Superior Capsular Reconstruction Reverses Profound Pseudoparalysis in Patients With Irreparable Rotator Cuff Tears and Minimal or No Glenohumeral Arthritis

Superior capsular reconstruction with the long head of the biceps tendon achieves excellent clinical results and low rotator cuff rerupture rates one year after cuff repair surgery

PURPOSE

To analyze the clinical one-year evolution of healed and rerupture lesions in patients who received a rotator cuff repair plus Superior Capsular Reconstruction (SCR) with the long head of the biceps (LHB). Moreover, to compare this evolution between men and women.

METHODS

A pilot study was conducted on patients who underwent a rotator cuff repair plus SCR with LHB between February 2021 and June 2022. All patients completed pre-operative and one-year post-operative evaluations for tendon type of tear and tendon integrity using Magnetic Resonance Imaging (MRI)after one year of the surgery. Besides, functionality was evaluated with the American Shoulder and Elbow Surgeons (ASES) score; the visual analog scale for pain (VAS); and the Constant score.

RESULTS

A total of 38 patients completed the one-year final evaluation, they presented an increased functionality score to 83 and 86 in Constant and ASES scales (p < .001), respectively. Besides, 84% of the patients presented a healed cuff, while rerupture occurred in 16% of the patients. There were differences between the healed and rerupture patients in the total Constant score, with a remarkable increase in the strength subscale, almost double for patients with healed cuff (p < .001); in the same way, daily life activity score, and balance subscale increased, while pain score decreased in the healed cuff group (p < .05). There was no difference in functionality between men and women (p > .05). Besides, almost all patients achieved the MCID in both ASES and Constant total scores, irrespectively of the healing group.

CONCLUSION

The cuff repair using SCR with the LHB achieved a low percentage of rerupture and a functional improvement after one year of follow-up. Patients who healed the lesion presented more strength and better performance in daily life activities than those with cuff repurture. Thus, SCR + LHB procedure can be considered an efficient technique for rotator cuff repair surgery for both men and women. Although a comparison with a control group is needed to confirm these findings.

Margin convergence vs. superior capsular reconstruction for massive irreparable rotator cuff tears: outcomes are equivalent unless there is preoperative pseudoparesis

BACKGROUND

Margin convergence (MC) and superior capsular reconstruction (SCR) are common treatment options for irreparable rotator cuff tears in younger patients, although they differ in associated costs and operative times. The purpose of this study was to compare range of motion, patient-reported outcomes (PROs), and reoperation rates following MC and SCR. We hypothesized superior outcomes after SCR relative to MC regarding functional outcomes, subjective measures, and reoperation rates.

METHODS

This was a multicenter retrospective review of 59 patients from 3 surgeons treating irreparable rotator cuff tears with either MC (n = 28) or SCR (n = 31) and minimum 1-year follow-up from 2014-2019. Visual analog scale (VAS) for pain, Subjective Shoulder Value (SSV), active forward flexion (FF), external rotation (ER), retear rate, and conversion rate to reverse shoulder arthroplasty were evaluated. t tests and χ2 tests were used for continuous and categorical variables, respectively (P < .05).

RESULTS

Baseline demographics, range of motion, and magnetic resonance imaging findings were similar between groups. Average follow-up was 31.5 months and 17.8 months for the MC and SCR groups, respectively (P < .001). The MC and SCR groups had similar postoperative FF (151° ± 26° vs. 142° ± 38°; P = .325) and ER (48° ± 12° vs. 46° ± 11°; P = .284), with both groups not improving significantly from their preoperative baselines. However, both cohorts demonstrated significant improvements in VAS score (MC: 7.3 to 2.5; SCR: 6.4 to 1.0) and SSV (MC: 54% to 82%; SCR: 38% to 87%). There were no significant differences in postoperative VAS scores, SSV, and rates of retear or rates of conversion to arthroplasty between the MC and SCR groups. In patients with preoperative pseudoparesis (FF < 90°), SCR (n = 9) resulted in greater postoperative FF than MC (n = 5) (141° ± 38° vs. 67° ± 24°; P = .002).

CONCLUSION

Both MC and SCR demonstrated excellent postoperative outcomes in the setting of massive irreparable rotator cuff tear, with significant improvements in PROs and no significant differences in range of motion. Specifically for patients with preoperative pseudoparesis, SCR was more effective in restoring forward elevation. Further long-term studies are needed to compare outcomes and establish appropriate indications.

Superior Capsular Reconstruction with the mini open key-hole Technique using Achilles allograft demonstrates favorable outcomes for patients with preoperative pseudoparalysis but worse outcome and strength with longer duration pseudoparalysis

PURPOSE

The purpose of this study was to analyze whether unique SCR with key-hole technique using Achilles allograft can improve pseudoparalysis in patients with irreparable rotator cuff tears and additionally to identify preoperative factors that influence clinical outcomes.

METHODS

Between January 2018 and October 2021, patient data from SCR with our institution's unique key-hole technique using Achilles were retrospectively collected (minimum 2-years follow up). The patients were categorized into pseudoparalysis group (P group) and no pseudoparalysis group (NP group). Active range of motion (ROM) of shoulder, clinical scores (constant and pain visual analog scale scores) and muscle strength was assessed preoperatively and at 2-years postoperatively. And the correlation between preoperative and postoperative clinical data was analyzed through simple linear regression in the P group.

RESULTS

69 patients who underwent SCR with key-hole technique using Achilles, were included in the study. Group P and NP had 24 and 45 cases, respectively. Preoperative ROM (FE, ER), constant score and muscle strength (FE, ER) were significantly lower in P group than NP group. At 2-year follow-up the active ROM (FE, p<0.001, ER, p<0.001), constant score, VAS, muscle strength (FE, p<0.001, ER, p<0.001) were improved in the P group. In P group, pseudoparalysis recovered in 21 out of 24 patients (87.5%) at 2-year after surgery. The minimum clinically important difference of patient reported outcomes (Constant Score / VAS) were 8.15/1.05 for the P group and 9.47/0.92 for the NP group. Among the 3 cases of recovery failed, 2 cases were due to graft failure, and 1 case had delayed recovery. Prolonged preoperative pseudoparalysis and weaker preoperative external rotation strength were associated with worse clinical outcomes.

CONCLUSIONS

Superior capsular reconstruction with mini open key-hole technique using Achilles allograft demonstrates favorable outcomes for patients with preoperative pseudoparalysis. However, for SCR with the pseudoparalyis patients the careful attention is needed because the longer pseudoparalysis duration and the weaker external rotation strength could have the tendency of worse postoperative outcomes.

Pseudoparalysis and Pseudoparesis of the Shoulder: Definitions, Management, and Outcomes

Loss of shoulder function can be a complex condition to manage. Specifically, the definition between the terms pseudoparalysis and pseudoparesis remains inconsistent in the literature based on various factors including chronicity, present pathology, and the role of pain in the loss of function. There is also debate as to the optimal management strategies for these challenging conditions. In the setting of advanced glenohumeral arthritis or arthropathy in the correct patient, arthroplasty provides consistent and reliable results. However, in younger patients or the patient without arthritis, arthroplasty may not be the best option. In some cases, addressing pain with biceps procedures, balloon spacer placement, débridement, or others may be appropriate. However, other instances may require attempts at improving shoulder kinematics with procedures such as rotator cuff repair, superior capsular reconstruction, and tendon transfer. In this review, we discuss current definitions for pseudoparalysis and pseudoparesis, in addition to reviewing the indications for the various treatment options and their respective outcomes.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Bridging repair reinforced with artificial ligament as an internal brace for irreparable massive rotator cuff tears

BACKGROUND

The irreparable massive rotator cuff tear (IMRCT) is challenging to manage. Although various surgical options have been proposed to treat IMRCTs, the optimal surgical technique remains controversial. Arthroscopic bridging patch repair is clinically used for treating IMRCTs, but the healing rate of the patch graft is negatively affected by superior shift of the humeral head. This study aimed to evaluate the clinical efficacy of artificial ligament as an internal brace (IB) reinforcing fascia lata autograft bridging repair (ABR) in the treatment of IMRCTs.

METHODS

The data of 50 patients with IMRCTs who underwent ABR reinforced with artificial ligament as an IB (ABR + IB) (internal brace group) or ABR alone (control group) were retrospectively evaluated preoperatively and at 2-year follow-up. Clinical outcomes were assessed based on the shoulder activity, of which the strength was measured using a 0-10 points manual muscle test scale, American Shoulder and Elbow Surgeons score, and visual analog scale for pain. Imaging outcomes were evaluated based on acromiohumeral distance (AHD), Hamada grade, Goutallier grade, and the status of fascia lata grafts as per radiographs or magnetic resonance imaging findings.

RESULTS

Both groups showed significantly better results in shoulder activity, American Shoulder and Elbow Surgeons score, visual analog scale score, and AHD at 2-year follow-up compared with preoperative levels (P < .001). Compared with the control group (n = 24), the internal brace group (n = 26) had better mean AHD (7.0 ± 1.4 mm vs. 5.9 ± 1.0 mm, P = .002), mean improvement in AHD (3.3 ± 1.5 mm vs. 2.0 ± 0.6 mm, P < .001), healing rate of autografts (92.3% vs. 54.2%, P = .002), and improvement rate of Hamada grade (73.1% vs. 41.7%, P = .025) at 2-year follow-up. No significant differences were found in active elevation, active external rotation, active internal rotation, abduction strength, external rotation strength, internal rotation strength, American Shoulder and Elbow Surgeons score, or visual analog scale between the 2 groups at 2-year follow-up.

