Indication matters: effect of indication on clinical outcome following reverse total shoulder arthroplasty-a multicenter study

BACKGROUND

As the utilization and success of reverse total shoulder arthroplasty (RTSA) have continued to grow, so have its surgical indications. Despite the adoption of RTSA for the treatment of glenohumeral osteoarthritis (GHOA) with an intact rotator cuff and irreparable massive rotator cuff tears (MCTs) without arthritis, the literature remains sparse regarding the differential outcomes after RTSA among these varying indications. Thus, the purpose of this study was to examine the postoperative clinical outcomes of RTSA based on indication.

METHODS

A retrospective review of 2 large institutional databases was performed to identify all patients who underwent RTSA between 2015 and 2019 with minimum 2-year follow-up. Patients were stratified by indication into 3 cohorts: GHOA, rotator cuff tear arthropathy (CTA), and MCT. Baseline demographic characteristics were collected to determine differences between the 3 cohorts. Clinical outcomes were measured preoperatively and postoperatively, including active range of motion, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation score, and visual analog scale pain score. Multivariate linear regression was performed to determine the factors independently predictive of the postoperative ASES score.

RESULTS

A total of 625 patients (383 with GHOA, 164 with CTA, and 78 with MCTs) with a mean follow-up period of 33.4 months were included in the analysis. Patients with GHOA had superior ASES scores (85.6 ± 15.7 vs. 76.6 ± 20.8 in CTA cohort [P < .001] and 75.9 ± 19.9 in MCT cohort [P < .001]), Single Assessment Numeric Evaluation scores (86 ± 20.9 vs. 76.7 ± 24.1 in CTA cohort [P < .001] and 74.2 ± 25.3 in MCT cohort [P < .001]), and visual analog scale pain scores (median [interquartile range], 0.0 [0.0-1.0] vs. 0.0 [0.0-2.0] in CTA cohort [P < .001] and 0.0 [0.0-2.0] in MCT cohort [P < .001]) postoperatively. Postoperative active forward elevation (P < .001) and improvement in active external rotation (P < .001) were greatest in the GHOA cohort compared with other indications. Multivariate linear regression demonstrated that the factors independently associated with the postoperative ASES score included a diagnosis of GHOA (β coefficient, 7.557 [P < .001]), preoperative ASES score (β coefficient, 0.114 [P = .009]), female sex (β coefficient, -4.476 [P = .002]), history of surgery (β coefficient, -3.957 [P = .018]), and postoperative complication (β coefficient, -13.550 [P < .001]).

CONCLUSION

RTSA for the treatment of GHOA generally has superior patient-reported and functional outcomes when compared with CTA and MCTs without arthritis. Long-term follow-up is needed to identify the lasting implications of such outcome differences.

Mid-term outcomes of arthroscopically assisted lower trapezius tendon transfer using Achilles allograft in treatment of posterior-superior irreparable rotator cuff tear

BACKGROUND

Arthroscopically assisted lower trapezius tendon (aLTT) transfer is one of the treatment options for posterior-superior irreparable rotator cuff tears (PSIRCTs). Although short-term clinical outcomes have shown promising results, there are currently no reported clinical outcomes over a longer follow-up period. This study evaluated the mid-term outcomes of aLTT transfer in patients with a diagnosis of PSIRCT.

METHODS

This retrospective case-series study included patients who underwent aLTT transfer between May 2017 and May 2019. The clinical outcome assessment included the visual analog scale (VAS) pain score, Constant score, American Shoulder and Elbow Surgeons score, University of California-Los Angeles score, Activities of Daily Living Requiring Active External Rotation (ADLER) score, active range of motion, Single Assessment Numeric Evaluation score, and return-to-work rate. The radiographic analysis included the acromiohumeral distance, Hamada grade, and integrity of the transferred tendon at final follow-up. Subgroup analyses were performed based on the integrity of the transferred tendon and the trophicity of the teres minor (Tm).

RESULTS

This study enrolled 36 patients with a mean age of 63.4 years who met the inclusion criteria and were followed up for a mean of 58.2 ± 5.3 months. At final follow-up, the patients showed significant improvement in mean VAS score, Constant score, American Shoulder and Elbow Surgeons score, University of California-Los Angeles score, ADLER score, and active range of motion in all directions except internal rotation. A decrease in the acromiohumeral distance and an increase in the Hamada grade were observed at final follow-up (P = .040 and P = .006, respectively). Retears of the transferred tendon occurred in 7 patients, and postoperative infections developed in 2 individuals. An interesting finding was that the retear group still demonstrated improvement in the VAS score but did not show improvement in external rotation at the side by the final follow-up. Compared with the Tm non-hypertrophy group, the Tm hypertrophy group showed significantly better improvement in external rotation at 90° of abduction and at the side, as well as the ADLER score. Of the study patients, 30 (83.3%) were able to successfully resume their previous work.

CONCLUSION

In this study, aLTT transfer in patients with PSIRCTs demonstrated significant improvements in clinical and radiologic outcomes by the final follow-up. These findings provide support for the mid-term safety and effectiveness of aLTT transfer as a viable joint-preserving treatment option for PSIRCTs. However, larger and longer-term studies are still needed to further validate these findings.

Reversing chronic pseudoparesis secondary to massive, irreparable rotator cuff tear: superior capsular reconstruction vs. reverse total shoulder arthroplasty

INTRODUCTION

Recent studies have defined pseudoparesis as limited active forward elevation between 45° and 90° and maintained passive range of motion (ROM) in the setting of a massive rotator cuff tear (RCT). Although pseudoparesis can be reliably reversed with reverse total shoulder arthroplasty (RSA) or superior capsular reconstruction (SCR), the optimal treatment for this indication remains unknown. The purpose of this study was to compare the clinical outcomes of RSA to SCR in patients with pseudoparesis secondary to massive, irreparable RCT (miRCT).

METHODS

This was a retrospective cohort study of consecutive patients aged 40-70 years with pseudoparesis secondary to miRCT who were treated with either RSA or SCR by a single fellowship-trained shoulder surgeon from 2016 to 2021 with a minimum 12-month follow-up. Multivariate linear regression modeling was used to compare active ROM, visual analog pain scale (VAS), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score between RSA and SCR while controlling for confounding variables.

RESULTS

Twenty-seven patients were included in the RSA cohort and 23 patients were included in the SCR cohort with similar mean follow-up times (26.2 ± 21.1 vs. 21.9 ± 14.7 months, respectively). The patients in the RSA group were significantly older than those in the SCR group (65.2 ± 4.4 vs. 54.2 ± 7.8 years, P < .001) and had more severe arthritis (1.8 ± 0.9 vs. 1.2 ± 0.5 Samilson-Prieto, P = .019). The pseudoparesis reversal rate among the RSA and SCR cohorts was 96.3% and 91.3%, respectively. On univariate analysis, the RSA cohort demonstrated significantly greater mean improvement in active FF (89° ± 26° vs. 73° ± 30° change, P = .048), greater postoperative SSV (91 ± 8% vs. 69 ± 25%, P < .001), lower postoperative VAS pain scores (0.6 ± 1.2 vs. 2.2 ± 2.9, P = .020), and less postoperative internal rotation (IR; 4.6° ± 1.6° vs. 6.9° ± 1.8°, P = .004) compared with SCR. On multivariate analysis controlling for age and osteoarthritis, RSA remained a significant predictor of greater SSV (β = 21.5, P = .021) and lower VAS scores (β = -1.4, P = .037), whereas SCR was predictive of greater IR ROM (β = 3.0, P = .043).

CONCLUSION

Although both RSA and SCR effectively reverse pseudoparesis, patients with RSA have higher SSV and lower pain scores but less IR after controlling for age and osteoarthritis. The results of this study may inform surgical decision making for patients who are suitable candidates for either procedure.

Full arthroscopic vs. arthroscopically assisted posterosuperior latissimus dorsi tendon transfer for shoulders with failed and irreparable rotator cuff repair: matched case-control study

PURPOSE

To compare clinical outcomes and complication rates of full arthroscopic latissimus dorsi tendon transfer (LDTT) vs. arthroscopically assisted LDTT, for the treatment of irreparable posterosuperior massive rotator cuff tears (mRCTs) in shoulders that had failed rotator cuff repair (RCR).

METHODS

We evaluated a continuous series of 191 patients who underwent LDTT over 4 consecutive years. A total of 107 patients did not have previous shoulder surgery, leaving 84 patients who had prior surgical procedures. All procedures performed over the first 2 years were arthroscopically assisted (n = 48), whereas all procedures performed over the last 2 years were full arthroscopic (n = 36). We noted all complications, as well as clinical scores and range of motion at ≥24 months. To enable direct comparison between the 2 techniques, propensity score matching was used to obtain 2 groups with equivalent age, sex, and follow-up.

RESULTS

Compared with the 48 patients who underwent arthroscopically assisted LDTT, the 36 patients who underwent full arthroscopic LDTT had comparable complications (13% vs. 11%) and conversions to RSA (8.3% vs. 5.6%). Propensity score matching resulted in 2 groups, each comprising 31 patients, which had similar outcomes in terms of clinical scores (except mobility component of Constant score, which was better following fully arthroscopic LDTT; P = .037) and range of motion at a minimum follow-up of 2 years.

CONCLUSION

At a minimum follow-up of 24 months, for the treatment of irreparable posterosuperior mRCTs in shoulders that had surgical antecedents, full arthroscopic LDTT had significantly better mobility component of the Constant score than arthroscopically assisted LDTT, although there were no significant differences in the other clinical or functional outcomes. Arthroscopically assisted LDTT and full arthroscopic LDTT had comparable rates of complications (8.3% vs. 13%) and conversion to RSA (5.6% vs. 8.3%).

Preoperative MRI Rotator Cuff Tendon Stump Classification Correlates with the Surgical Outcomes Following Superior Capsular Reconstruction

PURPOSE

To investigate the correlation between rotator cuff stump classification and postoperative outcomes after superior capsular reconstruction (SCR).

METHODS

A total of 75 patients who underwent SCR between June 2013 and May 2021 were included in this study. Based on stump classification using the signal intensity ratio of the tendon rupture site to the deltoid muscle in the coronal view of preoperative T2-weighted, fat-suppressed MRI scans, the patients were classified into types 1, 2, and 3 with ratios of < 0.8, 0.8-1.3, and > 1.3 (44, 17, and 14 patients, respectively). The American Shoulder and Elbow Surgeons (ASES), Constant, and visual analog scale (VAS) scores for pain and range of motion were evaluated at a minimum of 1 year of follow-up postoperatively. The acromiohumeral distance and RC tear arthropathy according to the Hamada classification were assessed on plain radiography. Postoperative graft integrity was evaluated by MRI at 3 and 12 months postoperatively and annually thereafter. Graft failure was defined as complete discontinuity.

