Massive irreparable rotator cuff tear and associated deltoid tear. Does the reverse shoulder arthroplasty and deltoid repair be a possible option of treatment?

Influence of lateralized versus medialized reverse shoulder arthroplasty design on external and internal rotation: a systematic review and meta-analysis

BACKGROUND

Restoration of external (ER) and internal rotation (IR) after Grammont-style reverse shoulder arthroplasty (RSA) is often unreliable. The purpose of this systematic review was to evaluate the influence of RSA medio-lateral offset and subscapularis repair on axial rotation after RSA.

METHODS

We conducted a systematic review of studies evaluating axial rotation (ER, IR, or both) after RSA with a defined implant design. Medio-lateral implant classification was adopted from Werthel et al. Meta-analysis was conducted using a random-effects model.

RESULTS

Thirty-two studies reporting 2,233 RSAs were included (mean patient age, 72.5 years; follow-up, 43 months; 64% female). The subscapularis was repaired in 91% (n=2,032) of shoulders and did not differ based on global implant lateralization (91% for both, P=0.602). On meta-analysis, globally lateralized implants achieved greater postoperative ER (40° [36°-44°] vs. 27° [22°-32°], P<0.001) and postoperative improvement in ER (20° [15°-26°] vs. 10° [5°-15°], P<0.001). Lateralized implants with subscapularis repair or medialized implants without subscapularis repair had significantly greater postoperative ER and postoperative improvement in ER compared to globally medialized implants with subscapularis repair (P<0.001 for both). Mean postoperative IR was reported in 56% (n=18) of studies and achieved the minimum necessary IR in 51% of lateralized (n=325, 5 cohorts) versus 36% (n=177, 5 cohorts) of medialized implants.

CONCLUSIONS

Lateralized RSA produces superior axial rotation compared to medialized RSA. Lateralized RSA with subscapularis repair and medialized RSA without subscapularis repair provide greater axial rotation compared to medialized RSA with subscapularis repair. Level of evidence: 2A.

Poor evidence is used to support commercial payers' coverage policies for shoulder arthroplasty

BACKGROUND

The incidence of shoulder arthroplasty has continued to increase over the past decade. In response, commercial payers have implemented strategies to control the medical requirement of these surgeries in attempt to contain the growing costs. For example, most payers require a prolonged trial of conservative management prior to shoulder arthroplasty for patients who may otherwise be surgical candidates. However, little is known regarding the evidence used to support these indications. The purpose of this study was to analyze the references used by commercial payers to substantiate their coverage policies for shoulder arthroplasty.

METHODS

Ten of the leading commercial payers for total shoulder arthroplasty were identified. Publicly available coverage policies were searched on the internet or requested directly from the payer via email or telephone. Cited references were reviewed independently by two authors for type of document, level of evidence, and mention of the efficacy of conservative management.

RESULTS

A total of 5 coverage policies were obtained with 118 references. The most common reference type was primary journal article (n = 70; 59.3%) followed by review or expert opinion articles (n = 35; 29.7%). Most references were of level IV evidence (n = 60; 52.2%), with only 6 (5.2%) of level I or II evidence. Only 4 (3.5%) references mentioned the efficacy of conservative management in patients who may be candidates for shoulder arthroplasty.

CONCLUSION

The majority of references used to substantiate the coverage policies for shoulder arthroplasty among major commercial payers within the United States are of low scientific evidence and fail to demonstrate the success of required nonoperative intervention strategies. Our study underscores the need for high-quality, comparative trials that evaluate the outcomes of conservative management vs. shoulder arthroplasty in end-stage glenohumeral osteoarthritis patients in order to determine the most cost-effective treatment algorithm.

Spontaneous Deltoid Tear in Cuff Tear Arthropathy and Its Effect on the Outcome of Reverse Total Shoulder Arthroplasty: A Comparison Using Propensity Score Matching

Background

Deltoid function critically influences the results of reverse total shoulder arthroplasty (RTSA), and spontaneous deltoid attrition tears are frequently detected in cuff tear arthropathy (CTA) patients; however, the clinical impacts of these tears on RTSA outcomes are undetermined. Our aim was to determine the effect of spontaneous deltoid attrition tears on postoperative outcomes after RTSA without an additional deltoid procedure.

Methods

Seventy-two patients who underwent RTSA for CTA with preoperative magnetic resonance imaging (MRI) and a minimum clinical follow-up of 1 year (mean, 32 months) were retrospectively reviewed in the study. Patients with a history of previous shoulder surgery or injury were excluded. The presence and location of deltoid attrition tears were determined in preoperative MRI. Propensity score matching (1:1) was performed to construct tear and no-tear groups. Finally, 21 patients, matched with respect to age, sex, hand dominance, symptom duration, medical comorbidity (obesity, diabetes mellitus, and coronary artery disease), Hamada grade, and implant type, were assigned to each group. Clinical outcomes (functional scores, isometric power, and range of motion) in the two groups were compared.

Results

Deltoid attrition tears were detected in 21 of the 72 enrolled cases (29.1%). Anterolateral deltoid was the most frequent location and no tear was detected in the posterior deltoid. The tear rate increased with disease severity (Hamada G2, 4.8%; G3, 23.8%; > G4, 71.4%). No pre- or postoperative clinical variables differed significantly between the tear and no tear groups.

Conclusions

Deltoid attrition tears were detected in 29% of CTA patients who underwent RTSA. The most common site was the anterolateral region and tear prevalence tended to increase with CTA progression. However, RTSA was found to provide satisfactory outcomes regardless of the presence of a deltoid attrition tear.

