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Hsu KL, Kuan FC, Velasquez Garcia A, Hong CK, Chen Y, Shih CA, Su WR. Factors associated with reparability of rotator cuff tears: a systematic review and meta-analysis. J Shoulder Elbow Surg 2024; 33:e465-e477. [PMID: 38642872 DOI: 10.1016/j.jse.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 02/18/2024] [Accepted: 03/03/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND To identify and quantify the factors associated with the reparability of rotator cuff tears (RCTs). METHODS PubMed, Scopus, and Web of Science databases were searched for clinical studies published in English focusing on RCT reparability by using the keywords "rotator cuff tear" and "reparability". A meta-analysis was conducted if ≥3 studies examined the same factor and provided enough data to assess RCT reparability. Quality assessment was completed using the quality assessment of diagnostic accuracy studies tool. RESULTS Eighteen studies (2700 patients) were enrolled and 26 factors were included in the meta-analysis. The dichotomous variables associated with irreparability were Patte stage 3 (odds ratio (OR): 8.0, 95% confidence interval [CI]: 4.3-14.9), massive tear vs. large tear (OR: 3.1, 95% CI: 1.3-7.2), Goutallier stage for each tendon, and tangent sign (OR: 11.1, 95% CI: 4.3-28.4). The continuous variables associated with irreparability were age (mean difference (MD): 3.25, 95% CI: 1.4-5.1), mediolateral tear size (MD: 12.3, 95% CI: 5.8-18.9), anteroposterior tear size (MD: 10.4, 95% CI: 5.2-15.6), acromiohumeral distance on X-ray (MD: -2.3, 95% CI: -3.0 to -1.6) and magnetic resonance imaging (MD: -1.8, 95% CI: -2.8 to -0.9), and inferior glenohumeral distance on magnetic resonance imaging (MD: 2.2, 95% CI: 1.4-3.0). CONCLUSION This study revealed that older age, larger tear size, severe fatty infiltration, muscle atrophy, and advanced superior migration of the humeral head were strongly associated with irreparable RCTs. Conversely, clinical symptoms provided limited information for predicting reparability. Additionally, the tangent sign emerged as a powerful and simple tool for individual prediction, and several quantitative scoring systems also proved useful.
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Affiliation(s)
- Kai-Lan Hsu
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Fa-Chuan Kuan
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ausberto Velasquez Garcia
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Orthopedic Surgery, Clinica Universidad de los Andes, Santiago, Chile
| | - Chih-Kai Hong
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yueh Chen
- Department of Orthopedics, Kaohsiung Veterans General Hospital Tainan Branch, Tainan, Taiwan
| | - Chien-An Shih
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ren Su
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Bi AS, Anil U, Colasanti CA, Kwon YW, Virk MS, Zuckerman JD, Rokito AS. Comparison of Multiple Surgical Treatments for Massive Irreparable Rotator Cuff Tears in Patients Younger Than 70 Years of Age: A Systematic Review and Network Meta-analysis. Am J Sports Med 2024; 52:2919-2930. [PMID: 38291995 DOI: 10.1177/03635465231204623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Massive irreparable rotator cuff tears (MIRCTs) remain a challenging treatment paradigm, particularly for nonelderly patients without pseudoparalysis or arthritis. PURPOSE To use a network meta-analysis to analyze comparative studies of surgical treatment options for MIRCTs in patients <70 years of age for several patient-reported outcomes, range of motion (ROM), and acromiohumeral distance (AHD). STUDY DESIGN Network meta-analysis of comparative studies; Level of evidence, 3. METHODS A systematic review of the literature, using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, of the MEDLINE, Embase, and Cochrane Library databases was conducted from 2017 to 2022. Inclusion criteria were (1) clinical comparative studies of MIRCTs (with several study-specific criteria); (2) ≥1 outcome of interest reported on, with standard deviations; (3) minimum 1-year follow-up; and (4) mean age of <70 years for both cohorts, without arthritis or pseudoparalysis. There were 8 treatment arms compared. Outcomes of interest were the American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, visual analog scale for pain, AHD, and forward flexion and external rotation ROM. A frequentist approach to network meta-analysis with a random-effects model was performed using the netmeta package Version 0.9-6 in R. RESULTS A total of 23 studies met the inclusion criteria, with 1178 patients included in the network meta-analysis. There was a mean weighted age of 62.8 years, 568 (48.2%) men, with a mean follow-up of 28.9 months. There were no significant differences between groups in regard to sex (P = .732) or age (P = .469). For the ASES score, InSpace balloon arthroplasty (mean difference [MD], 12.34; 95% CI, 2.18 to 22.50; P = .017), arthroscopic bridging graft (aBG) (MD, 7.07; 95% CI, 0.28 to 13.85; P = .041), and long head of biceps augmented superior capsular reconstruction (BSCR) (MD, 5.16; 95% CI, 1.10 to 9.22; P = .013) resulted in the highest P-scores. For the Constant-Murley score, debridement (MD, 21.03; 95% CI, 8.98 to 33.08; P < .001) and aBG (MD, 6.97; 95% CI, 1.88 to 12.05; P = .007) resulted in the highest P-scores. For AHD, BSCR resulted in the highest P-score (MD, 1.46; 95% CI, 0.45 to 2.48; P = .005). For forward flexion ROM, debridement (MD, 45.77; 95% CI, 25.41 to 66.13; P < .001) resulted in the highest P-score, while RSA resulted in the lowest P-score (MD, -16.70; 95% CI, -31.20 to -2.20; P = .024). CONCLUSION For patients <70 years with MIRCT without significant arthritis or pseudoparalysis, it appears that graft interposition repair techniques, superior capsular reconstruction using the long head of the biceps tendon, arthroscopic debridement, and balloon arthroplasty provide superiority in various outcome domains, while RSA provides the least benefit in forward flexion.
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Affiliation(s)
- Andrew S Bi
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Utkarsh Anil
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Christopher A Colasanti
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Young W Kwon
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Mandeep S Virk
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Joseph D Zuckerman
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Andrew S Rokito
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
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DeFoor MT, Riem L, Cognetti DJ, Cousins M, DuCharme O, Feng X, Blemker SS, Antosh IJ, Cote MP, Werner BC, Sheean AJ. Novel 3D MRI-based volumetric assessment of rotator cuff musculature demonstrates stronger correlation with preoperative functional status when compared to the Goutallier grading scheme. J Shoulder Elbow Surg 2024:S1058-2746(24)00245-3. [PMID: 38604396 PMCID: PMC11464636 DOI: 10.1016/j.jse.2024.02.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 02/20/2024] [Accepted: 02/24/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND The Goutallier classification (GC) is used to assess fatty atrophy in rotator cuff (RC) tears, yet limitations exist. A battery of 3-dimensional (3D) magnetic resonance imaging (MRI) volumetric scores (VSs) was developed to provide comprehensive characterization of RC pathology. The purposes of this study were to (1) describe the correlation between GC and VSs for supraspinatus changes in RC tears, (2) characterize the chronicity of RC tears using a battery of 12 VS measurements, and (3) compare GC and VSs to determine which method most closely corresponds with preoperative patient-reported outcome measures (PROMs). METHODS Preoperative shoulder MRIs were reviewed after arthroscopic RC repair. Preoperative GC stage and Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores were collected. The battery of VSs included fat infiltration (FIS), muscle size (MSS), and relative volume contribution (RCS) for each RC muscle. Backward linear regression was performed to compare GC stage with preoperative PROMIS PF and PI to determine which VS measurement most closely correlated with preoperative PROMs. RESULTS Eighty-two patients underwent RC repair (mean age 55 ± 8.2 years, 63% male, 68% GC stage ≤1). In evaluation of the supraspinatus, there was a moderate positive correlation between GC and FIS (r = 0.459, P < .001); strong negative correlations were observed between MSS (r = -0.800, P < .001) and RCS (r = -0.745, P < .001) when compared to GC. A negligible linear correlation was observed between GC and preoperative PROMIS PF (r = -0.106, P = .343) and PI (r = -0.071, P = .528). On multivariate analysis, subscapularis MSS (β >0, P = .064) was a positive predictor and subscapularis FIS (β <0, P = .137), teres minor MSS (β <0, P = .141), and FIS (β <0, P = .070) were negative predictors of preoperative PF (r = 0.343, P = .044); in contrast, supraspinatus MSS (β >0, P = .009) and FIS (β >0, P = .073), teres minor FIS (β >0, P = .072), and subscapularis FIS (β >0, P = .065) were positive predictors of preoperative PI (r = 0.410, P = .006). CONCLUSION Although the criterion standard in evaluation of RC pathology, GC demonstrated negligible correlation with preoperative functional disability. Alternatively, a battery of 3D VSs showed strong correlation with GC through a quantitative, comprehensive evaluation of the RC unit including several moderate predictors of preoperative functional disability.
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Affiliation(s)
| | - Lara Riem
- Springbok Analytics, Charlottesville, VA, USA
| | | | | | | | - Xue Feng
- Springbok Analytics, Charlottesville, VA, USA
| | | | - Ivan J Antosh
- San Antonio Military Medical Center, San Antonio, TX, USA
| | - Mark P Cote
- Massachusetts General Hospital, Boston, MA, USA
| | - Brian C Werner
- University of Virginia Health System, Charlottesville, VA, USA
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Guevara-Alvarez A, Valencia-Ramon EA, Bothorel H, Collin P, Zbinden J, Guizzi A, Lädermann A. Traumatic and Atraumatic Rotator Cuff Tears Have the Same Rates of Healing. Arthrosc Sports Med Rehabil 2024; 6:100867. [PMID: 38379596 PMCID: PMC10877195 DOI: 10.1016/j.asmr.2023.100867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 12/15/2023] [Indexed: 02/22/2024] Open
Abstract
Background To examine whether traumatic rotator cuff repairs (RCRs) differ in postoperative rotator cuff tendon integrity and functional outcomes from degenerative RCRs. Methods RCRs performed by a single surgeon were retrospectively identified. The inclusion criteria were repairable Goutallier grades 0 to 2 full-thickness rotator cuff tears. Demographic and clinical data as well as radiological results were compared. A multivariate logistic regression of the of patient acceptable symptom state for American Shoulder and Elbow Surgeons (ASES) score was performed to evaluate whether the origin of tear led to a different relative risk (RR) independently from tear and surgical characteristics. Results A total of 616 consecutive shoulders (304 traumatic and 312 degenerative) were finally included. Traumatic ruptures presented a greater distribution of male (72% vs 51%, P < .001) and younger patients (53 vs 57 years, P < .001), as well as earlier onset of symptoms (3 vs 15 months, P < .001), reduced range of motion in preoperative assessment for forward elevation (130° vs 150°, P < .001), and slightly greater preoperative ASES (46.5 ± 19.7 vs 50.0 ± 18.0, P = .022) and Constant (47.0 ± 20.2 vs 52.0 ± 18.9, P = .001) scores. Degenerative tears presented a lower proportion of grade 3 tendon coronal retraction (11% vs 18%, P = .031). Postoperative tendon integrity at 6 months was comparable for both groups, predominantly Sugaya types 1 and 2 (91% traumatic; 92% degenerative, P = .371). Both groups exhibited favorable outcomes in range of motion and postoperative functional scores at last follow-up. The multivariate regression confirmed that the tear origin was not significantly associated with patient acceptable symptom state achievement (P = .201) but rather with greater preoperative ASES score (RR, 1.01), men (RR, 1.16) and workers' compensation (RR, 0.65) (P < .05). Conclusions Traumatic cases were frequent, involved younger patients, more frequently affected the anterior rotator cuff, and were associated with more severe tendon retraction. Traumatic and degenerative RCRs lead to comparable clinical and radiologic results. Level of Evidence Level III, retrospective comparative study.
