Arthroscopic repair of massive, contracted, immobile rotator cuff tears using single and double interval slides: technique and preliminary results

The use of a subacromial spacer-inspace balloon in managing patients with irreparable rotator cuff tears

Aim

The objective of this prospective non-randomized study was to establish the role of biodegradable sub-acromial spacer (InSpace™) insertion in the management of patients with massive irreparable rotator cuff tear by reporting beneficial effects on the pain relief and functional outcomes in these patients.

Methods

This is a prospective non-randomized study of patients treated for irreparable cuff tears during a period between January 2014 and November 2016.14 patients with symptomatic massive irreparable rotator cuff tears were managed with arthroscopic debridement and implantation of a biodegradable subacromial spacer and were followed up for at least one year (8-16 m). Inclusion criteria were patients with irreparable rotator cuff tears that failed the conservative management, with muscle retraction (Patte > stage 2), muscle atrophy, and fatty infiltration (Goutalier type 3). Patients with osteoarthritis grade 3 in the Hamada classification and/or without preserved passive motion were excluded from our study. Outcome measures included pre and postoperative, the range of motion, Constant and Oxford shoulder scores. The decision to perform surgery was made after failure of nonoperative treatment and rehabilitation (massive rotator cuff tear protocol, reading shoulder unit)for at least six months.

Results

Fourteen shoulders (14 patients, ten male four female) met the inclusion criteria. The mean age of patients was 76.2 (70-85) years. During the last follow-up (8-16 months mean 12.6 months), the range of motion was significantly increased in all patients with anterior elevation (from 80 to 105°), abduction (from 70 to 110°), and external rotation (from 25 to 35°). The mean Constant score was also significantly (P < 0.001) improved from 22.5 (13-33) preoperatively to 51.4 (30-64) at the last follow-up. The Oxford shoulder score improved from 26 preoperatively (21-28) to 48.2 postoperatively (34-56). No night pain following surgery and ADL increased by 40%, which is significant in these patients. No significant perioperative complications were found except for one patient who had a spacer migration. However, no action was required in that case.

Conclusions

Arthroscopic implantation of a subacromial spacer for irreparable rotator cuff tear resulted in a noticeable improvement in pain relief and shoulder function at a mean 12.6 months follow up. It is a quick, safe and a minimally invasive procedure that is suitable for elderly patients with irreparable cuff tears and medical co-morbidities.

Shear Wave Elastography Can Predict Passive Stiffness of Supraspinatus Musculotendinous Unit During Arthroscopic Rotator Cuff Repair for Presurgical Planning

PURPOSE

To determine the feasibility of shear wave elastography (SWE) with B-mode ultrasound in predicting the stiffness of the rotator cuff muscle before arthroscopic rotator cuff repair to evaluate the difficulty of the surgical procedure, as well as to compare SWE with the Goutallier stage on magnetic resonance imaging (MRI).

METHODS

Thirty-eight patients with a full-thickness supraspinatus tear requiring arthroscopic rotator cuff repair participated. The Goutallier stage of fatty infiltration on MRI was measured before surgery, as was the SWE modulus of the anterior superficial, anterior deep, posterior superficial, and posterior deep (PD) regions of the supraspinatus muscle. To measure the stiffness of the supraspinatus musculotendinous unit during surgery, the supraspinatus tendon was axially stretched until the anatomic insertion site was reached, and force per deformation was recorded. The correlation between stiffness of the supraspinatus and SWE value in each region of the supraspinatus muscle or Goutallier stage was determined. In addition, patients were divided into 2 groups: (1) In the complete footprint coverage group, greater than 50% of the footprint was covered during the stiffness measurement, and (2) in the incomplete footprint coverage group, less than 50% of the footprint was covered during the stiffness measurement. Differences in SWE value and Goutallier stage were measured between the 2 groups.

RESULTS

The best correlation of stiffness with the SWE modulus of the PD muscle of the supraspinatus was R = 0.69, and the correlation of stiffness with the Goutallier stage on MRI was R = 0.48. The SWE value of the PD region was greater in the incomplete footprint coverage group than in the complete footprint coverage group, although the Goutallier stage was not significantly different.

CONCLUSIONS

The highest correlation with stiffness of the supraspinatus musculotendinous unit was with the SWE modulus of the PD muscle, as compared with SWE evaluation of the other regions or the Goutallier stage on MRI. Ultrasound SWE can predict the stiffness of the supraspinatus musculotendinous unit best.

CLINICAL RELEVANCE

Rotator cuff retraction adds difficulty to arthroscopic rotator cuff repair. Ultrasound SWE may be used for presurgical planning.

Clinical and Radiologic Outcomes After Medializing and Not Medializing Rotator Cuff Tendon Attachment Site on Chronic Retracted Rotator Cuff Tears

PURPOSE

To compare the clinical and radiologic outcomes of chronically retracted rotator cuff tears by arthroscopic medializing and non-medializing repair (restoring anatomic footprint and performing conventional repair).

METHODS

This study retrospectively reviewed 195 patients who underwent arthroscopic double-row modified Mason-Allen repair for large, full-thickness rotator cuff tears from January 2013 to July 2015. We included a total of 60 of these patients and divided them into 2 groups: those who underwent medialization (n = 24) and those who did not (n = 36). Magnetic resonance imaging was performed at a minimum of 6 months (mean, 15.2 months; range, 6-24 months) postoperatively to assess cuff integrity. Patients were clinically evaluated at least 1 year postoperatively (mean, 18.9 months; range, 12-60 months) with a visual analog scale, the American Shoulder and Elbow Surgeons score, the University of California-Los Angeles Shoulder Rating Scale score, and the Constant score.

RESULTS

The mean medialization length was 10.5 mm (range, 6.5-15.6 mm) on magnetic resonance imaging. The retear rate was 8.3% (n = 2) in the medialization group and 31% (n = 11) in the non-medialization group (P = .041). At last follow-up, the mean visual analog scale, American Shoulder and Elbow Surgeons, University of California-Los Angeles, and Constant scores improved significantly from 5.3 ± 1.4, 38.5 ± 8.8, 22.5 ± 3.1, and 41.7 ± 9.9, respectively, to 1.8 ± 1.1, 85.3 ± 7.5, 31.8 ± 2.5, and 90.2 ± 6.9, respectively, with medialization and from 4.0 ± 1.6, 51.5 ± 10.5, 20.0 ± 3.9, and 55.9 ± 10.5, respectively, to 1.4 ± 1.0, 88.6 ± 9.0, 31.0 ± 9.3, and 89.4 ± 9.3, respectively, with non-medialization (P < .001), although there were no significant differences between the groups (P = .165, P = .653, P = .250, and P = .113, respectively).

CONCLUSIONS

Medialization of approximately 10.5 mm reliably shows good clinical results, and medializing rotator cuff tendons should be considered as a treatment option for repairing rotator cuff tears with chronic retracted tendons.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Options for Failed Rotator Cuff Repair

Failed rotator cuff repairs can pose a clinical challenge to the treating orthopedic surgeon. There are many nonsurgical and surgical options available to address the failed rotator cuff repair. Surgical options include revising the primary repair, partial or nonanatomic repair, tendon transfer, biological augmentation or use of tissue-engineered grafts for reconstruction, or total joint arthroplasty (typically with a modern reverse total shoulder arthroplasty system). The treating surgeon must assess the patient's functional status, health status, and expectations in order to customize the appropriate treatment plan for addressing the failed rotator cuff repair. With the abundance of treatment options available, there is typically an adequate solution to help the patient regain function and experience less pain.

Repair of Massive and Irreparable Rotator Cuff Tear Using Arthroscopic Method

Rotator cuff tear stands as one of the major origins of shoulder discomfort and disability, especially in elderly patients over 60 years. Improvement of performance and reduction of pain hardly occur in patients with contracted rotator cuff tear. Despite therapeutic advances, yet there are many discussions over choosing the best type of treatment for major rotator cuff tear. Complete care of massive rotator cuff tear continues to be a challenge in shoulder surgery. Treatment options have changed in comparison with traditional treatment methods in open or arthroscopic debridement surgery with or without decompression. Recently, many treatments have been introduced, including a range of non-surgical treatments, acromioplasty by debridement, minor repair biceps tenotomy, tuberoplasty by biceps tenotomy, minor repair, mini-open rotator cuff repair, arthroscopic rotator cuff, muscle movement, reverse shoulder arthroscopy, soft tissue reinforcement and hemiarthroplasty. Non-surgical massive rotator cuff control is typically assigned for patients with insignificant pain. This therapy functions by changing activities, proper use of steroid injections and physical therapy with an emphasis on the anterior deltoid exercises. But the main problem is the selection of the best treatment and making the final decision. In general, in the arthroscopic, morbidity, postoperative pain along with hospital stay are less and the operation has better cosmetic results. So this information and our results have prompted us to study a variety of rotator cuff treatment methods with a focus on the arthroscopic treatment.

