Augmentation of Massive Rotator Cuff Repairs Using Biceps Transposition Without Tenotomy Improves Clinical and Patient-Reported Outcomes: The Biological Superior Capsular Reconstruction Technique

Subacromial Balloon Spacer for Massive Irreparable Rotator Cuff Tear is Cost-Effective in Older, Low-Demand Patients With Massive Irreparable Rotator Cuff Tear and Severe Comorbidities

The InSpace subacromial balloon spacer (Stryker, USA) is indicated for the treatment of massive irreparable rotator cuff tears. The device is placed in the subacromial space with the aim of restoring shoulder function by limiting painful acromiohumeral contact and recentering the superiorly migrated humeral head. However, controversy exists because two randomized controlled trials have produced conflicting findings with regards to efficacy. These findings, along with narrow indications have led to low utilization of the balloon amongst European and Latin American Surgeons. The controversy generated by conflicting RCTs poses challenges in the interpretation of cost effectiveness especially when the role of the balloon amongst a plethora of other options including superior capsule reconstruction (either with long head of biceps or dermal allograft), graft augmentation, tendon transfer, biologic tuberoplasty, acromial resurfacing, and reverse shoulder arthroplasty is not well defined. However, it is my opinion that the balloon has particular value in older, low-demand patients, in whom severe co-morbidities make a shorter surgical duration and quicker recovery appealing.

Reduced retear rates yet similar clinical outcomes following arthroscopic partial repair of large and massive irreparable rotator cuff tears with biceps augmentation compared to repairs without biceps augmentation: A systematic review and meta-analysis

PURPOSE

To compare the clinical outcomes between arthroscopic partial rotator cuff repair with biceps augmentation (BA) and partial repair (PR) without BA.

METHODS

This systematic review included studies comparing outcomes of arthroscopic repair for large to massive irreparable rotator cuff tears with and without the BA. The focus was on postoperative clinical results and retear rates. Mean differences were used to express continuous outcomes, while odds ratios (ORs) were employed for dichotomous outcomes.

RESULTS

Ten studies (733 shoulders, all level 3 evidence) were included. The BA group showed a significant reduction in retear rates (OR = 0.40, 95% confidence interval [CI]: 0.20-0.77, P = 0.007) and comparable postoperative outcomes across various measures: American Shoulder and Elbow Surgeons (ASES) score, visual analogue scale for pain, University of California-Los Angeles shoulder score, active forward flexion motion and active external rotation at the arm-at-side position compared to the PR group. Subgroup analysis of two BA techniques-rerouting and supplementation following supraglenoid tenotomy-showed no significant differences in ASES score for either technique versus PR. However, rerouting significantly lowered retear rates (OR = 0.21, 95% CI: 0.12-0.36, p < 0.001), while supplementation showed similar retear rates to PR (OR = 0.87, 95% CI: 0.37-2.02, n.s.).

CONCLUSION

Arthroscopic partial rotator cuff repair with BA for large to massive irreparable rotator cuff tears is a reliable technique, resulting in improved postoperative outcomes. BA using supplementation following supraglenoid tenotomy showed similar clinical outcomes and range of motion but with lower retear rates compared to the PR group.

LEVEL OF EVIDENCE

Level III.

Improved Clinical Outcomes After Partial Repair and In Situ Biceps Tenodesis for the Treatment of Massive Irreparable Rotator Cuff Tears

PURPOSE

To present the short-term outcomes of arthroscopic in situ biceps tenodesis combined with partial rotator cuff repair in patients with massive irreparable rotator cuff tears (MIRCTs) and minimal arthritis.

METHODS

A retrospective review was conducted using prospectively maintained institutional databases to identify patients who had undergone a partial rotator cuff repair with in situ biceps tenodesis between March 2017 and December 2022. Patients were included if they (1) were diagnosed pre- or intraoperatively with MIRCT and (2) had complete preoperative and minimum 1-year postoperative patient-reported outcome measures.

RESULTS

Thirty-nine patients met the eligibility criteria and were included for analysis. The mean age of the study participants was 65 ± 7 years (range, 46-76) with 76.9% (n = 30) being male. The average follow-up was 21 ± 12 months (range, 12-58). Patients experienced significant improvement in visual analog scale for pain (VAS), American Shoulder and Elbow Surgeons (ASES) score, and subjective assessment numeric evaluation (SANE) score (P < .001 for all comparisons). The pre- to postoperative improvement was 3.1 ± 2.3 for VAS, 27.5 ± 20.6 for ASES, and 31.3 ± 24.8 for SANE. Postoperatively, the average scores for VAS, ASES, and SANE were 1.3 ± 1.5, 79.5 ± 17.0, and 69.6 ± 20.1, respectively. Twenty-six patients (66.7%) achieved the minimal clinically important difference (MCID) for VAS, 33 patients (84.6%) achieved the MCID for ASES, and 30 patients (76.9%) achieved the MCID for SANE.