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Affiliation(s)
| | | | - Hugo Bothorel
- Research Department, La Tour Hospital, Meyrin, Switzerland
| | | | - Jeanni Zbinden
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | - Alberto Guizzi
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia (BS), Italy
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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Ho SW, Martinho T, Amiri A, Zbinden J, Chong XL, Bothorel H, Collin P, Lädermann A. Clinical and Radiologic Outcomes of Arthroscopic Rotator Cuff Repair in Medial Bursal-Side Fosbury Flop Tears Compared With Tendinous Avulsion Lesions. Arthrosc Sports Med Rehabil 2024; 6:100879. [PMID: 38362484 PMCID: PMC10867421 DOI: 10.1016/j.asmr.2023.100879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 12/22/2023] [Indexed: 02/17/2024] Open
Abstract
Purpose To determine the clinical and radiologic outcomes after surgical repair of medial bursal-side Fosbury flop rotator cuff tears compared with traditional avulsion of tendinous attachments lesions. Methods A retrospective cohort study was performed. All patients who had undergone arthroscopic posterosuperior repair were recruited. Patients with previous shoulder rotator cuff surgery were excluded. Recruited patients were divided into 2 groups: one presenting Fosbury flop tears and the other presenting with standard avulsion lesions. Preoperative demographics such as age, gender, and arm dominance were recorded. Range of motion (ROM), visual analog scale (VAS) for pain and satisfaction, Constant score, Single Alpha-Numeric Evaluation score, and American Shoulder and Elbow Surgeons score were evaluated at 3 points in time: preoperatively, and at 6 months and minimum 1-year postoperatively. The healing of repaired cuffs was evaluated by ultrasound at 6 months. Results Two hundred thirty-six patients were recruited, with 27 (11.4%) Fosbury flop tears and 209 (88.6%) tendon avulsions. Although there was no significant difference in gender or arm dominance between the groups, Fosbury flop tears had significantly older patients (P < .05) with a mean age 61.6 years (standard deviation 9.0), compared with tendon avulsions with a mean age of 56.1 years (standard deviation 9.1). There was no significant difference in tendon retraction between the groups. Both groups demonstrated significant improvement in ROM, visual analog scale, American Shoulder and Elbow Surgeons, Single Alpha-Numeric Evaluation, and Constant score postoperatively at 6 months and minimum 1 year. The groups demonstrated no significant difference in the ROM and clinical scores. There was a nonsignificant difference in re-tear rate of 7.4% (2/27) in Fosbury flop tears compared with 2.8% (6/209) in tendon avulsions (P = .361). Conclusions Arthroscopic rotator cuff repair of medial bursal side Fosbury Flop rotator cuff tears results in favorable clinical and radiologic outcomes at 4 years after surgery. These outcomes are comparable with surgically repaired avulsion lesions, with an acceptable retear rate after arthroscopic repair. Level of Evidence Level III, retrospective comparative prognostic trial.
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Affiliation(s)
- Sean W.L. Ho
- Department of Orthopedic Surgery, Tan Tock Seng Hospital, Singapore
| | - Tiago Martinho
- Division of Orthopaedics and Trauma Surgery, Hôpital de La Tour, Meyrin, Switzerland
| | - Arash Amiri
- Division of Orthopaedics and Trauma Surgery, Hôpital de La Tour, Meyrin, Switzerland
| | - Jeanni Zbinden
- Division of Orthopaedics and Trauma Surgery, Hôpital de La Tour, Meyrin, Switzerland
| | | | - Hugo Bothorel
- Research Department, Hôpital de La Tour, Meyrin, Switzerland
| | | | - Alexandre Lädermann
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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Sewpaul Y, Sheean AJ, Rashid MS, Hartzler RU. Subacromial Balloon Spacer for the Massive Irreparable Cuff Tear. Curr Rev Musculoskelet Med 2024; 17:47-57. [PMID: 38194186 PMCID: PMC10806962 DOI: 10.1007/s12178-023-09879-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW The purpose of the review is to provide an updated overview of a relatively novel but controversial surgical device (InSpace subacromial balloon, Stryker, Kalamazoo, MI) that can be readily incorporated into the armamentarium of the shoulder surgeon. The authors review the critical clinical and surgical decision-making aspects of InSpace. A recommended surgical technique and rehabilitation protocol are outlined. The authors present a nuanced view of the balloon spacer in the continuum of care of the irreparable rotator cuff tear. RECENT FINDINGS Within the last year, two Level I clinical trials have been published, and the data from these studies offer conflicting evidence regarding the utility of the subacromial balloon spacer. The current review contrasts these two recent studies and offers a framework by which the available evidence can be practically understood with respect to clinical decision-making. The literature currently supports a limited indication for use of InSpace: the elderly, low-demand patient with preserved active range of motion with an operatively irreparable, posterosuperior rotator cuff tear with an intact subscapularis. The InSpace subacromial balloon spacer is a simple device that can yield substantial improvements in clinical outcomes among a subset of patients with irreparable rotator cuff tears. InSpace is not a panacea for the complex, irreparable rotator cuff tear. Individualized decision-making is necessary in this diverse and challening patient population.
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Affiliation(s)
- Yash Sewpaul
- Lancaster University Medical School, Lancaster, UK
| | | | | | - Robert U Hartzler
- TSAOG Orthopaedics, 19138 U.S. Hwy 281 N, San Antonio, TX, 78258, USA.
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Kuan FC, Shih CA, Su WR, Garcia AV, Kuroiwa T, Iida N, Hsu KL. Definition of irreparable rotator cuff tear: a scoping review of prospective surgical therapeutic trials to evaluate current practice. BMC Musculoskelet Disord 2023; 24:952. [PMID: 38066535 PMCID: PMC10704799 DOI: 10.1186/s12891-023-07067-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 11/25/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND The definition of irreparable rotator cuff tear (IRCT) is controversial. This scoping review provides definitions used to describe IRCT in the literature. This scoping review (1) identified criteria used in the definition of IRCT and (2) investigated the current state of those criteria in prospective surgical therapeutic trials. METHODS This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. PubMed, Scopus, and Web of Science were searched in March 2023. Studies were screened against predetermined inclusion and exclusion criteria. Criteria regarding clinical symptoms, preoperative images, and intraoperative findings were captured respectively. RESULTS A total of 41 prospective studies were eligible for inclusion, and 35 studies (85.4%) defined IRCT. IRCT was defined on the basis of the following main criteria: preoperative image findings (28/35), intraoperative findings (24/35), and symptoms (16/35). With regard to preoperative images, IRCT was mainly defined on the basis of retraction of the tendon in the coronal plane (22/28), the severity of fatty degeneration (19/28), and ruptured tendon number or width of the defect in the sagittal plane (17/28). CONCLUSION This scoping review highlights the lack of a standardized definition for IRCT in clinical practice, with common predictive criteria including a duration of over 6 months, retraction beyond 5 cm, Goutallier grade 3 fatty infiltration, and the rupture of two or more tendons. However, surgeons should apply more than one criterion when examining preoperative images and confirm reparability during surgery. A more objective manner of evaluating intraoperative reparability is necessary.
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Affiliation(s)
- Fa-Chuan Kuan
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Rd, Tainan, Taiwan
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
- Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Division of Traumatology, National Cheng Kung University Medical Center, Tainan, Taiwan
| | - Chien-An Shih
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Rd, Tainan, Taiwan
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ren Su
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Rd, Tainan, Taiwan
- Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Ausberto Velasquez Garcia
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Orthopedic Surgery, Clinica Universidad de los Andes, Santiago, Chile
| | - Tomoyuki Kuroiwa
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Naoya Iida
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kai-Lan Hsu
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Rd, Tainan, Taiwan.
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.
- Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan.
- Division of Traumatology, National Cheng Kung University Medical Center, Tainan, Taiwan.
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
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Denard PJ. An Algorithmic Approach to the Surgical Management of Massive Rotator Cuff Tears Based on Imaging, Function, and Repairability. Arthroscopy 2023; 39:2392-2397. [PMID: 37866877 DOI: 10.1016/j.arthro.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/03/2023] [Accepted: 06/04/2023] [Indexed: 10/24/2023]
Abstract
Massive rotator cuff tears are one the most challenging conditions to treat in the shoulder. A variety of surgical approaches have been used to manage massive rotator cuff tears, such as repair with or without augmentation, superior capsule reconstruction, tendon transfer, and reverse shoulder arthroplasty. The choice between joint preservation or reverse shoulder arthroplasty is first considered based on preoperative imaging and functional status, as well as patient factors. When joint preservation is the goal of treatment, a combination of repairability, patient function, and age can be used to provide an algorithmic approach to treatment. LEVEL OF EVIDENCE: Level V, expert opinion.