RESULTS

Clinical and radiological outcomes were significantly improved after SCR. In comparison with type 2 and 3 patients, type 1 patients had significantly higher ASES scores (type 1, 2, and 3 = 84 ± 10, 75 ± 15, and 76 ± 14; all P = 0.014), constant scores (type 1, 2, and 3 = 65 ± 5, 61 ± 9, and 56 ± 13; all P = 0.005), and forward flexion (type 1, 2, and 3 = 155 ± 10, 154 ± 15, and 145 ± 13; all P = 0.013). However, these statistical differences between groups were below the established minimum clinically important difference values for the ASES and Constant scores after rotator cuff repair. The graft failure rate after surgery was lower in the type 1 group than that in the other two groups; however, the difference was not statistically significant (P = 0.749).

CONCLUSION

Patients with stump classification type 1 showed significantly better functional scores (ASES and VAS scores) and forward flexion; however, the clinical importance of these differences may be limited. Stump classification may be useful for predicting postoperative clinical outcomes.

Pseudoparesis and pseudoparalysis in the setting of massive irreparable rotator cuff tear: demographic, anatomic, and radiographic risk factors

BACKGROUND

The primary purpose of this study was to identify demographic, anatomic, and radiographic risk factors for active forward elevation (AFE) <90° in the setting of massive, irreparable rotator cuff tear (miRCT). The secondary purpose was to identify characteristics differentiating between patients with pseudoparalysis (AFE <45°) and pseudoparesis (AFE >45° but <90°).

METHODS

This was a retrospective case-control study reviewing patients with miRCTs at a single institution between January 12, 2016 and November 26, 2020. Patients were separated into 2 cohorts based on presence or absence of preoperative AFE <90° with maintained passive range of motion. Demographics, RCT pattern, and radiographic parameters were assessed as risk factors for AFE <90°. A secondary analysis was conducted to compare patients with pseudoparalysis and pseudoparesis.

RESULTS

There were 79 patients in the AFE <90° cohort and 50 patients in the control cohort. Univariate analysis confirmed significant differences between the AFE <90° and control cohort in age (71.9 ± 11.0 vs. 65.9 ± 9.1 years), arthritis severity (34.2% vs. 16.0% grade 3 Samilson-Prieto), acromiohumeral distance (AHD; 4.8 ± 2.7 vs. 7.6 ± 2.6 mm), fatty infiltration of the supraspinatus (3.3 ± 0.9 vs. 2.8 ± 0.8) and subscapularis (2.0 ± 1.2 vs. 1.5 ± 1.0), and proportion of subscapularis tears (55.7% vs. 34.0%). On multivariate analysis, age (odds ratio [OR] 1.08, P = .014), decreased AHD (OR 0.67, P < .001), severe arthritis (OR 2.84, P = .041), and subscapularis tear (OR 6.29, P = .015) were independent factors predictive of AFE <90°. Secondary analysis revealed tobacco use (OR 3.54, P = .026) and grade 4 fatty infiltration of the supraspinatus (OR 2.22, P = .015) and subscapularis (OR 3.12, P = .042) as significant predictors for pseudoparalysis compared to pseudoparesis.

CONCLUSIONS

In patients with miRCT, increased age, decreased AHD, severe arthritis, and subscapularis tear are associated with AFE <90°. Furthermore, patients with AFE <90° tend to have greater supraspinatus and subscapularis fatty infiltration. Lastly, among patients with AFE <90°, tobacco use and grade 4 fatty infiltration of the supraspinatus and subscapularis are associated with pseudoparalysis compared with pseudoparesis.

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.

Effect of Anterior Acromial Coverage on Functional and Radiological Outcomes After Arthroscopic Repair of Anteroposterior Massive Rotator Cuff Tears

BACKGROUND

Rotator cuff tear size, fatty infiltration, and scapular morphology are correlated with tendon healing and functional outcomes after arthroscopic repair; however, the association between anteroposterior acromial coverage and the clinical outcomes of anteroposterior massive rotator cuff tears (AP-MRCTs; involving all 3 tendons) remains unclear.

PURPOSE

To identify the association between AP acromial coverage and functional and radiological outcomes after arthroscopic repair of AP-MRCTs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 98 patients who underwent arthroscopic repair of AP-MRCTs between January 2015 and December 2020 were included in the study and classified according to whether anterior acromial coverage (AAC) was anterior (46 patients; positive AAC group) or posterior (52 patients; negative AAC group) to the scapular line on true lateral shoulder radiographs. Demographic characteristics, surgical details, and functional outcomes were prospectively collected. Acromial morphological features, global tear extension (GTE), the global fatty infiltration index (GFII), tendon integrity after repair, proximal humeral migration, and glenohumeral abduction were measured and calculated on radiographs or magnetic resonance imaging scans preoperatively and at 2 years postoperatively. Multivariate logistic regression was performed to identify the independent risk factors of a rotator cuff retear.

RESULTS

The positive AAC group showed larger AAC, posterior acromial tilt, and anterior acromial slope as well as smaller posterior acromial coverage compared with the negative AAC group. Postoperatively, the American Shoulder and Elbow Surgeons score (82.5 ± 8.3 vs 77.2 ± 11.5, respectively; P = .013), active abduction (157.8°± 27.1° vs 142.7°± 39.6°, respectively; P = .048), and glenohumeral abduction (45.6°± 10.4° vs 39.7°± 14.9°, respectively; P = .041) in the positive AAC group were significantly higher than those in the negative AAC group, while the retear rate (23.9% vs 44.2%, respectively; P = .035) and proximal humeral migration (1.7 ± 1.0 vs 2.3 ± 1.2 mm, respectively; P = .006) were significantly lower in the positive AAC group than in the negative AAC group. Smaller AAC (odds ratio [OR], 0.93 [95% CI, 0.87-1.00]; P = .040), larger GTE (OR, 1.03 [95% CI, 1.01-1.06]; P = .017), and a higher GFII (OR, 3.49 [95% CI, 1.09-11.19]; P = .036) were associated with an increased risk of a rotator cuff retear.

CONCLUSION

Increased AAC was associated with a lower retear rate and better functional outcomes after arthroscopic repair of AP-MRCTs. A preliminary risk evaluation integrating GTE, the GFII, and AAC is recommended to consider the necessity of additional procedures for patients in need of arthroscopic rotator cuff repair.

Minimum 5-Year Clinical Outcomes of Arthroscopically Repaired Massive Rotator Cuff Tears: Effect of Age on Clinical Outcomes

BACKGROUND

Massive rotator cuff tears (MRCTs) can be challenging to treat, and the efficacy of repair of MRCTs in older patients has been debated.

PURPOSE

To report minimum 5-year outcomes after primary arthroscopic rotator cuff repair of MRCT and determine whether age affects outcomes.

STUDY DESIGN

Case series; Level of evidence 4.

METHODS

The study included consecutive patients with MRCTs who were treated with arthroscopic rotator cuff repair by a single surgeon between February 2006 and October 2016. MRCTs were defined as ≥2 affected tendons with tendon retraction to the glenoid rim and/or a minimum exposed greater tuberosity of ≥67. Patient-reported outcome (PRO) data collected preoperatively and at a minimum of 5 years included the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numeric Evaluation (SANE) score; the shortened version of the Disabilities of the Arm, Shoulder and Hand score (QuickDASH); the 12-Item Short Form Health Survey (SF-12) Physical Component Summary (PCS); and patient satisfaction. Surgical failure was defined as subsequent revision rotator cuff surgery or conversion to reverse total shoulder arthroplasty. Regression analysis was performed to determine whether age had an effect on clinical outcomes.

RESULTS

A total of 53 shoulders in 51 patients (mean age, 59.7 years; range, 39.6-73.8 years; 34 male, 19 female) met inclusion criteria with a mean follow-up of 8.1 years (range, 5.0-12.1 years). Three shoulders (5.7%) failed at 2.4, 6.0, and 7.1 years. Minimum 5-year follow-up was obtained in 45 of the remaining 50 shoulders (90%). Mean PROs improved as follows: ASES from 58.8 to 96.9 (P < .001), SANE from 60.5 to 88.5 (P < .001), QuickDASH from 34.2 to 6.8 (P < .001), and SF-12 PCS from 41.1 to 52.2 (P < .001). Patient satisfaction was a median of 10 (on a scale of 1-10). Age was not associated with any PRO measures postoperatively (P > .05).

CONCLUSION

This study demonstrated significantly improved clinical scores, decreased pain, and increased return to activity for patients with MRCT at midterm follow-up (mean, 8.1 years; range, 5.0-12.1 years). In this patient cohort, no association was found between age and clinical outcomes.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

Matched Cohort Study Comparing Arthroscopic-Assisted Versus Full-Arthroscopic Latissimus Dorsi Tendon Transfer for Irreparable Massive Rotator Cuff Tears

Background

Latissimus dorsi tendon transfer (LDTT) is increasingly performed with arthroscopic assistance, requiring an open axillary incision, which could increase risks of infection, hematoma, and lymphoedema. Technological advancements now enable LDTT to be fully arthroscopic, but its benefits and safety have not yet been confirmed.

Purpose

To compare the clinical outcomes and complication rates of arthroscopic-assisted versus full-arthroscopic LDTT for irreparable posterosuperior massive rotator cuff tears in shoulders with no surgical antecedents.

Study Design

Cohort study; Level of evidence, 3.

Methods

The study included 90 patients who had undergone LDTT over 4 consecutive years by the same surgeon and did not have prior surgery. During the first 2 study years, all procedures were arthroscopically assisted (n = 52), while during the last 2 years, all procedures were fully arthroscopic (n = 38). Procedure duration and all complications were recorded, as well as clinical scores and range of motion at minimum 24-month follow-up. To enable direct comparison between the techniques, propensity score matching was used to obtain 2 groups with equivalent age, sex, and follow-up.