CONCLUSIONS

Partial rotator cuff repair with in situ biceps tenodesis is an effective treatment for MIRCT, leading to significant improvements in patient-reported outcome and range-of-motion measures compared to preoperative conditions.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Editorial Commentary: Lower Trapezius Transfer May Be Indicated for Surgical Management of Massive Irreparable Rotator Cuff Tears in Younger, Non-Arthritic Patients

Although shoulder rotator cuff repair fixation constructs and suture anchor design have evolved, repair of massive or functionally irreparable tears historically has relied on tendon mobilization and compression, optimizing footprint biology, and attempting a tension-free repair. However, despite these efforts, rates of failure of complete healing may be high, ranging from 20% to 94%. This has led to a search for alternative approaches, including bridging grafts, subacromial balloons, superior capsular reconstructions, biologic tuberoplasties, bursal acromial grafts, and, ultimately, renewed interest in tendon transfers. The latissimus dorsi transfer was traditionally a preferred tendon-transfer technique for posterosuperior massive cuff tears, but inconsistent outcomes have resulted in declining popularity. Recently, the lower trapezius transfer (LTT) has gained acceptance for the treatment of posterosuperior tears, particularly with external rotation weakness and lag signs. The LTT is biomechanically superior to the latissimus dorsi transfer, offering a more native vector of pull and in-phase activation. LTT could be indicated for younger patients with massive cuff tears. However, LTT is relatively contraindicated in patients with cuff tear arthropathy; combined loss of elevation and external rotation; irreparable subscapularis tear; teres minor involvement; and/or those of advanced age or unable to comply with rigid rehabilitation guidelines.

Outcomes of Superior Capsular Reconstruction Using the Long Head of the Biceps Tendon in Large to Massive Rotator Cuff Tears: A Meta-Analysis and Systematic Review

(1) Background: Addressing large to massive rotator cuff tears (LMRCTs) poses complex challenges. This systematic review investigated outcomes of superior capsular reconstruction (SCR) with the long head of the biceps tendon (LHBT) compared to conventional rotator cuff repair (RCR) for LMRCTs. (2) Methods: A systematic search across the MEDLINE/PubMed, EMBASE, Cochrane Library, and Scopus databases until 1 October 2023 identified studies that directly compared SCR with LHBT with conventional RCR in patients with LMRCTs and included a minimum of a 12-month follow-up period. The assessed outcome measures encompassed retear rates, functional outcomes, range of motion (ROM), and acromiohumeral interval (AHI). Risk of bias assessment was conducted via the Robins-I tool. (3) Results: In six studies with 456 cases (210 SCR using LHBT and 246 using RCR), SCR with LHBT significantly reduced retear rates (OR = 0.21; 95% CI, 0.12-0.36; p < 0.01; I2 = 0%). Furthermore, SCR with LHBT showed significant improvement in range of forward flexion (SMD 0.32, 95% CI: 0.09-0.55, p < 0.01, I2 = 39%) and AHI (SMD 0.61, 95% CI: 0.31-0.92, p < 0.01, I2 = 0%) postoperatively. (4) Conclusion: SCR with LHBT is a safe and effective treatment for LMRCTs, reducing retear rates, maintaining greater postoperative AHI, and improving ROM compared to conventional RCR. Additional high-quality interventional studies are needed to confirm these results.

Editorial Commentary: Shoulder Long Head of the Biceps Tendon Transposition Without Tenotomy May Be a Beneficial Augment for Massive Rotator Cuff Tear Repair

Although many surgeons discard the long head of the biceps (LHB) tendon during arthroscopic rotator cuff repairs, several authors have argued that the LHB tendon may serve as a biologic and structural augment for massive repairs. There are multiple benefits of incorporating the LHB tendon autograft in difficult-to-repair massive rotator cuff tears. First, by maintaining the glenoid origin, the tendon likely retains a significant native blood supply, as well as tenocytes, which may support the healing process. In addition, there are several biomechanical benefits. The LHB may act as a dynamic humeral head depressor since it is still attached to the muscular unit distally. The tendon could also serve as a convergence post, while proving robust tissue for the repair. Also, the LHB tendon may decrease undue tension on the repair, bringing us closer to a tension-free repair. Finally, this may be a cost-conscious technique. One concern, requiring additional investigation, is that some surgeons believe the LHB may be a pain generator in patients with rotator cuff tears. One surgeon's trash is another surgeon's treasure.