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Mizuki Y, Senjyu T, Ito T, Ueda K, Uchimura T. Extreme Medialized Repair for Challenging Large and Massive Rotator Cuff Tears Reveals Healing and Significant Functional Improvement. Arthroscopy 2023; 39:2122-2130. [PMID: 37116547 DOI: 10.1016/j.arthro.2023.03.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/18/2023] [Accepted: 03/29/2023] [Indexed: 04/30/2023]
Abstract
PURPOSE To evaluate range of motion, muscle strength, clinical outcomes, and radiographic results of the extreme medialized procedure on rotator cuff tears that were initially irreparable. METHODS From arthroscopic rotator cuff repair cases performed at our institution (June 2017 and August 2020), we retrospectively reviewed cases in which the rotator cuff was (1) unable to be withdrawn to the greater tuberosity, (2) repaired using the extreme medialized procedure, and (3) followed up for a minimum of 2 years. Patients with a history of previous surgery were excluded. Preoperative and postoperative scores were used for clinical evaluation. Imaging evaluation used 2-year postoperative magnetic resonance (MR) images. RESULTS Sixty-four patients met the criteria; mean age 68.2 ± 7.9 (range 51-82) years; mean follow-up period 26 ± 2 (24-37) months. Tear size: 45 ± 7.1 (30-70) mm in medial to lateral diameters, 40 ± 9.3 (30-60) mm in anteroposterior diameter; suture anchor number: 5.5 ± 1.2 (4-8). The visual analog scale score (50.7 to 11.8), the University of California, Los Angeles, score (12 to 31), constant score (45 to 31), and the American Shoulder and Elbow Surgeons score (53 to 31) at the final follow-up improved compared with preoperative values (all P < .0001). Preoperative and postoperative changes in range of motion also showed improvement in anterior elevation (107° to 151°, P < .0001), abduction (100° to 154°, P < .0001), external rotation (41° to 47°, P = .0238), and internal rotation (L1 to Th10, P < .0001). Muscle strength was also improved in abduction (from 1.9 kg to 5.0 kg, P < .0001) and external rotation (from 3.5 kg to 7.7 kg, P < .0001). MR imaging evaluation revealed 2 cases (3.1%) of retears that fell into type 4 Sugaya classification. CONCLUSIONS Extremely medialized repair of large and massive tears not able to be repaired using conventional techniques led to improved clinical outcomes compared to preoperative conditions. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
| | | | | | - Koki Ueda
- Sasebo Kyosai Hospital, Nagasaki, Japan
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Dommer LM, Chlasta A, Rojas JT, Hayoz A, Schär M, Zumstein MA. Massive rotator cuff tears with short tendon length can be successfully repaired using synthetic patch augmentation. J Shoulder Elbow Surg 2023; 32:2089-2096. [PMID: 37178963 DOI: 10.1016/j.jse.2023.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/24/2023] [Accepted: 03/30/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Choosing the optimal treatment for massive rotator cuff tears (MRCTs) still poses a surgical problem. In MRCTs with good muscle quality, but short tendon length, nonaugmented repairs lead to high failure rates of up to 90%. The aim of the study was to evaluate midterm clinical and radiologic outcomes of massive rotator cuff tears with good muscle quality, but short tendon length, which were repaired with synthetic patch augmentation. METHODS A retrospective study of patients who underwent arthroscopic or open rotator cuff repairs with patch augmentation between 2016 and 2019 was performed. We included patients older than 18 years, who presented with an MRCT confirmed by an magnetic resonance imaging (MRI) arthrogram showing good muscle quality (Goutallier ≤ II) and short tendon length (length <15 mm). Constant-Murley score (CS), Subjective Shoulder Value (SSV), and range of motion (ROM) were compared pre- and postoperatively. We excluded patients older than 75 years or with presence of rotator cuff arthropathy Hamada stage ≥2a. Patients were followed up for 2 years minimum. Clinical failures were defined by reoperation, forward flexion <120° or a relative CS < 70. Structural integrity of the repair was assessed using an MRI scan. Comparison between different variables and outcomes was performed using Wilcoxon-Mann-Whitney and χ2 tests. RESULTS Fifteen patients (mean age 57 years, 13 [86.7%] male, 9 [60%] right shoulders) were reevaluated with a mean follow-up of 43.8 months (27-55 months). There was a significant improvement in the absolute CS (from 33 to 81 points, P = .03), the relative CS (from 41% to 88%, P = .04), the SSV (from 31% to 93%, P = .007), and forward flexion (from 111° to 163°, P = .004) but not in external rotation (from 37° to 38°, P = .5). There were 3 clinical failures (1 atraumatic, 2 traumatic) with reoperations (2 reverse total shoulder arthroplasties and 1 refixation). Structurally, there were 3 Sugaya grade 4 and 5 Sugaya grade 5 reruptures resulting in a retear rate of 53%. The presence of a complete or partial rerupture was not associated with inferior outcomes compared with intact cuff repairs. There were no correlations between the grade of retraction, muscle quality, or rotator cuff tear configuration and rerupture or functional outcomes. CONCLUSION Patch augmented cuff repair leads to a significant improvement of functional and structural outcomes. Partial reruptures were not associated with inferior functional outcomes. Prospective randomized trials are needed to confirm the results found in our study.
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Affiliation(s)
- Lukas M Dommer
- Shoulder, Elbow and Orthopaedic Sports Medicine, Sonnenhof Orthopaedics, Bern, Switzerland
| | - Adrian Chlasta
- Shoulder, Elbow and Orthopaedic Sports Medicine, Sonnenhof Orthopaedics, Bern, Switzerland
| | - J Tomás Rojas
- Shoulder, Elbow and Orthopaedic Sports Medicine, Sonnenhof Orthopaedics, Bern, Switzerland; Department of Orthopaedics and Trauma Surgery, Hospital San José - Clínica Santa María, Santiago, Chile
| | - Annabel Hayoz
- Shoulder, Elbow and Orthopaedic Sports Medicine, Sonnenhof Orthopaedics, Bern, Switzerland
| | - Michael Schär
- Shoulder, Elbow and Orthopaedic Sports Medicine, Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Matthias A Zumstein
- Shoulder, Elbow and Orthopaedic Sports Medicine, Sonnenhof Orthopaedics, Bern, Switzerland; Shoulder, Elbow and Orthopaedic Sports Medicine, Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Bern, Switzerland; Campus Stiftung Lindenhof Bern, Swiss Institute for Translational and Entrepreneurial Medicine, Bern, Switzerland.
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Hommen JP, Heifner JJ, Sakalian PA, Grewal G, Benito J. Irreparable Rotator Cuff Tear Treated With Combined Reconstruction of the Superior Capsule and Rotator Cuff: Technique Guidelines. Arthrosc Tech 2023; 12:e965-e973. [PMID: 37424647 PMCID: PMC10323923 DOI: 10.1016/j.eats.2023.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/23/2023] [Accepted: 02/14/2023] [Indexed: 07/11/2023] Open
Abstract
Irreparable rotator cuff tears in young patients can be challenging for the patient and orthopaedic surgeon. Interposition rotator cuff reconstruction has gained popularity in patients with retracted tears and a viable rotator cuff muscle belly. Superior capsular reconstruction is an emerging treatment option that was developed to restore native glenohumeral joint mechanics by creating a superior constraint, which provides a stable glenohumeral fulcrum. Reconstructing both the superior capsule and rotator cuff tendon in the setting of an irreparable tear may improve clinical results in younger patients with viable rotator cuff muscle belly and a maintained acceptable acromiohumeral distance.
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Affiliation(s)
- Jan Pieter Hommen
- Larkin Hospital Department of Orthopaedics, Coral Gables, Florida, U.S.A
| | - John J. Heifner
- Miami Orthopaedic Research Foundation, Miami, Florida, U.S.A
| | - Philip A. Sakalian
- Larkin Hospital Department of Orthopaedics, Coral Gables, Florida, U.S.A
| | - Gagan Grewal
- Larkin Hospital Department of Orthopaedics, Coral Gables, Florida, U.S.A
| | - Jorge Benito
- Larkin Hospital Department of Orthopaedics, Coral Gables, Florida, U.S.A
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12
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Hsieh YC, Kuo LT, Hsu WH, Tsai YH, Peng KT. Comparison of Outcomes after Arthroscopic Rotator Cuff Repair between Elderly and Younger Patient Groups: A Systematic Review and Meta-Analysis of Comparative Studies. Diagnostics (Basel) 2023; 13:1770. [PMID: 37238254 PMCID: PMC10217625 DOI: 10.3390/diagnostics13101770] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/06/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
This study aimed to compare the outcomes of arthroscopic rotator cuff repair (ARCR) surgery between younger and older patients. We performed this systematic review and meta-analysis of cohort studies comparing outcomes between patients older than 65 to 70 years and a younger group following arthroscopic rotator cuff repair surgery. We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and other sources for relevant studies up to 13 September 2022, and then assessed the quality of included studies using the Newcastle-Ottawa Scale (NOS). We used random-effects meta-analysis for data synthesis. The primary outcomes were pain and shoulder functions, while secondary outcomes included re-tear rate, shoulder range of motion (ROM), abduction muscle power, quality of life, and complications. Five non-randomized controlled trials, with 671 participants (197 older and 474 younger patients), were included. The quality of the studies was all fairly good, with NOS scores ≥ 7. The results showed no significant differences between the older and younger groups in terms of Constant score improvement, re-tear rate, or other outcomes such as pain level improvement, muscle power, and shoulder ROM. These findings suggest that ARCR surgery in older patients can achieve a non-inferior healing rate and shoulder function compared to younger patients.
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Affiliation(s)
- Yu-Chieh Hsieh
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi 61363, Taiwan; (Y.-C.H.); (Y.-H.T.); (K.-T.P.)
| | - Liang-Tseng Kuo
- Division of Sports Medicine, Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi 61363, Taiwan;
- School of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Wei-Hsiu Hsu
- Division of Sports Medicine, Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi 61363, Taiwan;
- School of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Yao-Hung Tsai
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi 61363, Taiwan; (Y.-C.H.); (Y.-H.T.); (K.-T.P.)
| | - Kuo-Ti Peng
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi 61363, Taiwan; (Y.-C.H.); (Y.-H.T.); (K.-T.P.)
