biceps tenodesis, and subacromial decompression were conducted first, followed by elbow arthroscopy 2 months later. Post surgery, there was no recurrence either clinically or radiologically at 2 years follow-up. Despite some loss of the range of motion of the shoulder and muscle strength, the elbow functions recovered fully, and the patient was extremely satisfied with the clinical outcome. We recommend a staged arthroscopic procedure consisting of a thorough synovectomy and joint debridement for this condition.