Results

From the initial cohort of 52 patients who underwent arthroscopic-assisted LDTT, 8 had complications (15.4%), of which 3 (5.7%) required conversion to reverse shoulder arthroplasty and 2 (3.8%) required drainage or lavage. From the initial cohort of 38 patients who had full-arthroscopic LDTT, 5 had complications (13.2%), of which 2 (5.2%) required conversion to reverse shoulder arthroplasty but no patients (0%) required other procedures. Propensity score matching resulted in 2 groups, each comprising 31 patients, with similar outcomes in terms of clinical scores and range of motion. The procedure time was about 18 minutes shorter for full-arthroscopic LDTT, which had different complications (2 axillary nerve pareses) as compared with arthroscopic-assisted LDTT (1 hematoma and 2 infections).

Conclusion

Equivalent outcomes at minimum 24-month follow-up were found for arthroscopic-assisted and full-arthroscopic LDTT in terms of complications rates (15.4% and 13.2%, respectively), conversion to reverse shoulder arthroplasty (5.7% and 5.2%), clinical scores, and range of motion.

A Knitted PET Patch Enhances the Maturation of Regenerated Tendons in Bridging Reconstruction of Massive Rotator Cuff Tears in a Rabbit Model

BACKGROUND

Although nondegradable synthetic grafts for bridging reconstruction of massive rotator cuff tears (MRCTs) have shown satisfactory clinical outcomes, their function and details on graft-tendon healing and enthesis regeneration have not been fully studied.

HYPOTHESIS

The knitted polyethylene terephthalate (PET) patch as a nondegradable synthetic graft could provide sustained mechanical support, facilitating enthesis and tendon regeneration in the treatment of MRCTs.

STUDY DESIGN

Controlled laboratory study.

METHODS

A knitted PET patch was fabricated for bridging reconstruction (PET group) in a New Zealand White rabbit model of MRCTs (negative control group), and an autologous Achilles tendon was used as a control (autograft group). The animals were sacrificed, and tissue samples were harvested for gross observation as well as histological and biomechanical analyses at 4, 8, and 12 weeks postoperatively.

RESULTS

Histological analysis showed no significant difference in the graft-bone interface score between the PET and autograft groups at 4, 8, and 12 weeks postoperatively. Interestingly, in the PET group, Sharpey-like fibers were observed at 8 weeks, while fibrocartilage formation and the ingrowth of chondrocytes were recognized at 12 weeks. Meanwhile, the tendon maturing score was significantly higher in the PET group than in the autograft group (19.7 ± 1.5 vs 15.3 ± 1.2, respectively; P = .008) at 12 weeks, with parallel-oriented collagen fibers around the knitted PET patch. Moreover, the ultimate failure load of the PET group was similar to that of a healthy rabbit tendon at 8 weeks (125.6 ± 13.6 vs 130.8 ± 28.6 N, respectively; P > .05) and no different from that of the autograft group at 4, 8, and 12 weeks.

CONCLUSION

The knitted PET patch could not only immediately reconstruct the mechanical support for the torn tendon postoperatively in the rabbit model of MRCTs but also enhanced maturation of the regenerated tendon by fibrocartilage formation and improved the organization of collagen fibers. Herein, the knitted PET patch could be a promising candidate graft adopted in bridging reconstruction of MRCTs.

CLINICAL RELEVANCE

A nondegradable knitted PET patch can safely bridge MRCTs with satisfactory mechanical strength and the promotion of tissue regeneration.

Preliminary Outcomes of Arthroscopic Biologic Tuberoplasty in the Treatment of Massive Irreparable Rotator Cuff Tears

INTRODUCTION

Several treatment options exist for the treatment of massive, irreparable rotator cuff tears. A novel technique has been described whereby an acellular dermal allograft is secured to the greater tuberosity which acts as an interpositional tissue preventing bone-to-bone contact between the greater tuberosity and acromion. The preliminary results of this arthroscopic procedure are being presented.

METHODS

Patients who underwent a biologic tuberoplasty procedure between 2015 and 2022, by a single surgeon, were included in this study. Pre- and postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and visual analogue pain scores (VAS) were prospectively recorded and retrospectively reviewed. Postoperative MRI was obtained in some cases. Paired t-test was used to calculate significance set at <0.05.

RESULTS

Ten patients met the inclusion criteria. The mean age was 70.4+4.7 years (range 65-78). There were five males. The mean length of follow-up was 21+27 months (range six to 95 months). There was significant improvement in ASES (24.3+4 to 91.5+10.3, P<0.00001), SANE (22.5+10.3 to 88+11.6, P<0.00001), and VAS (8.8+0.6 to 1.1+2.5, P<0.00001). MRI was obtained in seven patients at a mean of 5.3+2.9 months and showed a healed graft to the tuberosity in all cases.

CONCLUSION

Biologic tuberoplasty is an effective procedure in improving pain and functional outcomes in patients with massive, irreparable rotator cuff tears.

[Effectiveness of arthroscopic long head of biceps tendon transposition combined with Swivelock anchor double fixation for massive and irreparable rotator cuff tears]

Objective

To investigate the effectiveness of arthroscopic long head of biceps tendon (LHBT) transposition combined with Swivelock anchor double fixation in treatment of massive and irreparable rotator cuff tears.

Methods

Between June 2019 and November 2021, 25 patients with massive and irreparable rotator cuff tears were treated by arthroscopic LHBT transposition combined with Swivelock anchor double fixation. There were 12 males and 13 females. The age ranged from 47 to 74 years (mean, 62.4 years). The disease duration ranged from 1 to 62 months (median, 7 months). The rotator cuff tears were classified as Hamada grade 2 in 25 cases and Goutallier grade 1 in 2 cases, grade 2 in 22 cases, and grade 3 in 1 case. Pre- and post-operative shoulder range of motion (ROM), visual analogue scale (VAS) score, University of California Los Angeles (UCLA) score, and Constant-Murley score were recorded. Postoperative complications were observed. The reconstructed tissue integrity was confirmed by MRI.

Results

All operations were successfully completed. The operation time was 120-330 minutes (mean, 189.6 minutes). All incisions healed by first intention. All patients were followed up 10-36 months (mean, 22.0 months). At last follow-up, the ROM in forward flexion, abduction, and external rotation, VAS score, UCLA score, and Constant-Murley score were superior to those before operation, and the differences were significant ( P<0.05). According to UCLA scoring standard, shoulder joint function was rated as excellent in 5 cases, good in 18 cases, and poor in 2 cases, with an excellent and good rate of 92.0%. No other complications occurred except shoulder joint adhesion in 2 cases. At last follow-up, MRI examination showed no retear of rotator cuff, and LHBT was intact.

Conclusion

For massive and irreparable rotator cuff tears, arthroscopic LHBT transposition combined with Swivelock anchor double fixation can increase the force of pressing the humeral head, effectively relieve the pain, improve the ROM of joints, maximize the recovery of shoulder function, and do not increase the number of anchor nails.

Glenoid wear and its impact on clinical results after humeral head replacement using a single prosthesis in cuff tear arthropathy with more than 8 years of follow-up

BACKGROUND

Glenoid wear (GW) is a long-term complication after humeral head replacement (HHR) and is one of the major reasons for revision surgery. This study aimed to evaluate GW at >8 years of follow-up after HHR in patients with cuff tear arthropathy (CTA) by use of a modified classification of GW, to examine the relationship between GW and clinical outcomes, and to identify risk factors for GW progression.

METHODS

This retrospective case-series study included 34 shoulders that were monitored for >8 years after HHR in patients with CTA (13 men and 21 women; mean age at surgery, 70.9 years [range, 55-82 years]). Patients were monitored for a mean of 10.3 years (range, 8.1-13.2 years). GW was classified using plain radiographs as follows: grade 0, no remarkable postoperative changes; grade 1, postoperative glenohumeral joint space narrower than preoperative glenohumeral joint space; grade 2, contact between glenoid and humeral head prosthesis; and grade 3, glenoid erosion. Grade 3 cases were further classified into the following subtypes: grade 3A, partial erosion of anterior glenoid; grade 3B, partial erosion of superior glenoid; and grade 3C, concentric erosion of glenoid. Clinical outcomes including range of motion (active flexion and active external rotation) and postoperative pain (Constant score) were compared between grade 0-2 shoulders and grade 3 shoulders, as well as between the grade 3 subtypes. Age, sex, preoperative range of motion, preoperative pain, and number of ruptured tendons were analyzed as possible risk factors for progression to grade 3.

RESULTS

The final GW grade was grade 0 in 3 shoulders, grade 1 in 10, grade 2 in 6, and grade 3 in 15 (grade 3A in 2, grade 3B in 6, and grade 3C in 7). The grade 3 group had lower pain scores (10.7 ± 6.2 vs. 14.2 ± 1.9, P = .044) and limited active flexion (108.2° ± 42.3° vs. 140.6° ± 26.7°, P = .041) compared with the grade 0-2 group. Subtype comparison showed that the grade 3B group had lower pain scores (7.0 ± 6.7 vs. 15.0 ± 0.0, P = .007) and limited active flexion (80.0° ± 26.2° vs. 140.8° ± 27.5°, P = .010) compared with the grade 3C group. Limited preoperative active external rotation was an individual risk factor for grade 3 GW (odds ratio, 0.93; 95% confidence interval, 0.88-0.99; P = .009).

CONCLUSIONS

In the long term (>8 years) after HHR with tendon transfer in patients with CTA, patients with the development of grade 3C GW ultimately achieve pain relief even without revision surgery whereas grade 3B GW is associated with persistent pain and might require revision surgery.

Partial Superior Capsular Reconstruction to Augment Arthroscopic Repair of Massive Rotator Cuff Tears Using Autogenous Biceps Tendon: Effect on Retear Rate

BACKGROUND

Massive rotator cuff tears have a high incidence of postoperative retear that can reach 90%. It is still unclear which intervention may reduce the incidence of retear and improve the functional and clinical outcomes.

PURPOSE/HYPOTHESIS

The purpose of this study was to investigate the clinical and structural outcomes at 2 years after repair of reparable massive rotator cuff tears with and without the use of partial superior capsular reconstruction (pSCR), using the autologous long head of the biceps tendon (LHBT) as a graft. It was hypothesized that augmentation with a pSCR would decrease retear rates.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The authors compared arthroscopic repair of massive posterosuperior rotator cuff tears with and without augmentation using the LHBT for pSCR between 2015 and 2017. After applying the selection criteria, 106 patients were included in the study and distributed into 2 groups of 50 and 56 patients. Patients in the first group (50 patients) underwent arthroscopic repair without use of the LHBT (AR group), and patients in the second group (56 patients) underwent arthroscopic repair with use of the LHBT for pSCR (AR-LHBT group). The structural outcome was evaluated by ultrasound at 2 years of follow-up. Function and pain were evaluated preoperatively and at the 2-year follow-up using the American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS). Pre- and postoperative active range of motion, including forward elevation, external rotation, and abduction, were also documented.