CONCLUSION

Both the ABR + IB and ABR improved the postoperative short-term clinical and imaging outcomes in managing IMRCTs, the ABR + IB is statistically superior to ABR alone in terms of healing rate of the bridging graft, AHD, and Hamada grade at 2-year follow-up, while further clinical investigations with larger sample size and longer follow-ups are required to validate the clinical significance of this novel technique for IMRCTs.

Surgical Management of Massive Irreparable Cuff Tears: Superior Capsule Reconstruction and Rotator Cable Reconstruction

PURPOSE OF REVIEW

Massive irreparable rotator cuff tears (MIRCTs) present treatment challenges. Recently, superior capsule reconstruction (SCR) and anterior cable reconstruction have emerged as surgical options, but no single approach is superior. This review provides an overview of SCR and cable reconstruction techniques, including biomechanical studies, clinical outcomes, and surgical considerations.

RECENT FINDINGS

Biomechanical studies show SCR with autografts or allografts improves glenohumeral stability and mechanics. Clinical outcomes of SCR demonstrate improved range of motion, function scores, and pain relief in short-term studies. Anterior cable reconstruction reduces superior humeral head translation and subacromial pressures in biomechanical models. Early clinical studies report improved rotator cuff healing and outcomes for cable reconstruction in specific irreparable tear patterns. SCR and cable reconstruction are viable surgical options for MIRCTs based on early encouraging results. However, higher-level comparative studies with long-term follow-up are still needed. Careful consideration of tear pattern, patient factors, and surgical goals is required to optimize treatment of MIRCTs. Further research is necessary to determine the optimal role for these procedures.

Latin American formal consensus on the indications for the surgical treatment of massive and irreparable rotator cuff tears

OBJECTIVES

To implement the Formal Consensus Method among a group of experts in shoulder surgery in Latin America, in order to establish appropriate indications for the surgical treatment of massive and irreparable rotator cuff injuries.

METHODS

The Formal Consensus Method was used to develop surgical treatment recommendations for massive and irreparable rotator cuff tears (MIRCT). Three independent groups of experts in shoulder surgery were confirmed. The steering group conducted a systematic literature review and constructed a voting matrix consisting of 348 clinical scenarios. The rating group, composed of 15 members, rated each scenario on two occasions: first anonymously and then during an in-person discussion meeting. The median and voting ranges were used to classify each scenario as inappropriate, uncertain, or appropriate for each surgical technique. Finally, the reading group, consisting of 10 surgeons, reviewed, evaluated and rated the recommendations derived from the detailed analysis of the voting grids.

RESULTS

The main finding of the study reveals a high percentage (70%) of clinical scenarios in which consensus was achieved regarding the appropriateness or inappropriateness of different surgical alternatives for the treatment of massive and irreparable rotator cuff injuries. Through a detailed analysis of the voting grids, a total of 20 recommendations were elaborated concerning the appropriateness of various surgical techniques in addressing irreparable rotator cuff tears.

CONCLUSIONS

The indications for the operative treatment of MIRCT were determined based on expert consensus and the best available evidence, they seek to provide guidance on the appropriateness of various surgical techniques for different clinical scenarios.

LEVEL OF EVIDENCE

V.

Postoperative results of arthroscopic superior capsule reconstruction using fascia lata: a retrospective cohort study

BACKGROUND

Superior capsule reconstruction (SCR) was developed to improve shoulder function and alleviate pain in patients with primary irreparable rotator cuff tears. Although suitable clinical results of SCR have been reported, only a few studies have investigated the clinical outcomes of arthroscopic superior capsule reconstruction (ASCR) using tensor fascia at a minimum follow-up period of 2 years after surgery.

METHODS

Among 100 consecutive patients who underwent ASCR since April 2010, this retrospective cohort study included 49 patients with a Hamada classification of ≤3 who were available for at least 2-year follow-up after surgery. The mean follow-up period was 34.5 (24-74) months. We analyzed preoperative and postoperative Japanese Orthopaedic Association (JOA) scores, University of California at Los Angeles (UCLA) shoulder scores, preoperative and postoperative active elevation angles, external and internal rotations with the arms in the anatomical position, manual muscle test (MMT) scores, preoperative and postoperative acromiohumeral distance (AHD), and cuff integrity on postoperative magnetic resonance imaging using the Hasegawa classification. We compared 27 pseudoparalyzed (elevation of <90°) shoulders with 22 nonpseudoparalyzed shoulders. We also evaluated the treatment of patients with subscapularis tendon tears and compared the outcomes of patients with good graft repair and those with graft retear.

RESULTS

The JOA score, UCLA score, active elevation angle, internal and external rotation angles, and muscle strength (MMT) significantly improved at the time of investigation preoperatively and 2 years postoperatively. The mean AHD also improved from 5 ± 2.6 mm preoperatively to 9 ± 2.8 mm postoperatively. No significant difference in graft tear rate was observed between pseudoparalyzed shoulder and nonpseudoparalyzed shoulder groups. The subscapularis tendon was torn in 26 of 49 (53%) patients, and all patients underwent repair. The graft repair group showed a significant improvement in JOA scores, UCLA shoulder scores, joint range of motion, MMT, and AHD postoperatively, but not in internal rotation strength. In contrast, the graft tear group did not show any significant improvement. All patients could return to work, except for those performing heavy labor. Complications included graft tear in five patients, postoperative infection in two patients, and progressive postoperative arthropathic changes in one patient.

CONCLUSION

Good clinical results of ASCR were obtained using tensor fascia lata at 2 years after surgery, with few complications and low graft tear rates.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level IV, therapeutic case series.

Superior Capsular Reconstruction Versus Middle Trapezius Tendon Transfer for Isolated Irreparable Supraspinatus Tendon Tears: Static Versus Dynamic Reconstruction

BACKGROUND

Both superior capsular reconstruction (SCR) and middle trapezius tendon (MTT) transfer can be performed in nonarthritic young and active patients with isolated irreparable supraspinatus tendon tears (IISTTs). However, to our knowledge, no comparative clinical studies have been conducted on these procedures.

PURPOSE

To evaluate and compare the clinical and radiological outcomes of SCR and arthroscopic-assisted MTT transfer in patients with IISTTs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 60 patients with IISTTs were categorized into 2 groups according to the surgical procedure-Group S underwent SCR (n = 34); Group M underwent MTT transfer (n = 26). The clinical outcomes included the visual analog scale score for pain, active shoulder range of motion, American Shoulder and Elbow Surgeons score, and University of California, Los Angeles, shoulder score. Radiological outcomes included the assessment of the acromiohumeral distance, progression of cuff tear arthropathy (Hamada grade), subacromial bone erosion, and graft failure.

RESULTS

The mean follow-up time was 39.3 ± 5.2 months (range, 26-59 months) and 37.6 ± 9.8 months (range, 27-54 months) in Group S and Group M, respectively. Significant improvements in clinical outcomes were observed in both groups, while the active forward flexion (148.2°± 24.1° vs 165.9°± 8.7°; P = .003) and abduction (131°± 37.3° vs 152.5°± 17.9°; P = .035) were significantly higher in Group M at the final follow-up. No significant differences were found in the postoperative Constant, American Shoulder and Elbow Surgeons, and University of California, Los Angeles, shoulder scores between the 2 groups. Radiologically, although no difference was found in the Hamada grade at the final follow-up between the 2 groups (P = .143), the rates of acromial wear (58.8% vs 15.4%; P < .001) and graft retear (47.1% vs 7.7%; P < .001) were significantly higher in Group S than in Group M.

CONCLUSION

Both SCR and MTT transfer improved the overall clinical outcomes of IISTTs postoperatively, whereas MTT transfer was superior to SCR in terms of active forward flexion and abduction range of motion. Although higher rates of graft failure and subacromial bone erosion were observed in Group S, no difference was found in the clinical scores between the 2 groups at the short-term follow-up. However, further well-structured, prolonged comparative trials should be conducted in the future.

Midterm outcome of superior capsular reconstruction using doubled acellular human dermal allograft for irreparable rotator cuff tear

BACKGROUND

Thicker (folded) facia lata autografts have been shown to be superior to thinner grafts and single-layered acellular human dermal (HD) allografts for superior capsular reconstruction (SCR) in biomechanical studies. The aim of this study was to evaluate the midterm clinical outcomes following SCR for irreparable supraspinatus tears using doubled (folded) HD allograft.

METHODS

Thirty-two patients who had undergone SCR using doubled HD allograft between February 2012 and January 2020 were recruited in a continuous manner in this retrospective study. The inclusion criteria were SCR performed for irreparable supraspinatus tear and a minimum of 2 years' follow-up. The primary outcome measure was the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score. The secondary outcome measures were complications and revision surgery. A subgroup analysis was performed between patients who received a "standard" graft of mean 3-mm thickness or a "thick" graft of mean 4.4-mm thickness.

RESULTS

One patient was lost to follow-up. A total of 31 patients (31 shoulder joints) were analyzed with a mean follow-up duration of 48 months (range, 25-96 months). Following surgery, there was significant improvement in the ASES score from 18.1 ± 14.3 (preoperative) to 76.3 ± 25.1 (postoperative) (P < .001), with a satisfactory clinical outcome obtained in 83.8% of the patients. In a subset of 8 patients completing 5 years' follow-up, the clinical improvements were sustained. The percentage of patients with a clinically successful outcome was higher among those with thick grafts compared to those with standard grafts, although this failed to reach statistical significance (94.4% vs. 69.2%, risk ratio 1.36, 95% confidence interval 0.93-1.99, P = .13). One patient within the standard group underwent revision surgery.

CONCLUSION

SCR for irreparable rotator cuff tears with doubled HD allograft results in improved clinical outcomes and low reoperation at midterm follow-up duration.