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13
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Sheth MM, Shah AA. Massive and Irreparable Rotator Cuff Tears: A Review of Current Definitions and Concepts. Orthop J Sports Med 2023; 11:23259671231154452. [PMID: 37197034 PMCID: PMC10184227 DOI: 10.1177/23259671231154452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/09/2022] [Indexed: 05/19/2023] Open
Abstract
Background While massive and irreparable rotator cuff tears (MIRCTs) have been abundantly studied, inconsistent definitions in the literature and theories about pain and dysfunction related to them can be difficult to navigate when considering an individual patient. Purpose To review the current literature for definitions and critical concepts that drive decision-making for MIRCTs. Study Design Narrative review. Methods A search of the PubMed database was performed to conduct a comprehensive literature review on MIRCTs. A total of 97 studies were included. Results Recent literature reflects added attention to clarifying the definitions of "massive, "irreparable," and "pseudoparalysis." In addition, numerous recent studies have added to the understanding of what generates pain and dysfunction from this condition and have reported on new techniques for addressing them. Conclusion The current literature provides a nuanced set of definitions and conceptual foundations on MIRCTs. These can be used to better define these complex conditions in patients when comparing current surgical techniques to address MIRCTs, as well as when interpreting the results of new techniques. While the number of effective treatment options has increased, high-quality and comparative evidence on treatments for MIRCTs is lacking.
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14
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Ó Conaire E, Delaney R, Lädermann A, Schwank A, Struyf F. Massive Irreparable Rotator Cuff Tears: Which Patients Will Benefit from Physiotherapy Exercise Programs? A Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5242. [PMID: 37047860 PMCID: PMC10094518 DOI: 10.3390/ijerph20075242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 06/19/2023]
Abstract
Massive irreparable rotator cuff tears can cause significant shoulder pain, disability and reduction in quality of life. Treatment approaches can be operative or non-operative. Operative approaches include reverse total shoulder arthroplasty, arthroscopic debridement, partial rotator cuff repair, subacromial balloon spacers, superior capsule reconstruction, and tendon transfer procedures. Non-operative approaches include physiotherapy exercise programs and corticosteroid injections. There are no randomized controlled trials comparing the different treatment approaches. It is therefore challenging for clinicians to advise patients on what is their best treatment pathway. Physiotherapy exercise programs are less expensive and have lower risks for patients than surgical approaches. However, the success of physiotherapy in patients with massive irreparable rotator cuff tears is highly variable with published success rates of 32-96%. Several cohort studies have sought to identify if certain factors are predictive of success with physiotherapy. Several biomechanical factors were identified as possibly being related to a successful or unsuccessful outcome following physiotherapy, with complete tear of subscapularis demonstrating the strongest evidence. However, there were no appropriately designed prognostic studies. There has been a strong emphasis on biomechanical factors. Other domains such as psychosocial factors, which are important in similar patient populations, have not been explored. We recommend that further research is needed in this area and should include randomized controlled trials comparing treatment approaches and longitudinal prospective prognostic studies to identify predictors of treatment success.
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Affiliation(s)
- Eoin Ó Conaire
- Department of Rehabilitation Sciences and Physiotherapy/MOVANT, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium; (A.S.); (F.S.)
- Evidence-Based Therapy Centre, First Floor Geata na Cathrach, Fairgreen Road, H91 W26K Galway, Ireland
| | - Ruth Delaney
- Dublin Shoulder Institute, Sports Surgery Clinic, Santry, D09 C523 Dublin, Ireland;
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, 1217 Meyrin, Switzerland;
- Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Ariane Schwank
- Department of Rehabilitation Sciences and Physiotherapy/MOVANT, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium; (A.S.); (F.S.)
- Institute for Therapy and Rehabilitation, Canton Hospital Winterthur, 8400 Winterthur, Switzerland
| | - Filip Struyf
- Department of Rehabilitation Sciences and Physiotherapy/MOVANT, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium; (A.S.); (F.S.)
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15
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Ardebol J, Hwang S, Horinek JL, Menendez ME, Pak T, Denard PJ. A Step-by-Step Approach to Arthroscopic Repair of Massive Rotator Cuff Tears. Arthrosc Tech 2023; 12:e377-e382. [PMID: 37013016 PMCID: PMC10066416 DOI: 10.1016/j.eats.2022.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/27/2022] [Accepted: 11/06/2022] [Indexed: 04/05/2023] Open
Abstract
Arthroscopic repair of massive rotator cuff tears can be technically challenging but is achievable in many cases. Performing adequate releases are important for successful tendon mobility and avoiding excessive tension in the final repair, thus restoring the native anatomy and biomechanics. This Technical Note provides a step-by-step approach to release and mobilize massive rotator cuff tears to or near anatomical tendon footprints.
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Affiliation(s)
| | | | | | | | | | - Patrick J. Denard
- Address correspondence to Patrick J. Denard, M.D., Oregon Shoulder Institute, 2780 E. Barnett Rd, Suite 200, Medford, OR 97504, U.S.A.
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16
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Kim E, Kopp B, Kortlever JT, Johnson A, Ring D. Correlation of defect size with fatty infiltration on MRIs of rotator cuff tendinopathy. J Orthop 2023; 36:125-129. [PMID: 36748092 PMCID: PMC9898575 DOI: 10.1016/j.jor.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/21/2023] Open
Abstract
Introduction Sizable rotator cuff defects with limited muscle atrophy and fat replacement may represent acute traumatic ruptures that are less likely to recur after surgery to close the defect, while closure of defects with poor quality muscle are associated with defect recurrence. These distinct lesions are both referred to as tears. We analyzed the relationship between rotator cuff defect size and muscle quality to determine the relative proportion of sizable defects associated with good muscle and factors associated with muscle deterioration. Material and methods A cohort of 230 consecutive shoulder MRIs in patients with full-thickness rotator cuff tendon defects, limited acromioclavicular arthrosis (to avoid hindrance of defect measurement), and a duration of symptoms in the radiology report from a large urban center in the United States was evaluated for the measured distance between the supraspinatus tendon edge and the greater tuberosity medial to lateral (coronal plane defect size), anterior to posterior (sagittal plane defect width), and fatty infiltration (Goutallier classification), and atrophy (Warner classification) of the supraspinatus. We sought factors independently associated with fatty infiltration and muscle atrophy in multivariable logistic regression analyses. Results Forty-nine of 109 shoulders (45%) with a coronal plane defect >20 mm had reasonable muscle quality as defined by Goutallier grade less than 2 and Warner grade less than 2. Both greater fatty infiltration of the supraspinatus muscle and greater supraspinatus muscle atrophy were associated with older age and greater coronal plane defect size. Conclusion The observation that supraspinatus muscle health deteriorates with age and defect size, but nearly half of the largest defects had good muscle, suggests an important distinction between relatively recent traumatic ruptures and old untreated rupture or gradual attrition that may be obfuscated by referring to all lesions as tears. Level of evidence Level III; Retrospective diagnostic cohort.
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Affiliation(s)
- Eugene Kim
- Department of Surgery and Perioperative Care, Dell Medical School – the University of Texas at Austin, 1701 Trinity Street, Austin, TX, 78705, USA
| | - Benjamin Kopp
- Department of Surgery and Perioperative Care, Dell Medical School – the University of Texas at Austin, 1701 Trinity Street, Austin, TX, 78705, USA
| | - Joost T.P. Kortlever
- Department of Surgery and Perioperative Care, Dell Medical School – the University of Texas at Austin, 1701 Trinity Street, Austin, TX, 78705, USA
| | - Anthony Johnson
- Department of Surgery and Perioperative Care, Dell Medical School – the University of Texas at Austin, 1701 Trinity Street, Austin, TX, 78705, USA
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School – the University of Texas at Austin, 1701 Trinity Street, Austin, TX, 78705, USA
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17
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Tsuchiya S, Bois AJ, Matthewson G, Oiwa S, More KD, Lo IKY. The relationship between preoperative Goutallier stage and retear rates following posterosuperior rotator cuff repair: a systematic review. J Shoulder Elbow Surg 2023; 32:435-443. [PMID: 36252788 DOI: 10.1016/j.jse.2022.09.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/12/2022] [Accepted: 09/20/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND An association between higher preoperative Goutallier stage and higher retear rates following primary rotator cuff repairs has been previously reported. However, there are few reviews which have described clear retear rates for each repaired tendon classified according to preoperative Goutallier stage. The purpose of this study was therefore to systematically review the literature on the relationship between preoperative Goutallier stage and retear rates and provide predictable retear rates following primary repair of posterosuperior rotator cuff tears. METHODS A systematic literature review was performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist utilizing PubMed, MEDLINE, and Cochrane Library. English-language studies of Level I through IV evidence examining the clinical results of primarily repaired posterosuperior rotator cuff tears as a function of Goutallier stage using magnetic resonance imaging were included. The primary outcome of interest was retear rates according to preoperative Goutallier stage. As a secondary outcome, rotator cuff tears were divided into 2 subgroups (Goutallier stage 0-2 and 3-4) and retear rates were assessed between the 2 subgroups. A random effects model with binomial within-study variance was used for both outcomes. RESULTS Nine studies (687 shoulders) satisfied all inclusion criteria and reported sufficient data for statistical analysis. In the supraspinatus muscle group, rotator cuff muscles with preoperative Goutallier stages of 0, 1, and 2 had retear rates of 19.1%, 27.8%, and 33.5%, respectively, with no significant differences between each category. In contrast, when preoperative Goutallier stage of 3 and 4 existed, significant differences compared to Goutallier 0, 1, and 2 were observed with a retear rate of 74.1% and 78.5%, respectively. In the infraspinatus muscle group, the retear rates following rotator cuff repairs were 20.0%, 32.1%, and 35.1% in Goutallier 0, 1, and 2, respectively, with no significant differences between each category. In Goutallier 3 and 4, the rate was 76.6% and 100.0%, respectively, with significant differences compared to Goutallier 0, 1, and 2. CONCLUSION The results of this study have clearly demonstrated that retear rates following surgical repair of the rotator cuff increased in proportion to the preoperative Goutallier stage in both the supraspinatus and infraspinatus muscles.
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Affiliation(s)
- Saho Tsuchiya
- Department of Orthopaedic Surgery, JCHO Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Aaron J Bois
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada; University of Calgary Sport Medicine Centre, University of Calgary, Calgary, AB, Canada
| | - Graeme Matthewson
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Shin Oiwa
- Department of Orthopaedic Surgery, Akabane East Side Hospital, Tokyo, Japan
| | - Kristie D More
- University of Calgary Sport Medicine Centre, University of Calgary, Calgary, AB, Canada
| | - Ian K Y Lo
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada.