Biomechanical outcomes of superior capsular reconstruction for irreparable rotator cuff tears by different graft materials-a systematic review and meta-analysis

Background

Irreparable rotator cuff tears (IRCT) are defined as defects that cannot be repaired due to tendon retraction, fat infiltration, or muscle atrophy. One surgical remedy for IRCT is superior capsular reconstruction (SCR), which fixes graft materials between the larger tuberosity and the superior glenoid.

Patients and methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) criteria were followed for conducting the systematic review and meta-analysis. From their inception until February 25, 2022, Pubmed, Embase, and Cochrane Library's electronic databases were searched. Studies using cadavers on SCR for IRCT were also included. The humeral head's superior translation and subacromial peak contact pressure were the primary outcomes. The humeral head's anteroposterior translation, the kind of graft material used, its size, and the deltoid load were the secondary outcomes.

Results

After eliminating duplicates from the search results, 1,443 unique articles remained, and 20 papers were finally included in the quantitative research. In 14 investigations, the enhanced superior translation of the humeral head was documented in IRCTs. In 13 studies, a considerable improvement following SCR was found, especially when using fascia lata (FL), which could achieve more translation restraints than human dermal allograft (HDA) and long head of bicep tendon (LHBT). Six investigations reported a subacromial peak contact pressure increase in IRCTs, which could be rectified by SCR, and these studies found a substantial increase in this pressure. The results of the reduction in subacromial peak contact pressure remained consistent regardless of the graft material utilized for SCR. While there was a statistically significant difference in the change of graft material length between FL and HDA, the change in graft material thickness between FL and HDA was not significant. The humeral head's anterior-posterior translation was rising in IRCTs and could be returned to its original state with SCR. In five investigations, IRCTs caused a significant increase in deltoid force. Furthermore, only one study showed that SCR significantly decreased deltoid force.

Conclusion

With IRCT, SCR might significantly decrease the glenohumeral joint's superior and anterior-posterior stability. Despite the risks for donor-site morbidity and the longer recovery time, FL is still the best current option for SCR.

Magnetic resonance imaging of deltoid muscle/tendon tears: a descriptive study

OBJECTIVE

To describe the MRI features of deltoid tears and to evaluate tear characteristics in patient groups based on history of trauma and rotator cuff tear (RCT).

MATERIALS AND METHODS

The records of patients who underwent shoulder MRI at our institution between July 2007 and June 2018 were retrospectively reviewed to identify deltoid tears, and patients were divided into groups based on history of recent trauma and presence of RCT. Images were reviewed to identify the location and size of the deltoid tear; the presence or absence of RCT, muscle atrophy, tendon retraction, humeral head subluxation, soft tissue edema, and additional pathologies were also noted. Medical records were reviewed for information about history of steroid injection, previous rotator cuff surgery, and treatments used.

RESULTS

Among 69 patients with deltoid tears (45 men; mean age, 65.2 years; range, 19-89 years), patients with RCTs and no trauma had the highest frequency of deltoid tears in the middle portion (p = 0.005). Only patients with RCTs had undergone steroid injection or rotator cuff surgery. Two patients had deltoid tear without RCT and without recent trauma; these patients demonstrated evidence of calcific tendinopathy and chronic subacromial-subdeltoid bursitis.

CONCLUSION

The middle (acromial) portion of the deltoid is more frequently affected in patients with RCTs than in those with trauma. Although deltoid tears are commonly associated with RCT, calcific tendinopathy and chronic bursitis may also be seen in patients with deltoid tears.

Isolated Traumatic Tear of the Middle Head of the Deltoid Muscle: A Case Report

CASE

A 27-year-old male pedestrian struck presented with left shoulder pain and weakness 4 months postinjury, with an isolated middle head of the deltoid tear. The patient's pain persisted despite extensive nonoperative management. The deltoid was primarily repaired to the lateral acromion using a transosseous suture repair technique.

CONCLUSION

Suture repair of the deltoid to the acromion using transosseous tunnel fixation is a successful treatment for traumatic, isolated tears of the middle head of the deltoid muscle that fail conservative treatment. After surgical repair and physical therapy, our patient recovered full, pain-free range of motion and strength at 6 months.

Posterosuperior shoulder dislocation due to the rupture of deltoid posterior fibers: a case report

Background

Superior shoulder dislocation is a rare type of shoulder dislocation. Its occurrence is thought to be associated with rupture of the deltoid; however, few reports are available on the mechanism of onset and the treatment of a superior shoulder dislocation. Here we describe a case of dislocation in the direction of the posterior acromion, referred to as posterosuperior shoulder dislocation, caused by the traumatic rupture of deltoid posterior fibers.

Case presentation

An 83-year-old woman who fell on her right elbow in the hospital presented to our department with complaints of right shoulder pain. She had been undergoing conservative treatment for a massive rotator cuff tear and a rupture of the long head of biceps tendon 5 years previously. X-ray radiography images at the time of the trauma revealed that the right humeral head was dislocated upwards and in the direction of the posterior acromion. Magnetic resonance imaging (MRI) revealed newly ruptured deltoid posterior fibers, in addition to the massive rotator cuff tear. Closed reduction was performed and the shoulder joint was held in external rotation at 30 degrees for 6 weeks. However, re-dislocation was observed at an early stage after the removal of the orthosis and marked instability remained.

Conclusions

This is the first case of posterosuperior shoulder dislocation. It suggests that rupture of the deltoid posterior fibers contributes to the onset of posterosuperior shoulder dislocation in patients with a massive rotator cuff tear. Moreover, in superior shoulder dislocation, conservative treatment may result in continuing instability which requires surgical treatment.

Management of full thickness rotator cuff tears in the elderly: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to synthesize the best available evidence on the effectiveness of non-surgical and surgical treatment on the clinical and functional outcomes of elderly patients with full thickness rotator cuff tear.