Superior Capsular Reconstruction With a Long Head of the Biceps Tendon Autograft: A Cadaveric Study

Background:

Several procedures have been proposed to address irreparable rotator cuff (RC) tears with pseudoparalysis. One recently proposed procedure is superior capsular reconstruction (SCR) using a tensor fasciae latae (TFL) autograft.

Hypothesis:

SCR with a locally available long head of the biceps tendon (LHB) autograft is biomechanically equivalent to SCR using TFL autograft for preventing superior humeral migration and the development of RC arthropathy in patients with irreparable RC tears.

Study Design:

Controlled laboratory study.

Methods:

Ten cadaveric shoulders (5 matched pairs) were tested. One shoulder from each pair was randomly assigned to the LHB reconstruction group using our novel technique, while the contralateral side was assigned to the TFL reconstruction group. SCR with a TFL autograft was performed based on previously described techniques. Massive RC tears were created by detachment of the supraspinatus and infraspinatus footprints from the greater tuberosity. The force required to superiorly translate the humerus 1.5 cm was then tested and recorded using a servohydraulic testing machine under 2 conditions: (1) after a massive RC tear and (2) after SCR with either a TFL autograft or an LHB autograft.

Results:

SCR with an LHB autograft required 393.2% ± 87.9% (P = .029) of the force needed for superior humeral migration in the massive RC tear condition, while SCR with a TFL autograft required 194.0% ± 21.8% (P = .0125). The LHB reconstruction group trended toward a stronger reconstruction when normalized to the torn condition (P = .059).

Conclusion:

SCR with an LHB autograft is a feasible procedure that is shown to be biomechanically equivalent and potentially even stronger than SCR with a TFL autograft in the prevention of superior humeral migration.

Clinical Relevance:

This new technique may help to prevent superior humeral migration and the development of RC arthropathy in patients with irreparable RC tears.

Prediction of the Irreparability of Rotator Cuff Tears

PURPOSE

To determine the influence of preoperative factors on reparability of rotator cuff tears (RCTs) and yield a predictive model for predicting irreparability preoperatively.

METHODS

Among patients with full-thickness RCTs, the reparable group underwent arthroscopic rotator cuff repairs for reparable RCTs whereas the irreparable group underwent alternative surgical procedures for irreparable RCTs. We analyzed age, sex, chronic pseudoparalysis (CPP), mediolateral and anteroposterior tear sizes, acromiohumeral distance (AHD), tangent sign, fatty infiltration (FI) (group 1, Goutallier stage 0 or 1; and group 2, Goutallier stage 2, 3, or 4), and tendon involvement (TI) (type 1, supraspinatus; type 2, supraspinatus and subscapularis; type 3, supraspinatus and infraspinatus; and type 4, all 3 tendons).

RESULTS

The irreparability rate was 12.5%. Between the reparable (663 patients) and irreparable (95 patients) groups, significant differences were found in age (58.8 ± 8.3 years vs 65.6 ± 8.0 years, P < .001); female sex (46.9% vs 63.2%, P = .014); CPP (6.5% vs 36.8%, P < .001); mediolateral tear size (23.7 ± 12.1 mm vs 47.4 ± 9.1 mm, P < .001); anteroposterior tear size (17.9 ± 11.5 mm vs 43.4 ± 16.2 mm, P < .001); AHD (9.0 ± 1.7 mm vs 5.8 ± 1.6 mm, P < .001); tangent sign (2.9% vs 61.1%, P < .001); group 2 FI of the subscapularis (6.9% vs 20.0%, P < .001), supraspinatus (12.1% vs 58.9%, P < .001), infraspinatus (26.8% vs 69.5%, P < .001), and teres minor (4.2% vs 10.5%, P = .008); and type 1, 2, 3, and 4 TI (88.1%, 6.2%, 5.4%, and 0.3%, respectively, vs 29.5%, 21.1%, 28.4%, and 21.1%, respectively; P < .001). Multiple logistic regression analysis showed CPP, mediolateral tear size, AHD, tangent sign, group 2 FI of the supraspinatus, and type 4 TI were significant independent predictors of irreparability, with odds ratios of 3.539 (P = .007), 1.087 (P < .001), 0.624 (P < .001), 6.141 (P < .001), 2.233 (P = .034), and 12.350 (P = .016), respectively. These factors yielded a predictive model for irreparability as follows: Logit P = 1.264 × CPP + 0.084 × Mediolateral tear size - 0.472 × AHD + 0.804 × Group 2 FI of supraspinatus + 1.815 × Tangent sign + 2.514 × Type 4 TI - 3.460.

CONCLUSIONS

The irreparability of RCTs is strongly associated with CPP, mediolateral tear size, AHD, tangent sign, group 2 FI of the supraspinatus, and type 4 TI and can be preoperatively calculated using the predictive equation.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Treatment Strategy for Irreparable Rotator Cuff Tears

Recently, patients with shoulder pain have increased rapidly. Of all shoulder disorders, rotator cuff tears (RCTs) are most prevalent in the middle-aged and older adults, which is the primary reason for shoulder surgery in the population. Some authors have reported that up to 30% of total RCTs can be classified as irreparable due to the massive tear size and severe muscle atrophy. In this review article, we provide an overview of treatment methods for irreparable massive RCTs and discuss proper surgical strategies for RCTs that require operative management.

Preoperative Radiographic Risk Factors for Incomplete Arthroscopic Supraspinatus Tendon Repair in Massive Rotator Cuff Tears

PURPOSE

To determine if preoperative imaging findings of massive rotator cuff (RC) tears were associated with (1) incomplete arthroscopic repair and (2) the use of advanced mobilization techniques (interval slides) and/or the use of a load-sharing rip stop repair construct.

METHODS

Eighty-six consecutive patients who underwent arthroscopic repair for massive RC tears performed by a single surgeon between July 2013 and July 2015 were retrospectively evaluated. Previously proposed radiographic risk factors for irreparability (acromiohumeral distances, tangent sign, and the Goutallier stage of fatty infiltration for the supraspinatus) were analyzed. Associations between preoperative imaging characteristics and intraoperative results of RC surgery were determined using binary logistic regressions and Fisher's exact tests. The interobserver reliability of imaging characteristics was determined using intraclass correlation coefficients (ICCs).

RESULTS

Seventy-six massive RC tears were fully reparable (88%). In the case of 10 RC tears (12%), a complete repair was not obtained. Inability to obtain a complete repair of the supraspinatus was associated with a positive tangent sign (30% irreparable) versus a negative tangent sign (6.3% irreparable, odds ratio [OR] = 6.3, P = .0102) and with Goutallier grade 3-4 fatty infiltration of the supraspinatus (42.9% irreparable) versus grade 0-2 fatty infiltration (5.7% irreparable, OR = 11.8, P = .001). Advanced arthroscopic techniques (interval slides or load-sharing rip stop) for dealing with poor-quality or retracted tendon were used in 62% of cases; however, no associations were found between preoperative imaging characteristics and these techniques. Interobserver reliability was moderate (ICC = 0.75-0.90) for the tangent sign (ICC = 0.78) and high-grade (Goutallier 3-4) fatty infiltration of the supraspinatus (ICC = 0.74).

CONCLUSIONS

A positive tangent sign and/or high-grade fatty infiltration (Goutallier 3-4) of the supraspinatus were risk factors for incomplete RC repair. However, these were not completely predictive of reparability because the majority of massive RC tears with these imaging characteristics were still fully reparable.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Partial and Full-Thickness RCT: Modern Repair Techniques

PURPOSE OF REVIEW

The purpose of this article is to review the recent literature concerning modern repair techniques related to partial- and full-thickness rotator cuff tears.

RECENT FINDINGS

The understanding of rotator cuff pathology and healing continues to evolve, beginning with emerging descriptions of the anatomic footprint and natural history of rotator cuff tears. Significant controversy remains in treatment indications for partial-thickness rotator cuff lesions as well as optimal surgical repair techniques for both partial- and full-thickness tears. Techniques such as margin convergence and reduction of the so-called "comma" tissue have improved the ability to anatomically reduce large and retracted tears. Repair strength and contact pressures are improved with double-row repairs and transosseus-equivalent techniques compared to traditional single-row repairs. Future work is directed towards obtaining reliable radiographic healing and demonstrating clinical superiority and cost-effectiveness of a single technique. Much recent work regarding rotator cuff anatomy and pathology has been reported. Newer techniques improve repair strength. Despite these advances, significant questions remain concerning surgical indications and clinical outcomes.

