Results of arthroscopic decompression and tuberoplasty for irreparable massive rotator cuff tears

Shoulder balloon spacer for massive irreparable rotator cuff tears results in significant improvements

PURPOSE

The aim of the present study was to assess the effectiveness of balloon implantation in patients with irreparable supraspinatus tears alone or in combination with other rotator cuff (RC) tendon tears and the effect of several covariables, such as age, gender, status of the long head biceps, with or without tendon repair and regardless the number of tendon involved.

METHODS

Patients enrolled from 'San Carlo' Hospital of Potenza (Italy, IT), from January 2012 to September 2014, underwent arthroscopic implantation of shoulder balloon by a single surgeon, and followed for 3 years. The American Shoulder and Elbow Surgeons (ASES) and Constant score (CS) were administered pre-, post-operatively at 12 months, and then annually. Patients were classified on the basis of the number of tendons involved in the tears and treatment performed, considering the reparability of the tendons themselves. Gleno-humeral joint osteoarthrosis (OA) was evaluated through shoulder radiographs and classified according to the Samilson-Prieto classification, at the first examination and at the final follow-up. Statistical improvements were evaluated using a variance model (least-squares means) and a T distribution test for the evaluation between different treatment groups.

RESULTS

A total of 61 procedures were performed, and eight patients were lost during follow-up. The mean baseline CS was 30.2 ± 15.4 with statistically significant improvement, respectively, at 1-, 2- and 3-year follow-up to 69.3 ± 4.2, 74.6 ± 3.6 and 69.7 ± 5.1 respectively. ASES score at baseline was 22.5 ± 10.9, with a statistically significant improvement to 69.7 ± 9.2, 68 ± 17.8 and 71.2 ± 16.6 at 1-, 2- and 3-year follow-up, respectively. Tenotomy or absence of long head biceps at presentation did not influence results (n.s.), with no difference according to gender and age. At final follow-up, 24 patients (43.9%) showed progression of glenohumeral OA. One patient required secondary surgery for shoulder replacement after 18 months for persistent pain and one patient required implant removal following post-operative laser treatment.

CONCLUSION

Arthroscopic rotator cuff tears repair with subacromial spacer balloon implantation showed statistically significant clinical and functional improvement at 3-year follow-up. Patients treated with combined partial repair and subacromial spacer balloon implantation experienced good results independent of gender, age, type of tear and long-head biceps tendon status. The risks related to this procedure appear to be minimal.

LEVEL OF EVIDENCE

Level IV.

Mid-Term Outcome of Superior Capsular Reconstruction Using Fascia Lata Autograft (At Least 6 mm in Thickness) Results in High Retear Rate and No Improvement in Muscle Strength

PURPOSE

To report and evaluate clinical and radiologic outcomes of superior capsular reconstruction (SCR) using fascia lata autograft in patients with irreparable rotator cuff tears (IRCTs) over a mid-term duration and to assess the overall survival rate of the graft.

METHODS

We retrospectively reviewed patients who underwent SCR with fascia lata autograft between June 2017 and August 2018. The graft, folded 3 or 4 times, achieved a minimum thickness of 6 mm during the surgical procedure. The inclusion criteria encompassed patients with isolated supraspinatus IRCTs or posterosuperior IRCTs exhibiting poor muscle quality (Goutallier grade ≥3) and without arthritis (Hamada grade ≤ 2). The exclusion criteria included lack of follow-up data or magnetic resonance imaging. Clinical assessments included the visual analog scale score, Constant score, and American Shoulder and Elbow Surgeons (ASES) score; active range of motion; and strength. Radiographic analysis included the acromiohumeral distance, Hamada grade, and graft integrity at final follow-up. A Kaplan-Meier curve was generated to depict SCR graft survivorship.

RESULTS

In total, 45 patients (mean age, 64.8 ± 5.7 years) were included, and the average follow-up duration was 63.2 ± 5.9 months (range, 50-79 months). There was significant improvement in pain (visual analog scale score of 4.4 ± 1.3 preoperatively vs 1.4 ± 0.4 at final follow-up, P < .001). Yet, 18 patients (40.0%) and 17 patients (37.7%) achieved the minimal clinically important difference in the ASES score and Constant score, respectively. Active forward elevation increased from 119° ± 23° to 137° ± 23° (P < .001), and external rotation at the side improved from 29° ± 11° to 36° ± 12° (P = .002). However, strength did not exhibit improvement in any direction. The acromiohumeral distance decreased from 8.5 ± 1.7 mm to 6.5 ± 1.9 mm (P < .001), and the Hamada grade increased from 1.1 ± 0.3 to 1.8 ± 1.1 (P < .001). Finally, the infection rate was 13.3% (n = 6).

CONCLUSIONS

Despite a substantial graft retear rate of 62.2%, SCR led to a significant improvement in pain. Nonetheless, 18 patients (40.0%) and 17 patients (37.7%) achieved the minimal clinically important difference in the ASES score and Constant score, respectively. Forward elevation and external rotation at the side showed significant improvement, but no improvement in muscle strength was observed. Finally, significant arthritis progression was observed.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Tuberoplasty reduces resistance force in dynamic shoulder abduction for irreparable rotator cuff tears: a cadaveric biomechanical study

BACKGROUND

Arthroscopic tuberoplasty is an optional technique for managing irreparable rotator cuff tears. However, there is a lack of studies investigating the resistance force during shoulder abduction in cases of irreparable rotator cuff tears and tuberoplasty.

HYPOTHESES

In shoulders with irreparable rotator cuff tears, impingement between the greater tuberosity (GT) and acromion increases the resistance force during dynamic shoulder abduction. Tuberoplasty is hypothesized to reduce this resistance force by mitigating impingement.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight cadaveric shoulders, with a mean age of 67.75 years (range, 63-72 years), were utilized. The testing sequence included intact rotator cuff condition, irreparable rotator cuff tears (IRCTs), burnishing tuberoplasty, and prosthesis tuberoplasty. Burnishing tuberoplasty refers to the process wherein osteophytes on the GT are removed using a bur, and the GT is subsequently trimmed to create a rounded surface that maintains continuity with the humeral head. Deltoid forces and actuator distances were recorded. The relationship between deltoid forces and actuator distance was graphically represented in an ascending curve. Data were collected at five points within each motion cycle, corresponding to actuator distances of 20 mm, 30 mm, 40 mm, 50 mm, and 60 mm.

RESULTS

In the intact rotator cuff condition, resistance forces at the five points were 34.25 ± 7.73 N, 53.75 ± 7.44 N, 82.50 ± 14.88 N, 136.25 ± 30.21 N, and 203.75 ± 30.68 N. In the IRCT testing cycle, resistance forces were 46.13 ± 7.72 N, 63.75 ± 10.61 N, 101.25 ± 9.91 N, 152.5 ± 21.21 N, and 231.25 ± 40.16 N. Burnishing tuberoplasty resulted in resistance forces of 32.25 ± 3.54 N, 51.25 ± 3.54 N, 75.00 ± 10.69 N, 115.00 ± 10.69 N, and 183.75 ± 25.04 N. Prosthesis tuberoplasty showed resistance forces of 29.88 ± 1.55 N, 49.88 ± 1.36 N, 73.75 ± 7.44 N, 112.50 ± 7.07 N, and 182.50 ± 19.09 N. Both forms of tuberoplasty significantly reduced resistance force compared to IRCTs. Prosthesis tuberoplasty further decreased resistance force due to a smooth surface, although the difference was not significant compared to burnishing tuberoplasty.

CONCLUSION

Tuberoplasty effectively reduces resistance force during dynamic shoulder abduction in irreparable rotator cuff tears. Prosthesis tuberoplasty does not offer a significant advantage over burnishing tuberoplasty in reducing resistance force.

CLINICAL RELEVANCE

Tuberoplasty has the potential to decrease impingement, subsequently reducing resistance force during dynamic shoulder abduction, which may be beneficial in addressing conditions like pseudoparalysis.

Massive Irreparable Rotator Cuff Tears Treated With a Tuberoplasty Yield Favorable Clinical Outcomes With Variable Rates of Complications: A Systematic Review

PURPOSE

To systematically review the patient-reported outcomes and postoperative complications following tuberoplasty for the treatment of massive irreparable rotator cuff tears.

