Massive rotator cuff tears repaired on top of humeral head by McLaughlin's procedure

Long-term outcomes of hemiarthroplasty using a smaller head combined with rotator cuff reconstruction in patients with cuff-tear arthropathy

Background

Hemiarthroplasty (HHR) using a smaller head with rotator cuff reconstruction is a treatment option for cuff-tear arthropathy, offering advantages like facilitating rotator cuff-tear closure, increasing the lever arm of deltoid, and restoring function in irreparable cuff tears. This study aimed to evaluate the long-term outcomes of this procedure.

Methods

A retrospective analysis was conducted for 91 shoulders undergoing HHR using a smaller head with rotator cuff reconstruction between May 2005 and September 2012. Surgery involved reducing the size of humeral head and performing rotator cuff reconstruction based on the site of the deficient rotator cuff. The study analyzed University of California, Los Angeles shoulder scores, Japanese Orthopaedics Association shoulder scores, range of motion, and postoperative radiographs.

Results

Twenty-eight patients, divided into an elderly group (14 women, 2 men, mean age 74.5 ± 3.8 years) and a younger group (6 women, 6 men, mean age 63.5 ± 3.1 years) were followed up for a mean of 133.2 ± 14.1 months. No complications were reported. The clinical scores and range of motion significantly improved postoperatively and remained over 10 years. Radiographs revealed high incidence of glenoid wear (82.1%), bone resorption (43%) and cranial humeral head migration (54%), with no prosthesis loosening.

Conclusion

We believe that HHR using a smaller head with rotator cuff reconstruction is a surgical technique that can maintain stable long-term outcomes in both elderly and younger individuals with cuff-tear arthropathy.

Arthroscopic superior capsule reconstruction augmentation using a semitendinosus autograft in massive reparable rotator cuff tears

Background

Arthroscopic superior capsule reconstruction (SCR) augmentation is a viable treatment option for massive reparable cuff tears. This study aimed to retrospectively compare clinical and imaging outcomes of patients with reparable massive rotator cuff tears after arthroscopic rotator cuff repair (ARCR) with those after SCR augmentation using a semitendinosus autograft.

Methods

We retrospectively compared 50 patients with massive reparable rotator cuff tears who underwent ARCR and SCR augmentation (n = 25 each). Patients were clinically followed up for at least 2 years, and the American Shoulder and Elbow index, other patient-reported outcomes, active range of motion, and radiography and magnetic resonance imaging findings were assessed.

Results

At the final follow-up, both patient groups showed significant improvements in forward elevation in range of motion and visual analog scale scores. Improvements in the American Shoulder and Elbow scores in the SCR augmentation group were significantly superior to those in the ARCR group (48.3 and 28.9, P < .01). There was a significant difference in the retear rate between the SCR augmentation group and ARCR group (20% and 56%, respectively; P = .009).

Conclusion

Our study demonstrated that patient-reported outcomes and retear rates in patients who underwent SCR augmentation with rotator cuff repair for massive rotator cuff tears significantly improved compared with those in patients who underwent ARCR without augmentation. Augmentation with semitendinosus autografting during rotator cuff repair represents a solution for patients with massive reparable rotator cuff tears.

The remaining teres minor and subscapularis may contribute to preventing superior migration of the humeral head and progression of osteoarthritic change in rotator cuff tears

Background

Superior migration of the humeral head is common in large and massive rotator cuff tears (RCTs). Humeral heads migrate superiorly according to an increase in the RCT size; however, the relevance of the remaining cuff has not been elucidated. This study investigated the relation between superior migration of the humeral head and the remaining rotator cuff, especially the teres minor (TM) and subscapularis (SSC), in RCTs involving tears and atrophy of the infraspinatus (ISP).

Methods

Plain anteroposterior radiographic and magnetic resonance imaging examinations were performed on 1345 patients between January 2013 and March 2018. A total of 188 shoulders with tears of the supraspinatus and ISP with atrophic ISP were evaluated. Gradings of superior migration of the humeral head and osteoarthritic change were evaluated using the acromiohumeral interval, Oizumi classification, and Hamada classification on plain anteroposterior radiographs. The cross-sectional area of the remaining rotator cuff muscles was evaluated using oblique sagittal magnetic resonance imaging. The TM was classified as hypertrophic (H) and normal and atrophic (NA). The SSC was classified as nonatrophic (N) and atrophic (A). All shoulders were classified as groups A (H-N), B (NA-N), C (H-A), and D (NA-A). Age- and sex-matched patients with no cuff tears were also enrolled (control).