Mesenchymal Stem Cell Secretome Improves Tendon Cell Viability In Vitro and Tendon-Bone Healing In Vivo When a Tissue Engineering Strategy Is Used in a Rat Model of Chronic Massive Rotator Cuff Tear

BACKGROUND

Massive rotator cuff tears (MRCTs) represent a major clinical concern, especially when degeneration and chronicity are involved, which highly compromise healing capacity.

PURPOSE

To study the effect of the secretome of mesenchymal stem cells (MSCs) on tendon cells (TCs) followed by the combination of these activated TCs with an electrospun keratin-based scaffold to develop a tissue engineering strategy to improve tendon-bone interface (TBi) healing in a chronic MRCT rat model.

STUDY DESIGN

Controlled laboratory study.

METHODS

Human TCs (hTCs) cultured with the human MSCs (hMSCs) secretome (as conditioned media [CM]) were combined with keratin electrospun scaffolds and further implanted in a chronic MRCT rat model. Wistar-Han rats (N = 15) were randomly assigned to 1 of 3 groups: untreated lesion (MRCT group, n = 5), lesion treated with a scaffold only (scaffold-only group, n = 5), and lesion treated with a scaffold seeded with hTCs preconditioned with hMSCs-CM (STC_hMSC_CM group, n = 5). After sacrifice, 16 weeks after surgery, the rotator cuff TBi was harvested for histological analysis and biomechanical testing.

RESULTS

The hMSCs secretome increased hTCs viability and density in vitro. In vivo, a significant improvement of the tendon maturing score was observed in the STC_hMSC_CM group (mean ± standard error of the mean, 15.6 ± 1.08) compared with the MRCT group (11.0 ± 1.38; P < .05). Biomechanical tests revealed a significant increase in the total elongation to rupture (STC_hMSC_CM, 11.99 ± 3.30 mm; scaffold-only, 9.89 ± 3.47 mm; MRCT, 5.86 ± 3.16 mm; P < .05) as well as a lower stiffness (STC_hMSC_CM, 6.25 ± 1.74 N/mm; scaffold-only, 6.72 ± 1.28 N/mm; MRCT, 11.54 ± 2.99 N/mm; P < .01).

CONCLUSION

The results demonstrated that hMSCs-CM increased hTCs viability and density in vitro. Clear benefits also were observed when these primed cells were integrated into a tissue engineering strategy with an electrospun keratin scaffold, as evidenced by improved histological and biomechanical properties for the STC_hMSC_CM group compared with the MRCT group.

CLINICAL RELEVANCE

This work supports further investigation into the use of MSC secretome for priming TCs toward a more differentiated phenotype, and it promotes the tissue engineering strategy as a promising modality to help improve treatment outcomes for chronic MRCTs.

Does Additional Biceps Augmentation Improve Rotator Cuff Healing and Clinical Outcomes in Anterior L-Shaped Rotator Cuff Tears? Clinical Comparisons With Arthroscopic Partial Repair

BACKGROUND

The repair of anterior L-shaped tears is usually difficult because of the lack of anterior rotator cuff tendon to cover the footprint. The biceps tendon is usually exposed from the retracted anterolateral corner of the torn tendon and can be easily used to augment rotator cuff repair. Hypothesis/Purpose: This study compared the clinical outcomes of the biceps augmentation technique with those of partial tendon repair for the arthroscopic treatment of large anterior L-shaped rotator cuff tears to evaluate the role of additional biceps augmentation in tendon healing. We hypothesized that the biceps augmentation technique would lead to a lower rotator cuff tendon retear rate and provide satisfactory functional outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study included 64 patients with anterior L-shaped rotator cuff tears who underwent arthroscopic repair. Patients were divided into 2 groups: group A (31 patients) underwent repair of an anterior L-shaped tear combined with biceps augmentation, and group B (33 patients) had a partially repaired tendon whose footprint was exposed after repair without undue tension on the retracted tendon. Clinical evaluations were performed using the American Shoulder and Elbow Surgeons (ASES) score, Constant score, muscle strength, visual analog scale for pain, and patient satisfaction. Magnetic resonance imaging (MRI) was performed for tendon integrity at 6 months postoperatively.

RESULTS

The mean period of follow-up was 29.1 ± 3.5 months (range, 24-40 months). The mean ASES and Constant scores significantly improved from 52.8 ± 10.6 and 43.2 ± 9.9 preoperatively to 88.2 ± 6.9 and 86.8 ± 6.2 at final follow-up in group A ( P < .001) and from 53.0 ± 11.8 and 44.3 ± 11.3 preoperatively to 87.4 ± 7.2 and 87.9 ± 7.3 at final follow-up in group B ( P < .001). Overall muscle strength (given as % of the other side's strength) significantly increased from preoperatively to final follow-up in group A (forward flexion [FF]: 62.0 ± 8.2 to 89.0 ± 8.6; external rotation [ER]: 57.5 ± 9.9 to 86.8 ± 9.3; internal rotation [IR]: 68.1 ± 10.8 to 88.1 ± 8.4; P < .001) and group B (FF: 59.9 ± 9.6 to 87.7 ± 9.0; ER: 58.6 ± 9.3 to 86.2 ± 7.5; IR: 70.0 ± 9.3 to 87.0 ± 8.4; P < .001). Twenty-one patients (67.7%) in group A and 20 patients (60.6%) in group B showed a healed rotator cuff tendon on postoperative MRI. The retear rate between the 2 groups showed no significant difference ( P = .552). Regarding clinical outcomes, both groups had no significant difference in the ASES score ( P = .901), Constant score ( P = .742), and muscle strength.

CONCLUSION

There was no significant difference in the clinical outcomes and retear rate of anterior L-shaped tears between biceps augmentation and partial tendon repair. Additional biceps augmentation proved to have no enhancement in tendon healing. A precise method such as only partial tendon repair for reducing the footprint exposure without undue tension may be considered as one of the treatment options for large anterior L-shaped rotator cuff tears.

Arthroscopic Partial Repair of Irreparable Rotator Cuff Tears: Factors Related to Greater Degree of Clinical Improvement at 2 Years of Follow-Up

PURPOSE

This study aimed to evaluate the clinical outcomes of irreparable rotator cuff tears (RCT) treated with an arthroscopic partial repair, as well as the preoperative factors that may be related to greater improvement of clinical outcomes at short-term follow-up.

METHODS

We retrospectively reviewed patients with irreparable RCT who underwent arthroscopic partial rotator cuff repair between January 2011 and April 2014. Minimal follow-up of 24 months was required. Partial repair was defined as repairing the less retracted posterosuperior rotator cuff with a residual defect of the tendon-footprint junction. Tearing involving the subscapularis tendon was excluded. Factors collected included age, sex, diabetes, smoking, night pain, duration of symptoms, pain visual analog scale (VAS) score, acromiohumeral distance (AHD), and American Shoulder and Elbow Surgeons (ASES) score. Magnetic resonance images without intra-articular contrast were assessed for healing 6 months after surgery for all patients. Functional outcome was evaluated with ASES score. Degree of functional improvement was defined as the difference of ASES scores pre- and postoperatively (d-ASES). Paired t-test and simple linear analysis were used for statistical analysis.

RESULTS

Thirty-seven patients were included with a mean follow-up period of 29.6 ± 6.6 months. VAS score improved from 5.22 to 1.51 (P < .001). ASES score improved from 46.0 to 78.6 (P < .001). The incidence of night pain improved from 70.3% to 8.1% (P < .001). Only a preoperative lower ASES score, higher VAS score, and night pain were related to the higher d-ASES score (P < .001, P = .005, P = .017, respectively). The rate of repair failure was 41.6% at a mean follow-up of 6.4 months.

CONCLUSIONS

Arthroscopic partial repair of irreparable RCTs is an effective treatment to improve the shoulder function and decrease the pain, despite the high repair failure rate of 41.6%. Patients with preoperative lower functional score, higher VAS score, or night pain experienced a greater degree of functional improvement from the surgery. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

A clinical and radiological study of biodegradable subacromial spacer in the treatment of massive irreparable rotator cuff tears

PURPOSE

The aim of this retrospective study was to report the clinical and radiographic results of the biodegradable subacromial spacer (InSpace Balloon®) implantation in patients with massive irreparable rotator cuff tears.