METHODS

A literature search was conducted using PubMed and EMBASE computerized databases from database inception to June 2023 in accordance with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Included studies evaluated clinical outcomes, postoperative complications, and reoperation rates following tuberoplasty for the treatment of massive irreparable rotator cuff tears. Exclusion criteria consisted of non-English language, cadaveric studies, case reports, animal studies, studies with overlapping cohorts, letters to editors, and review articles. Study quality was assessed using the Methodological Index for Non-Randomized Studies criteria. Clinical outcome scores included the visual analog scale for pain, University of California Los Angeles score, and Constant score.

RESULTS

Seven studies from 2002 to 2023 consisting of 123 patients with a mean age of 66.5 years (mean range, 63-70.4 years) were included. The mean follow-up time ranged from 18 to 98 months. The mean Methodological Index for Non-Randomized Studies score was 13.5 (range, 13-15). At final follow-up, the mean postoperative visual analog scale pain scores ranged from 2.3 to 2.5, University of California-Los Angeles shoulder score from 27.2 to 27.7, and Constant scores from 59.2 to 90.6. Postoperative active forward flexion and abduction ranged from 131° to 165°, and 123° to 160°, respectively. The change in acromiohumeral distance postoperatively ranged from -1 mm to -0.6 mm. The rate of postoperative complications ranged from 0% to 19% of patients, while 0% to 19% of patients underwent revision surgery to reverse shoulder arthroplasty.

CONCLUSIONS

Tuberoplasty for the treatment of massive irreparable rotator cuff tears results in good clinical outcomes with significant pain relief in select populations. However, the variable reoperation rates should be considered when counseling patients.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Comparison of Subacromial Bursitis on the Shoulder of the Same Individual After Superior Capsule Reconstruction Using Allograft and Rotator Cuff Tear: A Case Report

This paper reports a pathological comparison between the synovium of the shoulder with rotator cuff tears (RCTs) with or without an allograft in the same patient and assesses allograft remodeling after superior capsular reconstruction (SCR). A 49-year-old man underwent SCR with a fascia lata allograft for irreparable RCTs. Two years postoperatively, the patient underwent arthroscopic rotator cuff repair for left RCTs and arthroscopic debridement to alleviate right shoulder pain. Additionally, revascularization was confirmed in the allograft of the fascia lata. In conclusion, allografts are considered highly safe and expected to be engrafted after SCR.

Partial rotator cuff repair versus debridement for irreparable rotator cuff tears: A systematic review

Introduction

Massive irreparable rotator cuff tears (MIRCT) are a significant cause of shoulder disability and pain, presenting a unique challenge in terms of management with multiple options for care ranging from debridement alone to partial rotator cuff repair. In this study we investigate how clinical outcomes and complications of partial rotator cuff repair compare to simple debridement in the treatment of irreparable rotator cuff tears.

Materials and methods

A total of 1594 publications were identified on PubMed from 1946 to 2017 with 16 level III to level IV studies that were reviewed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

A total of 709 shoulders from 706 patients were reviewed, with 380 patients receiving a partial repair and 329 shoulders receiving debridement. Fifteen outcome measures were utilized with visual analog scale (VAS) pain score and patient satisfaction being the most common. Pre- and post-operative mean VAS scores reported in 155 shoulders treated with partial repair were 6.0 (5.1-6.9) and 2.0 (1.7-3.2), respectively. Pre- and post-operative mean VAS scores in 113 shoulders treated with debridement were 6.5 (4.5-7.9) and 1.9 (1-2.9), respectively. Patient satisfaction in 111 shoulders treated with partial repair was reported as 75 % (51.6-92). In 153 shoulders treated with debridement, post-operative satisfaction was 80.7 % (78-83.9).

Conclusion

This systematic review study demonstrates that both partial repair and debridement alone can result in acceptable clinical outcomes with no significant differences noted for patients with irreparable rotator cuff tears in short to mid-term follow up.

Acellular Human Dermal Allograft Tuberoplasty Improved the Biomechanics in Mid-Range and Higher Abduction Angles in a Cadaveric Model of Massive Irreparable Rotator Cuff Tears

Purpose

To evaluate the biomechanical effects of acellular human dermal allograft tuberoplasty (AHDAT) in a cadaveric model of an irreparable supraspinatus + anterior one-half infraspinatus (stage III) rotator cuff tear.

Methods

Eight cadaveric shoulders were tested at 20°, 40°, and 60° of glenohumeral abduction (AB) and 0°, 30°, 60°, and 90° of external rotation (ER). Superior humeral translation, acromiohumeral distance, and subacromial contact were quantified for 4 conditions: (1) intact, (2) stage III tear (entire supraspinatus and anterior one-half infraspinatus), (3) single-layer AHDAT, and (4) double-layer AHDAT.

Results

Stage III tear significantly increased superior translation at 20° and 40° AB and all ER angles and at 60° AB/60° ER (P ≤ .045 vs intact). Compared to the stage III tear, the single-layer AHDAT significantly decreased superior translation at 60° AB/60° ER (P = .003), whereas the double-layer AHDAT significantly decreased superior translation at 40° and 60° AB at all ER angles except 60° AB/0° ER (P ≤ .028). The stage III tear significantly decreased acromiohumeral distance at 20° AB (P ≤ .003); both grafts increased acromiohumeral distance to intact levels (P ≥ .055 vs intact). Stage III tear increased subacromial contact pressure at 20° and 40° AB/0° and 30° ER and at 60° AB/30° and 60° ER (P ≤ .034). Both AHDAT groups decreased contact pressure at 40° AB/30° and 60° ER back to intact, whereas the double-layer AHDAT also decreased contact pressure at 20° AB/0° and 60° ER and 60° AB/30° ER (P ≥ .051 vs intact).

Conclusions

Both single- and double-layer grafts for AHDAT improved superior translation, subacromial contact characteristics, and acromiohumeral distance after a stage III rotator cuff tear, with varying effectiveness due to the position-dependent nature of greater tuberosity to acromial contact with abduction.

Clinical Relevance

The best treatment for massive or irreparable rotator cuff tears is a matter of concern. The results of this study will help determine whether an acellular human dermal allograft tuberoplasty is a potential treatment option worthy of further investigation.

Arthroscopic-Assisted Lower Trapezius Tendon Transfer Using a Fasciae Lata Autograft in Treatment of Posterior Superior Irreparable Rotator Cuff Tears in Lateral Decubitus Position

The optimal treatment for patients with posterior superior irreparable rotator cuff tears (PSIRCTs) is still a topic of ongoing debate. Lower trapezius tendon transfer is one of the effective surgical treatments for PSIRCTs in younger patients and elderly patients with high activity levels without arthritis. In this report, we describe an arthroscopic-assisted technique for lower trapezius transfer using a fascia lata autograft for patient with PSIRCTs in lateral decubitus position.

InSpace Balloon for the Management of Massive Irreparable Rotator Cuff Tears: A Systematic Review and Meta-Analysis

Background

The best course of action for massive irreparable rotator cuff tears (MIRCTs) is not universally agreed upon. Numerous surgical techniques have been discussed. The implantation of a biodegradable spacer into the subacromial area has been documented since 2012 by several authors. The implantation method is touted as being simpler, repeatable, and less invasive than other solutions that are now available. The purpose of this systematic review and meta-analysis, being the first of its kind, was to evaluate the literature to see the efficacy of InSpace balloon (ISB) implantation in the management of MIRCTs.

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, and with 2 researchers assessing and analyzing each study separately, an extensive electronic search of the literature was conducted in the PubMed database from 1961 until July 27, 2022.

Results

Fourteen studies were included in this systematic review and three in the meta-analysis. Eleven out of fourteen studies favored ISB use for MIRCTs, while only three were against its use. All spacers were arthroscopically implanted in the subacromial space. Three studies were included in the meta-analysis. The differences in the compared outcomes were statistically insignificant.

Conclusions

A controversy about the use of ISB remains in patients with MIRCTs. Both good and bad outcomes were reported. However, the majority of patients had good clinical outcomes across several grading scales, radiographic evidence of improved impingement, and self-report that they would redo the procedure in hindsight. To draw more solid conclusions and have statistically significant results in the meta-analysis, more randomized controlled trials and comparative studies comparing this device to other treatments are needed.