Clinical effectiveness of superior capsular reconstruction using Teflon felt graft in the elderly for pain relief: a comparison using tensor fascia lata graft

Background

The graft material generally used in superior capsular reconstruction (SCR) may be a human dermal allograft or an autologous tensor fascia lata (TFL) graft. According to a previous biomechanical study, a dermal graft (3 mm) was found to be insufficient and a thicker and stiffer graft was required. However, graft-site mobility should be considered when harvesting TFL, especially in the elderly. We have used Teflon felt as a graft material for SCR in the elderly for pain relief. This study aimed to compare the pain-relieving effects and clinical outcomes between Teflon felt and TFL graft.

Methods

This study included 39 patients (Teflon felt group: 19 patients, TFL group: 20 patients) who underwent SCR with a minimum of 2-year follow-up. Patients with painful irreparable rotator cuff tears but with shoulder elevation (abduction or flexion) of at least 130° were included in the study. Shoulder range of motion, acromiohumeral distance, and the numerical rating scale were evaluated preoperatively and 2 years postoperatively.

Results

There were no significant differences between the Teflon felt and TFL groups in terms of shoulder elevation (151 ± 33° vs. 164 ± 15°, P = .57), acromiohumeral distance (8.3 ± 2.2 mm vs. 7.5 ± 2.5 mm, P = .14), and numerical rating scale (1.0 ± 1.2 vs. 0.9 ± 0.8, P = .93).

Conclusion

SCR with Teflon graft provided pain relief equivalent to TFL graft. It may be an effective treatment option in elderly patients for irreparable rotator cuff tears with respect to pain relief.

Minimal inter-surgeon agreement on the diagnosis of pseudoparalysis in patients with massive rotator cuff tears

BACKGROUND

Pseudoparalysis is commonly used to describe patients with severe loss of active elevation associated with advanced rotator cuff disease, but its definition in the literature has been variable. This study aimed to determine how 15 expert shoulder surgeons use the term "pseudoparalysis" when presented with clinical cases and assess clinical agreement on the diagnosis of pseudoparalysis.

METHODS

Fifteen expert shoulder surgeons were surveyed regarding 18 patients with magnetic resonance imaging-diagnosed massive rotator cuff tears, restricted active range of motion (ROM), full passive ROM, and without advanced rotator cuff arthropathy (Hamada grade <3). The survey included 18 patient vignettes with key clinical details and a deidentified video demonstrating the physical examination of the patient. For all patients, surgeons were instructed to assume that the patient has a full passive ROM. An anteroposterior radiograph and T2 sequences of the patient's coronal, axial, and sagittal magnetic resonance imaging were also provided. After each case, the surgeons were asked: (1) does the patient have pseudoparalysis, and (2) if so, how severe it is. At the end of the patient vignettes, surgeons were asked to define pseudoparalysis using a checklist with predefined options. Surgeons were also asked if there was a difference between the term pseudoparalysis and pseudoparesis. Fleiss' kappa (κ) correlation coefficient was used to determine intersurgeon agreement.

RESULTS

There was minimal inter-rater agreement on the diagnosis of pseudoparalysis (κ = 0.360) and no agreement on describing the severity of pseudoparalysis (κ = -0.057). Although 80% of surgeons stated that an active glenohumeral elevation less than 90° was a diagnostic feature of pseudoparalysis, there was disagreement on the remaining criteria, leading to no agreement on a set of universal criteria that defines pseudoparalysis. A total of 67% included maintained full passive elevation, 33% included the absence of pain, 67% included elevation causing anterosuperior escape, and 27% included an additional unlisted factor. There was minimal agreement among the 15 surgeons on the diagnostic criteria of pseudoparalysis (κ = 0.092). Finally, 7 surgeons stated that pseudoparalysis and pseudoparesis are identical, whereas 8 surgeons stated that they are 2 different clinical diagnoses.

CONCLUSION

Among this panel of expert shoulder surgeons, there was a lack of consensus on the definition of pseudoparalysis and minimal agreement on the diagnosis of pseudoparalysis based on clinical scenarios. In addition, half the surgeons believed that pseudoparalysis and pseudoparesis are identical, whereas the other half believed that they represent 2 separate clinical entities. A standardized definition of pseudoparalysis would be of value to facilitate communication and research efforts.

Do Magnets Have the Potential to Serve as a Stabilizer for the Shoulder Joint in Massive Rotator Cuff Tears?: A Biomechanical Cadaveric Study

Background

Disruption of the rotator cuff muscles compromises concavity compression force, which leads to superior migration of the humeral head and loss of stability. A novel idea of using the magnetic force to achieve shoulder stabilization in massive rotator cuff tears (MRCTs) was considered because the magnets can stabilize two separate entities with an attraction force. This study aimed to investigate the biomechanical effect of the magnetic force on shoulder stabilization in MRCTs.

Methods

Seven fresh frozen cadaveric specimens were used with a customized shoulder testing system. Three testing conditions were set up: condition 1, intact rotator cuff without magnets; condition 2, an MRCT without magnets; condition 3, an MRCT with magnets. For each condition, anterior-posterior translation, superior translation, superior migration, and subacromial contact pressure were measured at 0°, 30°, and 60° of abduction. The abduction capability of condition 2 was compared with that of condition 3.

Results

The anterior-posterior and superior translations increased in condition 2; however, they decreased compared to condition 2 when the magnets were applied (condition 3) in multiple test positions and loadings (p < 0.05). Abduction capability improved significantly in condition 3 compared with that in condition 2, even for less deltoid loading (p < 0.05).

Conclusions

The magnet biomechanically played a positive role in stabilizing the shoulder joint and enabled abduction with less deltoid force in MRCTs. However, to ensure that the magnet is clinically applicable as a stabilizer for the shoulder joint, it is necessary to thoroughly verify its safety in the human body and to conduct further research on technical challenges.

Postoperative graft integrity affects clinical outcomes after superior capsule reconstruction using fascia lata autograft in posterior-superior rotator cuff tears: a multicenter study

BACKGROUND

Previous studies have postulated that graft thickness and graft healing may be important factors for optimizing clinical outcomes of superior capsule reconstruction (SCR) for patients with irreparable rotator cuff tears (RCTs). However, the relationship between postoperative graft integrity and clinical outcomes after SCR remains unclear. We aimed to assess the relationship between postoperative graft integrity, including graft thickness and size of graft tear, and clinical outcomes after SCR in patients with irreparable RCTs.

METHODS

This retrospective multicenter study included 188 patients (86 women, 102 men; mean age, 69.2 years; range, 49-87 years) with irreparable RCTs who underwent arthroscopic SCR using fascia lata autografts. Using magnetic resonance imaging, the graft integrity was evaluated postoperatively at or after 1 year and was classified, according to Hasegawa's classification, into 4 categories: type I-II, intact graft of sufficient thickness; type III, thinned graft without discontinuity; type IV, presence of a minor discontinuity; and type V, presence of a major discontinuity. We compared (1) baseline characteristics, (2) visual analog scale (VAS) for pain, (3) American Shoulder and Elbow Surgeons (ASES) score, (4) active shoulder range of motion, and (5) acromiohumeral distance (AHD) among 4 groups based on postoperative graft integrity.

RESULTS

Magnetic resonance imaging scans revealed 152 shoulders (80.9%) with type I-II graft, 13 (6.9%) with type III graft, 13 (6.9%) with type IV graft, and 10 (5.3%) with type V graft. VAS and ASES scores significantly improved after SCR in all graft types (P < .0001 to P = .02). However, shoulders with type V grafts had significantly inferior postoperative VAS and ASES scores compared to those with type I-II grafts (P = .001 and P < .0001, respectively). Shoulders without graft tears (types I-II and III) showed significant improvements in shoulder elevation and internal rotation after SCR (P < .0001 to P = .02). In contrast, shoulders with large graft tears (type V) showed no significant improvement in shoulder range of motion. Postoperative acromiohumeral distance significantly increased only in shoulders with type I-II grafts (P < .0001).

CONCLUSION

Postoperative graft thickness and size of graft tear affected clinical and radiographic outcomes after SCR using a fascia lata autograft. Patients with large graft tears had significantly inferior postoperative clinical scores compared to those with intact grafts of sufficient thickness, although arthroscopic SCR provided pain relief even in patients with graft tears. Shoulders with intact grafts of sufficient thickness restored glenohumeral stability and showed better clinical outcomes than those with graft thinning or tears.

Outcomes After Superior Capsular Reconstruction With an Achilles Tendon-Bone Allograft Using the Modified Keyhole Technique: A 2-Year Follow-up of a Novel Technique for Irreparable Rotator Cuff Tears

Background

Despite improved outcomes, failure or nonhealing of graft materials has been reported after superior capsular reconstruction (SCR) for massive irreparable rotator cuff tears.

Purpose

To evaluate the short-term clinical and radiological outcomes of a novel technique for SCR using an Achilles tendon-bone allograft.

Study Design

Case series; Level of evidence, 4.

Methods

We performed a retrospective review of patients who underwent SCR using an Achilles tendon-bone allograft with the modified keyhole technique and who had a minimum follow-up of 2 years. The visual analog scale score for pain, American Shoulder and Elbow Surgeons score, and Constant score were evaluated as subjective outcomes, while range of motion of the shoulder joint and isokinetic strength were evaluated as objective outcomes. The acromiohumeral interval (AHI), bone-to-bone healing of the allograft and humeral head on computed tomography, and graft integrity on magnetic resonance imaging were evaluated as radiological outcomes.