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18
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Tendon Transfers in Rotator Cuff Deficiency. OPER TECHN SPORT MED 2023. [DOI: 10.1016/j.otsm.2023.150986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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19
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Mancini MR, Horinek JL, Phillips CJ, Denard PJ. Arthroscopic Rotator Cuff Repair. Clin Sports Med 2023; 42:81-94. [DOI: 10.1016/j.csm.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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20
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Evuarherhe A, Condron NB, Gilat R, Knapik DM, Patel S, Wagner KR, Garrigues GE, Romeo A, Verma N, Cole BJ. Defining Clinically Significant Outcomes Following Superior Capsular Reconstruction With Acellular Dermal Allograft. Arthroscopy 2022; 38:1444-1453.e1. [PMID: 34863902 DOI: 10.1016/j.arthro.2021.11.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/12/2021] [Accepted: 11/20/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To define clinically significant outcomes (CSO) thresholds for minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptomatic state (PASS) in patients undergoing superior capsular reconstruction (SCR) with an acellular dermal allograft. We also evaluated patient-specific variables predictive of achieving CSO thresholds. METHODS The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), and subjective Constant-Murley (Constant) scores were collected preoperatively and at the most recent follow up for patients undergoing SCR from 2010 to 2019. A distribution-based approach was used to calculate MCID, and an anchor-based approach was used to calculate SCB and PASS. Logistic regression was used to determine factors associated with CSO achievement. RESULTS Fifty-eight patients were identified (n = 39 males; n = 19 females) with a mean age of 53.4 ± 14.1 years at surgery and an average follow-up of 23 months. The MCID, SCB, and PASS were 11.2, 18.02, and 68.82 for ASES, 14.5, 23.13, and 69.9 for SANE, and 3.6, 10, and 18 for Constant, respectively. Subscapularis tear, female sex, and workers compensation (WC) status reduced odds of achieving MCID. Reduced odds of achieving Constant SCB were associated with older age, female sex, and WC status, while concomitant distal clavicle excision during SCR and lower preoperative ASES increased odds of achieving ASES SCB. Reduced odds for achieving ASES PASS were associated with female sex and WC status, while reduced odds for achieving SANE PASS were associated with subscapularis tearing preoperatively. CONCLUSION On the basis of calculated values for MCID, SCB, and PASS, subscapularis tearing, WC status, age, and sex are associated with failure to achieve clinically significant outcomes following SCR. Concomitant distal clavicle excision during SCR and lower preoperative ASES was predictive for achievement of MCID and SCB. By defining the thresholds and variables predictive of achieving CSOs following SCR, surgeons may better counsel patients prior to SCR. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Aghogho Evuarherhe
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Nolan B Condron
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Ron Gilat
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Derrick M Knapik
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Sumit Patel
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Kyle R Wagner
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Anthony Romeo
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Nikhil Verma
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A
| | - Brian J Cole
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, U.S.A..
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21
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Kucirek NK, Hung NJ, Wong SE. Treatment Options for Massive Irreparable Rotator Cuff Tears. Curr Rev Musculoskelet Med 2021; 14:304-315. [PMID: 34581991 PMCID: PMC8497660 DOI: 10.1007/s12178-021-09714-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW Massive irreparable rotator cuff tears present a significant challenge to the orthopedic surgeon. No single treatment, particularly among joint-preserving options, has been shown to be superior. The purpose of this review is to discuss recent advances in the treatment of massive irreparable rotator cuff tears, including partial repair with and without graft augmentation, interposition grafts, superior capsule reconstruction, subacromial balloon spacers, tendon transfer, and reverse total shoulder arthroplasty. We will also offer guidance on surgical indications based on our clinical experience. RECENT FINDINGS Partial repair may offer reasonable clinical improvement for patients with lower preoperative function despite high re-tear rates. Additionally, several types of interposition grafts have shown promising short-term results and may outperform repair alone. Subacromial balloon spacers may lead to clinical improvement, especially in patients without glenohumeral osteoarthritis or pseudoparalysis, and recently received FDA approval for use in the USA. Superior capsule reconstruction is a technically demanding procedure that appears to produce excellent short-term results particularly when performed at high volume, but long-term studies in heterogeneous study groups are needed. Tendon transfers improve function by restoring force coupling in the shoulder, offering a promising option for younger patients. Reverse total shoulder arthroplasty (RTSA) is a reliable option for treatment of irreparable cuff tears in elderly patients with lower functional demands. Irreparable cuff tears remain a difficult condition to treat. Recommended treatment for younger patients without glenohumeral osteoarthritis is particularly controversial. For older patients with low-demand lifestyles and glenohumeral osteoarthritis, RTSA is an effective treatment option. For all discussed procedures, patient selection appears to play a critical role in clinical outcomes.
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Affiliation(s)
- Natalie K. Kucirek
- School of Medicine, University of California, San Francisco, San Francisco, CA USA
| | - Nicole J. Hung
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Stephanie E. Wong
- Department of Orthopaedic Surgery, University of California, San Francisco, 1500 Owens Street, San Francisco, CA 94158 USA
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22
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Alarcon JF, Uribe-Echevarria B, Clares C, Apablaza D, Vargas JC, Benavente S, Rivera V. Superior Capsular Reconstruction With Autologous Fascia Lata Using a Single Lateral-Row Technique Is an Effective Option in Massive Irreparable Rotator Cuff Tears: Minimum 2-Year Follow-Up. Arthroscopy 2021; 37:2783-2796. [PMID: 33957215 DOI: 10.1016/j.arthro.2021.04.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/02/2021] [Accepted: 04/08/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate clinical and radiologic outcomes of arthroscopic superior capsular reconstruction (ASCR) with fascia lata autograft in patients with irreparable rotator cuff tears (IRCTs) performed using a single lateral-row fixation technique. METHODS We studied a retrospective case series of patients with large or massive IRCTs for ASCR with fascia lata autograft. Clinical outcomes were evaluated using the Visual Analog Scale (VAS) and the Constant score. Healing of the graft was assessed by magntic resonance imaging or ultrasound. Acromiohumeral distance was evaluated by radiographs. RESULTS Thirty-one patients with an average age of 61 years and an average follow-up of 35 months (24-51 months) underwent ASCR with fascia lata autograft. There was a significant improvement in VAS (7.7-0.7), Constant score (36.0-78.7), forward elevation (115°-171°), external rotation (33°-50°), strength (0.3 kg-2.3 kg), and acromiohumeral distance (6.1 mm-8.6 mm) (P < 0.001). Graft failure was present in 13.8% of patients, as shown by magnetic resonance imaging (26 patients) or ultrasound (3 patients). Patients with failed ASCR showed worse Constant scores (68.5.8 vs 80.2, P = 0.007), worse VAS (2.5 vs 0.4, P = 0.00002), worse external rotation (20° vs 54°, P = 0.004), lower acromiohumeral distance (5mm vs 9mm, P = 0.007), and a high association with the presence of os acromiale (χ2P = 0.003). No revision or subsequent surgical procedures were required. CONCLUSIONS ASCR, with autologous fascia lata and single lateral row configuration, is an effective option in irreparable rotator cuff tears and results in clinical and radiologic improvement. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
| | - Bastian Uribe-Echevarria
- Centro de Especialides Traumatologicas, Puerto Varas, Chile; Centro de Especialides Traumatologicas, Puerto Varas, Chile.
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Editorial Commentary: If the Massive Rotator Cuff Tear is Irreparable, Just Fix the Rotator Cable. Arthroscopy 2021; 37:1411-1413. [PMID: 33896496 DOI: 10.1016/j.arthro.2021.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 01/13/2021] [Indexed: 02/02/2023]
Abstract
Large and massive rotator cuff tears are not always reparable and present a difficult clinical problem. If surgery is warranted surgical options range from arthroscopic debridement, partial repairs, degradable spacers, tendon transfers, and more superior capsular reconstruction. The rotator cable is formed by the deep layer of the coracohumeral ligament and the crescent structure running from the anterior insertion site of the supraspinatus to the inferior border of the infraspinatus. The role of the rotator cable is not clear but seems to play a role in reducing tendon stress and influence glenohumeral kinematics. In this laboratory-based cadaver study the anterior cable was reconstructed with semitendinosus allograft treating large "irreparable" rotator cuff defects. Reconstruction resulted in reduced superior migration and subacromial contact forces without inhibiting range of motion.
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Incomplete footprint coverage under tension in repair of isolated supraspinatus full-thickness tear. Sci Rep 2021; 11:7425. [PMID: 33795780 PMCID: PMC8016972 DOI: 10.1038/s41598-021-86800-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/19/2021] [Indexed: 11/22/2022] Open
Abstract
Although it is well known that repairing large or massive tears under tension may have an adverse effect on healing of the repaired tendons, only few studies have addressed this issue in medium-sized isolated supraspinatus full-thickness tear. The purpose of this study was to compare the clinical outcomes and structural integrity of arthroscopic rotator cuff repair with tension versus without it. This study retrospectively investigated 90 patients who underwent arthroscopic repair in a single-row for medium-sized isolated supraspinatus full-thickness tear. The patients were assigned to either repaired under tension (Group A, n = 38) or repaired without tension (Group B, n = 52) groups. Functional outcomes were assessed using the patient reported subjective values and the active range of motion (ROM). Postoperative radiographic evaluation was performed 6 months after the surgery to assess the structural integrity of the repaired tendons. Changes in the subjective shoulder scores from initial to 2 years after surgery showed no statistical significance between the two groups. The ROMs measured at initial and 2 years after surgery also showed no statistical difference between the two groups. Postoperative radiological evaluations found a significantly higher re-tear rate in Group A (28.9%, 11/38) than in Group B (9.6%, 5/52). The torn cuff tendons that were repaired under tension as retraction with limited mobility had significantly higher re-tear rate despite having immobilized for 6 weeks after surgery, but their clinical outcomes showed no significant difference from the outcomes of repaired tendons without tension.