Management of Massive Rotator Cuff Tears Without Arthropathy

Arthroplasty is not an optimal treatment for massive rotator cuff tears in patients who are active and without glenohumeral arthritis. Several surgical techniques have been developed for these patients, including arthroscopic rotator cuff repair with single-/double-row repair (with or without interval slides, margin convergence, graft augmentation), graft bridging, superior capsular reconstruction, tuberoplasty, and tendon transfers. Complete, tension-free, anatomic repair is ideal; however, tendon atrophy and retraction associated with massive tears often complicate repairs. All surgical treatments significantly increase patient-reported functional outcomes 1 year after intervention, with many treatments demonstrating improved mid-term and long-term outcomes. [Orthopedics. 2023;46(1):e1-e12.].

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.

Does arthroscopic superior capsule reconstruction using porcine dermal xenograft represent a viable option in case of massive irreparable posterosuperior rotator cuff tear?

INTRODUCTION

The aim of the present study was to evaluate clinical and structural outcomes of patients with a massive irreparable rotator cuff tear treated with arthroscopic superior capsule reconstruction using an acellular porcine dermal xenograft. We hypothesized that this procedure would lead to improvement in clinical and functional results and that structural failure would not influence the final clinical results.

MATERIALS AND METHODS

A retrospective analysis on arthroscopic superior capsule reconstruction performed from October 2016 to January 2019 was conducted. The procedure was performed in patients with a massive irreparable posterosuperior rotator cuff tear without a severe glenohumeral arthropathy (Hamada I and II) and complaining a painful pseudoparalysis. Clinical evaluation and MRI study were performed before surgery and after at least 14 months.

RESULTS

A comprehensive group of 21 patients with 11 females and 10 males and a mean age of 57 ± 8.5 years underwent arthroscopic superior capsule reconstruction. The graft had a thickness of 1.5 mm in the first 9 cases (43%) since it was used in a single layer. The graft was thereafter doubled for technique evolution in the following 12 cases (57%) achieving a graft thickness of 3 mm. Active ROM significantly improved with a mean increase of active forward flexion from 72.8° ± 7.5° to 120.6° ± 4.5°, active abduction from 68.3° ± 10.2° to 140.2° ± 8.8° and external rotation from 38.2° ± 11.2° to 56.7° ± 6.8° at the last follow-up. The mean Constant score significantly improved from 40.4 ± 6.7 to 73.3 ± 8.2. A graft tear revealed in 52% (11/21) of overall patients was significantly more frequent in single layer graft when compared to double layer (77% vs 33%, p < 0.05). Location and type of graft tear significantly influenced final outcomes. Patients with a healed (graft continuity with bone at medial and lateral insertion) or medial graft tear showed statistically significant better outcomes when compared with patients in which the graft was completely reabsorbed or torn on humeral side (p < 0.05).

CONCLUSION

Arthroscopic superior capsule reconstruction using an acellular porcine dermal xenograft may be a viable alternative to treat massive posterosuperior rotator cuff tear in patients with a painful pseudoparalysis without anterosuperior escape. Structural failure may strongly influence final outcomes with significant role played by tear location.

The robustness of glenohumeral centering measurements in dependence of shoulder rotation and their predictive value in shoulders with rotator cuff tears

OBJECTIVE

De-centering of the shoulder joint on radiographs is used as indicator for severity of rotator cuff tears and as predictor for clinical outcome after surgery. The objective of the study was to assess the effect of malrotation on glenohumeral centering on radiographs and to identify the most reliable parameter for its quantification.

SUBJECTS AND METHODS

In this retrospective study (2014-2018), 249 shoulders were included: 92 with imaging-confirmed supra- and infraspinatus tears (rupture; 65.2 ± 9.9 years) and 157 without tears (control; 41.1 ± 13.0 years). On radiographs in neutral position and external rotation, we assessed three radiographic parameters to quantify glenohumeral centering: acromiohumeral distance (ACHD), craniocaudal distance of the humeral head and glenoid center (Deutsch), and scapulohumeral arch congruity (Moloney). Non-parametric statistics was performed.

RESULTS

In both positions, only the distance parameters ACHD (< 0.5 mm) and Deutsch (< 1 mm) were comparable in the two study groups rupture and control. Comparing the parameters between the study groups revealed only ACHD to be significantly different with a reduction of more than 2 mm in the rupture group. Among the parameters, ACHD ≤ 6 mm was the only cut-off discriminating rupture (12-21% of the shoulders with ACHD ≤ 6 mm) and control (none of the shoulders with ACHD ≤ 6 mm). Ninety percent of shoulders with ACHD ≤ 6 mm presented with a massive rotator cuff tear (defined as ≥ 67% of the greater tuberosity exposed).

CONCLUSION

Glenohumeral centering assessed by ACHD and Deutsch is not affected by rotation in shoulders with and without rotator cuff tear. An ACHD ≤ 6 mm has a positive predictive value of 90% for a massive rotator cuff tear.

Superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement or balloon spacers for large and massive irreparable rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

Multiple non-arthroplasty surgical techniques are described for the management of large and massive irreparable rotator cuff tears. There is currently no consensus on the best management strategy. Our aim was to compare clinical outcomes following arthroscopic debridement, arthroscopic partial cuff repair, superior capsule reconstruction, balloon spacers or graft interposition for the management of large and massive irreparable rotator cuff tears.

METHODS

A comprehensive search was performed of the following databases: Medline, Embase, CINAHL and Cochrane Database of Systematic Reviews. Data were extracted from relevant studies published since January 2000 according to the pre-specified inclusion criteria. The primary outcome was the post-operative improvement in shoulder scores. Meta-analysis of the primary outcome was performed. Secondary outcomes included retear rates and complications.

RESULTS

Eighty-two studies were included reporting the outcomes of 2790 shoulders. Fifty-one studies were included in the meta-analysis of the primary outcome. The definition of an irreparable tear varied. All procedures resulted in improved shoulder scores at early follow-up. Shoulder scores declined after 2 years following balloon spacers, arthroscopic debridement and partial cuff repair. High retear rates were seen with partial cuff repairs (45%), graft interposition (21%) and superior capsule reconstruction (21%).

CONCLUSIONS

Large initial improvements in shoulder scores were demonstrated for all techniques despite high retear rates for reconstructive procedures. Shoulder scores may decline at mid- to long-term follow-up.

Arthroscopic Biologic Tuberoplasty for Irreparable Rotator Cuff Tears: An Expedited Technique

Massive irreparable rotator cuff tears in patients for whom arthroplasty is not an option can be a challenging clinical scenario for shoulder surgeons to manage. To achieve the best patient outcomes, a myriad of options has been presented in the literature, including debridement with biceps tenotomy or tenodesis, various tendon transfer procedures, superior capsular reconstruction, biceps tendon rerouting, bursal acromion resurfacing, balloon spacers, and tuberoplasty. While debridement with biceps tenotomy and superior capsular reconstruction have historically provided improvements in patient-reported outcomes, high rates of arthritis progression and failure of graft healing have been noted with these techniques, respectively. The superior capsular reconstruction has also proven to be technically challenging. The biologic tuberoplasty procedure was developed after several studies noted a lack of correlation between graft healing and improvement in patient-reported outcomes in superior capsular reconstructions, as long as the tuberosity remained covered with the graft. We present a technically efficient and expedited technique using an acellular human dermal allograft.

The subacromial spacer system for irreparable posterosuperior rotator cuff tears: A retrospective study of 47 patients with a two-year follow-up

BACKGROUND

Numerous surgical options are available for the management of massive irreparable rotator cuff tears, but there are no current definitive guidelines concerning the optimal treatment modality. The purpose of this study was to evaluate the efficacy and safety of a biodegradable subacromial spacer (InSpace) implantation in patients with irreparable rotator cuff tears.

METHODS

A retrospective study was conducted involving 47 patients treated with the InSpace balloon between 2016 and 2018. Shoulder function was assessed using Constant Score. Pain was scored using a visual analogue scale, with scores ranging from 0 to 10.

RESULTS

At an average follow-up of 24.6 months (range 12-38), the Constant Score had improved from 39.4 to 71.5 points (p < 0.0001). The range of motion, a main component of Constant Score, was improved after two years, from 27.6 to 42.2 points (p < .001). The visual analogue scale score decreased from 6.32 at baseline to a mean score of 2.7 points (p < 0.0001).