Results

This study included 32 patients with a mean age of 56.8 ± 4.2 years and a mean follow-up of 28.4 ± 6.2 months. A significant improvement from preoperatively to the last follow-up was seen in the mean visual analog scale score for pain (from 6.7 to 1.8), American Shoulder and Elbow Surgeons score (from 42.7 to 83.8), Constant score (from 47.2 to 78.5), and AHI (from 4.8 to 8.2 mm) (P < .001 for all) as well as range of motion in forward elevation and internal rotation (P < .001 for both). Medial-to-lateral graft integrity was good in all patients. Nonunion at the fitting zone of the keyhole on the greater tuberosity was diagnosed in 1 case (3.1%), and failure of incorporation between the allograft and remnant tendon at the site of posterior margin convergence was observed in 4 cases (12.5%).

Conclusion

The outcomes after SCR using an Achilles tendon-bone allograft and the keyhole technique improved, with an increased AHI and excellent integrity in the medial and lateral directions compared with preoperatively. This technique is a reasonable option for the surgical treatment of irreparable rotator cuff tears.

Editorial Commentary: Superior Capsular Reconstruction Employing Allograft Heals and Functions Well if the Graft Is Sufficiently Thick and Stiff

Superior capsular reconstruction (SCR) has fallen into disrepute, and the numbers performed appear to be on the decline because it is technically demanding and time-consuming, requires a long postoperative recovery, and does not always heal or function as expected. In addition, two "new kids on the block," the subacromial balloon spacer and the lower trapezius tendon transfer, have emerged as viable alternatives for low-demand patients who cannot tolerate a lengthy recovery and for high-demand patients who lack external rotation strength, respectively. However, carefully selected patients continue to do well after SCR, when surgery is meticulously performed using a graft that is sufficiently thick and stiff. The clinical results and healing rates after SCR using allograft tensor fascia lata are comparable with those after SCR using tensor fascia lata autograft and without donor-site morbidity. Robust comparative clinical study is needed to sort out the optimal graft type and thickness for SCR and the precise indications for each of the surgical treatment options for the irreparable rotator cuff tear, but let's not "throw the baby out with the bathwater" and abandon SCR altogether.

Combined Arthroscopic-Assisted Lower Trapezius Tendon Transfer and Superior Capsule Reconstruction for Massive Irreparable Posterior-Superior Rotator Cuff Tears: Surgical Technique

Primary or revision irreparable rotator cuff tears remain a challenge. Clear algorithms do not exist. Several joint-preserving options are available, but no technique has been definitely proven to be better than another. Although superior capsule reconstruction has been shown to be effective in restoring motion, lower trapezius transfer can provide strong external rotation and abduction moment. The aim of the present article was to describe an easy and reliable technique to combine both options in 1 surgery, aiming to maximize the functional outcome by getting motion and strength back.

Allograft-enhanced latissimus dorsi transfer is better than the conventional technique for irreparable posterosuperior rotator cuff tears. A retrospective matched cohort

PURPOSE

Latissimus dorsi tendon (LDT) transfer (LDTT) to the greater tuberosity to treat irreparable posterosuperior rotator cuff tears (RCTs) in young active patients has been shown to have up to 36% of clinical failures, most of them happening because of either deltoid origin disruption or post-operative transfer rupture from the greater tuberosity. In an attempt to simultaneously prevent both complications, a modified technique includes the following adaptations to the original technique: reinforcement and augmentation of the LDT with a tendinous allograft, enabling the use of a single deltopectoral approach. The aim of this study is to compare mid-term outcomes of the traditional LDTT technique with this modified transfer.

METHODS

Retrospective cohort study comparing two groups who underwent either the traditional (group 1; n = 19) or the modified technique (group 2; n = 27). Group homogenization was assured by statistical comparison of 24 baseline independent variables. The outcome variables were the gains to active shoulder range of motions (ROM) and UCLA scores (and all its subscores, independently), at a minimum follow-up of two years. A p value < .05 was considered to be statistically significant.

RESULTS

At a mean follow-up of 25 months, both groups have shown improvements to most variables. However, group two (modified technique) achieved greater improvements to UCLA score (p = .009), active external rotation (p = .006) and internal rotation (p = .008).

CONCLUSION

At mid-term follow-up, improvements to outcomes of the modified (single approach, allograft-enhanced) latissimus dorsi transfer were greater than those of the original technique.

Arthroscopic Superior Capsule Reconstruction with Combined Fascia Lata Autograft and Synthetic Scaffold Patch Graft for the Treatment of Irreparable Rotator Cuff Tears Yields Favorable Clinical and Radiographic Outcomes at Minimum Two-Year Follow-Up

PURPOSE

To report the results of the arthroscopic superior capsule reconstruction (ASCR) technique with a combined fascia lata autograft and synthetic scaffold patch graft for irreparable massive rotator cuff tears (RCTs).

METHODS

The period for this retrospective study was between December 2016 and December 2020. The criteria for inclusion were patients treated arthroscopically for an incompletely reparable massive RCT (dimension > 5 cm and two tendons fully torn, intact or reparable subscapularis tendons and teres minor tendon with or without irreparable infraspinatus, a radiological Hamada classification between grade 0 and 4, and a minimum 24-month postoperative follow-up).. Clinical outcomes were evaluated pre-operatively and at a final follow-up by a visual analog scale (VAS) for pain and range of motion along with the American Shoulder and Elbow Surgeons score (ASES), the University of California Los Angeles score (UCLA), and the Constant-Murley score (CMS). Radiological outcomes were assessed according to the rotator cuff arthropathy (RCA) and the acromiohumeral distance (AHD) stages. Graft integrity and muscle fatty infiltration were evaluated by magnetic resonance imaging (MRI).

RESULTS

A total of 43 patients were enrolled in the study with a mean follow-up duration of 45.6 months (range 24 to 64). All clinical scores also improved at the two-year follow-up (mean VAS 0.7 [SD 0.7] vs. 5.4 [SD 1.1], P < 0.001; mean ASES 92.6 [SD 8.0] vs. 34.8 [SD 13.4], P < 0.001; mean UCLA 31.5 [SD 3.9] vs. 11.0 [SD 3.2], P < 0.001; and mean CMS 86.6 [SD 7.2] vs. 40.0 [SD 11.6], P < 0.001), and 39 of 43 fascia lata grafts were fully intact on MRI (91%).

CONCLUSIONS

ASCR with a combined fascia lata autograft and synthetic scaffold patch graft resulted in good functional outcomes, with a high rate of graft healing at the two-year follow-up. All patients achieved clinically relevant improvement (met minimal clinically important differences (MCID)) on ASES, UCLA, and VAS with improved abduction strength restoration.

Superior Capsular Reconstruction Partially Restores Native Glenohumeral Joint Loads In A Dynamic Biomechanical Shoulder Model

PURPOSE

To evaluate the effect of an irreparable posterosuperior rotator cuff tear (PSRCT) on glenohumeral joint loads and to quantify improvement following superior capsular reconstruction (SCR) using an acellular dermal allograft.

METHODS

Ten fresh-frozen cadaveric shoulders were tested using a validated dynamic shoulder simulator. A pressure mapping sensor was placed between the humeral head and glenoid surface. Each specimen underwent the following conditions: (1) native, (2) irreparable PSRCT, (3) SCR using a 3mm-thick acellular dermal allograft. Glenohumeral abduction angle (gAA) and superior humeral head migration (SM) were measured using 3D motion tracking software. Cumulative deltoid force (cDF) and glenohumeral contact mechanics, including contact area (gCA) and contact pressure (gCP), were assessed at rest,15°,30°,45°, and maximum angle of glenohumeral abduction.

RESULTS

The PSRCT resulted in a significant decrease of gAA along with an increase in SM, cDF, and gCP (P<.001, respectively). SCR did not restore native gAA (P<.001), however, SM was significantly reduced (P<.001). Further, SCR significantly reduced deltoid forces at 30° (P=.007) and 45° of abduction (P=.007) when compared to the PSRCT. SCR did not restore native cDF at 30°(P=.015), 45°(P<.001), and maximum angle (P<.001) of glenohumeral abduction. Compared to the PSRCT, SCR resulted in a significant decrease of gCP at 15°(P=.008), 30°(P=.002), and 45°(P=.006). However, SCR did not completely restore native gCP at 45° (P=.038) and maximum abduction angle (P=.014).

CONCLUSION

In this dynamic shoulder model, SCR only partially restored native glenohumeral joint loads. However, SCR significantly decreased glenohumeral contact pressure, cumulative deltoid forces, and superior migration, while increasing abduction motion, when compared to the posterosuperior rotator cuff tear.

CLINICAL RELEVANCE

These observations raise concerns regarding the true joint preserving potential of SCR for an irreparable posterosuperior rotator cuff tear, along with its ability to delay progression of cuff tear arthropathy and eventual conversion to reverse shoulder arthroplasty.

Editorial Commentary: Shoulder Superior Capsular Reconstruction Remains to Be Proven Superior to Partial Repair of the Rotator Cuff for Active Patients With Irreparable Tears and Without Osteoarthritis

The management of irreparable rotator cuff tears in active patients without severe osteoarthritis is challenging. Retracted tears of the superior cuff result in devastating glenohumeral kinematics and decreased shoulder function. Surgical solutions such as superior capsular reconstruction (SCR) or tendon transfers may improve shoulder function. Regarding SCR, the superior capsule has been described as a static stabilizer allowing for the centering of the humeral head. However, some bases for SCR are based on biomechanical studies that should be regarded as time zero, absent healing, and generally oversimplified as ball-and-socket research rather than replicating complex functional shoulder kinematics. SCR may be waning in popularity. SCR using autograft may, or may not, prove effective in the long run. For now, it remains to be seen whether SCR is superior to partial repair of the rotator cuff.