RESULTS

No significant differences were found between groups regarding the baseline characteristics. After 24 months, both groups showed significant improvement from preoperative ASES scores, VAS score, and active range of motion (P < .01 for all). Patients in the AR-LHBT group showed significant improvements in postoperative functional and pain scores compared with the AR group in all measurements at the 2-year follow-up (ASES score: 77.23 ± 7.45 vs 71.04 ± 9.28, P < .01; VAS score: 1.64 ± 1.03 vs 2.12 ± 1.06, P < .01). Final range of motion was significantly increased for the AR-LHBT group for forward elevation (155 [interquartile range {IQR}, 150-160] vs 150 [IQR, 140-170]; P < .01) and abduction (150 [IQR, 140-157.5] vs 120 [IQR, 100-140]; P < .01), but external rotation was significantly greater for the AR group (54.43 ± 10.55 vs 59.5 ± 10.55; P < .01). Postoperative ultrasonography at the 2-year follow-up revealed a higher retear rate in the AR group than in the AR-LHBT group (46% vs 14%; P < .01).

CONCLUSION

Use of the LHBT for pSCR to augment massive rotator cuff tears resulted in markedly lower retear rates and modestly improved pain and function outcomes compared with repair alone.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Restoration of active internal rotation following reverse shoulder arthroplasty: anterior latissimus dorsi and teres major combined transfer

BACKGROUND

Reverse shoulder arthroplasty (RSA) for irreparable massive rotator cuff tear (mRCT) and cuff tear arthropathy (CTA) demonstrates satisfactory clinical outcomes. However, many studies have reported no significant improvements in internal and external rotation. To our knowledge, there have been no studies on new attempts to restore active internal rotation following RSA. The purpose of this study was to compare RSA alone and RSA with anterior latissimus dorsi and teres major (aLDTM) tendon transfer in patients with CTA and mRCT with combined loss of active elevation and internal rotation (CLEIR).

METHODS

This retrospective cohort study included patients who underwent RSA with a lateralized design and had CLEIR between October 2014 and January 2019. Two groups were classified: patients who underwent RSA alone (group R, n = 36) and patients who underwent RSA with aLDTM tendon transfer (group T, n = 24). Clinical outcomes, including the visual analog scale score, Constant score, American Shoulder and Elbow Surgeons score, active range of motion, score for activities of daily living requiring active internal rotation (ADLIR), and ability to perform toileting activity, were compared. Moreover, radiologic outcomes and complications were compared.

RESULTS

The mean follow-up period was 36.8 ± 11.6 months (range, 24-67 months). Both group R and group T showed significant improvements in clinical scores and active range of motion preoperatively and postoperatively. In group T, the Constant score (65.2 ± 7.5 vs. 58.1 ± 12.3, P = .008), ADLIR score (26.1 ± 3.1 vs. 20.3 ± 5.0, P < .001), internal rotation level with the arm behind the back (P < .001), and subscapularis-specific physical examination findings (P < .001) were significantly better than in group R. However, no significant difference in the American Shoulder and Elbow Surgeons score, forward flexion, and external rotation at 0° and 90° of abduction were found at final follow-up. Transient axillary nerve palsy was found in 2 patients in group T. However, there were no significant differences in complication rates between 2 groups.

CONCLUSION

Lateralized RSA with aLDTM tendon transfer for patients with CTA and mRCT with CLEIR restored shoulder function and improved clinical outcomes, especially the ability to perform ADLIR and toileting activity.

Tendon transfers for massive rotator cuff tears

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

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

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

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

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

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

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

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

lateralized humeral implant in reverse total shoulder arthroplasty: the comparison of outcomes in pseudoparalysis with massive rotator cuff tear

BACKGROUND

With the increasing use of lateralized humeral implants in reverse total shoulder arthroplasty (RTSA), it is still unclear whether this design will be as advantageous as the medialized humeral implants in the setting of pseudoparalysis (PP).

METHODS

A total of 51 eligible RTSA cases for PP signs due to massive rotator cuff deficiency were selected for the retrospective review. Twenty-five patients were allocated to group L in which the isolated humeral side lateralization was performed (neck-shaft angle of 145°), and 26 patients were allocated to group M (neck-shaft angle of 155°). Pre- and postoperative radiologic measurements including critical shoulder angle, acromiohumeral distance (AHD), lateral humeral offset (LHO), and deltoid wrapping offset (DWO), as well as range of motion (ROM) and clinical outcome scores, were compared. The mean age was 71.0 ± 6.5 years for group L and 70.3 ± 7.0 years for group M, and the overall mean follow-up period was 49.0 ± 13.5 months (range, 25.7-68.9).

RESULTS

The preoperative radiologic measurements were similar, but the postoperative LHO and DWO were significantly larger for group L, whereas the postoperative AHD was larger for group M compared with group L, with the values being 39.8 ± 9.7 mm and 33.6 ± 10.4 mm, respectively (P = .034). For the ROM, active forward elevation did improve significantly for both, starting preoperatively with the active ranges of 39° ± 19° (passively 153° ± 24°) for group L and 42° ± 18° (passively 156° ± 11°) for group M-the final postoperative active ranges being 142° ± 16° and 133° ± 33°, respectively, without significant difference between the groups (P = .426). The postoperative recovery of PP for group L was 100% (25 of 25), whereas for group M, it was 96.2% (25 of 26). The final visual analog scale (VAS) scores and University of California Los Angeles (UCLA) shoulder scores improved significantly for both groups, but the differences between the groups at the final assessments were insignificant. The 4 complications were periprosthetic fracture, acromial stress fracture, periprosthetic joint infection, and neuropraxia, all of which were in group M, and scapular notching with higher grades were more prevalent for group M (26.9%, 7 of 26).

CONCLUSIONS

With RTSA, good outcomes and recovery were achieved in most cases of PP. The postoperative active elevation range and functional outcomes were not affected by medialization or lateralization of the humeral implant. Earlier recovery of motion was observed with the lateralized group, but no significant differences were seen in the final ROM between the groups.

Histologic and biomechanical evaluation of the thoracolumbar fascia graft for massive rotator cuff tears in a rat model

BACKGROUND

Fascial autografts, which are easily available grafts, have provided a promising option in patients with massive rotator cuff tears. However, no fascial autografts other than the fascia lata have been reported, and the exact healing process of the fascia-to-bone interface is not well understood. The objective of this study is to histologically and biomechanically evaluate the effect of the thoracolumbar fascia (TLF) on fascia-to-bone healing.

METHODS

A total of 88 rats were used in this study. Eight rats were killed at the beginning to form an intact control group, and the other rats were divided randomly into 2 groups (40 rats per group): the TLF augmentation group (TLF group) and the repair group (R group). The right supraspinatus was detached, and a 3 × 5 mm defect of the supraspinatus was created. The TLF was used to augment the torn supraspinatus in the TLF group, whereas in the R group, the torn supraspinatus was repaired in only a transosseous manner. Histology and biomechanics were assessed at 1, 2, 4, 8, and 16 weeks postoperatively.

RESULTS

The modified tendon maturation score of the TLF group was higher than that of the R group at 8 weeks (23.00 ± 0.71 vs. 24.40 ± 0.89, P = .025) and 16 weeks (24.60 ± 0.55 vs. 26.40 ± 0.55, P ≤ .001). The TLF group showed a rapid vascular reaction, and the peak value appeared at 1 week. Later, the capillary density decreased, and almost no angiogenesis was observed at 8 weeks postoperatively. Immunohistochemistry results demonstrated a significantly higher percentage of collagen I in the TLF group at 4, 8, and 16 weeks (24.78% ± 2.76% vs. 20.67% ± 2.11% at 4 weeks, P = .046; 25.46% ± 1.77% vs. 21.49% ± 2.33% at 8 weeks, P = .026; 34.77% ± 2.25% vs. 30.01% ± 3.17% at 16 weeks, P = .040) postoperatively. Biomechanical tests revealed that the ultimate failure force in the TLF group was significantly higher than that in the R group at the final evaluation (29.13 ± 2.49 N vs. 23.10 ± 3.47 N, P = .022).

CONCLUSIONS

The TLF autograft can promote a faster biological healing process and a better fixation strength. It could be used as an alternative reinforcement or bridging patch when the fascia lata is not appropriate or available for superior capsule reconstruction (SCR).

Cost comparison and complication profiles of superior capsular reconstruction, lower trapezius transfer, and reverse shoulder arthroplasty for irreparable rotator cuff tears

BACKGROUND

Irreparable rotator cuff tears (IRCTs) pose treatment challenges both clinically and financially. As cost-effectiveness initiatives are prioritized, value-based health care delivery models are becoming increasingly common. The purpose of this study was to perform a comprehensive analysis of the cost, complications, and readmission rates of 3 common surgical treatment options for IRCTs: superior capsular reconstruction (SCR), arthroscopically assisted lower trapezius tendon transfer (LTTT), and reverse shoulder arthroplasty (RSA).

METHODS

Between 2018 and 2020, 155 patients who underwent shoulder surgery at a single institution for IRCT with minimal to no arthritis were identified. Procedures performed included 20 SCRs, 47 LTTTs, and 88 RSAs. A cost analysis was designed to include a period of 60 days preoperatively, the index surgical hospitalization, and 90 days postoperatively, including costs of any readmission or reoperation.

RESULTS

Mean standardized costs were as follows: preoperative evaluation SCR $507, LTTT $507, and RSA $730; index surgical hospitalization SCR $19,675, LTTT $15,722, and RSA $16,077; and postoperative care SCR $655, LTTT $686, and RSA $404. Significant differences were observed in the index surgical costs (P < .001), with SCR incurring an additional average cost of $3953 and $3598 compared with LTTT and RSA, respectively. The 90-day complication, reoperation, and readmission rates were 0%, 0%, and 0% in the SCR group; 2.1%, 0%, and 0% in the LTTT group; and 3.4%, 0%, and 1.1% in the RSA group, respectively. With the numbers available, differences among the 3 surgical procedures with respect to complication (P = .223), reoperation (P = .999), and readmission rates (P = .568) did not reach statistical significance.

CONCLUSIONS

The mean standardized costs for the treatment of 3 common IRCT procedures inclusive of 60-day workup and 90-day postoperative recovery were $16,915, $17,210, and $20,837 for LTTT, RSA (average added cost $295), and SCR (average added cost $3922), respectively. This information may provide surgeons and institutions with cost-related information that will become increasingly relevant with the expansion of value-based surgical reimbursements.