DISCUSSION

Arthroscopic deployment of the InSpace device was found to be a safe, reliable treatment option in patients with painful irreparable rotator cuff tears, with meaningful improvement in shoulder function without serious complications.

Outcomes of Arthroscopic Tuberoplasty for Symptomatic Irreparable Rotator Cuff Tendon Tear Without Pseudoparalysis

Background

The purpose of this study is to report the outcomes in patients undergoing arthroscopic tuberoplasty for symptomatic irreparable rotator cuff tear (RCT).

Methods

This is a retrospective cohort study comparing preoperative and postoperative data of patients undergoing arthroscopic tuberoplasty for symptomatic irreparable RCT. Exclusion criteria included open tuberoplasty, concomitant partial RCT repair, glenohumeral arthritis, concomitant ipsilateral extremity fractures, <12 months follow-up, or pseudoparalysis. Demographics, shoulder range of motion (ROM), RCT morphology, re-operation rates, satisfaction and outcome scores were collected from medical records and questionnaires. Outcome scores included Patient Reported Outcome Measurement Information System Upper Extremity (PROMIS), American Shoulder and Elbow Surgeons score (ASES), Subjective Shoulder Value (SSV), and pain Visual Analog Score (VAS).

Results

Out of 28 patients identified between 2012 and 2019, 20 (21 shoulders) were available for follow-up at a mean of 43.3 ± 20.9 months. Mean age was 64.6 ± 8.8 years. Mean PROMIS was 37.7 ± 7.3, ASES was 82.9 ± 13.8, and SVV was 67.1 ± 19.4. VAS with activity decreased from 5.0 ± 2.9 preoperatively to 2.3 ± 2.6 (P = .0029). Pre- and post-operative ROM were unchanged. There were 4 failures requiring revision. The remaining 17 patients reported high satisfaction scores (3.4 ± 0.7) and 15 (88.2%) answered “yes” to getting the procedure again, with 3/4 failures stating they would also undergo arthroscopic tuberoplasty again.

Conclusion

Arthroscopic tuberoplasty demonstrates high levels of satisfaction and pain reduction in symptomatic irreparable RCT. In appropriately indicated patients, this treatment should be considered prior to other salvage options.

Subacromial Spacer Implantation During Arthroscopic Partial Repair in Patients With Massive Irreparable Rotator Cuff Tears Provides Satisfactory Clinical and Radiographic Outcomes: A Retrospective Comparative Study

Purpose

To compare the clinical and radiographic outcomes of partial rotator cuff repair (RCR) with and without implantation of a biodegradable subacromial spacer in the treatment of symptomatic irreparable massive rotator cuff tears (MRCTs).

Methods

Patients with MRCT who underwent arthroscopic partial repair alone (PR) or combined with subacromial spacer augmentation (PRS) were included. Patient-reported outcomes, including visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES), and Constant scores in addition to range of motion (ROM) were collected preoperatively and at the final follow-up. Additionally, we determined the percentages of all of the patients in groups that achieved the minimal clinical important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptomatic state (PASS) for the VAS, ASES, and Constant scores. Acromiohumeral distance (AHD) was determined as well.

Results

A total of 32 patients were included. Group PR included 20 patients with a median age of 68 years (range: 64-73) and median follow-up 28.0 months (14.0-60.0). Group PRS included 12 patients with a median age of 68.5 years (range: 63-74) and median follow-up of 17.0 months (12.0-32.0). At the final follow-up, the ASES, VAS, and Constant scores were significantly higher in the PRS group (75.5 [55-88.3], 1.0 [0-3], and 70.0 [43-79], respectively, compared to the PR group (55.0 [37.5-65], 2.0 [0-4], and 55.0 [31-79], respectively; P < .05). The only statistically significant differences were found between the PR and PRS groups in terms of the proportions of the patients who achieved MCID for the ASES (70% vs. 100%; P = .04) and in terms of the proportions of the patients who achieved SCB for the ASES (60% vs 100%; P = .01) There was also statistically significant difference between the PR and PRS groups, in terms of the proportions of the patients who achieved PASS for the VAS and ASES ([30 % vs 66.7 %; P = .04] and [0 % vs 50 %; P = .001], respectively). AHD was also improved in the PRS group (8.4 [7-9.5] vs 7.85 [5.5-9]; P < .05). ROM was greater in the PRS group at final follow-up with median forward flexion degree, 140.0° (90°-150°) versus 120.0° (80°-153°) (P < .001) and median abduction degree, 100.0° (70°-130°) versus 90.0° (70°-110°). There was no difference in terms of external rotation between groups (3° [2°-5°] vs 3.0° (2°-4°); P = .4).

Conclusions

Arthroscopic partial RCR with implantation of a subacromial spacer leads to satisfactory clinical and radiographic outcomes in patients with symptomatic irreparable MRCT compared with patients treated with partial repair alone.

Level of Evidence

Level III, retrospective comparative study.

Arthroscopic debridement for management of massive, irreparable rotator cuff tears: a systematic review of outcomes

Background

Surgical management of massive irreparable rotator cuff tears remains controversial. Arthroscopic debridement (AD) has shown promising results especially in the population older than 65 years; however, there is no consensus on the benefits of various AD procedures. The aim of this systematic review was to evaluate the functional midterm to long-term outcomes in patients treated with AD in combination with subacromial decompression, biceps tenotomy, tuberoplasty, or bursectomy, without repair of the rotator cuff tear.

Methods

A comprehensive search was performed in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane databases for studies reporting clinical outcomes of AD of massive rotator cuff tears. Quality was determined using the Methodological Index for Nonrandomized Studies (MINORS) criteria by two independent reviewers. Pooled frequency-weighted means and standard deviations were calculated for patient-reported outcomes.

Results

Sixteen articles containing 643 patients and 662 shoulders met the eligibility criteria. The mean age at the time of surgery was 65.9 ± 4.4 years with a mean follow-up period of 46.5 ± 27.3 months. There was notable clinically significant improvement across all patient-reported outcome scores postoperatively: Constant 70.4 ± 8.9 (P value = .06), University of California, Los Angeles ultrasonography 26.7 ± 5.2 (P value = .001), American Shoulder and Elbow Surgeons score 71.7 ± 2.1 (P value = .12), Disabilities of the Arm, Shoulder, and Hand score 35.3, and visual analog score 1.7 ± 0.9. Forty-nine patients (7%) required reoperation, which most commonly was a reverse total shoulder arthroplasty for the development of rotator cuff arthropathy.

Conclusion

Arthroscopic debridement with a combination of subacromial decompression, tuberoplasty, subacromial bursectomy, and biceps tenotomy, for treatment of massive irreparable rotator cuff tears, produces good functional outcomes and improvement in pain at mid to long term follow up for the low-demand population greater than 65 years of age looking for pain relief over substantial increase in function.

Arthroscopic superior capsule reconstruction using semitendinosus tendon autograft for irreparable rotator cuff tears: Preliminary results

Background

To examine prospectively the functional and structural results of arthroscopic superior capsule reconstruction using semitendinosus tendon autograft for irreparable superior rotator cuff tears.

Methods

5 patients (40.8 months average follow-up) were evaluated clinical preoperatively and at the end of the follow-up. Magnetic resonance imaging (MRI) was used preoperatively and at 12 months.

Results

The mean ASES and the Constant scores increased from 56.2 to 92 and 46.8 to 82.8. The MRI showed continuity of the ligamentoplasty.

Conclusions

Given the small number of cases, few conclusions can be drawn. Nonetheless, the results regarding this technique may be considered promising.

Level of evidence

Level IV; Case series; Treatment Study.

