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Glazier M, Turnow M, Spencer P, Metha V, Pharis H, Long N, Wiseman S. Chronic recurrent shoulder instability treated with a hemiarthroplasty, Glenojet allograft glenoid reconstruction, and anterior capsular reconstruction: a case report. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:493-498. [PMID: 39157242 PMCID: PMC11329055 DOI: 10.1016/j.xrrt.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Affiliation(s)
- Matthew Glazier
- OhioHealth Doctors Hospital Orthopedic Surgery Department, Columbus, OH, USA
| | - Morgan Turnow
- OhioHealth Doctors Hospital Orthopedic Surgery Department, Columbus, OH, USA
| | - Peter Spencer
- Ohio University Heritage College of Osteopathic Medicine, Cleveland, OH, USA
| | - Vishvam Metha
- Ohio University Heritage College of Osteopathic Medicine, Dublin, OH, USA
| | - Hunter Pharis
- OhioHealth Doctors Hospital Orthopedic Surgery Department, Columbus, OH, USA
| | - Nathaniel Long
- OhioHealth Doctors Hospital Orthopedic Surgery Department, Columbus, OH, USA
| | - Stephen Wiseman
- OhioHealth Doctors Hospital Orthopedic Surgery Department, Columbus, OH, USA
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Tytgat H, Macdonald P, Verhaegen F. Management of irreparable subscapularis tears: Current concepts. J ISAKOS 2024; 9:53-58. [PMID: 37879604 DOI: 10.1016/j.jisako.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/09/2023] [Accepted: 10/18/2023] [Indexed: 10/27/2023]
Abstract
Primary repair of acute subscapularis (SSC) tears provides excellent results, but tendon retraction, muscle atrophy, fatty infiltration, and humeral head migration may render a more chronic tear irreparable. These irreparable SSC tears present a diagnostic and treatment challenge for orthopaedic surgeons. Careful physical examination and imaging evaluation can help to distinguish those with reparable versus irreparable tears, but they are still not very reliable due to the methodological limitations of current evidence. Therefore, future research using 3D and quantitative measurement techniques is necessary to better predict the irreparability of the SSC. When conservative treatment of an irreparable SSC tear fails, reversed shoulder arthroplasty has been established as the preferred treatment option for older, low-demand patients with arthropathy, providing reliable improvements in pain and function. In younger patients without significant arthropathy, musculotendinous transfers are the treatment of choice. The pectoralis major transfer is historically the most frequently performed procedure and provides improved range of motion and pain relief, but fails to adequately restore strength and shoulder function. The latissimus dorsi transfer has gained increased interest over the last few years due to its biomechanical superiority, and early clinical studies suggest improved outcomes as well. More recently, anterior capsular reconstruction has been proposed as an alternative to musculotendinous transfers, but clinical data are completely lacking. Future high-quality randomised controlled trials are necessary to reliably compare the different musculotendinous transfers and anterior capsular reconstruction.
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Affiliation(s)
- Hannes Tytgat
- AZ St. Dimpna Geel, J.-B. Stessenstraat 2, 2440 Geel, Belgium.