Monitoring Rotator Cuff Muscle Fatty Infiltration Progression by Magnetic Resonance Imaging T1 Mapping: Correlation With Direct Evaluation Findings in Rats

BACKGROUND

Monitoring the fatty infiltration (FI) process in rotator cuff muscles is of value in establishing a treatment plan and predicting the postoperative prognosis. Quantitative T1 mapping shows promise for evaluating muscle degeneration, while its validity in monitoring rotator cuff muscle FI progression needs further investigation.

PURPOSE

To determine the validity of T1 mapping in monitoring FI progression of rotator cuff muscles.

STUDY DESIGN

Controlled laboratory study.

METHODS

Sprague-Dawley rats (N = 108) underwent left supraspinatus (SS) and infraspinatus (IS) tenotomy only (TT), suprascapular nerve transection only (NT), or SS and IS tenotomy plus suprascapular nerve transection (TT+NT). Sham surgery on the right shoulder served as the control. The magnetic resonance imaging examination included T1 mapping performed at 12, 16, and 20 weeks postoperation. SS and IS muscles were harvested to quantitatively evaluate FI via direct evaluation (triglyceride quantification assay and histological analysis) at the same predetermined intervals. The correlation of the imaging data with direct evaluation of rotator cuff muscles was analyzed.

RESULTS

T1 values were significantly lower in left SS and IS muscles at 12, 16, and 20 weeks postoperation as compared with those on the right side. T1 values of the left SS and IS muscles were continuously decreased in all groups. The TT+NT group had a greater decrease in T1 value than did the TT and NT groups. Triglyceride quantification assay and histological analysis demonstrated significant and progressive FI of the left SS and IS muscles in the 3 groups. The most serious FI changes were observed in the TT+NT group. T1 values were also well correlated with triglyceride contents and area fractions of fat.

CONCLUSION

T1 mapping can be an effective imaging modality for sensitive and quantitative monitoring of FI progression in rotator cuff muscles.

CLINICAL RELEVANCE

The findings of this study provide a tool for researchers to noninvasively and quantitatively monitor the process of muscle degeneration, contributing to the evaluation of surgical indication and postoperative prognosis.

Quantitative magnetic resonance imaging assessment of the infraspinatus and teres minor in massive rotator cuff tear and its significance in clinical outcome after rotator cuff repair

BACKGROUND

Teres minor (TM) muscle hypertrophy in large to massive rotator cuff tears (RCTs) has been considered a compensatory change to atrophy of the infraspinatus (ISP). However, few reports have assessed its relation to the prognosis after rotator cuff repair.

METHODS

A total of 139 patients who underwent arthroscopic repair of large to massive RCTs involving the ISP between January 2013 and December 2015 were retrospectively investigated. Occupational ratios of the ISP (OR_ISP) and TM (OR_TM) were measured by sagittal magnetic resonance imaging (MRI). Rotator cuff healing was evaluated by MRI 1 year postoperatively, and functional outcomes using the Simple Shoulder Test (SST) and Constant score and external rotator (ER) strength by isokinetic muscle performance test (IMPT) were measured.

RESULTS

A total of 116 patients completed the MRI and IMPT at 1 year postoperatively, and functional scores were measured at least 2 years postoperatively. Of these, the repaired tendon had not healed in 34 patients (29%). There was a highly negative correlation between OR_ISP and OR_TM both pre- and postoperatively (Pearson correlation = -0.52 and -0.54, respectively). Preoperative OR_ISP was significantly higher in the healed than in the healing failure group (0.47 ± 0.10 vs. 0.41 ± 0.12, P = .02); however, postoperative OR_ISP and pre- and postoperative OR_TM were not. The preoperative OR_ISP cutoff value for healing was 0.46. For functional outcomes, only postoperative OR_ISP showed a statistical correlation with SST, Constant score (P = .04 and .03, respectively), and ER strength (P = .02).

CONCLUSION

TM muscle hypertrophy in large to massive RCT appears to be a compensatory change in the progression of atrophy of the ISP muscle and was not a significant indicator of either better healing of the repaired rotator cuff tendon or better function. Only preoperative OR_ISP was an independent prognostic factor affecting rotator cuff healing after repair of large to massive RCTs.

Bridging Allograft Reconstruction Is Superior to Maximal Repair for the Treatment of Chronic, Massive Rotator Cuff Tears: Results of a Prospective, Randomized Controlled Trial

BACKGROUND

Despite advances in surgical techniques, the use of maximal repair to treat large or massive rotator cuff tears results in a high retear rate postoperatively. Currently, no randomized controlled trials have compared the outcomes of maximal repair with interposition dermal allograft bridging reconstruction.

HYPOTHESIS

We hypothesized that large or massive rotator cuff tendon tears reconstructed using bridging dermal allograft would have better clinical outcomes 2 years postoperatively, as measured using the Western Ontario Rotator Cuff (WORC) index, than would those receiving the current gold standard treatment of debridement and maximal repair alone. We also expected that patients treated via bridging reconstruction using dermal allograft would have fewer postoperative failures as assessed using postoperative magnetic resonance imaging scans.

STUDY DESIGN

Randomized controlled trial; Level of evidence 1.

METHODS

A sample size of 30 patients (determined using a priori sample size calculation) with massive, retracted rotator cuff tears were randomly allocated to 1 of 2 groups: maximal repair or bridging reconstruction using dermal allograft. All patients completed questionnaires (WORC and Disabilities of the Arm, Shoulder and Hand [DASH]) preoperatively and postoperatively at 3 months, 6 months, 1 year, and 2 years. The primary outcome of this study was the WORC index at 2 years. Secondary outcomes included healing rate, progression of rotator cuff arthropathy, and postoperative acromiohumeral distance in both groups.

RESULTS

Patients treated via bridging reconstruction using dermal allograft had better postoperative WORC and DASH scores (23.93 ± 24.55 and 15.77 ± 19.27, respectively) compared with patients who received maximal repair alone (53.36 ± 31.93 and 34.32 ± 23.31, respectively). We also noted increased progression to rotator cuff arthropathy in the maximal repair group with an increased retear rate when compared with the reconstruction group (87% and 21%, respectively; P < .001). The acromiohumeral distance was maintained in the reconstruction group but significantly decreased in the maximal repair group.

CONCLUSION

Rotator cuff bridging reconstruction using a dermal allograft demonstrated improved patient-reported outcomes as measured using the WORC index 2 years postoperatively. This technique also showed favorable structural healing rates and decreased progression to arthropathy compared with maximal repair.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01987973).

Evaluating the role of graft integrity on outcomes: clinical and imaging results following superior capsular reconstruction

BACKGROUND

Superior capsular reconstruction (SCR) addresses massive, irreparable rotator cuff tears in young patients. The purpose of this study was to retrospectively evaluate clinical outcomes and graft integrity in patients following SCR.

METHODS

Thirty-four consecutive patients undergoing SCR by 2 surgeons with minimum 2-year follow-up were identified. Functional outcomes were obtained, including Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), visual analog scale (VAS), and Single Assessment Numeric Evaluation (SANE) scores. Graft integrity was evaluated on magnetic resonance images (MRIs).

RESULTS

Thirty-five shoulders in 34 patients were identified. Four patients underwent subsequent surgery. The mean preoperative scores were SST 21.6 ± 17.6, ASES 28.3 ± 10.1, SANE 50.6 ± 22.1, and VAS 6.6 ± 1.7. The mean postoperative outcomes were SST 79.1 ± 19.6, ASES 79.9 ± 17.4, SANE 74.3 ± 18.7, and VAS 1.5 ± 2.2. There was statistically significant improvement in SST, ASES, and VAS following SCR. MRI revealed graft failure in 62% (n = 13 of 21) of shoulders. Radiographic evidence of graft healing did not have any effect on SST, ASES, SANE, or VAS scores.

CONCLUSION

Given the high rate of graft failure without a significant difference in clinical outcomes, graft healing after SCR might not be an independent predictor of success. The improved clinical improvement in patients undergoing SCR may be due to other known beneficial aspects of the procedure, including partial rotator cuff repair, débridement, and biceps management.

Significance of the acromiohumeral distance on stress radiography for predicting healing and function after arthroscopic repair of massive rotator cuff tears

BACKGROUND

A decreased acromiohumeral distance (AHD) is commonly detected in patients with massive rotator cuff tears (mRCTs). Most studies evaluating fixed humeral elevation have used preoperative or postoperative standardized radiography and not stress radiography. This study aimed to evaluate the predictive role of the preoperative AHD measured using stress radiography (AHD_stress) in rotator cuff healing and function after arthroscopic repair of mRCTs.

METHODS

The data of 113 patients who underwent arthroscopic repair of mRCTs were analyzed. Postoperative cuff integrity was evaluated using magnetic resonance imaging at 1 year, and shoulder function was evaluated at a mean of 34.9 ± 17.8 months (range, 24-92 months) postoperatively. Forty-seven patients showed healing failure. Propensity score matching (1-1) was performed between the healed group and healing failure group. Thirty-eight patients in each group were matched in the final analysis. The AHD and AHD_stress were defined as the shortest distances from the inferior acromion to the superior humerus on standard anteroposterior radiography and stress radiography (5.4-kg weight applied inferiorly in a neutral position), respectively. The AHD difference (AHD_diff) was defined as the difference between the AHD and AHD_stress values. Receiver operating characteristic curve analysis was performed to determine cutoff values for significant variables.

RESULTS

No difference in the mean preoperative AHD was found between the healed group (7.5 ± 2.0 mm) and healing failure group (6.9 ± 2.2 mm, P = .234). The AHD_diff value was significantly higher in the healed group (4.4 ± 2.1 mm) than in the healing failure group (3.0 ± 2.0 mm, P = .002; cutoff, 3.2 mm). Patients with an AHD_diff value ≥ 3.2 mm showed a lower healing failure rate (28.9% vs. 71.1%, P < .001) and higher functional scores than patients with an AHD_diff value < 3.2 mm. The AHD_diff value was higher in patients with an American Shoulder and Elbow Surgeons (ASES) score ≥ 80 (4.9 ± 1.9 mm) than in those with an ASES score < 80 (3.1 ± 2.1 mm, P = .024). Among patients with healing failure, only the postoperative AHD showed a significant difference between those with an ASES score ≥ 80 (7.0 ± 2.5 mm) and those with an ASES score < 80 (4.8 ± 2.1 mm, P = .009; cutoff, 4.8 mm).