Biologic Tuberoplasty With an Acellular Dermal Allograft for Massive Rotator Cuff Tears

We present the technique of biologic tuberoplasty, where an acellular dermal allograft is used to cover the tuberosity in patients with massive irreparable cuff tears to prevent bone-to-bone contact between the tuberosity and acromion when active elevation is attempted. This technique can be performed in patients with massive rotator cuff tears who are low-demand and have significant medical comorbidities, poor bone quality, or who are not candidates for a reverse shoulder arthroplasty or who cannot tolerate a lengthy rehabilitation protocol. It is less time-consuming than a superior capsule reconstruction and more bone-sparing than traditional tuberoplasty. Patients with massive rotator cuff tears involving the supraspinatus and a portion of the infraspinatus lose their force couple, leading to superior humeral head migration with abutment of the tuberosity against the acromion upon deltoid activation. The center of rotation moves superiorly with deltoid contraction, developing an acromiohumeral articulation. This results in bone-to-bone contact between the acromion and humerus, leading to pain and acetabularization of the acromion over time. Coverage of the tuberosity with the acellular dermal allograft acts as an interpositional tissue and prevents bone-to-bone contact between the tuberosity and acromion.

Preliminary outcomes of arthroscopic biceps rerouting for the treatment of large to massive rotator cuff tears

BACKGROUND

We aimed to evaluate the short-term outcomes of arthroscopic biceps rerouting (ABR) for the treatment of large to massive rotator cuff tears (LMRCTs).

METHODS

A prospective evaluation of patients treated with ABR for the repair of LMRCTs was performed, with a minimum follow-up period of 18 months. Range of motion and functional outcomes (visual analog scale pain score, American Shoulder and Elbow Surgeons score, and Korean Shoulder Scale score) were assessed preoperatively and at final follow-up. Radiographs were used to evaluate the acromiohumeral interval (AHI). Magnetic resonance imaging was performed at 2 and 12 months postoperatively to examine the integrity of the repaired rotator cuff tendons.

RESULTS

Eighty patients who met the study criteria underwent ABR from March 2017 to January 2019 in our hospital. Of these patients, 61 could be evaluated ≥18 months after surgery. The average age of the enrolled patients was 64.5 years. The visual analog scale pain score decreased from 3.7 preoperatively to 1.6 at final follow-up (P = .019), the American Shoulder and Elbow Surgeons score improved from 60.0 to 85.2 (P < .001), and the Korean Shoulder Scale score improved from 64.3 to 85.3 (P = .001). Assessment of range of motion showed significant improvement in forward flexion (from 138° to 146°, P < .001), external rotation at 90° of abduction (from 80° to 85°, P = .037), and internal rotation (from spinal level 9 to spinal level 10, P = .015) from preoperatively to last follow-up. The AHI was 7.1 mm at baseline and improved significantly to 9.7 mm at 3 months postoperatively (P < .001). The mean AHI at last follow-up was only 9 mm, but this was still significantly better than the mean preoperative AHI (P < .001). Of the patients, 16 (26%) exhibited a retear of the repaired rotator cuff on magnetic resonance imaging at 12 months postoperatively. Male sex was the only significant risk factor for retear (P = .037).

CONCLUSION

ABR improved the functional and radiologic outcomes of patients with LMRCTs. The ABR technique can be a useful treatment option for LMRCTs.

Subacromial balloon spacer implantation for patients with massive irreparable rotator cuff tears achieves satisfactory clinical outcomes in the short and middle of follow-up period: a meta-analysis

PURPOSE

This meta-analysis was performed systematically to evaluate the efficacy of subacromial balloon spacers for patients with massive, irreparable rotator cuff tears.

METHODS

Electronic databases, including Medline/PubMed, Embase and Cochrane Library, were systematically searched to identify studies evaluating the efficacy of subacromial spacers for patients with irreparable or massive rotator cuff tears. Meta-analyses were performed to pool the outcome estimates of interest, such as the total constant score (TCS) and its sub-score (pain, activities of daily living [ADL], range of motion [ROM], and strength), Oxford shoulder score (OSS), American Shoulder and Elbow Society scores (ASES) and numeric rating scale (NRS), as well as different outcomes at different time points in the follow-up period.

RESULTS

Ten studies with a total of 261 patients involving 270 shoulders were deemed viable for inclusion in the meta-analysis. The combined results demonstrated significant improvements in the TCS at the final follow-up (pooled mean difference = 26.4, 95% confidence intervals [CIs] 23.3 to 29.5). A sensitivity analysis and subgroup analysis, which were implemented based on two factors, different follow-up points and sub-scores (pain, ADL, ROM, and strength), revealed a consistent trend. The combined shoulder motion results demonstrated significant improvements in the forward flexion and external rotation (0° abduction) variables rather than in the abduction and external rotation (90° abduction) variables. Additionally, significant improvements in the OSS and ASES and a decrease in the NRS were observed in the middle of the follow-up period.

CONCLUSION

This meta-analysis indicated that subacromial balloon spacer implantation for patients with massive irreparable rotator cuff tears may achieve satisfactory outcomes between 3 months and 3 years of follow-ups. Although the short- and middle- term effect is significant, the long-term effect needs to be confirmed by large-sample randomized controlled trial.

LEVEL OF EVIDENCE

IV.

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.

The subacromial balloon spacer for massive irreparable rotator cuff tears: approximately 3 years of prospective follow-up

BACKGROUND

Irreparable rotator cuff tears (RCT) are still a challenging problem. RCT can result in disability and severe pain. The optimal treatment for this disabling and painful diagnosis remains controversial. The arthroscopic implantation of a biodegradable subacromial balloon spacer is a possible treatment option. In this prospective study, we evaluate the clinical outcome of this balloon spacer after approximately 3 years.

METHODS

Between March 2014 and December 2015, the biodegradable balloon spacer was implanted into the subacromial space of 46 shoulders of 44 patients with massive irreparable RCT. Pain was evaluated using a numeric rating scale (NRS), and functional outcome was evaluated using the Oxford shoulder score (OSS). Patients were followed prospectively for approximately 3 years. This present study focuses on the comparison between the early and the midterm results up to approximately 3 years.

RESULTS

All patients were treated by surgical implantation of the subacromial balloon spacer. The comparison between the outcomes of the NRS and the OSS after one and 3 years was made and showed no mutual significant differences, respectively, p = 0.61 and p = 0.08. Significant pain reduction and functional improvement was noticed postoperatively and maintained after approximately 3 years. At last follow-up (mean: 34 months), pain was reduced to a NRS of 3.09 points (95% CI: 2.17-4.01). Functional outcome based on the OSS improved significantly from 21.32 preoperatively to 34.39 (95% CI: 29.17-36.70) at the last follow-up. Correction for estimated confounders did not show significant differences. 82% of the patients were satisfied with the outcome after implantation of the subacromial balloon spacer. No surgical or postoperative medical complications due to implantation of the balloon spacer were reported.

CONCLUSIONS

Arthroscopic implantation of the biodegradable balloon spacer in the subacromial space is a safe and minimally invasive intervention. It leads to significant reduction in pain and significant improvement of functional daily activities in patients with irreparable RCT during 3 years of follow-up starting postoperative and maintain over time beyond device degradation. A high percentage of patients are satisfied postoperatively. Despite of these positive results after 3 years of follow-up, the specific contribution of the balloon needs further investigation.

Arthroscopic Superior Capsular Reconstruction of the Shoulder Using Dermal Allograft

Irreparable massive cuff tears in young patients pose a difficult problem for shoulder surgeons. Arthroscopic superior capsular reconstruction has shown promise in recent years in the treatment of this challenging patient population. The majority of the literature is limited to surgical techniques. The authors present the 2-year clinical outcomes of 25 patients undergoing arthroscopic superior capsular reconstruction with dermal allograft from a single center. The Oxford Shoulder Score and range of motion were assessed preoperatively and then at 3 to 6 months, 1 year, and 2 years following surgery. Patient satisfaction was recorded at final follow-up. Magnetic resonance imaging was performed at 3 months postoperatively to assess graft integrity. All patients were available at 1-year follow-up, and 23 were available at 2 years. The mean Oxford Shoulder Score improved by a minimum of 10 points at all time points compared with preoperatively. The mean forward flexion and abduction improved by 20° and external rotation by 7°. Revision to reverse shoulder arthroplasty was seen in 3 patients (12%). Graft failure was seen in 4 patients (16%). Overall, 20 patients had successful outcomes at 1 year (80%) and 18 patients had successful outcomes at 2 years (72%). Superior capsular reconstruction offers a safe and effective short-term bridging option for young patients with irreparable supraspinatus tears in the absence of glenohumeral arthritis. However, long-term outcome studies are required to evaluate the true clinical effectiveness and failure rates. [Orthopedics. 2020;43(4):215-220.].