| | - Peter Macdonald
- Pan Am Clinic, Winnipeg, MB, R3M 3E4, Canada; Department of Surgery, Section of Orthopaedic Surgery, University of Manitoba, Winnipeg, MB, R3A 1R9, Canada
| | - Filip Verhaegen
- UZ Leuven, Department of Orthopedics, Herestraat 49, 3000 Leuven, Belgium
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Sheth MM, Shah AA. Massive and Irreparable Rotator Cuff Tears: A Review of Current Definitions and Concepts. Orthop J Sports Med 2023; 11:23259671231154452. [PMID: 37197034 PMCID: PMC10184227 DOI: 10.1177/23259671231154452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/09/2022] [Indexed: 05/19/2023] Open
Abstract
Background While massive and irreparable rotator cuff tears (MIRCTs) have been abundantly studied, inconsistent definitions in the literature and theories about pain and dysfunction related to them can be difficult to navigate when considering an individual patient. Purpose To review the current literature for definitions and critical concepts that drive decision-making for MIRCTs. Study Design Narrative review. Methods A search of the PubMed database was performed to conduct a comprehensive literature review on MIRCTs. A total of 97 studies were included. Results Recent literature reflects added attention to clarifying the definitions of "massive, "irreparable," and "pseudoparalysis." In addition, numerous recent studies have added to the understanding of what generates pain and dysfunction from this condition and have reported on new techniques for addressing them. Conclusion The current literature provides a nuanced set of definitions and conceptual foundations on MIRCTs. These can be used to better define these complex conditions in patients when comparing current surgical techniques to address MIRCTs, as well as when interpreting the results of new techniques. While the number of effective treatment options has increased, high-quality and comparative evidence on treatments for MIRCTs is lacking.
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Affiliation(s)
- Mihir M. Sheth
- Baylor College of Medicine, Houston, Texas, USA
- Mihir M. Sheth, MD, Baylor College of Medicine, 7200 Cambridge Street, Suite 10A, Houston, TX 77030, USA () (Twitter: @mihirmsheth)
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Open Anterior Capsular Reconstruction With a Dermal Allograft Is a Viable Nonarthroplasty Salvage Procedure for Irreparable Subscapularis Tears at a Minimum 2-Year Follow-up. Arthrosc Sports Med Rehabil 2022; 4:e1291-e1297. [PMID: 36033201 PMCID: PMC9402413 DOI: 10.1016/j.asmr.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 04/11/2022] [Indexed: 11/24/2022] Open
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Luo Z, Lin J, Sun Y, Zhu K, Wang C, Chen J. Outcome Comparison of Latissimus Dorsi Transfer and Pectoralis Major Transfer for Irreparable Subscapularis Tendon Tear: A Systematic Review. Am J Sports Med 2022; 50:2032-2041. [PMID: 34138660 DOI: 10.1177/03635465211018216] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Latissimus dorsi transfer (LDT) and pectoralis major transfer (PMT) were developed to treat an irreparable subscapularis tendon tear (ISScT); however, the difference in their outcomes remains unclear. PURPOSE To systematically review and compare the outcomes of LDT and PMT for ISScT. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic review was performed through a comprehensive search of Embase, PubMed, and the Cochrane Library. Studies of LDT or PMT were included according to the inclusion and exclusion criteria. The primary outcome was the Constant-Murley score (CMS) at the final follow-up. Secondary outcomes included the subjective shoulder value (SSV), visual analog scale (VAS) score for pain, active shoulder range of motion, and the belly-press and lift-off tests. Postoperative failure and complication rates were the safety outcome measures. Outcomes were summarized into the LDT and PMT groups, and results were compared statistically (P < .05). RESULTS Twelve studies were included in this review: 184 shoulders from 9 studies for the PMT group and 85 shoulders from 3 studies for the LDT group. For the PMT and LDT groups, the mean ages were 58.9 and 55.1 years, respectively, and the mean follow-up was 66.9 and 17.4 months, respectively. Overall, the LDT and PMT groups improved in the primary outcome (CMS) and secondary outcomes (SSV, VAS, ROM, and belly-press and lift-off tests), with low rates of failure and complication. When compared with the PMT group, the LDT group showed more significant improvements in CMS (35.2 vs 24.7; P < .001), active forward flexion (44.3° vs 14.7°; P < .001), abduction (35.0° vs 17.6°; P < .002), and positive belly-press test rate (45% vs 27%; P < .001). No statistically significant difference was seen between the groups in postoperative failure rate, complication rate, mean improvement of active internal rotation, VAS, or SSV. CONCLUSION In general, LDT showed significantly better clinical outcomes postoperatively than did PMT. The available fair-quality evidence suggested that LDT might be a better choice for ISScT. Further evaluations on the relative benefits of the 2 surgical approaches are required, with more high-quality randomized controlled studies.