MATERIALS AND METHODS

From February 2014 to October 2015, 30 patients affected by massive irreparable rotator cuff tears were treated with the implantation of InSpace Balloon®. Clinical evaluation (Constant Score and VAS), X-rays and MR imaging were performed preoperatively in all patients and 3, 6, 12 and 24 months after surgery, dividing patients in different groups according to the time elapsed from surgery.

RESULTS

Constant Score increased from 39.89 to 62.33 points (p 0.0002) in the 6 months group and from 41.66 to 65.38 points (p< 0.0001) in the 12 months group. ROM (Range of Movement) and ADL (Activity of Daily Living) significantly improved with the contemporary reduction of VAS and pain at 12 months and, furthermore, an increase of functional performance with reduction of pain was registered at 24 months.

CONCLUSIONS

Our results supported the surgical procedure of the arthroscopic implantation of biodegradable subacromial InSpace Balloon® for irreparable massive cuff tears in worker patients and with recreational activities' demands in order to recover the shoulder function with a reduction of the pain.

A clinical and radiological study of biodegradable subacromial spacer in the treatment of massive irreparable rotator cuff tears

Purpose: The aim of this retrospective study was to report the clinical and radiographic results of the biodegradable subacromial spacer (InSpace Balloon®) implantation in patients with massive irreparable rotator cuff tears. Materials and methods: From February 2014 to October 2015, 30 patients affected by massive irreparable rotator cuff tears were treated with the implantation of InSpace Balloon®. Clinical evaluation (Constant Score and VAS), X-rays and MR imaging were performed preoperatively in all patients and 3, 6, 12 and 24 months after surgery, dividing patients in different groups according to the time elapsed from surgery. Results: Constant Score increased from 39.89 to 62.33 points (p 0.0002) in the 6 months group and from 41.66 to 65.38 points (p< 0.0001) in the 12 months group. ROM (Range of Movement) and ADL (Activity of Daily Living) significantly improved with the contemporary reduction of VAS and pain at 12 months and, furthermore, an increase of functional performance with reduction of pain was registered at 24 months. Conclusions: Our results supported the surgical procedure of the arthroscopic implantation of biodegradable subacromial InSpace Balloon® for irreparable massive cuff tears in worker patients and with recreational activities’ demands in order to recover the shoulder function with a reduction of the pain. (www.actabiomedica.it)

Superior Capsular Reconstruction

Superior capsular reconstruction (SCR) of the shoulder has recently gained popularity as an option for joint-preserving shoulder surgery for patients with an irreparable rotator cuff tear. In the absence of glenohumeral arthritis, rotator cuff tear irreparability should only be diagnosed for most patients after a careful diagnostic arthroscopy. Superior capsular reconstruction adds biological, passive, superior constraint to the glenohumeral joint, thereby optimizing the rotator cuff force couples and improving joint kinematics. At short-term follow-up, SCR has been shown to be effective for pain relief and restoration of active shoulder motion, even in the worst cases of shoulder dysfunction (true shoulder pseudoparalysis). The rapid early adoption and expansion of SCR is justified by its excellent anatomical, biomechanical, and short-term clinical results. The techniques for arthroscopic SCR using dermal allograft continue to improve; however, the operation remains technically demanding. Patients with risk factors for irreparability and who might benefit from reconstruction of the superior capsule should be counseled about the operation as an additional, joint-preserving procedure that can be done in conjunction with arthroscopic, partial rotator cuff repair. [Orthopedics. 2017; 40(5):271-280.].

Reverse shoulder arthroplasty for irreparable massive rotator cuff tears: a systematic review with meta-analysis and meta-regression

BACKGROUND

Massive rotator cuff tears (MRCTs) are very large tears that are often associated with an uncertain prognosis. Indeed, some MRCTs even without osteoarthritis are considered irreparable, and nonanatomic solutions are needed to improve the patient's symptoms. Reverse shoulder arthroplasty (RSA) is an option that can provide a more predictable pain relief and recovery of function. Nonetheless, outcomes after RSA for irreparable MRCTs have not been well defined. The aim of this study was to quantitatively aggregate the findings associated with the use of RSA in this subset of patients and analyze the effect on patient functional status and pain.

METHODS

A comprehensive search was performed until October 2015 using MEDLINE, Scopus, Cochrane Database of Systematic Reviews, and Central Register of Controlled Trials databases. Studies that assessed the outcomes of RSA in patients with irreparable MRCT without osteoarthritis (with at least 2 years of follow-up) were included. If the results of MRCT without osteoarthritis were not possible to subgroup, the study was excluded. Methodologic quality was assessed using the Coleman Methodology Score.

RESULTS

Included were 6 studies (266 shoulders) with a follow-up ranging from 24 to 61.4 months. The mean Coleman Methodology Score was 58.2 ± 11.8 points. There was an overall improvement from preoperative to postoperative assessments of the clinical score (Cohen d = 1.35, P < .001), forward flexion (d = 0.50, P = .009), external rotation (d = 0.40, P < .001), function (d = 1.04, P < .001), and pain (d = -0.89, P < .001).

CONCLUSION

Patients with irreparable MRCT without presence of osteoarthritis have a high likelihood of achieving a painless shoulder and functional improvements after RSA.

Medialized repair for retracted rotator cuff tears

BACKGROUND

The purpose of this study was to evaluate the functional outcomes of medialized rotator cuff repair and the continuity of repaired tendon in chronic retracted rotator cuff tears.

METHODS

Thirty-five consecutive patients were selected from 153 cases that underwent arthroscopic rotator cuff repair for more than medium-sized posterosuperior rotator cuff tears between July 2009 and July 2012 performed with the medialized repair. All cases were available for at least 2 years of postoperative follow-up. The visual analog scale of pain, muscle strength, Constant score, American Shoulder and Elbow Surgeons (ASES) score, and University of California-Los Angeles score were evaluated.

RESULTS

At the final follow-up, all clinical outcomes were significantly improved. The visual analog scale score for pain improved from 6 ± 1 preoperatively to 2 ± 1 postoperatively. The range of motion increased from preoperatively to postoperatively: active forward elevation, from 134° ± 49° to 150° ± 16°; active external rotation at the side, from 47° ± 15° to 55° ± 10°; and active internal rotation, from L3 to L1. The shoulder score also improved: Constant score, from 53.5 ± 16.7 to 79 ± 10; American Shoulder and Elbow Surgeons score, from 51 ± 15 to 82 ± 8; and University of California-Los Angeles score, from 14 ± 4 to 28 ± 4. The retear cases at the final follow-up were 6 (17%).

CONCLUSIONS

Medialized repair may be useful in cases in which anatomic bone-to-tendon repair would be difficult because of the excessive tension of the repaired tendon and a torn tendon that does not reach the anatomic insertion.

Arthroscopic Repair of Anterosuperior Massive Rotator Cuff Tears: Does Repair Integrity Affect Outcomes?

BACKGROUND

The purpose of this study was to investigate clinical outcomes and structural integrity after arthroscopic repair of anterosuperior massive rotator cuff tears (RCTs) and to compare clinical outcomes between healed and retear groups.

HYPOTHESIS

The authors hypothesized that although both groups would exhibit improved clinical outcomes compared with their preoperative status, the healed group would have better clinical outcomes than the retear group, and in the retear group, the subscapularis retear subgroup would have inferior outcomes compared with the intact subscapularis repair subgroup.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This study included 73 of 90 eligible patients who underwent arthroscopic repair of an anterosuperior massive RCT. Functional outcomes after 2-year follow-up were assessed using the visual analog scale (VAS) pain score, subjective shoulder value (SSV), American Shoulder and Elbow Surgeons (ASES) score, University of California, Los Angeles (UCLA) shoulder score, and active range of motion. Patients were assigned to the healed group (group H, n = 34) or retear group (group R, n = 39) based on magnetic resonance arthrography results at 6 months postoperatively. Group R was composed of subgroup R1 (subscapularis retear) and subgroup R2 (intact subscapularis repair).