CONCLUSION

A reducible AHD, which increased by ≥ 3.2 mm under stress radiography, can be a favorable predictor of rotator cuff healing and function after arthroscopic repair of mRCTs. Our findings suggest that this new and simple radiologic parameter should be considered preoperatively and would be helpful to determine appropriate treatment strategies.

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.

Current concepts in the evolution of arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair has become one of the most common and successful surgeries performed in orthopedics. It represents the culmination of advances in many diverse fields such as optics, fluid dynamics, mechanical engineering, and most recently, orthobiologics. This article reviews the current state of the art of arthroscopic rotator cuff repair, through the lens of its historical context and evolution to our present understanding. We review the limitations in the current approach, and glance toward the future of rotator cuff regeneration with emerging technologies.

Chronic Pseudoparalysis Needs to Be Distinguished From Pseudoparesis: A Structural and Biomechanical Analysis

BACKGROUND

Chronic pseudoparalysis is generally defined as the inability to actively elevate the arm above 90° with free passive range of motion and no neurological deficits. It has been suggested that this arbitrary cutoff needs to be refined.

PURPOSE

To analyze whether there are structural and biomechanical differences in patients with chronic pseudoparalysis and those with chronic pseudoparesis.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

In this retrospective study, 50 patients with chronic massive rotator cuff tears (mRCTs; ≥2 tendons) and free passive and active scapular plane abduction <90° were divided into 2 groups: pseudoparalysis group (n = 24; active scapular plane abduction, <45°) and pseudoparesis group (n = 26; active scapular plane abduction, >45° and <90°). Radiographic measurements included the critical shoulder angle, acromiohumeral distance, posterior acromial tilt, anterior and posterior acromial coverages, and posterior acromial height on outlet views. Measurements on magnetic resonance imaging (MRI) included fatty infiltration of the rotator cuff muscles, anterior (subscapularis) and posterior (infraspinatus/teres minor) tear extensions, and global (anterior + posterior) tear extension in the parasagittal plane. A published musculoskeletal model was used to simulate the effect of different mRCTs on the muscle force required for scapular plane abduction.

RESULTS

Plain radiographs revealed no differences between patients with chronic pseudoparalysis and those with pseudoparesis. MRI assessment showed significant differences between patients with chronic pseudoparalysis and those with pseudoparesis with respect to fatty infiltration of the subscapularis (2.9 vs 1.6; P < .001) and infraspinatus (3.6 vs 3.0; P < .001) muscles, and anterior (-23° vs 4°; P < .001), posterior (-23° vs -14°; P = .034), and global rotator cuff (225° vs 190°; P < .001) tear extensions. The anterior tear extension in patients with chronic pseudoparalysis always involved more than 50% of the subscapularis, which was associated with an odds ratio of 5 for inability to actively abduct more than 45°. The biomechanical model was unable to find a combination of muscles that could balance the arm in space when the tear extended beyond the supraspinatus and the cranial subscapularis.

CONCLUSION

This study confirms that chronic pseudoparalysis and pseudoparesis are associated with different structural lesions. In the setting of a chronic mRCT, involvement of more than 50% of the subscapularis tendon with fatty infiltration of stage 3 is associated with pseudoparalysis of active scapular plane abduction <45°. The key function of the subscapularis was confirmed in the biomechanical model.

Functional outcome of arthroscopic debridement for massive, irreparable rotator cuff tears

Rotator cuff tears are a common cause of shoulder pain in the middle-aged population. The treatment of these lesions must be individualized on the basis of the type of patient, the clinical and anatomical picture. Arthroscopic debridement is indicated in painful massive tears, in the absence of severe functional impairment of the shoulder. The aim of this study is the evaluation of the medium term clinical results of this procedure.  We retrospectively assessed patients who underwent arthroscopic debridement surgery for massive rotator cuff injury in the period between January 2011 and December 2016 at our institution. A group of patients underwent a follow-up evaluation during which the Constant Score, Oxford Shoulder Score and NRS pain score were compiled. Those who were unable to attend the evaluation were assessed through a telephone questionnaire aimed at investigating pain and degree of satisfaction with the  treatment.  93% of patients were satisfied with the results obtained, with an average NRS of 1.31 for patients undergoing the medical examination and 0.68 for patients contacted by telephone. The mean Constant score of the evaluated patients was 75.6 ± sd, with a mean strength of 3.92 ± sd, while the mean value of the Oxford Shoulder Score was 16.8 ± sd.  The study suggests that arthroscopic debridement is a viable option for the surgical treatment of massive rotator cuff tears. The clinical results and patient satisfaction are conditioned by the preoperative functional status: an optimal outcome can be expected for painful shoulders with sufficiently preserved active mobility.

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.

Arthroscopic Rotator Cuff Repair With Muscle Advancement and Artificial Biodegradable Sheet Reinforcement for Massive Rotator Cuff Tears

Background

Because high failure rates have frequently been reported after arthroscopic rotator cuff repair (ARCR) of massive rotator cuff tears (mRCTs), we introduced the technique of ARCR with supraspinatus and infraspinatus muscle advancement (MA). However, for cases where the original footprint cannot be completely covered, additional surgery using an approved artificial biomaterial is performed.

Purpose

To investigate the postoperative clinical outcomes and failure rate after MA-ARCR, with and without our reinforcement technique.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 74 patients (mean ± SD age, 68.7 ± 7.7 years) diagnosed with mRCT with a minimum postoperative follow-up of 2 years were included in the current study. Of these patients, 47 underwent MA-ARCR with polyglycolic acid (PGA) sheet reinforcement (study group), and 27 patients underwent MA-ARCR alone (control group). PGA reinforcement was performed when full coverage of the footprint could not be achieved by MA alone, but where the latter was possible, reinforcement was not required. Thus, the study group had significantly worse muscle quality than the control group (P < .05). The pre- and postoperative range of motion (ROM), isometric muscle strength, acromiohumeral interval, and clinical outcomes were evaluated and compared between these 2 groups. Cuff integrity during the last follow-up period was assessed with magnetic resonance imaging, and the failure rate was calculated. In addition, the postoperative foreign body reaction was investigated in the study group.

Results

In both groups, significant postoperative improvements were seen in acromiohumeral interval, clinical scores, ROM in anterior flexion, and isometric muscle strength in abduction, external rotation, and internal rotation (P < .001 for all). The failure rate of the study group was 12.8% (6 patients) and that of the control group was 25.9% (7 patients). No significant differences were noted between the 2 groups on any of the data findings, even regarding the failure rate. Foreign body reactions in the early period were found in 3 patients, although these spontaneously disappeared within 3 months.

Conclusion

Patients who underwent PGA patch reinforcement for MA-ARCR when the footprint could not be completely covered had clinical results similar to isolated MA-ARCR when the footprint could be covered. Both procedures resulted in significant improvement in symptoms and function compared with preoperatively.

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.

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.

Scapular Morphologic Characteristics and Rotator Cuff Tear Pattern Are Independently Associated With Chronic Pseudoparalyis: A Matched-Pair Analysis of Patients With Massive Rotator Cuff Tears

BACKGROUND

It is unclear which structural parameters determine the development or the absence of chronic pseudoparalysis (PP) in patients with massive rotator cuff tears (mRCTs).

PURPOSE

To determine whether scapular morphologic characteristics and extent of rotator cuff tearing are independent factors associated with chronic PP.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

In this retrospective case-control study, 50 patients with chronic mRCT (≥2 fully detached tendons) and active scapular plane abduction less than 90° (PP group) were age- and sex-matched with a cohort of 50 patients with chronic mRCT and an active scapular plane abduction greater than 90° (non-PP; NPP group). Analysis of standardized, plain radiographs included measurement of the critical shoulder angle (CSA) and the acromiohumeral distance (ACHD) on anteroposterior views and measurement of posterior acromial tilt, anterior and posterior acromial coverage, and posterior acromial height on standardized outlet views. Measurements on magnetic resonance imaging included fatty muscle infiltration, anterior (subscapularis) and posterior (infraspinatus/teres minor) tear extension, and global tear extension (anterior + posterior tear extension) in the parasagittal plane.

RESULTS

Overall, no significant difference was found in patients' demographic characteristics (P > .05). Univariate analyses confirmed significant differences between the PP and NPP groups in active scapular plane abduction (51°± 22° vs 135°± 29°; P < .001). Multivariate analyses revealed independent factors associated with PP compared with the NPP group: CSA (38.2°± 4.6° vs 35.2°± 3.7°; P = .001); ACHD (4.7 ± 2.2 vs 7.3 ± 2.6 mm; P < .001); posterior acromial height (22 ± 10 vs 17 ± 7 mm; P = .005); and anterior (-9°± 21° vs 25°± 12°; P < .001) and posterior (-18°± 14° vs 2°± 14°; P < .001) tear extension. The NPP group had significantly less involvement and fatty infiltration of the subscapularis (1.4 ± 0.6) compared with the PP group (2.2 ± 0.9) (P < .001).

CONCLUSION

This study confirms that global RCT extension and the quality of the inferior half of the subscapularis are significantly associated with chronic pseudoparalysis. The study further shows that acromial morphologic characteristics are relevant in the development of pseudoparalysis. Patients with pseudoparalysis have a larger CSA, less ACHD, and a higher positioned acromion in the sagittal plane.

A Synthetic Graft With Multilayered Co-Electrospinning Nanoscaffolds for Bridging Massive Rotator Cuff Tear in a Rat Model

BACKGROUND

Graft bridging is used in massive rotator cuff tear (MRCT); however, the integration of graft-tendon and graft-bone is still a challenge.

HYPOTHESIS

A co-electrospinning nanoscaffold of polycaprolactone (PCL) with an "enthesis-mimicking" (EM) structure could bridge MRCT, facilitate tendon regeneration, and improve graft-bone healing.

STUDY DESIGN

Controlled laboratory study.

METHODS

First, we analyzed the cytocompatibility of the electrospinning nanoscaffolds, including aligned PCL (aPCL), nonaligned PCL (nPCL), aPCL-collagen I, nPCL-collagen II, and nPCL-nanohydroxyapatite (nHA). Second, for the EM condition, nPCL-collagen II and nPCL-nHA were electrospun layer by layer at one end of the aPCL-collagen I; for the control condition, the nPCL was electrospun on the aPCL. In 40 mature male rats, resection of both the supraspinatus and infraspinatus tendons was performed to create MRCT, and the animals were divided randomly into EM and control groups. In both groups, one end of the layered structure was fixed on the footprint of the rotator cuff, whereas the other end of the layered structure was sutured with the tendon stump. The animals were euthanized for harvesting of tissues for histologic and biomechanical analysis at 4 weeks or 8 weeks postoperatively.