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Affiliation(s)
- Zhiwen Luo
- Department of Sports Medicine, Fudan University Huashan Hospital Huashan Hospital, Shanghai, China
| | - Jinrong Lin
- Department of Sports Medicine, Fudan University Huashan Hospital Huashan Hospital, Shanghai, China
| | - Yaying Sun
- Department of Sports Medicine, Fudan University Huashan Hospital Huashan Hospital, Shanghai, China
| | - Kesen Zhu
- Department of Sports Medicine, Fudan University Huashan Hospital Huashan Hospital, Shanghai, China
| | - Chenghui Wang
- Department of Sports Medicine, Fudan University Huashan Hospital Huashan Hospital, Shanghai, China
| | - Jiwu Chen
- Department of Sports Medicine, Fudan University Huashan Hospital Huashan Hospital, Shanghai, China
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Subscapularis Tears: Evolution in Treatment Options. J Am Acad Orthop Surg 2022; 30:485-492. [PMID: 35294403 DOI: 10.5435/jaaos-d-21-00155] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/02/2022] [Indexed: 02/01/2023] Open
Abstract
Subscapularis tears occur more commonly than previously reported. Owing to the importance of the subscapularis in shoulder function, strong consideration should be given to repairing a full-thickness subscapularis tear when present. Historically, subscapularis repairs were done through a deltopectoral approach with good results. More recently, arthroscopic techniques have been developed with similar outcomes. When tears of the subscapularis are irreparable, reconstructive options, including tendon transfers, capsular reconstruction, and reverse shoulder arthroplasty, exist and continue to evolve.
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Chellamuthu G, Sundar S, Rajan DV. Current concepts review in the management of subscapularis tears. J Clin Orthop Trauma 2022; 28:101867. [PMID: 35494488 PMCID: PMC9043658 DOI: 10.1016/j.jcot.2022.101867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/08/2022] [Indexed: 11/24/2022] Open
Abstract
Subscapularis (SSc) is the prime internal rotator of shoulder. It is the most powerful rotator cuff muscle, maintaining the anterior force couple of shoulder. The tears in SSc as any other rotator cuff muscles might result from a traumatic event or more commonly from intrinsic degeneration. With the advent and widespread use of shoulder arthroscopy, SSc tears, which were once considered as "forgotten or hidden lesions" are now being increasingly recognized. Isolated SSc tears are relatively rare. They occur in combinations. Clinically internal rotation can be near normal because of the compensation provided by other internal rotators. It is not uncommon for patients with SSc tear to be normal on routine physical examination. The Bear Hug test (BHT) has high sensitivity and accuracy in the diagnosis of SSc tear. The combined use of BHT with Belly Press Test has been found optimal for diagnosis. US is an accurate and reliable method for diagnosing SSc tears and outperformed MRI in diagnosing partial-thickness SSc tears. The MRI is currently the most advanced imaging available for diagnosis. The specificity is up to 100%. However, the sensitivity is between 36 and 40%. The earliest classification system for SSc tears was by Fox et al. The commonly used classification is by Lafosse et al. The recent system by Yoo et al. is based on the insertion of SSc. The comma sign is gaining importance not only in arthroscopic diagnosis but also in MRI identification and repair of SSc. The mode of management is mainly arthroscopic. The techniques of repair of SSc are continuously progressing. However, there is no clear consensus on the double vs single-row repairs, biceps tendon management, and the role of coracoplasty. Future research must focus on these areas. Reserve shoulder arthroplasty is reserved for salvage in older age groups. Tendon transfers are performed in young active individuals with irreparable tears.
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Affiliation(s)
- Girinivasan Chellamuthu
- Corresponding author. Ortho One Orthopaedic Speciality Centre, Singanallur, Coimbatore, 641005, Tamil Nadu, India.