RESULTS

Retearing occurred in 53% of patients. At 2-year follow-up, group H exhibited better outcomes for all functional scores versus group R, respectively ( P < .001): VAS pain score (1.0 vs 2.1), SSV (90.2 vs 77.4), ASES score (90.8 vs 76.6), and UCLA shoulder score (31.0 vs 24.9). Within both groups, all scores improved significantly compared with preoperative values ( P < .001). At follow-up, group H had significantly better forward flexion ( P = .018) and internal rotation ( P = .002) than group R; within both groups, active range of motion improved in all planes compared with the preoperative condition ( P < .001). Subgroup R1 exhibited inferior outcomes versus subgroup R2, respectively: VAS pain score (2.6 vs 1.5; P = .012), ASES score (70.9 vs 83.6; P = .013), SSV (70.9 vs 85.4; P = .005), and UCLA shoulder score (22.0 vs 28.5; P = .001).

CONCLUSION

After arthroscopic repair of anterosuperior massive RCTs, 53% of patients exhibited retearing. The healed group had better functional outcomes than the retear group. The subscapularis retear subgroup exhibited significantly inferior outcomes compared with the intact subscapularis repair subgroup.

Latissimus Dorsi Transfer in Posterior Irreparable Rotator Cuff Tears

BACKGROUND

Massive rotator cuff tears pose a difficult and complex challenge even for the experienced surgeon; inability to repair these tears by conventional means designates them as irreparable, while management becomes quite taxing. Several operative options have been suggested for the management of such lesions with varying degrees of success, while it is imperative to match patient demands and expectations to the predicted outcome.

METHODS

Research articles are examined and key concepts are discussed, in order to provide an evidence based review of the available literature. The anatomy and pathomechanics along with the indications, contraindications and surgical techniques are reported.

RESULTS

Transfer of the Latissimus dorsi has been used with success to restore shoulder function in deficits of the posterior rotator cuff. Although it can be used in a variety of settings, the ideal patient for a Latissimus dorsi tendon transfer is a young and active individual, with no glenohumeral osteoarthritis that has a severe disability and weakness related to an irreparable posterior cuff tear.

CONCLUSION

Tendon transfers have proved to be a successful treatment option in salvaging this difficult problem, providing pain relief and restoring shoulder function. Despite the excellent functional outcomes and pain suppression following operation, a variety of factors may affect the outcome; thus making indications and preoperative assessment a valuable component.

[Irreparable rotator cuff tears. Debridement, partial reconstruction, tendon transfer or reversed shoulder arthroplasty]

Therapeutic options for the treatment of irreparable rotator cuff tears are fluent, are dependent on the patients' claims and demands and on the grade of the ongoing cuff tear arthropathy.A partial rotator cuff reconstruction with sufficient tenolysis combined with interval slide techniques to restore the anterior and posterior force couple may be indicated if there is no fatty degeneration > grade 3 of the rotator cuff muscles in a well-centered joint. The margin convergence technique with side-by-side adaptation of the tendon limbs may reduce the load on the reconstructed tendons.The role of the suprascapular nerve, which can probably be constricted by the retracted rotator cuff, and its therapy has not been completely clarified. When distinct symptoms are present neurolysis may be reasonable.Tendon transfers can be indicated in a cooperative patient < 65 years with a higher grade of muscular atrophy but without degenerative changes > grade II according to Hamada with the loss of active external rotation but performable active flexion. For posterosuperior tears the latissimus dorsi or recently the teres major tendon transfer to the rotator cuff footprint may be appropriate. For nonreconstructable anterosuperior tears a partial transfer of the pectoralis major tendon is possible.Careful subacromial debridement combined with biceps tenotomy and a cautious or reversed decompression may reduce the pain temporarily without having an influence on active motion until with the loss of active elevation the indication for a reversed shoulder arthroplasty is reached.In the mean time, absorbable subacromial spacers may re-center the humeral head, but the effectiveness of this therapy on clinical outcome should be analyzed in further studies.

The Rotator Cuff and the Superior Capsule: Why We Need Both

Tears of the rotator cuff are frequent. An estimated 250,000 to 500,000 repairs are performed annually in the United States. Rotator cuff repairs have been successful despite fatty infiltration and atrophy of the rotator cuff muscles. Although the emphasis in rotator cuff repair has historically focused on re-establishing the tendon attachment, there is growing interest in and understanding of the role of the superior capsule. The superior capsule is attached to the undersurface of the supraspinatus and infraspinatus muscle-tendon units, and it resists superior translation of the humeral head. Herein, we propose that it is the defect in the superior capsule that is the "essential lesion" in a superior rotator cuff tear, as opposed to the defect in the rotator cuff itself. We propose that rotator cuff repair must restore the normal capsular anatomy to provide normal biomechanics of the joint and thus a positive clinical outcome.

All-Arthroscopic Modified Rotator Interval Slide for Massive Anterosuperior Cuff Tears Using the Subdeltoid Space: Surgical Technique and Early Results

BACKGROUND

Traditional intra-articular arthroscopic repair techniques for massive anterosuperior rotator cuff tears are technically demanding and necessitate sacrifice of the rotator interval to enable visualization. An interval slide allows mobilization through release of the medial aspect of the rotator interval, while leaving the lateral, bridging fibers intact.

QUESTIONS/PURPOSES

The purpose of this study was to report a novel, arthroscopic, open-equivalent technique using the subdeltoid space to address these tears along with early clinical results.

METHODS

A retrospective review of prospectively collected data identified 11 consecutive arthroscopic massive anterosuperior rotator cuff repairs with a concomitant biceps tenodesis performed by the senior surgeon using a uniform technique. Outcome measures included range of motion, visual analog scale for pain, rotator cuff strength, American Shoulder and Elbow Surgeons (ASES) outcome scale, and Short Form-12 (SF-12).

RESULTS

Average length of follow-up was 22.2 months (range 12.5-30.0 months). Visual analog scale (VAS) pain scores, ASES, and SF-12 all demonstrated significant improvement from pre-op to final follow-up from 6.2 to 0.9 (p < 0.05), 27.4 to 82.8 (p < 0.05), and 26.6 to 45.5 (p < 0.05) respectively. Average forward flexion improved from 145° to 160° (p < 0.05). Seven of the nine patients with a positive preoperative belly press had a negative test at final follow-up. Nine of the 10 patients with a positive lift off test demonstrated a negative test on final follow-up. Ninety-one percent reported they were satisfied with their outcome.

CONCLUSIONS

The described modified all-arthroscopic subdeltoid approach for anterosuperior cuff repairs enabled an open-equivalent interval slide technique that preserved the bridging lateral fibers of the rotator interval and demonstrated promising early-term clinical results.

A vast majority of preliminary reports published in the shoulder literature are not followed by long-time follow-up studies - a literature review

INTRODUCTION

The aim of paper is to check how many preliminary reports (PR) reach a long-term publication (LT), and analyse differences in outcomes and complications between them.

METHODS

A literature search was performed to identify shoulder preliminary or early reports. Fifty one papers fulfilled criteria and were categorized for paper topic. Bibliographic searches were undertaken to find LT on the topic from the same author or research group. Outcomes and complications reported in PR were recorded and compared to those reported in LT.

RESULTS

Ten out of 51 PR (19.61 %) were followed by a LT with minimum follow-up of five years, by the same authors. Complication and reintervention rate were higher in the LT compared to PR (p < 0.05). Results published on PR were better than results published on LT even though these differences did not reach significance (p = 0.08).

DISCUSSION

PR may represent the fastest way to spread new findings. However, concerns regarding short-term follow-up, small sample size bias and decrease in outcomes over time can discourage promising preliminary results.

CONCLUSIONS

The vast majority of preliminary reports never reached a LT follow-up paper. Preliminary reports underestimate complications and tend to overestimate outcomes.

Outcomes of Combined Bone Marrow Stimulation and Patch Augmentation for Massive Rotator Cuff Tears

BACKGROUND

The high failure rate after surgical repair of massive rotator cuff tears is a consistent problem.

PURPOSE

To evaluate the clinical and radiological outcomes of arthroscopic rotator cuff repair with bone marrow stimulation and patch augmentation in patients with massive rotator cuff tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study included 21 patients who underwent bone marrow stimulation and patch augmentation (group 1) and 54 patients who underwent conventional repair (group 2) for massive rotator cuff tears. Postoperative clinical outcomes were evaluated based on visual analog scale (VAS) for pain, simple shoulder test (SST), University of California, Los Angeles (UCLA), Constant, and American Shoulder and Elbow Surgeons (ASES) scores at baseline, 1 year postoperatively, and final follow-up. Anatomic outcomes were evaluated by using postoperative magnetic resonance imaging at 1 year after surgery.