Comparison Between Autografts and Allografts in Superior Capsular Reconstruction: A Systematic Review of Outcomes

BACKGROUND

The treatment of irreparable rotator cuff tears (IRCTs) is a significant challenge, and various treatment options have emerged. Superior capsular reconstruction (SCR) is a promising procedure for patients with IRCTs.

PURPOSE

To investigate the clinical outcomes of SCR and compare allografts with autografts.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A search for relevant articles was carried out using the PubMed, Cochrane Library, Embase, Scopus, and Google Scholar databases. We used medical subject heading (MeSH) terms and natural keywords (superior AND (capsule OR capsular) AND reconstruction). Also, we filtered for high-quality articles using the Methodological Index for Non-Randomized Studies (MINORS). We summarized the characteristic data and commonly used outcome measures of each included study and performed a descriptive analysis using an evidence-based tendency concept as proposed by Huisstede et al (2013).

RESULTS

A total of 10 articles (374 shoulders) with a mean follow-up of 27.2 months were selected and analyzed. There were 4 articles on SCR with an autograft, 4 on SCR with an allograft, and 2 on SCR with both an autograft and allograft. For autografts and allografts, respectively, the mean gain in forward elevation (FE) was 48.7° and 33.3°, the visual analog scale for pain score improved by 3.5 and 3.3, the American Shoulder and Elbow Surgeons (ASES) score increased by 47.3 and 31.9, and the acromiohumeral distance increased by 1.2 and 1.8 mm. In addition, the number of graft tears was 16 (10.0%) and 17 (12.9%), the number of other complications was 12 (7.5%) and 6 (3.9%), and the number of reoperations was 5 (3.1%) and 14 (8.2%) for autografts and allografts, respectively.

CONCLUSION

Both autografts and allografts improved clinical outcomes. Although the graft tear rate appeared similar between the autograft and allograft groups, the autograft group had no cases of conversion to reverse total shoulder arthroplasty. In addition, we found 3 evidence-based tendencies: (1) a tendency for both autografts and allografts to have significantly improved FE and clinical scores, (2) a tendency that autografts improved internal rotation and allografts improved abduction, and (3) a weak tendency that autografts improved abduction and allografts improved internal and external rotation. Although it was not possible to compare the groups statistically, the differences in ASES scores might be clinically important and will need to be explored in future comparative studies.

Low level of evidence for all treatment modalities for irreparable posterosuperior rotator cuff tears

PURPOSE

This systematic review assesses evidence for improvements in outcome for all reported types of treatment modalities [physical therapy, tenotomy or tenodesis of the long head of the biceps, debridement, partial repair, subacromial spacer, deltoid flap, muscle transfer, rotator cuff advancement, graft interposition, superior capsular reconstruction (SCR), and reversed shoulder arthroplasty (RSA)] used for irreparable posterosuperior rotator cuff tears without glenohumeral osteoarthritis. The primary aim was to be able to inform patients about expectations of the amount of clinical improvement after these treatments.

METHODS

A systematic search was conducted in MEDLINE, EMBASE, CINAHL, and Cochrane databases for studies on irreparable posterosuperior rotator cuff lesions without glenohumeral osteoarthritis, published from January 2007 until January 2019, with minimum 2-year follow-up. Studies with pre-operative and/or intra-operative determination of cuff tear irreparability were included. We defined the non-adjusted Constant Score as the primary outcome.

RESULTS

Sixty studies (2000 patients) were included with a fair mean quality score, according to the Modified Coleman Methodology Score. The employed definitions of 'irreparable' were mainly based on MRI criteria and were highly variable among studies. The smallest weighted mean preoperative to post-operative improvements in Constant Score were reported for biceps tenotomy/tenodesis (10.7 points) and physical therapy (13.0). These were followed by debridement (21.8) and muscle transfer (27.8), whereas the largest increases were reported for partial repair (32.0), subacromial spacer (32.5), rotator cuff advancement (33.2), RSA (34.4), graft reconstruction (35.0), deltoid flap (39.8), and SCR (47.4). Treatment using deltoid flap showed highest mean weighted improvement in Constant Score among studies with available medium-term (4-5-year) follow-up. Treatments deltoid flap, muscle transfer, and debridement were the only treatments with available long-term (8-10-year) follow-up and showed similar improvements in Constant Score at this time point.

CONCLUSION

The variability in patient characteristics, co-interventions, outcome reporting, and length of follow-up in studies on irreparable rotator cuff tears without osteoarthritis complicates sound comparison of treatments. Clinically important treatment effects were seen for all 11 different treatment modalities.

LEVEL OF EVIDENCE

IV.

Outcomes of Subacromial Balloon Spacer Implantation for Massive and Irreparable Rotator Cuff Tears: A Systematic Review

Background

Selection of optimal treatment for massive to irreparable rotator cuff tears (RCTs) entails a challenging decision-making process in which surgeons must consider several factors, including duration of symptoms, tear pattern, tear size, and muscle quality, as well as patient characteristics such as age, comorbidities, shoulder dominance, and activity level. Unfortunately, no clear consensus has been reached regarding optimal management.

Purpose

To systematically review the published literature assessing outcomes after subacromial balloon spacer implantation for treatment of massive and irreparable RCTs.

Study Design

Systematic review; Level of evidence, 4.

Methods

A comprehensive literature search was performed in September 2018 through use of MEDLINE and the Cochrane Library electronic databases. Studies were assessed for multiple outcomes of interest including Constant score, Oxford Shoulder Score (OSS), University of California Los Angeles (UCLA) Shoulder Score, complications, and patient satisfaction.

Results

After applying the selection criteria, 12 clinical studies were included for data extraction and analysis. In total, 291 shoulders (in 284 patients) treated with subacromial balloon spacer implantation were pooled for evaluation, with a mean follow-up of 22.9 ± 14.9 months (range, 6-60 months). Constant scores were used as an outcome metric for 267 shoulders (91.7%; 11 studies), with improvements in mean Constant score ranging from 18.5 to 49.6 points. Patient satisfaction was assessed in 105 patients (37.0%; 5 studies), with rates of patients indicating they were satisfied or very satisfied with their treatment outcome ranging from 45.8% to 100%. A total of 6 patients (2.1%) experienced complications related to balloon spacer implantation, including transient neurapraxia of the lateral antebrachial cutaneous nerve, superficial wound infection, deep wound infection, and balloon migration. Of these, 3 patients (2 balloon migration, 1 deep wound infection) required subsequent surgeries for balloon removal.

Conclusion

Placement of the subacromial balloon spacer is a minimally invasive, technically simple procedure with favorable patient-reported outcomes at limited short-term follow-up. However, inherent methodological limitations and patient heterogeneity between studies may impair our ability to fully characterize the longer term efficacy, particularly relative to other potential surgical options. Further prospective randomized or comparative studies are warranted to ascertain clinical outcomes of subacromial balloon spacer in the management of massive and irreparable RCTs.

Comparing Clinical Outcomes After Subacromial Spacer Insertion Versus Other Reconstruction Methods in the Treatment of Irreparable Massive Rotator Cuff Tears

Background:

Previous studies on subacromial spacer (SAS) insertion have been limited to case series that did not compare the effectiveness of this technique with other techniques.

Hypothesis:

Outcomes after SAS insertion for the treatment of irreparable massive rotator cuff tears (IMRCTs) will be similar to those of other techniques.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This retrospective study was based on data collected from patients who underwent correction of IMRCTs between January 2010 and October 2017. Group 1 patients (n = 17) received SAS insertion with or without partial repair; group 2 patients (n = 36) were treated with other techniques (isolated partial repairs or bridging grafts). Preoperative tear size and global fatty degeneration index values were evaluated. Range of motion, visual analog scale for pain, American Shoulder and Elbow Surgeons (ASES) score, Constant score, Simple Shoulder Test (SST), Disabilities of the Arm, Shoulder and Hand score, and acromiohumeral distance (AHD) were assessed preoperatively and at final follow-up at least 2 years after the surgery (range, 24-60 months). In both groups, ultrasonographic examination was performed at 3 and 6 months postoperatively, and magnetic resonance imaging (MRI) was performed at 1 year.