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Rakowski DR, Zarkadis NJ, Ernat JJ. Combined Arthroscopic Superior and Anterior Capsular Reconstruction of the Glenohumeral Joint: A Case Report. JBJS Case Connect 2021; 11:01709767-202109000-00064. [PMID: 34739395 DOI: 10.2106/jbjs.cc.20.00943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 57-year-old male automobile mechanic presented with 1 year of atraumatic, bilateral shoulder pain and progressive loss of motion. Three months of physical therapy and nonsteroidal anti-inflammatory medications did not offer pain relief or increase his motion. He opted for right-sided dermal allograft superior capsular reconstruction (SCR) and anterior capsular reconstruction (ACR) with subsequent left-sided SCR and subscapularis repair 3 months later. CONCLUSION At the 18 months follow-up, combined SCR/ACR was effective in restoring motion and relieving pain. Although promising, additional studies are needed to determine the efficacy of this combined procedure.
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Omid R, Stone MA, Lin CC, Patel NA, Itami Y, McGarry MH, Lee TQ. Biomechanical analysis of anterior capsule reconstruction and latissimus dorsi transfer for irreparable subscapularis tears. J Shoulder Elbow Surg 2020; 29:374-380. [PMID: 31594727 DOI: 10.1016/j.jse.2019.07.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 07/07/2019] [Accepted: 07/17/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Anterior capsule reconstruction (ACR) and latissimus dorsi transfers (LTs) have been proposed as solutions for irreparable subscapularis tears. The purpose of this study was to biomechanically assess the effects of ACR and LT separately and together for treatment of irreparable subscapularis tears. MATERIALS AND METHOD Eight cadaveric shoulders underwent 5 testing conditions: (1) intact, (2) irreparable subscapularis tear, (3) ACR, (4) ACR+LT, and (5) LT alone. Anteroinferior translation loads of 20, 30, and 40 N were applied. Range of motion and magnitudes of glenohumeral anterior and inferior translation at 0°, 30°, and 60° of abduction and at 30° and 60° of external rotation were measured for each testing condition. RESULTS At 30° of abduction and 60° of external rotation, ACR and ACR+LT restored anterior and inferior translation to intact (P > .702) for 30 and 40 N of anteroinferiorly directed force. LT alone did not restore anteroinferior stability at 30 N of distraction force at 30° of glenohumeral abduction and 60° of external rotation (P < .001). However, ACR and ACR+LT led to significant decreases in total range of motion compared to intact at 0° and 30° of abduction (P < .007). CONCLUSIONS ACR with dermal allograft was able to restore anteroinferior stability in the setting of irreparable subscapularis tears but resulted in decreased total range of motion. LT alone was less effective than ACR in restoring glenohumeral stability. The addition of LT as a dynamic restraint did not increase the efficacy of ACR.
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Affiliation(s)
- Reza Omid
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael A Stone
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA.
| | - Charles C Lin
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA; Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Nilay A Patel
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, CA, USA; Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Yasuo Itami
- Department of Orthopaedic Surgery, Osaka Medical College, Takatsuki, Japan; Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Michelle H McGarry
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
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Shin JJ, Woodmass JM. Editorial Commentary: Anterior Capsular Reconstruction for Subscapularis Deficiency: The Definitive Treatment or a Helpful Adjunct? Arthroscopy 2019; 35:3009-3010. [PMID: 31699251 DOI: 10.1016/j.arthro.2019.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 02/02/2023]
Abstract
Anterior glenohumeral instability in the setting of irreparable subscapularis deficiency represents a difficult clinical scenario for the treating shoulder surgeon. Anterior capsular reconstruction with humeral dermal allograft improved glenohumeral translation stability and range of motion to near-normal values whereas pectoralis major tendon transfer was unable to do so. However, placement of a static spacer does not restore the dynamic force couple or shoulder kinematics. Further research is needed to evaluate the functional outcomes using this reconstruction technique.
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