RESULTS

No significant differences in demographic characteristics and baseline data were observed between groups 1 and 2. Clinical symptoms were significantly improved at the final follow-up in both groups (P < .001). At the final follow-up, no significant differences were found in VAS pain (P = .676), SST (P = .598), UCLA (P = .100), Constant (P = .469), or ASES (P = .880) scores. However, the retear rate was lower in group 1 (4/21, 19.0%) than in group 2 (25/54, 46.3%) (P = .036), and the medial-row failure rate (type 2 retears) was much lower in group 1 (0/4, 0%) than in group 2 (18/25, 72.0%) (P = .014).

CONCLUSION

Concomitant bone marrow stimulation and patch augmentation significantly reduced retear and medial-row failure rates in the arthroscopic repair of massive rotator cuff tears.

Rotator cuff tear shape characterization: a comparison of two-dimensional imaging and three-dimensional magnetic resonance reconstructions

BACKGROUND

The purpose of this study was to see if 3-dimensional (3D) magnetic resonance imaging (MRI) could improve our understanding of rotator cuff tendon tear shapes. We believed that 3D MRI would be more accurate than two-dimensional (2D) MRI for classifying tear shapes.

METHODS

We performed a retrospective review of MRI studies of patients with arthroscopically proven full-thickness rotator cuff tears. Two orthopedic surgeons reviewed the information for each case, including scope images, and characterized the shape of the cuff tear into crescent, longitudinal, U- or L-shaped longitudinal, and massive type. Two musculoskeletal radiologists reviewed the corresponding MRI studies independently and blind to the arthroscopic findings and characterized the shape on the basis of the tear's retraction and size using 2D MRI. The 3D reconstructions of each cuff tear were reviewed by each radiologist to characterize the shape. Statistical analysis included 95% confidence intervals and intraclass correlation coefficients.

RESULTS

The study reviewed 34 patients. The accuracy for differentiating between crescent-shaped, longitudinal, and massive tears using measurements on 2D MRI was 70.6% for reader 1 and 67.6% for reader 2. The accuracy for tear shape characterization into crescent and longitudinal U- or L-shaped using 3D MRI was 97.1% for reader 1 and 82.4% for reader 2. When further characterizing the longitudinal tears as massive or not using 3D MRI, both readers had an accuracy of 76.9% (10 of 13). The overall accuracy of 3D MRI was 82.4% (56 of 68), significantly different (P = .021) from 2D MRI accuracy (64.7%).

CONCLUSION

Our study has demonstrated that 3D MR reconstructions of the rotator cuff improve the accuracy of characterizing rotator cuff tear shapes compared with current 2D MRI-based techniques.

EXTENSIVE ROTATOR CUFF INJURIES: AN EVALUATION OF ARTHROSCOPIC REPAIR OUTCOMES

To assess the outcomes of the surgical treatment of extensive rotator cuff injuries through arthroscopy.

METHODS

Between June 1998 and October 2006, 61 patients with extensive rotator cuff injuries and submitted to surgical arthroscopy technique by the Shoulder and Elbow Group of the Department of Orthopaedics and Traumatology, Santa Casa de Misericórdia Medical School were reassessed. The study included all patients with at least two tendons affected or with retraction at least on two tendons up to the glenoidal cavity edge and with at least 12 months of follow-up.

RESULTS

According to UCLA's evaluation criteria, 54 (89%) patients showed excellent or good outcomes; no fair outcome in none of the patients; and seven (11%) poor outcomes. A satisfaction rate of 92% was reported. Postoperative joint motion went from a mean lifting value of 93° to 141°, the mean lateral rotation went from 32° to 48° and the mean medial rotation went from L1 to T10. These differences were regarded as statistically significant.

CONCLUSION

The arthroscopic repair of extensive rotator cuff injuries leads to satisfactory outcomes for most of the patients, with a high satisfaction degree.

Pseudoparalysis From a Massive Rotator Cuff Tear Is Reliably Reversed With an Arthroscopic Rotator Cuff Repair in Patients Without Preoperative Glenohumeral Arthritis

BACKGROUND

Pseudoparalysis is defined as active forward flexion less than 90° with full passive motion. There is controversy about the ideal surgical management of a massive rotator cuff tear with pseudoparalysis.

PURPOSE/HYPOTHESIS

The purpose of this study was to prospectively analyze the ability to reverse pseudoparalysis with an arthroscopic rotator cuff repair (ARCR). The hypothesis was that in the absence of substantial glenohumeral arthritis, preoperative fatty infiltration of grade 3 or higher and an acromiohumeral interval (AHI) of less than 7 mm would not prevent reversal of pseudoparalysis with an ARCR.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A prospective multicenter study of ARCR performed for preoperative pseudoparalysis was conducted. The minimum follow-up was 1 year. The mean patient age was 63 years, and pseudoparalysis was present for a mean of 4.2 months preoperatively. Preoperative radiographic evaluation included plain film evaluation of the AHI and Hamada classification and MRI evaluation of fatty degeneration and rotator cuff retraction. Functional outcome was determined by the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) Shoulder Score, visual analog scale (VAS), and subjective shoulder value (SSV).

RESULTS

Of the 58 patients enrolled, 56 had at least 1 year of follow-up. Mean active forward flexion improved from 47° preoperatively to 159° postoperatively (P < .001). Statistically significant improvements were seen in the SST (from 2.8 preoperatively to 10.1 postoperatively), SSV (from 28 to 83), ASES Shoulder Score (from 37 to 88), and VAS (from 5.7 to 1.1) (P < .001). Pseudoparalysis was reversed in 53 of 56 patients (95%). There was no difference in the rate of reversal of pseudoparalysis between those patients with an AHI of less than 7 mm (88.2%) and those with an AHI of 7 mm or more (96.9%) (P =.289). Pseudoparalysis was reversed in all 8 of the patients with fatty degeneration of grade 3 or higher in 1 or more of the rotator cuff muscles.

CONCLUSION

ARCR can lead to reversal of preoperative pseudoparalysis in patients with minimal preoperative glenohumeral arthritis. ARCR is a viable first line of treatment for patients with pseudoparalysis in the absence of advanced glenohumeral arthritis.

Massive rotator cuff tears: definition and treatment

PURPOSE

The aim of this review is to summarise tear pattern classification and management options for massive rotator cuff tears (MRCT), as well as to propose a treatment paradigm for patients with a MRCT.

METHOD

Data from 70 significant papers were reviewed in order to define the character of reparability and the possibility of alternative techniques in the management of MRCT.

RESULTS

Massive rotator cuff tears (MRCT) include a wide panoply of lesions in terms of tear pattern, functional impairment, and reparability. Pre-operative evaluation is critical to successful treatment. With the advancement of medical technology, arthroscopy has become a frequently used method of treatment, even in cases of pseudoparalytic shoulders. Tendon transfer is limited to young patients with an irreparable MRCT and loss of active rotation. Arthroplasty can be considered for the treatment of a MRCT with associated arthritis.

CONCLUSION

There is insufficient evidence to establish an evidence-based treatment algorithm for MRCTs. Treatment is based on patient factors and associated pathology, and includes personal experience and data from case series.

Arthroscopic repair of massive, contracted, immobile tears using interval slides: clinical and MRI structural follow-up

PURPOSE

The purpose of this study was to determine clinical and structural outcomes of arthroscopic repair of massive, contracted, immobile rotator cuff tears using interval slides.

METHODS

Eleven patients who had rotator cuff tears that were irreparable using standard mobilization techniques, but were repaired using interval slides were reviewed. Patients were evaluated at mean 25.2 months (±10.3) post-operatively utilizing a standardized clinical examination and by magnetic resonance imaging (MRI).

RESULTS

American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test (SST) scores improved significantly (ASES p = 0.0001; SST p = 0.0001) from pre- to post-operative. Range of motion in forward elevation and external rotation increased from pre- to post-operative, though not significantly. Strength via manual muscle testing improved on forward elevation (p = 0.001) and external rotation (p = 0.007) from pre- to post-operative. Post-operative MRI demonstrated massive re-tearing to the original size in 6 patients (55 %) and intact rotator cuffs with tissue spanning the defects in 5 (45 %) patients.

CONCLUSIONS

In patients with massive, contracted, immobile tears, an interval slide technique may be utilized as a salvage procedure. Arthroscopic repair of massive, contracted, immobile rotator cuff tears using interval slide techniques can lead to good clinical and satisfactory structural outcomes.

LEVEL OF EVIDENCE

IV.