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Ki SY, Lee YS, Kim JY, Lho T, Chung SW. Relationship between fatty infiltration and gene expression in patients with medium rotator cuff tear. J Shoulder Elbow Surg 2021; 30:387-395. [PMID: 32603896 DOI: 10.1016/j.jse.2020.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 05/26/2020] [Accepted: 06/08/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Fatty infiltration (FI) is a key prognostic factor that affects outcomes after rotator cuff repair and is radiologically evaluated using the Goutallier classification. The purpose of this study was to assess alterations in gene and protein expression according to the Goutallier classification in the supraspinatus muscle and any relationships among various gene expression profiles. METHODS Twenty-four samples of the supraspinatus muscle from 12 patients with a high FI grade (grade 3 or 4) and 12 patients with a low FI grade (grade 1 or 2) with medium-sized tears were acquired during arthroscopic surgery. Alterations in the expression of genes and proteins associated with adipogenesis, fibrosis, inflammation, and muscle atrophy were compared between the high- and low-FI groups using reverse-transcription quantitative polymerase chain reaction, Western blotting, and immunohistochemistry. RESULTS mRNA expression of not only the adipogenic genes (peroxisome proliferator-activated receptor γ and CCAAT/enhancer-binding protein α; P < .001 and P = .020) but also the fibrosis-related gene (α-smooth muscle actin; P < .001), inflammation-related genes (interleukin [IL]-1β and tumor necrosis factor α; P = .041 and P = .039), and muscle atrophy-related genes (atrogin 1 and myostatin; P = .006 and P < .001) was higher in the high-FI group compared with that in the low-FI group. In addition, adipogenic gene expression was significantly correlated with the expression of other categories of genes (all P < .05, except atrogin 1). A correlation of gene and protein expression was observed for IL-1β (P = .027) and myostatin (P = .029). CONCLUSIONS The radiologic grading of FI was associated with the expression of various genes, including adipogenic, fibrotic, inflammatory, and atrophy-related genes, and these genes were closely correlated with each other in terms of expression. This information could be helpful in patient counseling.
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Affiliation(s)
- Se-Young Ki
- Department of Orthopedic Surgery, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Yong-Soo Lee
- Department of Orthopedic Surgery, Konkuk University School of Medicine, Seoul, Republic of Korea; Joint Center, Barunsesang Hospital, Seongnam, Republic of Korea
| | - Ja-Yeon Kim
- Department of Orthopedic Surgery, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Taewoo Lho
- Department of Orthopedic Surgery, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Seok Won Chung
- Department of Orthopedic Surgery, Konkuk University School of Medicine, Seoul, Republic of Korea.
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Neyton L, Gossing L, Gasbarro G, Kirsch JM. Modified L'Episcopo tendon transfer for isolated loss of active external rotation. J Shoulder Elbow Surg 2020; 29:2587-2594. [PMID: 32669198 DOI: 10.1016/j.jse.2020.03.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with isolated loss of active external rotation (ILER) but preserved active forward elevation have recently been identified as a rare and distinct clinical entity. The modified L'Episcopo procedure attempts to restore horizontal muscle balance and restore active external rotation. METHODS A retrospective study was performed for all patients with ILER and preserved forward elevation with Hamada stage ≤2 changes undergoing the modified L'Episcopo tendon transfer. Preoperative rotator cuff fatty infiltration and morphology was reported. Clinical, radiographic, and functional outcomes were recorded preoperatively and compared to postoperative outcomes at a minimum of 24 months' follow-up. RESULTS Nine patients (8 male, 1 female) with a mean age of 58.4 years (range, 51-67 years) were evaluated at a mean follow-up of 64.3 months (range, 24-126 months). Significant improvement was demonstrated in active external rotation with the arm at the side (mean increase of 47°; range, 30°-60°, P = .004) and at 90° abduction (mean increase of 41°; range, 20°-70°, P = .004). The mean Constant score and pain score significantly improved at final follow-up (P = .004). All patients were either very satisfied or satisfied, with a mean subjective shoulder value of 74% (range, 60%-99%). CONCLUSION In appropriately selected patients with ILER and preserved active forward elevation, the modified L'Episcopo procedure can restore horizontal muscle balance and produce significant improvements in active external rotation, Constant score, and pain.
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Affiliation(s)
- Lionel Neyton
- Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France.
| | - Louis Gossing
- Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Gregory Gasbarro
- Orthopaedic Specialty Hospital, Mercy Medical Center, Baltimore, MD, USA
| | - Jacob M Kirsch
- Departments of Orthopaedic Surgery & Shoulder/Elbow Surgery, The Rothman Institute-Thomas Jefferson, Philadelphia, PA, USA
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Guo S, Zhu Y, Song G, Jiang C. Assessment of Tendon Retraction in Large to Massive Rotator Cuff Tears: A Modified Patte Classification Based on 2 Coronal Sections on Preoperative Magnetic Resonance Imaging With Higher Specificity on Predicting Reparability. Arthroscopy 2020; 36:2822-2830. [PMID: 32622802 DOI: 10.1016/j.arthro.2020.06.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 06/13/2020] [Accepted: 06/16/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To propose a modified Patte classification (evaluating tendon retraction on 2 coronal sections) and analyze whether this classification was better at predicting irreparability and retear of large to massive rotator cuff tears (RCTs). METHODS A retrospective study was performed. Imaging evaluation including tendon retraction, fatty infiltration, the acromiohumeral distance (AHD), and the tangent sign was performed using magnetic resonance imaging. The modified Patte classification was used to assess tendon retraction. Intraobserver and interobserver reliability was analyzed by calculating intraclass correlation coefficients. Factors affecting irreparability and retear were analyzed using both univariate and multivariate analyses. Sensitivity and specificity of tendon retraction to predict irreparability and retear were calculated. RESULTS A total of 121 shoulders with large to massive RCTs underwent arthroscopic rotator cuff repairs. The modified Patte classification system had excellent interobserver and intraobserver reliability. Several factors were associated with reparability and retear in the univariate analysis. However, in binary logistic regression analysis, the only factors affecting reparability were AHD less than 0.4 cm (P = .007) and modified Patte stage III tendon retraction (P = .023). Low-grade repair quality (P = .001) and modified Patte stage III tendon retraction (P = .031) were independent factors for retear. Modified Patte stage III had a high specificity for predicting irreparability (93.58%) and retear (98.78%), whereas the specificity of original Patte stage III was 76.15% and 84.15%, respectively. CONCLUSIONS For large to massive RCT repairs, modified Patte stage III tendon retraction with evaluation of 2 coronal cuts reveals higher specificity on predicting tendon irreparability and postoperative retear. An AHD less than 0.4 cm on magnetic resonance imaging and modified Patte stage III tendon retraction were independent risk factors for irreparability. Low-grade repair quality and modified Patte stage III tendon retraction were independent risk factors for postoperative retear. LEVEL OF EVIDENCE Level III, case-control study.
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Affiliation(s)
- Siyi Guo
- Sports Medicine Department, Beijing Ji Shui Tan Hospital, Peking University School of Medicine, Beijing, China
| | - Yiming Zhu
- Sports Medicine Department, Beijing Ji Shui Tan Hospital, Peking University School of Medicine, Beijing, China
| | - Guanyang Song
- Sports Medicine Department, Beijing Ji Shui Tan Hospital, Peking University School of Medicine, Beijing, China
| | - Chunyan Jiang
- Sports Medicine Department, Beijing Ji Shui Tan Hospital, Peking University School of Medicine, Beijing, China.
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Abraham PF, Nazal MR, Varady NH, Gillinov SM, Quinlan NJ, Alpaugh K, Martin SD. The new dynamic isotonic manipulation examination (DIME) is a highly sensitive secondary screening tool for supraspinatus full-thickness tears. J Shoulder Elbow Surg 2020; 29:2213-2220. [PMID: 32650076 DOI: 10.1016/j.jse.2020.06.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/13/2020] [Accepted: 06/22/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Traditional shoulder physical examination (PE) tests have suboptimal sensitivity for detection of supraspinatus full-thickness tears (FTTs). Therefore, clinicians may continue to suspect FTTs in some patients with negative rotator cuff PE tests and turn to magnetic resonance imaging (MRI) for definitive diagnosis. Consequently, there is a need for a secondary screening test that can accurately rule out FTTs in these patients to better inform clinicians which patients should undergo MRI. The purpose of this study was to assess the ability of 2 new dynamic PE tests to detect supraspinatus pathology in patients for whom traditional static PE tests failed to detect pathology. METHODS We prospectively enrolled 171 patients with suspected rotator cuff pathology with negative findings on traditional rotator cuff PE, who underwent 2 new dynamic PE tests: first, measurement of angle at which the patient first reports pain on unopposed active abduction and, second, the dynamic isotonic manipulation examination (DIME). Patients then underwent shoulder magnetic resonance arthrogram. Data from the new PE maneuvers were compared with outcomes collected from magnetic resonance arthrogram reports. RESULTS Pain during DIME testing had a sensitivity of 96.3% and 92.6% and a negative predictive value of 96.2% and 94.9% in the coronal and scapular planes, respectively. DIME strength ≤86.0 N had a sensitivity of 100% and 96.3% and a negative predictive value of 100% and 95.7% in the coronal and scapular planes, respectively. Pain at ≤90° on unopposed active abduction in the coronal plane had a specificity of 100% and a positive predictive value of 100% for supraspinatus pathology of any kind (ie, tendinopathy, "fraying," or tearing). CONCLUSION DIME is highly sensitive for supraspinatus FTTs in patients with negative traditional rotator cuff PE tests for whom there is still high clinical suspicion of FTTs. Thus, this test is an excellent secondary screening tool for supraspinatus FTTs in patients for whom clinicians suspect rotator cuff pathology despite negative traditional static PE tests. Given its high sensitivity, a negative DIME test rules out supraspinatus FTT well in these patients, and can therefore better inform clinicians which patients should undergo MRI. In addition, the angle at which patients first report pain on unopposed active shoulder abduction is highly specific for supraspinatus pathology.