RESULTS

All scaffolds showed good cytocompatibility in vitro. The graft-tendon tissue in the EM group had more regularly arranged cells, denser tissue, a significantly higher tendon maturing score, and more birefringence compared with the control group at 8 weeks after operation. Newly formed fibrocartilage could be observed at the graft-bone interface in both groups by 8 weeks, but the EM group had a higher graft-bone healing score and significantly more newly formed fibrocartilage than the control group. An enthesis-like structure with transitional layers was observed in the EM group at 8 weeks. Biomechanically, the values for maximum failure load and stiffness of the tendon-graft-bone complex were significantly higher in the EM group than in the control group at 8 weeks.

CONCLUSION

The co-electrospinning nanoscaffold of aPCL-collagen I could be used as a bridging graft to improve early graft-tendon healing for MRCT in a rat model and enhance early enthesis reconstruction in combination with a multilayered structure of nPCL-collagen II and nPCL-nHA.

CLINICAL RELEVANCE

We constructed a graft to bridge MRCT, enhance graft-tendon healing and graft-bone healing, and reconstruct the enthesis structure.

Clinical comparison of humeral-lateralization reverse total shoulder arthroplasty between patients with irreparable rotator cuff tear and patients with cuff tear arthropathy

Background

This study aimed to compare the clinical and radiologic outcomes between patients with irreparable cuff tears (ICTs) and those with cuff tear arthropathy (CTA) after reverse total shoulder arthroplasty (RTSA) with a humeral-lateralization prosthesis.

Methods

A total of 127 patients with ICTs and CTA who underwent RTSA were enrolled and matched at a 1:2 ratio by propensity score. Preoperative shoulder function was assessed for all patients. Radiologic parameters including the acromion-deltoid tuberosity (ADT) distance, lateral humeral offset, and scapular notching were evaluated.

Results

Thirty-four patients in the ICT group and 68 patients in the CTA group were matched for comparison. Preoperatively, mean active forward flexion in the ICT group (89.7° ± 29.4°) was significantly better than that in the CTA group (65.5° ± 24.0°, P < .001). In the CTA group, fatty infiltration of the supraspinatus was worse (3.7 ± 0.5) and the ADT distance was shorter (134.0 ± 12.0 mm) compared with the ICT group preoperatively (3.3 ± 0.8 [P = .008] and 140.7 ± 12.5 mm [P = .001], respectively). There was no significant difference in postoperative functional or radiologic outcomes between the 2 groups. However, gains in active forward flexion (37.9° in ICT group vs. 61.5° in CTA group, P < .01) and abduction (42.1° in ICT group vs. 60.6° in CTA group, P < .01) were significantly greater in the CTA group than in the ICT group.

Conclusions

Shoulder function was significantly improved after RTSA regardless of the preoperative diagnosis. Postoperatively, radiologic findings were not significantly different between the 2 groups. Due to the fact that preoperative range of motion and rotator cuff status were better in patients with ICTs, improvements in active forward flexion and abduction were significantly greater in patients with CTA.

Partial Rotator Cuff Repair With Superior Capsular Reconstruction Using the Biceps Tendon Is as Effective as Superior Capsular Reconstruction Using a Tensor Fasciae Latae Autograft in the Treatment of Irreparable Massive Rotator Cuff Tears

Background:

Several treatment options are available for stable massive rotator cuff tears, including partial repair with or without tissue augmentation, tendon transfer, superior capsular reconstruction (SCR), and reverse shoulder arthroplasty.

Purpose/Hypothesis:

The purpose of this study was to compare the outcomes and effectiveness of partial rotator cuff repair with SCR using the long head of the biceps tendon (PRCR-SCRB) and SCR with a tensor fasciae latae autograft (SCRTF) for the treatment of rotator cuff tears with severe fatty degeneration. The hypothesis of this study was that SCRTF would be superior to PRCR-SCRB in functional and anatomic outcomes.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 26 consecutive patients with massive and fatty degenerative rotator cuff tears were treated surgically. Patients were divided into either the PRCR-SCRB group (n = 14) or SCRTF group (n = 12). Functional outcomes were assessed at final follow-up, and the acromiohumeral distance (AHD) was measured.

Results:

All functional scores significantly improved in both groups at final follow-up. The PRCR-SCRB group showed better overall outcomes in terms of the visual analog scale for pain; American Shoulder and Elbow Surgeons score; and Quick Disabilities of the Arm, Shoulder and Hand, but these differences were not statistically significant. Better outcomes were found for only the AHD for the PRCR-SCRB group without statistical significance (P = .4). No statistical difference was found in terms of retear rate.

Conclusion:

PRCR-SCRB had comparable outcomes and improvement in AHD compared with SCRTF without the need for additional graft harvesting.

Is there a difference in the acromiohumeral distances measured on radiographic and magnetic resonance images of the same shoulder with a massive rotator cuff tear?

BACKGROUND

The purpose of our study was to compare the acromiohumeral distance (AHD) between radiographic and magnetic resonance images (MRIs) of the same shoulder with massive rotator cuff tears (MRCTs).

METHODS

Thirty-four shoulders with MRCTs that had an MRI and radiograph of the same shoulder within an average of 40.3 days (range: 8-109 days) were identified. AHD was measured digitally on radiograph and MRI by 3 examiners. Shoulders were grouped into Hamada grades <3 (group 1) and Hamada grades ≥3 (group 2).

RESULTS

The mean age was 66.4 years (range: 51-89). There were 19 men (59%). The Kappa for inter-rater reliability was 0.982 (95% confidence interval [CI] 0.975, 0.988) for radiographs and 0.88 (95% CI 0.75, 0.94) for MRI. There was a significant difference in the mean AHD of group 1 on radiograph vs. MRI (7.9 mm vs. 2.5 mm, respectively; P < .0001), but no difference in group 2 (1.8 mm vs. 2.2 mm, respectively; P = .45). There was no difference in AHD in group 1 between shoulders with Goutallier stage <3 (8.1 ± 1.9 mm) and those with Goutallier stage ≥3 (7.3 ± 2.1 mm) (P = .3479). There was no difference in AHD in group 2 between shoulders with Goutallier stage <3 (3.0 ± 0.1 mm) and those with Goutallier stage ≥3 (1.5 ± 1.0 mm) (P = .079).

CONCLUSION

There is a significant difference in AHD measurements between radiograph and MRI of the same shoulder with MRCT in early Hamada grades. AHDs measured on radiograph and MRI should not be used interchangeably in early Hamada grades to assess outcomes of superior capsule reconstruction and similar procedures.

Macroporous 3D Scaffold with Self-Fitting Capability for Effectively Repairing Massive Rotator Cuff Tear

The postoperative retear rate of direct repair of massive rotator cuff tear has risen up to 40% because of the dissatisfied tendon-to-bone healing and poor regenerative potential of remnant rotator cuff tissue. A biological scaffold that connects the remnant rotator cuff tissue and bone might be a promising substitute. In the present study, we have developed a macroporous three-dimensional scaffold poly(ester-urethane)urea (PEUU), with self-fitting capability employing thermally induced phase separation (TIPS) technique. The scaffold provides oriented connected macropores for cells migration, and promoted tendon-to-bone healing on the basis of surgical repair. The scaffolds were characterized by scanning electron microscopy, stress-strain test and cell biocompatibility study. In vitro studies exhibited that PEUU scaffold with suitable elastic mechanical properties can better support proliferation and migration of rabbit bone mesenchymal stem cells (RBMSCs). After three months postreconstruction of massive rotator cuff tear in a rabbit model using PEUU scaffold, there was complete regeneration of rotator cuff with physical tendon-to-bone interface and continuous tendon tissue, as observed from histological analysis. Further, biomechanical testing demonstrated that rotator cuff induced by PEUU scaffold had no significant difference as compared to normal rotator cuff. This macroporous, mechanically matched scaffold is potentially suitable for the application in massive rotator cuff repair. In conclusion, this study demonstrates the high efficiency of the macroporous 3D scaffold with self-fitting capability in facilitating rotator cuff regeneration.

Difficulty in performing activities of daily living associated with internal rotation after reverse total shoulder arthroplasty

BACKGROUND

Reverse total shoulder arthroplasty (RSA) is a widely accepted treatment for irreparable massive rotator cuff tear (mRCT) and cuff tear arthropathy (CTA), but its impact on activities of daily living (ADLs) remains unclear.

METHODS

We retrospectively analyzed 77 patients (age range, 54-87 years; follow-up range, 36.1-120.3 months) with irreparable mRCT and CTA treated by medialized RSA between 2008 and 2015. Ten activities considered essential for daily living were selected and scored from 0 to 3.

RESULTS

The mean visual analog scale scores during motion and University of California at Los Angeles and Constant scores significantly improved at final follow-up (all P < .001). Active forward flexion, external rotation at the side, and internal rotation to the posterior (IRp) were 92.5%, 79.6%, and 48.4% of the contralateral side, respectively, at final follow-up. Active forward flexion and external rotation at the side recovered within 6 months after surgery, similar to the level at final follow-up, but IRp did not reach the preoperative status until final follow-up. ADLs with mean scores of less than 2.0 at final follow-up were "wash the opposite shoulder," "wash the opposite axilla," "use a back pocket," "manage the toilet," and "wash the back" (only 36.4% of patients were able to wash their back at final follow-up).

CONCLUSIONS

RSA for irreparable mRCT and CTA showed satisfactory clinical outcomes. However, IRp was associated with a limited range compared with the other shoulder motions; therefore, all ADLs associated with internal rotation demonstrated lower recovery rates than expected.

Irreparable rotator cuff tears: Current treatment options

Rotator cuff disease is one of the most common causes of shoulder pain, yet controversy still exists regarding treatment of "irreparable" tears. Nonoperative management, including physical therapy and steroid injections, should be reserved for those without significant pain or functional impairment. Debridement may be used for low-demand patients, and should be performed with partial cuff repair, subacromial decompression, and/or acromioplasty to maximize outcomes. Biceps tenotomy and/or tenodesis have been shown to reduce postoperative pain and improve satisfaction when performed in conjunction with rotator cuff repairs, with no difference in functional outcome comparatively. Tendon transfers have been advocated with the potential benefit to improve function and decrease pain. More recently, extracellular matrix and human-derived dermal allografts have been used off-label as patch grafts in irreparable tears. Superior capsular reconstructive techniques and subacromial balloon spacers serve a similar function by acting to depress the humeral head in a cuff-deficient shoulder, however long-term data is needed before widespread adoption of these procedures. Finally, reverse shoulder arthroplasty serves as a salvage option for low demand elderly patients.