Decision-making in massive rotator cuff tear

Treatment of massive rotator cuff tears has developed over many years ranging from conservative treatment to open and arthroscopic repair, muscle transfers and reversed arthroplasty. The evolution of more advanced techniques in arthroscopic repair has changed the treatment approach and improved the prognosis for functional outcome despite low healing rates. Due to this rapid development, our evidence-based knowledge today is mainly founded in Level 3 and Level 4 studies. Based on the literature, the current knowledge on treatment of symptomatic massive rotator cuff tears is proposed in an algorithm. Level of evidence V.

Long-term outcome after arthroscopic rotator cuff treatment

PURPOSE

Arthroscopic techniques have become the gold standard in the operative management of several pathologic conditions of the shoulder. The purpose of this systematic review was to present the long-term outcomes following arthroscopic treatment of rotator cuff pathology.

METHODS

A comprehensive literature review was performed to identify studies reporting clinical or structural results of arthroscopic rotator cuff repairs (ARCRs) at least 5 years after surgery.

RESULTS

Ten articles were selected, which described 483 procedures. Study type, surgical approaches, complications, evidences of structural integrity of the repaired lesions, preoperative and postoperative functional scores are identified, analyzed and discussed. Satisfactory results are presented by all authors, and significant postoperative improvement is reported by all the studies with available preoperative data; 16 of 483 cases were re-operated.

CONCLUSION

Although high-level evidences are lacking, ARCR appears to be an effective and safe option to treat the symptoms of rotator cuff tears and to provide successful clinical results durable with time. Current evidences are insufficient to clearly define the relationship between structural integrity of repaired cuffs and long-term clinical outcome. The available data do not allow to draw conclusions regarding the long-term superiority of double-row versus single-row repairs.

LEVEL OF EVIDENCE

Review of level II, III and IV studies, Level IV.

Comparative analysis on arthroscopic sutures of large and extensive rotator cuff injuries in relation to the degree of osteopenia

OBJECTIVE

To analyze the results from arthroscopic suturing of large and extensive rotator cuff injuries, according to the patient's degree of osteopenia.

METHOD

138 patients who underwent arthroscopic suturing of large and extensive rotator cuff injuries between 2003 and 2011 were analyzed. Those operated from October 2008 onwards formed a prospective cohort, while the remainder formed a retrospective cohort. Also from October 2008 onwards, bone densitometry evaluation was requested at the time of the surgical treatment. For the patients operated before this date, densitometry examinations performed up to two years before or after the surgical treatment were investigated. The patients were divided into three groups. Those with osteoporosis formed group 1 (n = 16); those with osteopenia, group 2 (n = 33); and normal individuals, group 3 (n = 55).

RESULTS

In analyzing the University of California at Los Angeles (UCLA) scores of group 3 and comparing them with group 2, no statistically significant difference was seen (p = 0.070). Analysis on group 3 in comparison with group 1 showed a statistically significant difference (p = 0.027).

CONCLUSION

The results from arthroscopic suturing of large and extensive rotator cuff injuries seem to be influenced by the patient's bone mineral density, as assessed using bone densitometry.

Upregulation of transforming growth factor-β signaling in a rat model of rotator cuff tears

BACKGROUND

Muscle atrophy, fatty infiltration, and fibrosis of the muscle have been described as important factors governing outcome after rotator cuff injury and repair. Muscle fibrosis is also thought to have a role in determining muscle compliance at the time of surgery. The transforming growth factor-β (TGF-β) pathways are highly conserved pathways that exert a potent level of control over muscle gene expression and are critical regulators of fibrosis in multiple organ systems. It has been shown that TGF-β can regulate important pathways of muscle atrophy, including the Akt/mammalian target of rapamycin pathway. The purpose of this study was to evaluate the expression of TGF-β and its downstream effectors of fibrosis after a massive rotator cuff tear (RCT) in a previously established rat model.

METHODS

To simulate a massive RCT, infraspinatus and supraspinatus tenotomy and suprascapular nerve transection were performed on Sprague-Dawley rats with use of a validated model. Two and 6 weeks after surgery, supraspinatus muscles were harvested to study alterations in TGF-β signaling by Western blotting, quantitative polymerase chain reaction, and histologic analysis.

RESULTS

There was a significant increase in fibrosis in the rotator cuff muscle after RCT in our animal model. There was a concomitant increase in TGF-β gene and protein expression at both 2 and 6 weeks after RCT. Evaluation of the TGF-β signaling pathway revealed an increase in SMAD2 activation but not in SMAD3. There was an increase in profibrotic markers collagen I, collagen III, and α-smooth muscle actin.

CONCLUSIONS

TGF-β signaling is significantly upregulated in rat supraspinatus muscles after RCTs.

Single-row arthroscopic cuff repair with double-loaded anchors provides good shoulder function in long-term follow-up

PURPOSE

The purpose of this study was to evaluate the results of arthroscopic cuff reconstruction, which is currently preferred in our service, and to compare functional outcome after arthroscopic cuff reconstruction comparing different types and sizes of rotator cuff tears. We switched completely from open repair to the full-arthroscopic repair > ten years ago, and since then, we are developing a technique that can produce the best results. Therefore, we decided to verify results.

METHODS

Seventy-two patients with rotator cuff tear underwent arthroscopic shoulder surgery. Single-row arthroscopic repair using double-loaded metal anchors and margin-convergence sutures with concomitant procedures were performed in all cases. All patients were assessed and classified before and after surgery using the Constant scoring system and the Oxford Shoulder Score. Tears were measured and classified as medium (1-3 cm), large(3-5 cm) and massive (>5 cm).

RESULTS

The average age of participants was 59 ± 9 years (33-76). There were five medium, 43 large and 23 massive tears. The average functional Constant score at the last follow-up was 91.68 ± 10.62, and the Oxford score averaged 43.23 ± 5.84 without statistically significant differences (p > 0.05) among groups Best results were in the massive-tear group, with an overall Constant score of 98.60 ± 2.61 and an average Oxford score of 47.60 ± 0.55. Full recovery was obtained between six months and one year. We used our own modified rehabilitation protocol and found no postoperative stiffness in this series.

CONCLUSIONS

Single-row arthroscopic rotator cuff repair using double-loaded metal anchors and margin-convergence sutures with concomitant procedures, when necessary, provides excellent results. Pain, range of motion, muscle strength and function were significantly improved after single-row repair among all morphological types of cuff lesions.

Latissimus dorsi tendon transfer for massive, irreparable posterosuperior rotator cuff tears: surgical technique

Massive rotator cuff tears remain a complex and challenging problem for both the patient and the surgeon. Although significant advancements in surgical techniques as well as technology for arthroscopic and mini-open rotator cuff repairs have been made, many massive tears result in failed repair with continued progressive tendon retraction and degeneration. In cases when primary tendon to bone healing is impractical, latissimus dorsi tendon transfer provides promising and reproducible clinical results. Herein, we present a latissimus tendon transfer surgical technique, a procedure we have used as a salvage operation for failed arthroscopic/mini-open primary rotator cuff repair.

How do massive immobile rotator cuff tears behave after arthroscopic interval slides? Comparison with mobile tears

PURPOSE

the aim of this study was to compare clinical outcomes of contracted immobile massive rotator cuff tears mobilised through an arthroscopic interval slide technique versus massive mobile cuff tears directly repaired without any mobilisation.

METHODS

twenty-five patients who underwent arthroscopic repair for massive rotator cuff tears with a minimum of 18 months follow-up were included. The patients were retrospectively divided into two groups. In group 1, a single or double interval slide was performed to achieve adequate tendon mobilisation. In group 2 (control group), massive rotator cuff tears were arthroscopically repaired without any additional release. Patients were evaluated with validated outcomes scores: subjective and objective Constant score, a Visual Analogue Scale (VAS) for pain, and single Assessment Numeric Evaluation (SANE).

RESULTS

the two groups were comparable in terms of age, gender and involvement of the dominant arm. The mean follow-up duration was 31 months in group 1 and 28 months in group 2 (p = 0.4). The two groups showed no significant differences in SANE and VAS results (group 1: SANE 77%, VAS 1.3; group 2: SANE 88%, VAS 1.6), or in total Constant score (group 1: 66.5 ± 11; group 2: 75 ± 14; p = 0.1) and subjective Constant score (Group 1: 31 ± 5; group 2: 30.8 ± 7; p = 0.9). A significant difference was found for the objective Constant score, which was higher in the control group (group 1: 35.5 ± 7; group 2: 44 ± 8; p = 0.009).