Early Postoperative MRI Evaluation of a Fascia Lata Autograft With and Without Polypropylene Mesh Augmentation After Superior Capsular Reconstruction

BACKGROUND

Recently, a polypropylene mesh has been introduced and reported to improve clinical outcomes after superior capsular reconstruction (SCR) using a fascia lata autograft (FLA). However, mesh-related events such as a foreign body response may trigger inflammation, which might affect graft healing and remodeling.

PURPOSE/HYPOTHESIS

The aim was to investigate whether the healing and remodeling of an FLA were affected by the use of a mesh by comparing the signal intensity of an FLA-alone group vs an FLA + Mesh group on postoperative magnetic resonance imaging (MRI). The hypothesis was that the use of a mesh would decrease the MRI signal intensity of FLA during the early postoperative phase.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who had undergone SCR using an FLA with or without a mesh between March 2013 and August 2021 were retrospectively analyzed. Follow-up MRI was performed at 3 months. A total of 78 patients (24 in the FLA group and 54 in the FLA + Mesh group) with intact grafts were included. Graft remodeling was evaluated by analyzing the signal-to-noise quotient (SNQ) at the humeral, mid-substance, and glenoid sites. Theoretically, lower SNQ ratios indicate higher strength and better healing of the graft.

RESULTS

The mean SNQ was 30.603 (range, 11.790-72.710) in the FLA group and 18.367 (range, 4.464-69.500) in the FLA + Mesh group (P < .001). Furthermore, significant differences were found between the 2 groups at the humeral and mid-substance sites (37.863 [range, 5.092-81.187] vs 15.512 [range, 1.814-80.869], P < .001; and 29.168 [range, 6.103-73.900] vs 16.878 [range, 2.454-92.416], P = .003; respectively). However, there was no difference between the 2 groups at the glenoid site (25.346 [range, 7.565-86.353] vs 20.354 [range, 3.732-88.468], P = .057).

CONCLUSION

At the 3-month follow-up, the FLA + Mesh group showed a lower MRI signal intensity than the FLA group. The healing and remodeling of an FLA may be enhanced when a mesh is used.

Study of arthroscopic superior capsule reconstruction in the treatment of irreparable rotator cuff tears

Background

The objective of this study was to investigate the clinical outcome and radiographic findings after arthroscopic superior capsule reconstruction (ASCR) with a new augmented autograft technique for irreparable rotator cuff tears.

Methods

Between 2018 and 2020, 11 patients whose shoulders had irreparable rotator cuff tears underwent ASCR using a fascia lata weaving mesh. Physical examination, radiography, and magnetic resonance imaging (MRI) were performed before surgery and the average follow-up was 20 months (18-24 months) after surgery. Clinical outcome scores were recorded.

Results

Average clinical outcome scores improved significantly at the final follow-up, with 94.7 points scored on the American Shoulder and Elbow Surgeons scale (range, 85-100 points) and 34.5 points on the University of California, Los Angeles scale (33-35 points) (P < 0.05). Mean active elevation increased significantly from 30.1° to 150° (P < 0.05) and external rotation increased from 30° to 59.2° (P < 0.05). The acromiohumeral distance (AHD) increased from 3.9 ± 0.6 mm preoperatively to 10.1 ± 0.7 mm postoperatively (P < 0.05). No patient had graft tear or tendon retear during follow-up.

Conclusions

ASCR with a new augmented autograft can restore the function of the shoulder joint with irreparable rotator cuff tears. Our results suggest that this reconstruction technique can help obtain good clinical and radiographic outcomes, which can provide a reliable method for the treatment of irreparable rotator cuff tears.

Level of Evidence

Level IV, therapeutic case series.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Clinical and Functional Outcomes by Graft Type in Superior Capsular Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

In recent years, superior capsular reconstruction (SCR) has emerged as a promising treatment for massive rotator cuff tears and has been performed with an array of graft options, most commonly dermal allograft and tensor fascia lata (TFL) autograft.

PURPOSE

To compare the clinical outcomes, functional outcomes, and complication rates after SCR performed with dermal allograft, TFL autograft, long head of the biceps tendon (LHBT) autograft, and porcine xenograft.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

PubMed, Cochrane Library, and Embase were systematically reviewed for studies that enrolled ≥10 patients who underwent SCR and presented clinical outcome data at a minimum follow-up of 12 months. When available, pre- and postoperative patient-reported outcome scores and clinical examination data were extracted. Outcome data were then compared by graft type. A meta-analysis was also conducted of graft tear and reoperation rates after SCR with dermal allograft and TFL autograft.

RESULTS

Human dermal allograft and TFL autograft were each utilized in 7 studies, LHBT autograft in 2 studies, and porcine xenograft in 1 study. Dermal allograft, TFL autograft, and LHBT autograft demonstrated comparable median (range) postoperative American Shoulder and Elbow Surgeons scores of 85.3 (77.5-89), 88.6 (73.7-94.3), and 82.7 (80-85.4), respectively. The median postoperative pain scores per visual analog scale for dermal allograft, TFL autograft, and LHBT autograft were 0.8, 2.5, and 1.4. Median postoperative forward elevation was 159.0°, 147.0°, 163.8°, and 151.4° for dermal allograft, TFL autograft, LHBT autograft, and porcine xenograft. Meta-analysis demonstrated a comparable pooled graft tear rate between TFL autograft (9%; 95% CI, 4%-16%) and dermal allograft (7%; 95% CI, 2%-13%). Similarly, the pooled reoperation rate was similar for TFL autograft (3%; 95% CI, 0%-7%) and dermal allograft (6%; 95% CI, 2%-12%). Among the 3 studies with pre- and postoperative information on pseudoparalysis, 73 of 76 (96%) patients with an intact/repairable subscapularis had a reversal of their pseudoparalysis after SCR.

CONCLUSION

Dermal allograft, TFL autograft, and LHBT autograft are all suitable options for SCR and demonstrate significant improvements in American Shoulder and Elbow Surgeons score, pain score per visual analog scale, and forward elevation. Moreover, dermal allograft and TFL autograft have comparable rates of graft tear and reoperation.

Arthroscopic Superior Capsular Reconstruction Using Hamstring Allograft

Superior capsular reconstruction (SCR) has become an acceptable treatment option for patients with chronic shoulder pain in the setting of an irreparable rotator cuff tear. Several different techniques have been described with varying graft options. In this Technical Note, we introduce a technique for arthroscopic SCR using hamstring allograft tendon. Our described technique allows for a "one-size-fits-all" graft with a "build as you go" construct with no need for intraoperative dimensional defect measurements or specific graft modifications. This technique provides a reliable and reproducible procedure using readily available graft tissue.

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

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

Outcomes of combined anterior latissimus dorsi and teres major tendon transfer for irreparable anterosuperior rotator cuff tears

BACKGROUND

Irreparable anterosuperior rotator cuff tears (IASRCTs) can result in loss of active elevation, loss of internal rotation, and pseudoparalysis. Joint-preserving treatment options for IASRCTs in young and high-demand elderly patients are limited. The purpose of this study was to evaluate the clinical and radiologic outcomes of combined anterior latissimus dorsi and teres major (aLDTM) tendon transfer in patients with IASRCTs without reconstruction of the superior rotator cuff and capsular portion.

METHODS

This retrospective study was conducted between 2015 and 2018. We included patients who underwent combined aLDTM tendon transfer for IASRCTs. Clinical outcomes included visual analog scale for pain, Constant score, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder scores, activities of daily living requiring active internal rotation score, active range of motion, subscapularis-specific physical examination, and rate of return to work. Radiographic analyses included the assessment of acromiohumeral distance, Hamada grade for cuff tear arthropathy, rate of anterior glenohumeral subluxation reduction, and transferred tendon integrity at 2 years postoperatively.

RESULTS

The mean follow-up period was 38.1 ± 13.7 (range: 24-63) months. Of the patients, 30 (mean age: 64.1 years) met the study criteria. Postoperatively, mean Constant, American Shoulder and Elbow Surgeons, University of California Los Angeles, and activities of daily living requiring active internal rotation scores improved from 47.4 to 69.9 (P < .001), 44.9 to 79.2 (P < .001), 20.0 to 28.7 (P < .001), and 13.2 to 26.9 (P < .001), respectively. The mean active range of motion was significantly increased postoperatively for both forward elevation (P < .001) and internal rotation at the back (P < .001). Of the patients, 24 (83%) returned to their previous work. No significant progression of cuff tear arthropathy was observed at final follow-up (Hamada grade: preoperative 1.3 ± 0.5 to postoperative 1.5 ± 0.7; p=0.155). Fifteen of 30 patients (50%) restored the anterior glenohumeral subluxation that was apparent preoperatively. One patient presented with transient axillary nerve palsy after surgery. Two patients presented with partial nonretracted tears of the transferred tendon.

CONCLUSION

This minimum 2-year follow-up study demonstrated that combined aLDTM tendon transfer without reconstruction of the superior rotator cuff and capsular portion was a viable treatment option with favorable clinical and radiologic outcomes for patients with IASRCTs.

Irreparable Massive Rotator Cuff Tears: Subacromial Balloon Surgical Technique

Massive irreparable rotator cuff tears pose a significant challenge for both the treating orthopedic surgeon and patient. Surgical treatment options for massive rotator cuff tears include arthroscopic debridement, biceps tenotomy or tenodesis, arthroscopic rotator cuff repair, partial rotator cuff repair, cuff augmentation, tendon transfers, superior capsular reconstruction, subacromial balloon spacer, and ultimately reverse shoulder arthroplasty. The present study will provide a brief overview of these treatment options along with a description of the surgical technique for subacromial balloon spacer placement.