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Affiliation(s)
- Paul F Abraham
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Boston, MA, USA.
| | - Mark R Nazal
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Boston, MA, USA
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Boston, MA, USA
| | - Stephen M Gillinov
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Boston, MA, USA
| | - Noah J Quinlan
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Kyle Alpaugh
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, MA, USA
| | - Scott D Martin
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Boston, MA, USA
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Polacek M, Nyegaard CP. Superior Capsular Reconstruction Using 3-layered Fascia Lata Autograft Reinforced with a Nonresorbable Suture Mesh. Arthrosc Sports Med Rehabil 2020; 2:e489-e497. [PMID: 33134985 PMCID: PMC7588631 DOI: 10.1016/j.asmr.2020.05.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/18/2020] [Indexed: 01/29/2023] Open
Abstract
Purpose The purpose of this study was to evaluate the short-term clinical outcomes and the complications related to arthroscopic superior capsular reconstruction (SCR) using a 3-layered fascia lata autograft (FLA) reinforced with a nonresorbable suture mesh, in the treatment of irreparable massive rotator cuff tears (MRCTs). Methods Consecutive patients with irreparable MRCTs (Goutallier 4, Hamada grade 1-2, Bateman 3-4) who were treated with arthroscopic SCR using reinforced FLA in 2018 were included. Patients with an irreparable subscapularis/infraspinatus, serious cardiovascular condition, systemic infection, rheumatic disease, and known alcohol/drug abuse were excluded from the study. Range of motion and Shoulder Pain and Disability Index (SPADI) scores were assessed preoperatively, at 6 months, and at 12 months postoperatively. A simple t test was used to compare the outcomes. P values <.05 were considered significant. Complications and revision surgeries were registered. Results A total of 24 consecutive patients (15 males, 9 females) with a mean age of 61 years (range, 41-76) were enrolled. Twenty (83%) patients achieved minimal clinically important difference in the SPADI score (>18) and 14 (58%) experienced substantial clinical benefit in SPADI (>45). The mean SPADI score improved from 59.0 to 9.7 (P < .0001) at 1-year follow-up. Active abduction improved from 59.5° to 154.3° (P < .0001) and active forward flexion improved from 67.0° to 160.3° (P < .0001) at 1-year follow-up. Eighteen (75%) patients achieved substantial clinical benefit in active abduction (>28.5°) and active forward flexion (>35.4°). Complications included progression of osteoarthritis in 2 cases, tear of the graft in 1 case, and pullout of the anchor in another. Two patients experienced donor site morbidity after harvesting the fascia lata autograft. Conclusions Eighty-three percent of the patients achieved minimal clinically important difference and were successfully treated with arthroscopic SCR using a FLA reinforced with a suture mesh. The procedure had a complication rate of 17% and 8.5% of the patients experienced donor site morbidity. All complications occurred in patients who were previously treated with an attempted rotator cuff repair. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
- Martin Polacek
- Orthopedic Department, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway
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Superior Capsular Reconstruction for the Operatively Irreparable Rotator Cuff Tear: Clinical Outcomes Are Maintained 2 Years After Surgery. Arthroscopy 2020; 36:373-380. [PMID: 31864817 DOI: 10.1016/j.arthro.2019.08.035] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 08/18/2019] [Accepted: 08/19/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the results of arthroscopic superior capsular reconstruction (SCR) after 2-year minimum follow-up and to compare the results with those seen in a previously studied group of patients at 1 year postoperatively. METHODS The retrospective study period was October 2014 through September 2016. Inclusion criteria were arthroscopic dermal allograft SCR performed for operatively irreparable posterosuperior rotator cuff tear with intact or repairable subscapularis tendon, failure of nonoperative treatment, and clinical follow-up at 1 and minimum 2 years postoperatively. Patients lost to follow-up or undergoing revision of the SCR were excluded from the analysis. The primary outcome measure was American Shoulder and Elbow Surgeons (ASES) score (mean, [95% confidence interval], P value). Secondary outcomes included visual analog pain rating (0-10), subjective shoulder value, and active forward elevation and external rotation (degrees). Radiographic analysis included acromiohumeral interval (millimeters) and graft integrity 1-year postoperation. Complications and reoperations were reviewed from the medical record. RESULTS Forty-one patients met inclusion criteria at mean 34 months postoperatively, and 8 were excluded. ASES score improved from 52 (46-57) preoperative to 90 (87-92; P < .0001) and 89 (86-92; P < .0001) at 1-year postoperation and at final follow-up without diminishing in the interim (P = .9). All secondary clinical outcomes improved from preoperative to final follow-up. Subjective shoulder value diminished 5% between 1 year and final follow-up (P = .03), whereas active external rotation improved 11° during this time (P = .02). In total, 85% of grafts were fully healed, with acromiohumeral interval improved from 7 (6-8) mm to 8 mm (7-9; P = .04). There were 2 (5%) revisions and 6 (14%) failures to reach the minimally clinically important improvement in ASES score: a 19% rate of unsatisfactory outcomes. There was an additional 1 reoperation (2%) and 1 (2%) medical complication. CONCLUSIONS Arthroscopic joint preservation surgery for massive, operatively irreparable posterosuperior rotator cuff tears with dermal allograft SCR and associated procedures results in improved clinical outcomes that are durable between 1 and minimum 2-year follow-up. LEVEL OF EVIDENCE IV retrospective case series.
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Abstract
When evaluating patients with irreparable rotator cuff tears, orthopaedic surgeons have an increasingly wide array of surgical options, including both established techniques and emerging technologies. However, significant variability exists in the clinical evaluation and surgical indications in this subset, and definitions for pseudoparalysis and tear irreparability are inconsistent. In older patients with symptomatic rotator cuff arthropathy and relatively sedentary demands, the reverse total shoulder arthroplasty has been established as the preferred treatment option, producing reliable improvements in both pain and function. In younger patients without glenohumeral arthritis or pseudoparalysis, joint-preserving options are preferred, with recent literature highlighting alternative options including partial repair, bridging or interpositional graft placement, tendon transfers (ie, latissimus, trapezius, and pectoralis major), superior capsular reconstruction, and subacromial spacer placement. In this review article, we address the topic of irreparable rotator cuff tears, emphasizing the workup, indications for various treatment options, and clinical outcomes.
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Arthroscopic Rotator Cuff Repair in 2019: Linked, Double Row Repair for Achieving Higher Healing Rates and Optimal Clinical Outcomes. Arthroscopy 2019; 35:2749-2755. [PMID: 31500765 DOI: 10.1016/j.arthro.2019.02.048] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/08/2019] [Accepted: 02/21/2019] [Indexed: 02/02/2023]
Abstract
The primary aim of rotator cuff repair surgery is to restore the musculotendinous units by creating a complete, tension-free repair construct that optimizes conditions for tendon-to-bone healing. There are many factors outside the control of the surgeon that are capable of affecting the healing process; however, there are also a number of important technical considerations that the surgeon can control, including familiarity with methods to deal with immobile tissues and techniques to perform novel repair constructs. It is clear that linked double row repairs are more likely to heal, and healed rotator cuff repairs best restore shoulder strength, improve patients' satisfaction, and maximize functional outcomes.
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Naimark M, Trinh T, Robbins C, Rodoni B, Carpenter J, Bedi A, Miller B. Effect of Muscle Quality on Operative and Nonoperative Treatment of Rotator Cuff Tears. Orthop J Sports Med 2019; 7:2325967119863010. [PMID: 31428659 PMCID: PMC6683312 DOI: 10.1177/2325967119863010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Rotator cuff muscle atrophy and fatty infiltration are predictors of negative outcomes after rotator cuff repair. However, the impact of muscle degeneration on nonsurgical treatment is unknown. Hypothesis Rotator cuff muscle atrophy and fatty infiltration will reduce the outcomes of operative repair while having a minimal effect on nonsurgical treatment. Additionally, in the setting of atrophy and fatty infiltration, surgical and nonsurgical treatment will produce equivalent outcomes. Study Design Cohort study; Level of evidence, 2. Methods Patients undergoing operative and nonoperative treatment of full-thickness rotator cuff tears were prospectively enrolled into a nonrandomized cohort study. Muscle quality was assessed on magnetic resonance imaging by use of the supraspinatus tangent sign, Warner atrophy, and Goutallier fatty infiltration classifications. Grading was performed by 2 independent observers who were blinded to patient treatment and outcomes. Normalized Western Ontario Rotator Cuff (WORC) index was the primary patient-reported outcome. Multivariate linear regression analysis was used to determine the impact of muscle quality on treatment outcomes. Results The cohort consisted of 157 patients, 89 (57%) surgical and 68 (43%) nonsurgical, with a mean follow-up of 2.4 years (range, 1-5 years). Tangent sign had the best inter- and intrarater reliability, with kappa statistics of 0.81 and 0.86, respectively. Reliability for Warner atrophy was 0.69 to 0.76 and for Goutallier classification was 0.54 to 0.64. Overall, improvement in WORC scores was higher in the surgical group than the nonsurgical group (39.3 vs 21.2; P < .001). A positive tangent sign was the only independent predictor (P < .01) of worse outcomes in the surgical group, accounting for an estimated 22-point lower improvement in WORC scores. Conclusion A positive tangent sign was predictive of worse operative outcomes, resulting in equivalent improvements between surgical and nonsurgical treatment. The tangent sign is a reliable, prognostic indicator that clinicians can use when counseling patients on the optimal treatment of rotator cuff tears.
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Affiliation(s)
- Micah Naimark
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Thai Trinh
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher Robbins
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Bridger Rodoni
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - James Carpenter
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Asheesh Bedi
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Bruce Miller
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Ciccone W. Editorial Commentary: What's Hamada With Partial Rotator Cuff Repair? Arthroscopy 2019; 35:351-352. [PMID: 30712614 DOI: 10.1016/j.arthro.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 11/05/2018] [Indexed: 02/02/2023]
Abstract
Early repair of acute traumatic rotator cuff tears has been shown to restore functional range of motion, whether or not there is complete healing. The ability to predict those cuff tears that can achieve only a partial repair can help with preoperative patient counseling. The Hamada classification can be predictive in determining outcomes in the treatment of massive rotator cuff tears.