CONCLUSIONS

Subjective clinical outcomes of arthroscopic repair with or without interval slides did not differ and were satisfactory. Objectively, immobile cuff tears showed inferior results. The use of interval slides might be considered a first step or an alternative to more invasive procedures for low demanding patients.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

No prosthetic management of massive and irreparable rotator cuff tears

A massive rotator cuff tear is not necessarily irreparable. Number of tendons involved, muscle-tendon unit quality, and decreased acromionhumeral distance (AHD) are as important as tear size in determining reparability of lesion. Massive and irreparable rotator cuff tears cannot be anatomically repaired to the bone and are a common source of pain and disability even in middle-aged patients. In these patients when conservative management has failed, it is possible to perform different surgical techniques. A functional repair can help to restore the horizontal force couple of the cuff on the humeral head and to increase the AHD. Debridement of irreparable tears and biceps tenotomy or tenodesis can have a role in low functional demand patients but results deteriorate over time. Recently, several commercially available tissue-engineered biological and synthetic scaffolds have been developed to augment rotator cuff repairs. The aim is to provide a mechanical improvement in case of poor quality tissue at time zero and give a support to have a better cuff healing. In selected cases, the scaffold can be used also to bridge tendon defect. Patients who not have pseudoparalysis, cuff tear arthropathy and with intact deltoid function can benefit from tendon transfers with satisfactory outcomes. These different procedures should be chosen for each patient with selected criteria and after a satisfactory explanation about the really possible expectation after surgery.

Anatomical considerations of the suprascapular nerve in rotator cuff repairs

Introduction. When using the double interval slide technique for arthroscopic repair of chronic large or massive rotator cuff tears, the posterior interval release is directed toward the scapular spine until the fat pad that protects the suprascapular nerve is reached. Injury to the suprascapular nerve can occur due to the nerve's proximity to the operative field. This study aimed to identify safe margins for avoiding injury to the suprascapular nerve. Materials and Methods. For 20 shoulders in ten cadavers, the distance was measured from the suprascapular notch to the glenoid rim, the articular margin of the rotator cuff footprint, and the lateral border of the acromion. Results. From the suprascapular notch, the suprascapular nerve coursed an average of 3.42 cm to the glenoid rim, 5.34 cm to the articular margin of the rotator cuff footprint, and 6.09 cm to the lateral border of the acromion. Conclusions. The results of this study define a safe zone, using anatomic landmarks, to help surgeons avoid iatrogenic injury to the suprascapular nerve when employing the double interval slide technique in arthroscopic repair of the rotator cuff.

Arthroscopic repair of massive contracted rotator cuff tears: aggressive release with anterior and posterior interval slides do not improve cuff healing and integrity

BACKGROUND

Few studies of large-to-massive contracted rotator cuff tears have examined the arthroscopic complete repair obtained by a posterior interval slide and whether the clinical outcomes or structural integrity achieved are better than those after partial repair without the posterior interval slide.

METHOD

The study included forty-one patients with large-to-massive contracted rotator cuff tears, not amenable to complete repair with margin convergence alone. The patients underwent either arthroscopic complete repair with a posterior interval slide and side-to-side repair of the interval slide edge (twenty-two patients; Group P) or partial repair with margin convergence (nineteen patients; Group M). The patient assignment was not randomized. The Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) score, University of California at Los Angeles (UCLA) shoulder score, and range of motion were used to compare the functional outcomes. Preoperative and six-month postoperative magnetic resonance arthrography (MRA) images were compared within or between groups.

RESULTS

At the two-year follow-up evaluation, the SST, ASES score, UCLA score, and range of motion had significantly improved (p < 0.001 for all) in both groups. However, no significant differences were detected between groups. Even though the difference in preoperative tear size on MRA images was not significant, follow-up MRA images identified a retear in twenty patients (91%) in Group P and a significant difference in tear size between groups (p = 0.007).

CONCLUSIONS

The complete repair group with an aggressive release had no better clinical or structural outcomes compared with the partial repair group with margin convergence alone for large-to-massive contracted rotator cuff tears. In addition, the complete repair group had a 91% retear rate and a greater defect on follow-up MRA images. Even though this study had a relatively short-term follow-up, a complete repair of large-to-massive contracted rotator cuff tears, with an aggressive release such as posterior interval slide, may not have an increased benefit compared with partial repair without posterior interval slide.

Functional repair in massive immobile rotator cuff tears leads to satisfactory quality of living: results at 3-year follow-up

PURPOSE

The aim of this retrospective study was to report clinical results of a selective population undergone to arthroscopic functional repair of massive, contracted, immobile rotator cuff tears.

METHODS

From 2005 to 2009, 311 patients with rotator cuff tears were treated at our institution. Of them, 26 shoulders in 25 patients with a mean age of 64 years that presented a massive, contracted immobile tear repaired using an interval slide technique, were included in this study.

RESULTS

The mean postoperative follow-up period was 39 months (range 19-70 months). The mean postoperative disabilities of the arm, shoulder and hand (DASH) score and simple shoulder test (SST) score were, respectively, 20.91 and 8.8 (range DASH: 0.83-59.1; range SST: 2-12). Based on single assessment numeric evaluation score, the outcome of surgery was satisfactory with a mean of 76 % (range 0-100 %). The residual level of pain was low, as reported by a final mean visual analog scale score of 1.8 (range 0-8). The mean postoperative range of motion was 157.5° in forward elevation (range 90°-180°) and 55.3° in extra rotation (range 0°-90°). Eleven patients reached mid-back, in 7, the lower back and in 8 cases, upper back.

CONCLUSION

Arthroscopic functional repair could be considered an appropriate treatment option in case of massive, contracted and immobile cuff tears. This treatment can provide improvement in pain and function that positively affects patients' quality of life without precluding other, more invasive, eventually consequent solutions.

Efficacy of marrow-stimulating technique in arthroscopic rotator cuff repair: a prospective randomized study

PURPOSE

To evaluate the efficacy of a marrow-stimulating technique with microfractures of the greater tuberosity during arthroscopic rotator cuff repair.

METHODS

Eighty patients with a full-thickness rotator cuff tear underwent an arthroscopic single-row repair. Patients were divided into 2 groups of 40 cases each. In group 1, standard repair was performed; in group 2, microfractures of the greater tuberosity were performed to enhance tendon repair. Clinical outcome was assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score and normalized Constant score. Tendon integrity was assessed with magnetic resonance imaging. Multivariate analysis was performed to determine which predictors were independently associated with the outcome. Significance was set at P < .05.

RESULTS

The mean follow-up was 28.1 ± 3 months. Seven patients were lost to follow-up (2 in group 1 and 5 in group 2). Comparison between groups did not show significant differences for baseline characteristics. The mean DASH score was 28.6 ± 21.3 points in group 1 and 23.3 ± 20.1 points in group 2. Although the difference was not statistically significant, the confidence interval included a 10-point value (minimal clinically important difference) in favor of the microfracture group. The difference in the Constant score between groups was not significant. The tendon healing rate was 52.6% in group 1 and 65.7% in group 2, without a significant difference between groups. Subgroup analysis for tear size showed that group 2 had a significantly greater healing rate than group 1 for large tears (P = .040). Multivariate analysis showed that age, timing of symptoms, tear location, tendon retraction, and fatty infiltration significantly affected the outcomes.

CONCLUSIONS

Postoperative magnetic resonance imaging did not show any significant difference between groups in structural integrity. However, subgroup analysis showed a significantly greater healing rate in the microfracture group for large tears involving the supraspinatus and infraspinatus.

LEVEL OF EVIDENCE

Level I, high-quality randomized controlled trial with no statistically significant difference but narrow confidence intervals.

Rotator cuff repair in patients over 70 years of age

This study reports the clinical and sonographic outcome of arthroscopic rotator cuff repair in patients aged ≥ 70 years and aimed to determine factors associated with re-tear. A total of 69 consecutive repairs were performed in 68 patients with a mean age of 77 years (70 to 86). Constant-Murley scores were collected pre-operatively and at one year post-operatively. The integrity of the repair was assessed using ultrasound. Re-tear was detected in 20 of 62 patients (32%) assessed with ultrasound. Age at operation was significantly associated with re-tear free survival (p = 0.016). The mean pre-operative Constant score was 23 (sd 14), which increased to 58 (sd 20) at one year post-operatively (paired t-test, p < 0.001). Male gender was significantly associated with a higher score at one year (p = 0.019).

We conclude that arthroscopic rotator cuff repair in patients aged ≥ 70 years is a successful procedure. The gender and age of the patient are important factors to consider when planning management.

Cite this article: Bone Joint J 2013;95-B:199–205.