Longitudinal efficacy of acellular dermal allograft following superior capsular reconstruction of irreparable rotator cuff tears

Background

Superior capsular reconstruction (SCR) remains an option for irreparable rotator cuff tears, especially for active patients. While fascia lata grafts were first used with SCRs, acellular dermal allografts have demonstrated similar postoperative outcomes and complication rates. Few studies report long-term clinical outcomes following use of acellular dermal allografts. The aim of the current study is to evaluate long-term efficacy of allograft usage in SCR through patient reported clinical outcomes.

Methods

A retrospective review of patients undergoing SCR with use of dermal allografts from 2015 to 2021 was performed. Exclusion criteria included patients lost to follow up, revision or removal of graft, and inadequate follow up timepoints. Demographics and operative characteristics were collected. To evaluate efficacy of graft, numerical rating scale (NRS), American Shoulder and Elbow Score (ASES) were assessed postoperatively. Shoulder range of motion (ROM) was also evaluated by the 6-month postoperative timepoint. Improvement in NRS, ASES, and shoulder ROM from baseline values were evaluated using a t-test.

Results

The final cohort was 21 patients with two patients undergoing revision and removal of the graft. Mean follow up time was 36.9 months. No major postoperative complications were recorded. Mean preoperative NRS and ASES score was 5.7 and 38.4, which both significantly improved postoperatively (p < 0.001). Patients demonstrated improvements in forward flexion, abduction in 90° rotation, and external and internal rotation.

Conclusion

Use of acellular dermal grafts in SCR procedures for irreparable rotator cuff tears remains a viable long-term solution to restore shoulder function.

Resultados da transferência do grande dorsal alongado com enxerto tendíneo homólogo por via delto-peitoral para lesões póstero-superiores irreparáveis do manguito rotador

Objective  The primary aim of the present study is to evaluate the functional results of a modification to the latissimus dorsi (LD) transfer around the shoulder for irreparable posterosuperior rotator cuff tears. The secondary aim is to evaluate variables that might influence the outcomes.

Surgical Technique  Through a single deltopectoral approach, the LD tendon is detached, reinforced, and elongated with a tendinous allograft, transferred around the humerus, and fixed superolaterally to the greater tuberosity and anteriorly to the subscapularis.

Methods  Retrospective functional evaluation of 16 cases. The average follow-up was 21 months (12–47). The postoperative results (at last follow-up) were compared with the preoperative ones, as well as to other pre, intra, and postoperative variables.

Results  All (but one) patients were satisfied. Average University of California, Los Angeles (UCLA) score increased from 11.6 (8–16) to 27.3 (17–30) ( p  < 0.001). Improvements of shoulder pain, function, and strength achieved statistical significance ( p  < 0.001). Nonetheless, normal strength was never restored. Average active range of motion improved as follows: forward elevation, from 106° (60–140°) to 145° (130–160°) ( p  < 0.001); external rotation from 30° (0° to 60°) to 54° (40–70°) ( p  < 0.001); and internal rotation from L1 (gluteus to T7) to T10 (T12–T3) ( p  < 0.05). No complication has occurred. Preoperative pseudoparesis was reverted in all the six cases in which it was present. None of the variables analyzed influenced the outcomes, including pseudoparesis.

Conclusions  At early follow-up, this technique is safe and effective at recovering from pseudoparesis and at improving shoulder pain, function, and strength.

Rotator cuff tear reaching the superior half portion of the humeral head causes shoulder abduction malfunction

PURPOSE

To examine the biomechanical properties governing posterosuperior rotator cuff (RC) tear progression and dynamic shoulder abduction function, in the absence of excess loading.

METHODS

Twelve freshly frozen cadaveric shoulders were evaluated via an established dynamic shoulder abduction stimulator. The shoulder abduction functions were primarily evaluated using subacromial contact pressure (SACP) during an abduction procedure, and subsequent middle deltoid force (MDF) under 5 conditions: (1) intact, (2) anterior 1/3 posterosuperior rotator cuff (PSRC) tear, (3) anterior 2/3 PSRC tear, (4) entire PSRC tear, and (5) global RC tear (tear involving the entire superior RC).

RESULTS

No obvious differences were observed in the peak MDF required for abduction, and in the peak SACP among the four PSRC tear statuses (49.8 ± 9.2 N, 0.39 ± 0.05 mPa [1/3 PSRC tear]; 49.3 ± 6.8 N, 0.40 ± 0.06 mPa [2/3 PSRC tear]; 51.6 ± 7.0 N, 0.44 ± 0.08 mPa [entire PSRC tear]), as well as intact statuses (48.3 ± 9.8 N, 0.40 ± 0.05 mPa). However, significant elevations in the peak MDF and peak SACP levels were observed among the four PSRC tear statuses and global RC tear (68.1 ± 9.3 N; 4.12 ± 1.50 mPa, P < 0.01).

CONCLUSION

In the absence of excess loading, the biomechanical function of the shoulder was not impaired by a simple PSRC tear. However, once the tear size reached the half superior portion of the humeral head, the humeral head migrated to the surface of the subacromion, and this action markedly decreased shoulder abduction function.

Outcomes of reverse shoulder arthroplasty following failed superior capsular reconstruction

BACKGROUND

Superior capsular reconstruction (SCR) can be used for massive irreparable rotator cuff tears in the absence of significant degenerative changes; however, those who fail an SCR may require reverse shoulder arthroplasty (RSA). The effect of a previously performed SCR on outcomes following RSA remains unknown.

METHODS

Subjects who underwent RSA from May 2015 to January 2021 at 2 separate institutions were retrospectively identified through prospectively collected databases. Patients who underwent RSA after failed SCR were matched to those who underwent RSA after failed rotator cuff repair (RCR) based on the number of previous ipsilateral shoulder procedures (n = 1, 2, ≥3) and secondarily by age within 5 years. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain, and Western Ontario Osteoarthritis of the Shoulder index (WOOS) scores were compared between groups. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) thresholds were calculated to determine clinically relevant differences between groups.

RESULTS

Forty-five patients were included (32 RSA following RCR, 13 following SCR). There were more smokers (P = .001) and worker's compensation cases (P = .034) in the SCR group. The RCR cohort was older (P = .007) and had a greater incidence of mental health (P > .999) and somatic disorders (P = .698), although these did not reach statistical significance. The mean follow-up for the RCR and SCR groups were 24.2 ± 23.3 and 20.4 ± 14.9 months following RSA, respectively (P = .913). The time from index RCR or SCR to RSA were 94.4 ± 22.2 and 89.2 ± 5.3 months, respectively (P = .003). Pre- and postoperative range of motion were similar between groups, as was the overall change in forward flexion (P = .879), abduction (P = .971), and external rotation (P = .968) following RSA. The RCR group had lower postoperative VAS pain (P = .009), higher SANE (P = .015), higher ASES (P = .008), and higher WOOS (P = .018) scores. The percentage achieving the MCID (P = .676) and SCB (P > .999) were similar; however, 56.7% of the RCR group met the SANE PASS threshold compared with 0.0% in the SCR group (P = .005). There were no differences in postoperative complications (P = .698) or revision rates (P = .308) following RSA between cohorts.

CONCLUSION

When matched for number of previous procedures to the ipsilateral extremity and age, patients who underwent RSA following failed SCR had worse clinical outcome scores than their RSA following failed RCR counterparts. No patient in the SCR group met the SANE PASS threshold, whereas more than half of the RCR group did.

Acromial and humeral head osteolysis following superior capsular reconstruction using autologous tensor fascia lata graft

BACKGROUND

Graft tear is a critical complication following superior capsular reconstruction (SCR) as it directly links with clinical outcomes. No previous reports have described acromial and humeral head osteolysis following SCR. Acromial and humeral head osteolysis may incidentally occur after SCR using autologous tensor fascia lata graft. This study aimed to demonstrate the incidence of osteolysis following SCR using autologous tensor fascia lata graft and investigate the factors that affect osteolysis.

METHODS

This retrospective cohort study included patients who underwent SCR for irreparable rotator cuff tears between June 2014 and June 2019. The patients were divided into 2 groups-those with no osteolysis and those with osteolysis-and were compared. For subanalysis, patients in the osteolysis group were further divided into 3 groups according to the location of the osteolysis-acromial osteolysis, humeral head osteolysis, and acromial and humeral head osteolysis-to clarify the factors determining the location of osteolyses. The shoulder range of motion was evaluated preoperatively and 24 months postoperatively. Additionally, the following items were evaluated: condition of the subscapularis tendon, Hamada classification (grade 2 or 3), critical shoulder angle, acromiohumeral distance measured preoperatively and 24 months postoperatively, graft size, and graft thickness. In addition, the graft condition was evaluated using magnetic resonance imaging 12 months postoperatively.

RESULTS

In total, 57 patients were enrolled and followed up for a minimum of 2 years (follow-up rate, 92% [57 of 62 cases]). Overall, the incidence of osteolysis following SCR was 35.1% (20 of 57 cases; acromial osteolysis in 7, humeral head osteolysis in 3, and acromial and humeral head osteolysis in 10). Compared with the group with no osteolysis, the osteolysis group had no inferior clinical outcomes or higher graft tear rates. The proportions of Hamada grade 3 (P = .041) and involvement of the subscapularis tendon (P = .020) were significantly higher in the osteolysis group. The relative risks of subscapularis involvement and Hamada grade 3 for osteolysis were 2.9 and 5.1, respectively. In the subanalysis, the factors determining the location of the osteolysis could not be clarified.

CONCLUSIONS

This study suggested that the progression of the Hamada classification and condition of the subscapularis tendon affect the occurrence of osteolyses. However, these osteolyses were not associated with clinical outcomes, including graft tear rate and shoulder range of motion.

Allograft and autograft provide similar retear rates for the management of large and massive rotator cuff tears: a review and meta-analysis

PURPOSE

Currently, autografts and allografts are largely used to treat large or massive rotator cuff tear (RCT), without any evidence in favour of one graft or the other. The purpose of this study was to determine the rate of retear of autograft and allograft in the treatment of large or massive posterosuperior RCT.