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Di Benedetto P, Beltrame A, Cicuto C, Battistella C, Gisonni R, Cainero V, Causero A. Rotator cuff tears reparability index based on pre-operative MRI: our experience. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:36-46. [PMID: 30714997 PMCID: PMC6503408 DOI: 10.23750/abm.v90i1-s.8074] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 01/10/2019] [Indexed: 12/16/2022]
Abstract
Background and aim of the work: It is recognised that a significant percetage of large and massive rotator cuff tears (RCT) cannot be anatomically repaired and this correlates with a worste outcome in terms of pain, active range of motion, increased incidence of retair. The aim of our work is to find reliable index on pre-operative MRI shoulder image to assist orthopaedist in surgical planning of rotatator cuff tears repair. Methods: We performed a retrospective study on a population on 131 patients undergoing arthroscopic cuff repair by a single expert surgeon. Pre-operative MRI images were evaluated by a single orthopaedist, trained on MRI shoulder images ad blinded to surgical outcome. For each magnetic resonance we evaluated the following 9 parameters: fatty Infiltration (FI), Patte Stage (PS), tear size measured in medial-lateral (ML) and anterior-posterior (AP) dimension, Tangent Sign (TS), Occupation Grade (OG), Acromion-Humeral Distance (AHD), Inferior Gleno-Humeral Distance (IGHD), Glenoid Version Angle (GVA). We divided population into two groups: patients who obtained a complete repair of RCT (n=110) and patients who obtained only a partial repair of RCT (n=21). For each MRI index we conducted statistical analysis (Student’s t test, Mann-Whitney U test, Shapiro-Wilk test, Chi-square test, Fisher exact test, ROC curves and maximum Youden index) to find a Cut Off value useful to predict partial repair. Results: We have found statistical significance in predicting partial repair on MRI mesurements of Fatty Infiltration (FI grade ≥3; test di Fisher p<0.001), Patte Stage (grade= 3; test di Fisher p<0.001), Tear size measured in ML (>36 mm; Mann-Whitney p<0.001), Positive Tangent Sign (Chi-quadro p<0.001; sensitivity 95,3%, specificity 83,6%), Occupation Grade (OG <0,46; t-test p<0.001). Acromion-Humeral Distance (AHD <7 mm), Inferior Gleno-Humeral Distance (IGHD >5 mm). Tear size measured in AP (>21 mm; Mann-Whitney p<0.001) seems to be dependent on the contextual size of the lesion in ML. We haven’t found statistical significance in predicting partial repair of Glenoid Version Angle. Conclusions: A systematic observation of seven independent MRI parameters (FI, PS, tear size ML, TS, OG, AHD, IGHD) can help the surgeon to predict the impossibility to obtain complete repair of RCT and to consider different surgical approach. (www.actabiomedica.it)
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Rotator Cuff Repair: Single Row Repair Versus Double Row Repair and Superior Capsular Reconstruction. Sports Med Arthrosc Rev 2018; 26:171-175. [PMID: 30395062 DOI: 10.1097/jsa.0000000000000228] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The surgical management of rotator cuff (RC) tears has progressed considerably in recent decades. Arthroscopic procedures now represent the mainstay of contemporary treatment approaches. The success of repair is predicated upon the achievement of a secure, durable repair that promotes tendon-to-bone healing. Both single and double row (DR) suture anchor configurations have been described to achieve stable fixation. Although consensus is lacking with regard to the clinical superiority of one configuration over another, trends in the literature suggest that DR repairs may optimize the likelihood of tendon healing and restoration of shoulder strength. In cases of truly irreparable RC tears, superior capsular reconstruction is a promising alternative to open tendon transfer and arthroplasty procedures. The purposes of this concise review are to: (1) explain our preference for a DR repair configuration in almost all circumstances; and (2) advocate superior capsular reconstruction as a viable treatment tactic for truly irreparable RC tears in the absence of significant glenohumeral arthritis.
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Arthroscopic single-row repair of massive potentially irreparable postero-superior cuff tear. Musculoskelet Surg 2018; 102:13-19. [PMID: 30343476 DOI: 10.1007/s12306-018-0555-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 07/02/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE We retrospectively evaluated the results of complete repair of massive potentially irreparable postero-superior tears in a consecutive cohort of patients. With the increasing and widespread use of superior capsular reconstruction, a complete repair of the superior cuff, also if not functional, may be a valuable option for irreparable cuff lesions. METHODS A consecutive case series of massive potentially irreparable postero-superior cuff tears that underwent complete repair was included in the study. Irreparability of cuff tear was defined when on preoperative MRI images, a positive tangent sign, a Goutallier 3-4 stage of fatty infiltration, and an absent acromion-humeral distance were present. A single-row complete repair was performed using triple-loaded titanium suture anchors. Operative time was recorded, as well as intra- and postoperative complications. Patients were followed for 12 months post-op; they were clinically evaluated with the use of constant score (CS) and subjective shoulder value (SSV) at 3, 6, and 12 months; a 12-month postoperative ultrasound evaluation was obtained. RESULTS Thirty-two patients satisfying the inclusion criteria were enrolled. The mean age was 52 years (range 41-58). The repair was completed with a mean use of 2.4 triple-loaded suture anchors (range 2-4); the mean operative time was 70 min (range 45-90). The mean preoperative CS was 55 (range 45-75, SD 17), while the SSV was 40 (range 30-70, SD 22). At the final follow-up, the mean CS and SSV were 72 (range 62-85, SD 8) and 80 (range 60-90, SD 10) (p < 0.001 with respect to the preoperative scores), respectively. At the final follow-up, sonography showed a complete healing of the cuff in 20 cases (62.5%). No intra-operative complications occurred; at the final follow-up, five patients (15, 6%) were not satisfied of the results and asked for revision surgery. CONCLUSIONS The complete repair of massive potentially irreparable rotator cuff tear in patients younger than 60 years old yielded good results at a short-term follow-up, with a sonographic re-tear rate of about 20%. Even if it is logical to consider a tendon with severe fatty degeneration as non-functional, the superior soft tissue reconstruction we achieved may have at least the same results of a superior capsular reconstruction, with obvious lower costs. LEVEL OF EVIDENCE Level 4, case series with no comparison group.
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Bridging Repair of Large Rotator Cuff Tears Using a Multilayer Decellularized Tendon Slices Graft in a Rabbit Model. Arthroscopy 2018; 34:2569-2578. [PMID: 30078689 DOI: 10.1016/j.arthro.2018.04.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 04/16/2018] [Accepted: 04/24/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the efficacy of an extracellular matrix scaffold with multilayer decellularized tendon slices (MDTSs) for reconstructing large rotator cuff tears in a rabbit model. METHODS Large defects in the infraspinatus tendons were created bilaterally in 36 rabbits. The graft group underwent bridging repair of the defects with the MDTSs grafts from Achilles tendons of adult beagle dogs, and the control group underwent repair with the autologous excised tendon. Specimens underwent histologic observation, biomechanical testing, and microcomputed tomography analysis at 2, 4, and 8 weeks after surgery. RESULTS Histologic analysis confirmed that the MDTSs graft promoted cell ingrowth and tissue integration, and fibrocartilage and Sharpey fibers formed at the enthesis at 8 weeks. Accordingly, the MDTSs graft generated a histologic appearance similar to that of the autogenous tendon graft. Mechanical testing revealed a significant increase of the regenerated tendons in ultimate load and stiffness from 4 to 8 weeks postoperatively, which was similar to autologous tendon repair. Microcomputed tomography analysis demonstrated that the MDTSs graft promoted bone formation at the tendon-bone insertion, thus improving the mechanical properties of the repair tendon. CONCLUSIONS The MDTSs graft used to bridge large rotator cuff defects in a rabbit model promoted host cell ingrowth, enhanced the remodeling of regenerated tendon, and promoted fibrocartilage formation, thus improving the biomechanical properties of the repaired tendon. This study thereby provides fundamental information for rotator cuff regeneration with the MDTSs graft. CLINICAL RELEVANCE Rotator cuff regeneration using MDTSs grafts is a promising procedure for large rotator cuff tears.
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Burkhart SS. Editorial Commentary: Superior Capsule Reconstruction With Dermal Allograft: Achieving the Goal of Joint Preservation. Arthroscopy 2018; 34:1774-1775. [PMID: 29804601 DOI: 10.1016/j.arthro.2018.02.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 02/14/2018] [Indexed: 02/02/2023]
Abstract
Active patients with massive irreparable rotator cuff tears and no glenohumeral arthritis have long posed a dilemma for shoulder surgeons. Such high-demand patients do not do well with partial cuff repair, as their results tend to deteriorate over time. They are also not good candidates for reverse total shoulder arthroplasty due to high rates of complications and high revision rates. The early good results of superior capsular reconstruction for these challenging patients are very encouraging, and they highlight the potential for superior capsular reconstruction to be a reliable joint-preserving option with low morbidity.
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Lädermann A, Collin P, Athwal GS, Scheibel M, Zumstein MA, Nourissat G. Current concepts in the primary management of irreparable posterosuperior rotator cuff tears without arthritis. EFORT Open Rev 2018; 3:200-209. [PMID: 29951257 PMCID: PMC5994621 DOI: 10.1302/2058-5241.3.180002] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Various procedures exist for patients with irreparable posterosuperior rotator cuff tears (IRCT). At present, no single surgical option has demonstrated clinical superiority.There is no panacea for treatment and patients must be aware, in cases of palliative or non-prosthetic options, of an alarming rate of structural failure (around 50%) in the short term.The current review does not support the initial use of complex and expensive techniques in the management of posterosuperior IRCT.Further prospective and comparative studies with large cohort populations and long-term follow-up are necessary to establish effectiveness of expensive or complicated procedures such as superior capsular reconstruction (SCR), subacromial spacers or biological augmentation as reliable and useful alternative treatments for IRCT. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.180002.
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Tauro JC. Editorial Commentary: Put Down Your Saw and Pick Up Your Scope! Or, Why Burn Down the Bridge When the Road Ahead Is Full of Potholes? Reverse Total Shoulder Replacement Versus Arthroscopic Rotator Cuff Repair. Arthroscopy 2018; 34:1128-1129. [PMID: 29622249 DOI: 10.1016/j.arthro.2017.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 10/31/2017] [Indexed: 02/02/2023]
Abstract
Are we doing too many reverse total shoulder replacements and not fixing enough repairable rotator cuff tears? A convincing argument can be made for attempting to repair most, not all, very large rotator cuff tears in patients who do not have a significant arthritic change in the shoulder. My experience over more than 25 years of arthroscopic rotator cuff repair (ARCR) is that the only good way to know if it is repairable is to try. But some patients really do not pass my "eyeball test" as to whether they can rehabilitate and heal enough to make an ARCR reasonable. Magnetic resonance imaging scans are useful, mostly to help me with tear pattern recognition, how much time and skill I might need for the repair, and to help me council my patients as to their ultimate functional recovery. I have had surprises both ways: some ARCRs that I thought would be easy turned out to be very challenging and others that I thought would be "mission impossible" turned out to be "mission accomplished"! The rationale for jumping ahead primarily to reverse total shoulder replacements reminds me of certain tax cut plans I have heard talk of lately. Sounds great now (well, maybe the complication rate is a little high) but there might be a price to pay down the road.
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