Results:

Tear size and preoperative global fatty degeneration index were not significantly different between the groups (all P > .05). There were no differences in functional scores between the groups at final follow-up (all P > .05). AHD was maintained at final follow-up in group 1 (mean ± SD: 6.2 ± 2.1 mm [postoperatively] vs 6.7 ± 2.3 mm [final follow-up]; P = .678), and there was no difference compared with group 2 (7.2 ± 3.2 mm; P = .244). Patients with retears in group 2 (23 of 36, 63.9%) had lower ASES (P = .041) and SST (P = .027) scores at final follow-up when compared with patients in group 1. Six patients (35.3%) in group 1 had partial repairs; these patients had better external rotation at 90° (P = .047), better SST scores (P = .036), and higher AHDs at final follow-up (P = .046) than those in group 1 who had no repair. Three patients (50%) showed retears of partially repaired tendons on MRI. Of 13 patients (76.5%) in group 1 with postoperative MRI, 12 (92.3%) showed fibrotic tissue in the subacromial space not seen preoperatively.

Conclusion:

There was no difference in outcomes between SAS and the other reconstruction methods for treating IMRCTs. However, given the high retear rate associated with other techniques and poor functional outcomes after retear, SAS insertion could be a viable option for treating IMRCTs.

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.

Graft tears after arthroscopic superior capsule reconstruction (ASCR): pattern of failure and its correlation with clinical outcome

INTRODUCTION

Arthroscopic superior capsule reconstruction (ASCR) using fascia lata autograft is a new surgical technique developed to overcome irreparable rotator cuff tears. There is little information about graft tear after ASCR and its impact on clinical outcome. This study is to investigate the graft tear rate, pattern of failure, and its correlation with clinical outcomes after arthroscopic superior capsule reconstruction (ASCR).

MATERIALS AND METHODS

From June 2013 to June 2016, 31 shoulders in 31 consecutive patients (mean 65.3 years) underwent ASCR using fascia lata autograft for irreparable large-to-massive tears. Magnetic resonance imaging (MRI) was performed before surgery and at mean 12.8 months (12-24 months) after surgery to assess fatty infiltration progression and graft integrity. Graft tear was defined as the loss of graft continuity and was categorized as medial and lateral rows according to the failure location. Acromiohumeral distance (AHD) was pre- and postoperatively measured with the standard radiograph. Pain visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, constant score, and physical examination were used to assess clinical outcomes. Average follow-up was 15 months (range 12-24 months) after surgery.

RESULTS

Mean active forward elevation increased from 133° to 146° (P = 0.011). Mean VAS score, ASES score, and constant score significantly improved: from 6 to 2.5, 54.4 to 73.7, and 51.7 to 63.7, respectively (P < 0.001). There was no remarkable progression of fatty infiltration after surgery. AHD increased from 5.3 mm preoperatively to 6.4 mm postoperatively (P < 0.016). Nine patients (29%) showed graft tear on follow-up MRI: 7 and 2 at the medial and lateral rows, respectively. Although the intact graft group showed better outcomes than the graft tear group (pain VAS score 2.3 vs. 3.0; ASES score 74.1 vs. 69.8; constant score 63.4 vs. 57.9), the results were not statistically significant.

CONCLUSIONS

Graft tear rate after ASCR assessed by MRI was 29%, and failures mostly occurred at the medial row. The graft tear group showed clinical improvement despite the recurred superior capsule defect.

LEVEL OF EVIDENCE

IV, case series, treatment study.

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.

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.

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.

Arthroscopic In Situ Superior Capsular Reconstruction Using the Long Head of the Biceps Tendon

Large to massive rotator cuff tears are challenging to repair, although there are several options for dealing with them. Among them, superior capsular reconstruction was recently introduced as an effective procedure for retaining the static stability of the shoulder joint and preventing the progression to cuff tear arthropathy. The purpose of this technique-based article is to describe a surgical option, called arthroscopic in situ superior capsular reconstruction, for large to massive rotator cuff tears using the long head of the biceps tendon.

The Role of Superior Capsule Reconstruction in Rotator Cuff Tears

Massive, irreparable rotator cuff disease is a challenging problem to treat, especially in the younger active patient. This condition allows the deltoid to generate anterosuperior translation and shoulder dysfunction. Ideally, this dysfunction may be improved with rotator cuff repair. However, in the setting of irreparable rotator cuff disease, normal function is challenging to restore. Superior capsule reconstruction theoretically improves function by recentering the humeral head and improving glenohumeral kinematics. This restoration of stability results in a stable fulcrum, and may allow the deltoid and remaining cuff can function more effectively.

Biceps Tenotomy Does not Affect the Functional Outcomes of Patients Treated with Spacer Implantation Due to Massive Irreparable Rotator Cuff Tears

Background:

Lesions of the long head of the biceps (LHB) tendon are frequently associated with massive rotator cuff tears (RCT) and may be responsible for shoulder pain and disability.

Objective:

This study aimed to evaluate functional outcomes of arthroscopic biodegradable spacer implantation with or without biceps tenotomy as treatment for persistent shoulder dysfunction and pain due to a massive irreparable RCT.

Methods:

A total of 48 patients were implanted with the subacromial spacer using arthroscopic approach with or without biceps tenotomy. All patients were assessed for up to 12 months post-implantation and 18 patients were assessed for at least 24 months (and a maximum of 40 months). Improvement in shoulder function was assessed using Constant score.

Results:

Subacromial spacer implantation was performed arthroscopically in 48 patients. The mean total Constant score increased from 36 at baseline to 67 points at 12 months post implantation. Patients who underwent LHB tenotomy in addition to the subacromial spacer presented similar improvement of their shoulder function and score compared to the group that was treated with the spacer alone.

Conclusion:

Current study demonstrates that spacer implantation in this patient population provides significant improvement in function and decreases the pain. Additional LHB tenotomy did not influence the postoperative results during the follow-up.

Intraobserver and interobserver reliability of the Copeland-Levy classification for arthroscopic evaluation of subacromial impingement

BACKGROUND

Defining a simple and reliable classification for acromial and bursal impingement lesions is necessary to standardize terminology, to improve communication, and to allow better evaluation of the proper treatment of impingement lesions and rotator cuff tears. The purpose of this study was to assess orthopedic surgeons' intraobserver and interobserver reliability of the Copeland-Levy classification.

METHODS

Six fellowship-trained orthopedic surgeons reviewed shoulder arthroscopy videos of 69 consecutive patients who underwent shoulder arthroscopy for rotator cuff tear repair or subacromial decompression. The surgeons were asked to classify impingement lesions according to the Copeland-Levy classification. One month afterward, the surgeons were requested to repeat the evaluation of the same impingement lesions. Intraobserver reliability was calculated using Cohen's weighted κ. Interobserver reliability was calculated using Kendall's W.

RESULTS

Overall intraobserver reliability for acromial and bursal lesions was κ = 0.86 (95% confidence interval, 0.82-0.9) and κ = 0.97 (95% confidence interval, 0.95-0.98), respectively. Interobserver reliability for acromial and bursal lesions was W = 0.87 and W = 0.92, respectively.

CONCLUSION

Intraobserver and interobserver reliability of the Copeland-Levy classification among senior orthopedic surgeons is excellent. Hence, we suggest the Copeland-Levy classification be used to standardize terminology of the subacromial impingement lesion.

Early promising outcome following arthroscopic implantation of the subacromial balloon spacer for treating massive rotator cuff tear

BACKGROUND

Massive rotator cuff tear (RCT) can result in disability and severe pain. When conservative treatment fails, surgical treatment should be considered, as various surgical options can provide relatively satisfactory results. However, choosing an optimal treatment remains controversial. A relatively new treatment for irreparable RCT is the arthroscopic implantation of a biodegradable balloon spacer into the subacromial space. Here, we examined whether placement of this balloon spacer reduces pain and improves functional outcome in patients with an irreparable RCT. Patients were followed for 1 year following implantation.

METHODS

In this prospective single-arm study, a biodegradable balloon spacer was implanted into the subacromial space of patients with a massive RCT. Pain was evaluated using a numeric rating scale (NRS), and functional outcome was evaluated using the Oxford shoulder score (OSS) and the Constant-Murley shoulder score (CMS). Five follow-up visits were performed during the first postoperative year.