METHOD

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to perform this systematic review and meta-analysis of the results in the literature as well as the presentation of results. A search of the literature was performed in the electronic databases MEDLINE, Scopus, Embase, and the Cochrane Library. The quality of the included studies was evaluated according to the MINORS (Methodological Index for Nonrandomized Studies) score. Inclusion criteria were studies in English evaluating clinical and radiological results of surgical treatment with autograft or allograft for large or massive RCT since 2008. The main criterion was the retear rate of the graft assessed on MRI or US scan at 1-year minimum follow-up. Partial tear were classified as "tear".

RESULTS

The overall retear rate was 23.6% (15.5-32.7) at a mean follow-up of 18.4 ± 7.8 (12-36) months. There was no significant difference between the two kinds of graft, with a retear rate of 27.0% (15.4-40.2) and 20.9% (9.9-34.2) with autograft and allograft respectively (n.s.). Similar improvements of functional scores (+ 28.8 to 38.4 points for the Constant score, + 33.6 to 38.4 points for the ASES, and - 4.0 to - 4.1 points for pain-VAS) were reported in the two groups after at 27.2 ± 11.1 (12-48) months. The rate of complications except retear was 1.8% (0.2, 3.7) with autograft and 0.5% (0.8, 1.8) with allograft (n.s.).

CONCLUSION

The use of autograft and allograft for the treatment of large or massive RCT leads to similar retear rate and clinical outcomes at short to medium terms.

LEVEL OF EVIDENCE

Level IV.

Tear pattern after superior capsular reconstruction using an acellular dermal matrix allograft

BACKGROUND

The healing rate and tear pattern of grafts in superior capsular reconstruction (SCR) using acellular dermal matrix (ADM) allograft are poorly understood, and clinical results based on the graft status remain controversial.

METHODS

Fifty-one consecutive patients undergoing arthroscopic SCR with ADM between October 2017 and February 2020 were enrolled. Range of motion, strength, and the visual analog scale pain (PVAS) score, American Shoulder and Elbow Surgeons (ASES) score, and Constant score were evaluated preoperatively and at the last follow-up. Postoperative magnetic resonance imaging was performed in all patients and was obtained at least 6 months (mean, 8.9 ± 3.6 months) after surgery. The graft tear status was analyzed on magnetic resonance imaging, and the numbers of patients who achieved the minimal clinically important difference and patient acceptable symptomatic state were analyzed to determine the differences in outcome according to graft tear status.

RESULTS

The range of motion and clinical results improved at a minimum of 1 year (mean, 18 ± 5.4 months), whereas strength in forward flexion and external rotation did not (P = .676 and P = .995, respectively). The graft was intact in 36 of 51 patients (70.6%), 9 patients (17.6%) showed an incomplete graft tear with maintained continuity (partial graft rupture at 1 anchor on either the glenoid or humeral side), and 6 patients (11.8%) showed complete graft rupture (5 on the glenoid side and 1 on the humeral side). In cases with a tear (either incomplete or complete), the odds of achieving the minimal clinically important difference for the PVAS score (P = .047) and ASES score (P = .020) was significantly lower than that of the intact graft. However, when the continuity of the graft was maintained, even in cases with a partial tear, patients who reached the patient acceptable symptomatic state showed significantly higher odds for the PVAS score and trends for the ASES score.

CONCLUSION

After SCR using ADM, the graft status could be classified as intact, an incomplete graft tear (where the continuity between the glenoid and humerus was maintained), or an complete tear. When the graft continuity was maintained, even in incomplete graft tears, patients were generally satisfied with postoperative pain and function at 1 year following SCR.

Shoulder Superior Capsular Reconstruction Hybrid Graft Thickness Greater Than Preoperative Acromiohumeral Distance Increases Graft Retear Rate and Subacromial Erosion

PURPOSE

To evaluate the impact of graft thickness on clinical outcomes and graft retear after superior capsular reconstruction (SCR) using a hybrid graft combining both fascia lata autograft and dermal allograft in patients with massive rotator cuff tear (MRCT).

METHODS

Between January 2017 and February 2019, this study enrolled 58 patients with MRCT who underwent SCR using a hybrid graft combining both fascia lata autograft and dermal allograft. We evaluated clinical outcomes and compared differences between the graft intact and the graft retear group. Moreover, subgroup analysis was performed for patients having a preoperative acromiohumeral distance (AHD) less than or equal to the used graft thickness (group 1) and the results were compared with those for preoperative AHD greater than the used graft thickness (group 2).

RESULTS

Fifty-five patients who underwent MRCT with a mean age of 65.1 ± 5.7 years old were followed up during a mean period of 30.5 ± 6.5 (range, 24-37) months. There were significant differences in clinical outcome measures preoperatively and postoperatively (P < .05). There were no significant differences in clinical outcomes between the graft intact and graft retear groups (P > .05). The subgroup analysis revealed that the retear (68.6% vs 30.4%, P = .004) and subacromial erosion rates (91.4% vs 60.9%, P = .005) were significantly greater in for patients having a preoperative AHD less than or equal to the used graft thickness (group 1).

CONCLUSIONS

SCR using a hybrid graft combining both fascia lata autograft and dermal allograft is promising with improved clinical scores (P < .05) irrespective of the graft integrity. The use of a graft with a thickness greater than a patient's preoperative AHD could increase graft retear and subacromial erosion rates after SCR. However, there was no significant difference in clinical outcomes according to the relationship between used graft thickness and preoperative AHD.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Infraspinatus Muscle Fiber Moment Arms During Abduction: A Biomechanical Comparison of Values for Intact Rotator Cuff, Supraspinatus Tear, Superior Capsular Reconstruction, and Reverse Total Shoulder Arthroplasty

Background:

Lines of action of the superior, middle, and inferior infraspinatus muscle fibers work together to produce moment arms that change throughout abduction in an intact shoulder, after a supraspinatus tear, and after superior capsular reconstruction (SCR) and reverse total shoulder arthroplasty (rTSA).

Purpose:

To use moment arm values to indicate the efficacy of SCR and rTSA to restore infraspinatus function during shoulder abduction.

Study Design:

Descriptive laboratory study.

Methods:

A total of 5 human cadaveric shoulders placed in a testing apparatus were each actively abducted (0°-90°) under the following 4 conditions: intact, complete supraspinatus tear, SCR, and rTSA. The 3-dimensional coordinates of points were tracked along the origin and insertion of the superior, middle, and inferior infraspinatus fibers during abduction. Moment arm values were calculated using the origin-insertion method to determine abduction contribution of infraspinatus fiber sections. Analysis of variance and post hoc Tukey testing were used to compare differences in moment arms between the 4 conditions and between fiber sections.

Results:

In the intact condition, the superior infraspinatus fibers had an abduction moment that decreased with elevation until shifting to adduction. Conversely, the middle and inferior fibers had an adduction moment that turned to abduction (mean moment arm values from 0° to 90°: inferior, from –5.9 to 19.4 mm; middle, from –4.7 to 15.9 mm; superior, from 5.6 to –5.1 mm; P < .05). After a supraspinatus tear, superior fibers lacked any torque, and inferior and middle fibers lost adduction potential (inferior, from 4.8 to 14.0 mm; middle, from –0.2 to 9.6 mm; superior, from 1.0 to 0.7 mm; P < .05). SCR restored the initial superior fiber abduction moment (5.6 mm at 0°; P < .05); middle and inferior fibers had some restoration but were weaker than intact fibers. Loss of abduction moment in all fibers was seen with rTSA (inferior, from –9.6 to –1.6 mm; middle, from –10.5 to –3.6 mm; superior, from –1.7 to –4.6 mm; P < .05).

Conclusion:

Infraspinatus fiber groups had different and inverse moment arms during scapular plane elevation. SCR most closely resembled the intact shoulder, whereas rTSA transformed the infraspinatus into an adductor.

Clinical Relevance:

These results support the efficacy of SCR at restoring biomechanical muscle function and suggest that the changes in moment arms for each fiber group be considered when choosing treatment modalities and rehabilitation protocols after rotator cuff tear.

Prospective 1-Year Outcomes Are Maintained at Short-Term Final Follow-Up After Superior Capsular Reconstruction Augmentation of Complete Rotator Cuff Repair

PURPOSE

To evaluate the outcomes of arthroscopic superior capsular reconstruction (SCR) augmentation of complete, massive rotator cuff repair (RCR).

METHODS

A retrospective study of dermal allograft SCR-augmented RCRs performed by a single surgeon from June 2016 through December 2017 was performed with the following inclusion criteria: massive rotator cuff tear amenable to complete repair but with poor-quality native rotator cuff tissue. Radiographic follow-up was performed at 1 year, and clinical follow-up was performed at both 1 year and a minimum 2 years after surgery. Clinical follow-up included the American Shoulder and Elbow Surgeons score, visual analog scale score for pain, Subjective Shoulder Value score, active forward elevation, and external rotation. Radiographs and magnetic resonance imaging (MRI) scans were assessed for muscle quality using the Goutallier classification, and graft and cuff integrity was assessed according to the Sugaya classification.

