Arthroscopic Biological Augmentation for Massive Rotator Cuff Tears: The Biceps-Cuff-Bursa Composite Repair

Double Attack Repair for Massive Rotator Cuff Tears: Superior Capsular Reconstruction Using the Long Head of Biceps Tendon Plus Margin Convergence Repair

Arthroscopic repair of massive retracted rotator cuff tears is very challenging with a high incidence of retears. Many techniques have been described to improve the outcomes of arthroscopic repair. In this technique, a superior capsular reconstruction using the long head of the biceps is combined with margin convergence repair aimed at improving the mechanical strength of the repair. The long head of the biceps is used as a superior capsular reconstruction to stabilize the humeral head and prevent proximal migration. Moreover, margin convergence provides an efficient gap filling between remnants of the supraspinatus and infraspinatus tendons to restore an efficient rotator repair in anatomical, biological, and tension-free fashion.

The long head of the biceps tendon: a valuable tool in shoulder surgery

ANATOMY AND FUNCTION

The long head of the biceps tendon (LHBT) has different properties and characteristics that render it a valuable tool in the hands of shoulder surgeons. Its accessibility, biomechanical strength, regenerative capabilities, and biocompatibility allow it to be a valuable autologous graft for repairing and augmenting ligamentous and muscular structures in the glenohumeral joint.

SHOULDER SURGERY APPLICATIONS

Numerous applications of the LHBT have been described in the shoulder surgery literature, including augmentation of posterior-superior rotator cuff repair, augmentation of subscapularis peel repair, dynamic anterior stabilization, anterior capsule reconstruction, post-stroke stabilization, and superior capsular reconstruction. Some of these applications have been described meticulously in technical notes and case reports, whereas others may require additional research to confirm clinical benefit and efficacy.

CONCLUSION

This review examines the role of the LHBT as a source of local autograft, with biological and biomechanical properties, in aiding outcomes of complex primary and revision shoulder surgery procedures.

Arthroscopic Biological Augmentation With Subacromial Bursa for Bursal-Sided Partial-Thickness Rotator Cuff Tears

Background

Augmentation with subacromial bursa has not been fully established in bursal-sided partial-thickness rotator cuff tears (PT-RCTs).

Purpose

To compare the results of acromioplasty + arthroscopic debridement versus acromioplasty + augmentation with subacromial bursa for Ellman type 2 PT-RCTs involving 25% to 50% of the tendon surface area.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 40 patients (mean age, 47.8 years) with Ellman type 2 PT-RCTs whose symptoms did not regress despite 3 months of nonoperative treatment. The patients underwent either acromioplasty + debridement (group A; n = 18) or acromioplasty + augmentation (group B; n = 22). Outcome scores (visual analog scale [VAS] pain score, Constant-Murley score [CMS], and American Shoulder and Elbow Surgeons [ASES] score) were obtained preoperatively and at 6, 12, and 18 months postoperatively. Magnetic resonance imaging (MRI) scans performed at 6 months postoperatively were used to determine the integrity and state of healing.

Results

There were no significant differences between groups A and B in preoperative VAS, CMS, or ASES scores, and patients in both groups saw significant improvement at each follow-up time point on all 3 outcome scores (P = .001 for all). Scores on all 3 outcome measures were significantly better in group B than group A at each postoperative time point (P < .05 for all). Postoperative MRI scans revealed persistent partial tears in 5 of 18 patients in group A compared with 2 of 22 patients in group B (P < .05). Conversion to full-thickness tear (3/18 patients) was seen only in group A.

Conclusion

Patients who underwent biological augmentation of their PT-RCTs had improved outcome scores compared with those treated with acromioplasty and debridement alone.

Current Understanding and New Advances in the Surgical Management of Reparable Rotator Cuff Tears: A Scoping Review

Rotator cuff (RC) tears are among the most common musculoskeletal disorders and can be associated with pain, weakness, and shoulder dysfunction. In recent years, there have been significant advances with regard to the understanding of rotator cuff disease and its management. With technological improvements and advanced diagnostic modalities, there has been much progress as to improved understanding of the pathology. Similarly, with advanced implant designs and instrumentation, operative techniques have evolved. Furthermore, refinements in postoperative rehabilitation protocols have improved patient outcomes. In this scoping review, we aim to provide an overview of the current knowledge on the treatment of rotator cuff disorders and to highlight recent advances in its management.

Aktuelle Aspekte der Behandlung der Rotatorenmanschette

Rotatorenmanschettenrupturen gehören zu den häufigsten muskuloskeletalen Erkrankungen und können mit ausgeprägten Schmerzen und Funktionseinschränkungen einhergehen. Für ihre Entstehung ist eine Vielzahl von Faktoren relevant, u. a. die individuelle Anatomie des Akromions. Mit Hilfe der heutigen technischen Möglichkeiten wurde nun festgestellt, dass zusätzlich zu seiner lateralen Ausdehnung auch die sagittale Ausdehnung des Akromions eine Rolle zu spielen scheint. Die bildgebende Darstellung der Rotatorenmanschette (RM) hat von den technischen Fortschritten der letzten Jahrzehnte ebenfalls profitiert. Magnetresonanztomographie (MRT) und MR-Arthrographie werden heute flächendeckend eingesetzt. Letztere bietet die höchste Sensitivität für die Entdeckung selbst kleiner Partialläsionen. Neue Sequenzen und Nachbearbeitungsmöglichkeiten können als hilfreiche tools für die operative Planung eingesetzt werden. Grundsätzlich richtet sich die Behandlung der RM neben der Symptomatik nach der Rupturgenese und -morphologie sowie der erwarteten Gewebequalität des Muskel-Sehnen-Kontinuums. Auch das Gesamtprofil, die Erwartungshaltung und die Rehabilitationsmöglichkeiten des Patienten sind wichtig. Die heutigen operativen Techniken werden durch spannende Entwicklungen der Industrie mitbestimmt, die in den letzten Jahren immer bessere Fadenankersysteme, aber auch Augmentationsmaterialien auf den Markt gebracht hat. Letztere zielen nicht nur auf die mechanische Verstärkung der Sehnenrekonstruktion, sondern auch auf die Optimierung der biologischen Eigenschaften des Konstrukts ab. Hinsichtlich Fixation konnte die biomechanische Forschung zeigen, dass zweireihige oder Suture-Bridge-Fixationen einreihigen oder transossären Fixationen überlegen sind. Diese Überlegenheit im Labor spiegelt sich noch nicht klar in den klinischen Ergebnissen wider, dennoch sind die meisten Chirurgen heute auf diese Technik übergegangen. Was die postoperative Nachbehandlung angeht, stellen jüngste randomisiert-kontrollierte Untersuchungen das Konzept der postoperativen Immobilisation in Abduktion in Frage. Hier scheint das letzte Wort noch nicht gesprochen zu sein.