RESULTS

Forty-six shoulders in 44 patients with massive RCT were treated by surgical implantation of the subacromial balloon spacer. The mean reduction in NRS score was 3.5 points (95% CI 2.5-4.4), and 74% of patients achieved the minimal clinically important difference of 2 points by the 1-year follow-up visit. Functional outcome improved significantly based on OSS and CMS scores, and 80% of patients reported that they were satisfied with their outcome. No surgical or postoperative medical complications due to implantation of the balloon spacer were reported.

CONCLUSIONS

Our results suggest that arthroscopic implantation of a biodegradable balloon spacer in the subacromial space significantly reduces pain and improves activities of daily living in patients with massive RCT during 1 year of follow-up. The specific contribution of the balloon with respect to improved clinical outcome needs further study, ideally in a randomized controlled trial.

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.

The development of a quantitative scoring system to predict whether a large-to-massive rotator cuff tear can be arthroscopically repaired

AIMS

The aim of the study was to develop a quantitative scoring system to predict whether a large-to-massive rotator cuff tear was arthroscopically reparable prior to surgery.

PATIENTS AND METHODS

We conducted a retrospective review of the pre-operative MR imaging and surgical records of 87 patients (87 shoulders) who underwent arthroscopic repair of a large-to-massive rotator cuff tear. Patients were divided into two groups, based on the surgical outcome of the repair. Of the 87 patients, 53 underwent complete repair (Group I) and 34 an incomplete repair (Group II). Pre-operative MR images were reviewed to quantify several variables. Between-group differences were evaluated and multiple logistic regression analysis was used to calculate the predictive value of significant variables. The reparability index (RI) was constructed using the odds ratios of significant variables and a receiver operating characteristic curve analysis performed to identify the optimal RI cutoff to differentiate between the two groups.

RESULTS

The following variables were identified as independent predictors of arthroscopic reparability: the size of the defect with medial-lateral diameter (cutoff, 4.2 cm) and anterior-posterior diameter (cutoff, 3.7cm); Patte's grade of muscle atrophy (cutoff, grade 3) and Goutallier grade of fatty degeneration (cutoff, grade 3). An RI cutoff value of 2.5 provided the highest differentiation between groups I and II, with an area under the curve of 0.964, and a sensitivity of 73.5% and specificity of 96.2%.

CONCLUSION

The RI developed in our study may prove to be an efficient clinical scoring system to predict whether a large-to-massive rotator cuff tear is arthroscopically reparable. Cite this article: Bone Joint J 2016;98-B:1656-61.

The biodegradable spacer as a novel treatment modality for massive rotator cuff tears: a prospective study with 5-year follow-up

BACKGROUND

The management of massive, irreparable rotator cuff tears (RCT) is challenging and associated with high failure rates. There are no current consensus or definitive guidelines concerning the optimal surgical treatment for this devastating condition. This study was designed to confirm the long-term safety and efficacy of the biodegradable inflatable InSpace™ system in patients with massive reparable or irreparable RCTs.

METHODS

In this open-label, single arm, prospective study, subjects with massive RCT underwent subacromial implantation with the biodegradable spacer. Follow-up visits were scheduled according to routine clinical practice. Shoulder function was evaluated using Total Constant Score (TCS).

RESULTS

Twenty-four patients were treated and assessed. Four patients had partial tears, and in three of them RC repair was performed. These patients were not included in the efficacy analyses. Of the participating subjects who reached the 5-year follow-up, 84.6% of the patients showed a clinically significant improvement of at least 15 points in their score, while 61.54% showed at least 25 points of improvement. Only 10% of the treated patients showed no improvement or worsening in the shoulder score comparing to their baseline. An overall improvement in the total CS commencing at 3 months and sustained by 6 months through to 5 years of follow-up (P < 0.0001) was demonstrated.

CONCLUSIONS

We conclude that in this initial cohort, arthroscopic implantation of InSpace™ system represented an effective alternative to the existing arthroscopic procedures in patients with painful massive RCT refractory to conservative management. Further randomized controlled trials comparing the clinical and functional outcomes after implantation of the InSpace™ device are warranted.

Functional status and failed rotator cuff repair predict outcomes after arthroscopic-assisted latissimus dorsi transfer for irreparable massive rotator cuff tears

BACKGROUND

Arthroscopic-assisted latissimus dorsi tendon transfer (LDTT) has been recently introduced for treatment of irreparable, posterosuperior massive rotator cuff tears. We sought to evaluate the functional outcomes of this technique and to check for possible outcome predictors.

METHODS

The study reviewed 86 patients (aged 59.8 ± 5.9 years) who underwent an arthroscopic-assisted latissimus dorsi tendon transfer after 36.4 ± 9 months of follow-up. Of these, 14 patients (16.3%) sustained an irreparable massive rotator cuff tear after a failed arthroscopic rotator cuff repair. The Constant and Murley score (CMS) was used to assess patients' functionality preoperatively and at follow-up.

RESULTS

As a group, the CMS improved with surgery from 35.5 ± 6.1 to 69.5 ± 12.3 (P < .001). A lower preoperative CMS and a previous failed rotator cuff repair resulted in lower postoperative range of motion (P = .044 and P = .007, respectively) and CMS (P = .042 and P = .018, respectively). A previous rotator cuff repair resulted in lower satisfaction with surgery (P = .009). Gender and age did not affect the clinical outcomes.

CONCLUSIONS

Our results support the effectiveness of arthroscopic-assisted LDTT in the treatment of patients with an irreparable, posterosuperior massive rotator cuff tears in pain relief, functional recovery, and postoperative satisfaction. Patients with lower preoperative CMS and a history of failed rotator cuff repair have a greater likelihood of having a lower clinical result. However, the favorable values of summary postoperative scores do not exclude these patients as candidates for arthroscopic-assisted LDTT.

Long-term outcome of tuberoplasty for irreparable massive rotator cuff tears: is tuberoplasty really applicable?

BACKGROUND

Tuberoplasty is a therapeutic option for irreparable massive rotator cuff tear (RCT). However, no study has reported long-term outcomes after arthroscopic tuberoplasty.

METHODS

We evaluated 16 patients who underwent arthroscopic tuberoplasty for symptomatic irreparable massive RCT without pseudoparalysis. Patients were a mean age of 64 years (range, 43-80 years) at the time of the operation, and the mean duration of follow-up was 98 months (range, 84-126 months).

RESULTS

At the last follow-up, the visual analog scale score for pain during motion had decreased to 2.3 from a preoperative mean of 6.9 (P < .001). The mean University of California at Los Angeles and Constant scores improved from 10.3 and 37.9 preoperatively to 27.2 and 59.2, respectively, at the last follow-up (P < .001 for both). The best University of California at Los Angeles (UCLA) and Constant scores during the follow-up duration were 28.3 and 60.3, respectively, at 5 years. The mean acromiohumeral interval changed from 5 mm preoperatively to 4 mm at the last follow-up. The rate of continuity in the inferior scapulohumeral line decreased significantly from 69% (11 shoulders) preoperatively to 19% (3 shoulders) at the last follow-up (P = .011). Only 1 patient underwent revision surgery.

CONCLUSIONS

Arthroscopic tuberoplasty yielded satisfactory outcomes during a mean 8-year follow-up period. Although superior migration of the humeral head progressed with time, the clinical outcomes were not affected. Arthroscopic tuberoplasty is a good option for relieving pain and improving functionality in nonpseudoparalytic patients with painful irreparable massive RCT.

Arthroscopic Superior Capsular Reconstruction for Treatment of Massive Irreparable Rotator Cuff Tears

Massive irreparable rotator cuff tears have been troublesome entities to treat, especially in younger patients. Few good options exist, leaving most patients in recent years receiving a reverse total shoulder arthroplasty. Reverse shoulder arthroplasty carries serious risks, a limited lifespan, and no other viable options should it fail. Recent biomechanical studies have shown that the superior capsule is critical to containing the glenohumeral joint reduced, allowing the larger muscles like the deltoid and pectoralis major to function properly. The superior capsular reconstruction is an anatomic reconstruction of the superior capsule to restore the normal restraint to superior translation that occurs with a deficient rotator cuff. The technique described in this article is an arthroscopic reconstruction of the superior capsule with dermal allograft.