RESULTS

The inclusion criteria were met by 24 patients at 1 year and by 18 (75%) at a minimum of 2 years postoperatively. Patient-reported outcomes were improved compared with preoperative data and were maintained at minimum 2-year follow-up, with median American Shoulder and Elbow Surgeons scores of 42.5 (interquartile range [IQR], 30.8-58.7) versus 93.9 (IQR, 82.4-100) (P < .001); median Subjective Shoulder Value scores of 30 (IQR, 20-50) versus 90 (IQR, 86.2-97.2) (P < .001); and median visual analog scale pain scores of 5.5 (IQR, 1-9) versus 0 (IQR, 0-0.8) (P = .001). Evaluation of graft and tendon healing on postoperative MRI revealed poor interobserver agreement and showed 10 completely healed grafts (42%), 9 partially healed grafts (38%), and 5 completely disrupted grafts (21%), with 42% of supraspinatus tendons and 54% of infraspinatus tendons healed.

CONCLUSIONS

SCR with dermal allograft augmentation of complete RCR with poor-quality tissue shows very good clinical outcomes at minimum 2-year follow-up. Poor interobserver agreement regarding postoperative graft and rotator cuff integrity by MRI was found. The healing rate for the SCR grafts was 79%. The rates of healing of the native supraspinatus and infraspinatus tendons were 42% and 54%, respectively.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Superior Capsular Reconstruction Using Acellular Dermal Allograft Combined With Remaining Rotator Cuff Augmentation Improved Shoulder Pain and Function at 1 Year After The Surgery

PURPOSE

The purpose of this study is to report structural integrity and clinical outcomes of superior capsular reconstruction (SCR) using a 4- to 5-mm acellular dermal allograft combined with augmentation of the remaining rotator cuff to the graft.

METHODS

We prospectively recruited 21 patients with symptomatic irreparable rotator cuff tear who required SCR. At least 6 months after the SCR, we evaluated each patient's graft healing by magnetic resonance imaging (MRI). We also assessed the range of motion (ROM), strength for forward flexion and external rotation, visual analog scale for pain (PVAS), American Shoulder and Elbow Surgeon (ASES) score, and Constant score. At minimum of 1 year after the surgery, we evaluated the number of patients with minimal clinically important differences (MCIDs) for each score to compare patients with healed and unhealed grafts.

RESULTS

Postoperative MRI showed the grafts intact in 14 patients (66.7%). Among 7 patients with unhealed grafts, tears were observed in 3 patients (42.9%) on the glenoid side, 3 (42.9%) on the humeral side, and 1 (14.3%) on both sides. PVAS, ASES score, and the Constant score improved after surgery (4.0 to 0.7 for PVAS [P < .001], 55.5 to 87.0 for ASES score [P < .001], and 56.0 to 65.9 for Constant score [P = .007]). However, there were no differences in postoperative ROM and muscle strength compared to preoperative measurements. MCIDs were reached in 90.5% of patients (n = 19) for the PVAS and in 71.4% of patients (n = 15) for the ASES score. Only 33.3% of patients (n = 7) obtained MCIDs for the Constant score, and none of the patients with a graft tear obtained MCIDs in the Constant score (P = .047).

CONCLUSION

The graft complete healing rate was 66.7%, although pain relief and functional improvement were satisfactory regardless of graft structural integrity. However, muscle strength recovery was not optimal until 1 year after surgery.

LEVEL OF EVIDENCE

Level IV; case series.

Superior Capsular Reconstruction: A Salvage Option for Massive Irreparable Rotator Cuff Tears with Pseudoparalysis or Subscapularis Insufficiency

PURPOSE

We sought to examine superior capsular reconstruction (SCR) outcomes after minimum 2-year follow-up and determine risk factors that were predictive of outcomes.

METHODS

Forty consecutive patients (mean age 57.3 years, 87.5% male) who underwent SCR for massive irreparable rotator cuff tears (RCT) met the inclusion criteria. Minimum 2-year follow-up was obtained for 32 patients (80% follow-up). Patient demographics and preoperative clinical findings were collected. Postoperative data, including complications, patient satisfaction, strength and range-of-motion (ROM), and patient-reported outcomes were collected.

RESULTS

The Hamada score was ≤2 in 88% with average acromiohumeral interval distance of 6.8 mm. Preoperatively, 6 patients had external rotation lag (19%) and 6 had pseudoparalysis (19%). Intraoperative assessment of the subscapularis demonstrated true insufficiency in 38%. There was significant improvement in forward elevation (FE) (31° increase; P = .007) and strength in all planes (all P < .05). Patient-reported outcomes significantly improved (American Shoulder and Elbow Surgeon [ASES] 34-point increase; visual analog scale [VAS] 2.9-point decrease; single alpha-numeric evaluation [SANE] 48-point increase; all P < .05). Twenty-six patients (81%) were completely or somewhat satisfied with surgery. At time of final follow-up, 3/32 patients (9%) failed SCR and converted to reverse total shoulder arthroplasty. There were 4 (13%) reported complications (2 patients had postoperative falls; 1 patient had persistent severe pain; 1 had persistent stiffness). One patient was deceased. Patients with pseudoparalysis (n = 6) had significant improvement in post-operative FE (28 vs 154°; P < .0001) and SANE score (P = .016) with 66% patient satisfaction. However, outcome scores overall remained lower than SCR without pseudoparalysis. Regarding subscapularis insufficiency (n = 12), significant improvement was seen in postoperative FE (108 vs 158°; P = .019) and patient-reported outcome scores (P < .005). In patients converted from SCR to reverse total shoulder arthroplasty (n = 3), there were no distinguishing characteristics present.

CONCLUSION

Superior capsular reconstruction is an effective salvage operation for massive irreparable RCT. Patients with pseudoparalysis or subscapularis insufficiency demonstrate significant postoperative improvement in FE and patient-reported outcomes.

LEVEL OF EVIDENCE

IV, retrospective cohort.

Bursal Acromial Reconstruction (BAR) Using an Acellular Dermal Allograft for Massive, Irreparable Posterosuperior Rotator Cuff Tears: A Dynamic Biomechanical Investigation

PURPOSE

To investigate the effect of bursal acromial reconstruction (BAR) using an acellular dermal allograft on glenohumeral joint kinematics including maximum abduction angle, glenohumeral superior translation, cumulative deltoid force, and subacromial contact pressure.

METHODS

In this dynamic biomechanical cadaveric shoulder study, 8 fresh-frozen cadaveric shoulders (age 53.4 ± 14.2 years, mean ± standard deviation) were tested using a dynamic shoulder testing system. Maximum abduction angle (MAA), glenohumeral superior translation (ghST), maximum cumulative deltoid force (cDF), and subacromial peak contact pressure (sCP) were compared across 3 conditions: (1) intact shoulder; (2) massive retracted irreparable posterosuperior rotator cuff tear (psRCT) according to Patte III; and (3) BAR. Additionally, humeral head containment was measured using contact pressure.

RESULTS

Compared with the simulated psRCT, BAR significantly increased mean MAA and significantly decreased ghST (P < .001, respectively) and cDF (P = .017) Additionally, BAR was found to significantly decrease sCP compared with psRCT (P = .024).

CONCLUSION

In a dynamic biomechanical cadaveric shoulder simulator, resurfacing the undersurface of the acromion using the BAR technique leads to significantly improved ghST, MAA, cDF, and sCP compared with the irreparable rotator cuff tear.

CLINICAL RELEVANCE

With the BAR technique, native humeral containment may be restored, which can potentially delay progressive subacromial and glenoidal abrasive wear and improve overall shoulder function. As such, the proposed BAR technique can be considered as a technically feasible and potentially cost- and timesaving procedure, as no bone anchors are needed, glenoidal or humeral side graft ruptures can be avoided, and postoperative rehabilitation can be started immediately. However, future clinical studies are needed.

Outcomes of Reverse Shoulder Arthroplasty Following Failed Superior Capsular Reconstruction

Background

History of prior rotator cuff repair (RCR) may adversely affect the outcomes of reverse total shoulder arthroplasty (RTSA), but there is no information regarding the influence of prior superior capsular reconstruction (SCR) surgery on the outcomes of RTSA. The purpose of this study is to evaluate the outcomes of RTSA following failed arthroscopic SCR.

Methods

All patients who underwent RTSA for failed SCR (SCR cohort) at our institution were identified from our institutional database. A comparative cohort of patients who had RTSA with a history of failed RCR (Control cohort) was also reviewed. Demographic information, 90-day complication rate, 90-day emergency department visits, length of stay, and outcome scores (patient-reported outcomes measurement information system [PROMIS] physical function upper extremity, Visual Analog Scale score, and range of motion) were compared.

Results

From 2015 to 2020, 87 arthroscopic SCRs were performed at our institution and of these, 13 patients underwent RTSA at a mean time of 14.6 months (5.8-32.4) after SCR and were followed up for an average of 17.9 months (1.6-44.6). The average number of shoulder surgeries prior to RTSA was 2.8 (1-7), with the last surgery being SCR. During the same period, we identified 15 patients who underwent an RTSA after a failed RCR (control cohort). The RTSA in the control cohort was performed on average at 12.8 months (1.5-39.5) following the last RCR, and patients were followed up for an average of 27.7 months (2.8-53.9). The average number of shoulder surgeries before the RTSA in the control cohort was 1.4 (1-3). Although the SCR cohort had significant improvements in pain scores and forward flexion (FF), there was only a modest functional improvement with PROMIS scores and no meaningful improvement with external rotation. Complications (23%) in the SCR cohort included 1 periprosthetic joint infection requiring 2-stage revision, 1 acromion stress fracture, and 1 ulnar neuritis. Overall, compared to the SCR cohort, patients in the control cohort had better function (PROMIS physical function upper extremity), lower Visual Analog Scale score, and greater range of motion (FF and external rotation) preoperatively and at last follow-up, but there were no differences in the length of stay and 90-day emergency department visits, infection, and complication rate between the 2 cohorts.

Conclusion

RTSA after failed SCR improves pain and FF but is associated with modest functional improvements and high complication rates. However, these findings will require confirmation in a larger cohort with longer follow-up.