Failed Dermal Allograft Procedures for Irreparable Rotator Cuff Tears Can Still Improve Pain and Function: The "Biologic Tuberoplasty Effect"

Background:

Acellular dermal matrices (ADMs) have been used in the treatment of shoulders with massive rotator cuff tears (MRCTs). Despite clinical improvement, correlation of clinical findings with ADM integrity on imaging has not been investigated.

Hypothesis:

The pain in shoulders with MRCTs is partially due to bone-to-bone contact between the tuberosity and acromion. Coverage of the tuberosity with an intact graft or a graft that is torn in a way that the tuberosity remains covered will act as an interpositional tissue, preventing bone-to-bone contact and leading to clinical improvement.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between 2006 and 2016, a total of 25 shoulders with MRCTs underwent a procedure with an ADM. Pre- and postoperative visual analog scale (VAS) results, American Shoulder and Elbow Surgeons (ASES) score, Hamada grade, and Goutallier classification were reviewed. A postoperative magnetic resonance imaging (MRI) was obtained in 22 (88%) shoulders. The status of the graft was divided into the following categories: type I, intact graft; type II, graft tear with tuberosity covered; and type III, graft tear with tuberosity uncovered (bare).

Results:

The mean patient age was 61 years (range, 49-73 years), and the mean follow-up was 25.6 months (range, 10-80 months). Mean length from surgery to postoperative MRI was 13.9 months (range, 6-80 months). The graft was torn in 59% (13/22 shoulders). Significant improvements were found in VAS and ASES scores (7 vs 0.7 and 32.6 vs 91.2, respectively; P < .01) for type I grafts and in VAS and ASES scores (8.1 vs 1.3 and 26.3 vs 84.6, respectively; P < .01) for type II grafts. No difference was found in postoperative VAS and ASES (0.7 vs 1.3 and 91.2 vs 84.6, respectively; P = .8) between type I and type II grafts. No improvement was seen in VAS (7.3 vs 5.7; P = .2) or ASES (30.6 vs 37.2; P = .5) for type III grafts.

Conclusion:

MRI appearance of the graft has a significant impact on functional outcomes. Patients with an intact graft or a graft tear leaving the tuberosity covered have lower pain and higher functional scores than those in whom the torn graft leaves the tuberosity uncovered.

Superior capsule reconstruction using dermal allograft: early outcomes and survival

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The pathogenesis and management of cuff tear arthropathy

Massive rotator cuff tears may lead to the development of cuff tear arthropathy (CTA). Although this pathology has been recognized for more than 150 years, treatment strategies have continued to evolve. During the last decade, there has been increased understanding of the molecular and cellular changes that govern rotator cuff tear outcomes and development of new treatment strategies to repair or reconstruct the rotator cuff. These have included an expansion of the use of arthroscopic double-row transosseous-equivalent repairs and the development of superior capsule reconstruction. However, the greatest change in the management of CTA has been the expansion of the use of reverse total shoulder arthroplasty, which has become the standard of care for patients who do not have a repair option and when nonoperative management has failed. This review article summarizes the current literature on the management of CTA, including nonoperative, repair, reconstruction, and replacement options, with a focus on literature in the last 5 years.

Reverse Shoulder Arthroplasty for Primary Synovial Osteochondromatosis of the Shoulder with Massive Rotator Cuff Tear and Marked Degenerative Arthropathy

Synovial osteochondromatosis (SO) is a rare disease in which chondrometaplasia develops in the synovium of joints, bursa, and tendon sheaths. SO is found most frequently in the knee joint, while cases of SO developing in the shoulder joint are rare, accounting for only 1.9⁻5.2% of all SO cases. Moreover, most of these cases show secondary rather than primary involvement. In a patient with SO associated with extensive rotator cuff tearing and marked arthropathic changes, we performed mass resection and reverse shoulder arthroplasty (RSA), and obtained good pain relief and functional improvement. The patient was a 75-year-old woman who had developed left shoulder pain five years earlier without any known precipitating factor. The range of motion of the left shoulder showed extremely severe restriction, with flexion 80°, abduction 60°, and external rotation 0°, and prominent impingement symptoms. On plain radiographs and computed tomography (CT), prominent shoulder arthropathic changes were found. On plain magnetic resonance imaging (MRI), around the shoulder, an irregular hypointense region was identified in the center on T1-enhanced images, while hyperintense nodular lesions with a hypointense center were detected on T2-enhanced images. Since extensive rotator cuff tearing was also found, a diagnosis of OS associated with rotator cuff tearing and arthropathic changes was made. Surgery consisted of resection of a whitish mass-like floating body in the center of the joint followed by RSA. The postoperative course was uneventful, and one year postoperatively there was no recurrence of pain and the range of motion of the left shoulder had improved to flexion 140°, abduction 130°, and external rotation 30°. Moreover, no complications such as recurrence of osteochondromatosis, implant loosening, or infection were seen. On histopathological examination, the loose body was found to consist of a cartilage component and bone tissue with hyalinization. No findings indicative of malignancy were apparent, and since nodular cartilage arrangement was found, primary osteochondroma was diagnosed. These findings suggested that physical friction between the rotator cuff and the mass was the cause of the rotator cuff tearing, and that the extensive rotator cuff tearing accounted for the progression of the associated extremely severe arthropathic changes.

Neer Award 2018: Platelet-derived growth factor receptor α co-expression typifies a subset of platelet-derived growth factor receptor β-positive progenitor cells that contribute to fatty degeneration and fibrosis of the murine rotator cuff

BACKGROUND AND HYPOTHESIS

After massive tears, rotator cuff muscle often undergoes atrophy, fibrosis, and fatty degeneration. These changes can lead to high surgical failure rates and poor patient outcomes. The identity of the progenitor cells involved in these processes has not been fully elucidated. Platelet-derived growth factor receptor β (PDGFRβ) and platelet-derived growth factor receptor α (PDGFRα) have previously been recognized as markers of cells involved in muscle fibroadipogenesis. We hypothesized that PDGFRα expression identifies a fibroadipogenic subset of PDGFRβ⁺ progenitor cells that contribute to fibroadipogenesis of the rotator cuff.

METHODS

We created massive rotator cuff tears in a transgenic strain of mice that allows PDGFRβ⁺ cells to be tracked via green fluorescent protein (GFP) fluorescence. We then harvested rotator cuff muscle tissues at multiple time points postoperatively and analyzed them for the presence and localization of GFP⁺ PDGFRβ⁺ PDGFRα⁺ cells. We cultured, induced, and treated these cells with the molecular inhibitor CWHM-12 to assess fibrosis inhibition.

RESULTS

GFP⁺ PDGFRβ⁺ PDGFRα⁺ cells were present in rotator cuff muscle tissue and, after massive tears, localized to fibrotic and adipogenic tissues. The frequency of PDGFRβ⁺ PDGFRα⁺ cells increased at 5 days after massive cuff tears and decreased to basal levels within 2 weeks. PDGFRβ⁺ PDGFRα⁺ cells were highly adipogenic and significantly more fibrogenic than PDGFRβ⁺ PDGFRα^- cells in vitro and localized to adipogenic and fibrotic tissues in vivo. Treatment with CWHM-12 significantly decreased fibrogenesis from PDGFRβ⁺ PDGFRα⁺ cells.

CONCLUSION

PDGFRβ⁺ PDGFRα⁺ cells directly contribute to fibrosis and fatty degeneration after massive rotator cuff tears in the mouse model. In addition, CWHM-12 treatment inhibits fibrogenesis from PDGFRβ⁺ PDGFRα⁺ cells in vitro. Clinically, perioperative PDGFRβ⁺ PDGFRα⁺ cell inhibition may limit rotator cuff tissue degeneration and, ultimately, improve surgical outcomes for massive rotator cuff tears.

Arthroscopic-Assisted Latissimus Dorsi Tendon Transfer for Massive Rotator Cuff Tears: A Systematic Review

Background:

Arthroscopic-assisted latissimus dorsi tendon transfer (LDTT) has shown promising results with good outcomes in patients with massive rotator cuff tears (MRCTs), as reported by individual studies. However, to the best of the authors’ knowledge, no systematic review has been performed to assess the collective outcomes of these individual studies.

Purpose/Hypothesis:

The primary purpose of this study was to assess patient outcomes after arthroscopic-assisted LDTT for the management of MRCTs. The secondary objectives were to report on the management of MRCTs, including diagnostic investigations, surgical decision making, and arthroscopic techniques, as well as to evaluate the quality of evidence of the existing literature. It was hypothesized that nearly all patients were satisfied with arthroscopic-assisted LDTT and that they experienced improvements in pain symptoms, function, and strength after the procedure, with an overall complication rate of less than 10%.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

The databases MEDLINE, Embase, and PubMed were searched from database inception (1946) until August 18, 2017, with titles, abstracts, and full-text articles screened independently by 2 reviewers. Inclusion criteria were English-language studies investigating arthroscopic-assisted LDTT for the management of MRCTs on patients of all ages. Conference papers, book chapters, review articles, and technical reports were excluded. The quality of the included studies was categorized by level of evidence and the Methodological Index for Non-Randomized Studies (MINORS) checklist.

Results:

In total, 8 studies (7 case series [median MINORS score, 7 of 16] and 1 prospective comparative study [median MINORS score, 14 of 24]) were identified; the studies included 258 patients (258 shoulders) with MRCTs treated with LDTT using arthroscopic-assisted techniques. The decision to pursue surgery was based on both clinical findings and investigations in 5 studies, investigations only in 2 studies, and clinical findings only in 1 study. Overall, 88% of patients were satisfied with the results of surgery and experienced significant improvement in their symptoms, including shoulder pain, strength, range of motion, and overall function, over a mean follow-up period of 34.3 months. Overall, there was a low rate of complications (7%) associated with the procedure.

Conclusion:

Arthroscopic-assisted LDTT for MRCTs provides patients with marked improvement in shoulder pain, strength, and function, and the procedure is associated with a low risk of complication. Further high-quality comparative studies are warranted to validate these findings in comparison with other operative techniques.