Results

The acromiohumeral intervals of the control group and groups A-D were 11.4 ± 2.4, 9.5 ± 3.8, 7.8 ± 4.1, 7.2 ± 4.0, and 5.4 ± 3.5 mm (84, 74, 64, 21, and 29 shoulders, respectively), with significant differences between groups A and D (P < .001) and groups B and D (P = .016). Grade 3 of the Oizumi classification and grades 3, 4, and 5 of the Hamada classification were significantly higher in group D than in others (P < .001).

Conclusion

The group showing hypertrophic TM and nonatrophic SSC prevented significantly migration of the humeral head and cuff tear osteoarthritis compared to the group showing atrophic TM and SSC in posterosuperior RCTs. The findings indicate that the remaining TM and SSC may prevent superior migration of the humeral head and progression of osteoarthritic change in RCTs. In treating patients with large and massive posterosuperior RCTs, the status of the remaining TM and SSC muscles should be assessed.

Risk factors for eccentric glenoid wear after humeral head replacement for cuff tear arthropathy

Background

In our previous report, glenoid wear (GW) after humeral head replacement for cuff tear arthropathy was classified with modified Goya’s classification (grade 0-3), and, among 3 subtypes of grade 3 (glenoid bone erosion), grade 3B (superior eccentric erosion) showed significantly more pain and limited active flexion postoperatively compared to grade 3C (concentric erosion). The purpose of this study was to detect individual risk factors for the progression to grade 3B GW.

Methods

Seventy-nine shoulders in 70 patients who were followed up for a mean of 8.2 years (range, 5.0-13.2 years), including 29 men and 41 women, with a mean age at the surgery of 71.1 years (range, 54-87 years), were reviewed. Atrophy and fatty degeneration of torn cuff muscle, preoperative humeral head displacement (superior translation ratio [STR], anterior translation ratio, and other several parameters) on preoperative magnetic resonance imaging, and other individual factors were analyzed as possible risk factors.

Results

GW at the final follow-up was grade 0: 5 shoulders, grade 1: 17, grade 2: 20, and grade 3: 37 (3A: 4, 3B: 22, and 3C: 11). Preoperative higher STR was defined as a risk factor for grade 3 GW (odds ratio, 35.5; 95% confidence interval, 1.8-693.0; P = .018). Comparison among the three subtypes of grade 3 showed that patients with grade 3B GW had larger STR than 3C (41.4 ± 14.2% vs. 23.5 ± 13.3 % P = .006).

Conclusion

Patients with preoperative high STR are considered to have a risk for grade 3B GW, which possibly relates to poor clinical outcome and future revision.

Does Complete Footprint Coverage Affect Outcomes After Conventional Arthroscopic Repair of Large-Sized Rotator Cuff Tears?

Background:

In large-sized rotator cuff tears, tendon repair with incomplete footprint coverage is performed frequently as a way of tension-free or low-tension repair.

Purpose:

To compare clinical outcomes after arthroscopic repair of large-sized rotator cuff tears between patients with complete versus incomplete footprint coverage.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Among 297 patients who underwent arthroscopic surgery for a large-sized rotator cuff tear, we selected 58 patients (<50% coverage; mean age, 63.34 ± 6.8 years; 34 men and 24 women) with incomplete footprint coverage. Using propensity score matching, another 58 patients with complete footprint coverage (mean age, 63.4 ± 8.03 years; 34 men and 24 women) were selected after 1:1 matching for age, sex, and tear size—the main demographic and prognostic factors of outcomes after rotator cuff repair. Clinical outcomes were compared on magnetic resonance imaging or ultrasonography at minimum of 6 months postoperatively, and functional outcomes were compared using range of motion and pain visual analog scale; American Shoulder and Elbow Surgeons; Constant; University of California, Los Angeles; and Simple Shoulder Test scores at a minimum of 2 years postoperatively.

Results:

A total of 18 patients in the incomplete footprint coverage group (31.0%) and 20 patients in the complete footprint coverage group (34.5%) showed healing failure, with no significant difference between groups (P = .843). In addition, there were no differences in functional outcomes between groups (P > .05 for all).

Conclusion:

Whether the rotator cuff footprint was completely covered did not affect clinical outcomes in conventional arthroscopic repair of large-sized rotator cuff tears.

Irreparable Large to Massive Rotator Cuff Tears With Low-Grade Fatty Degeneration of the Infraspinatus Tendon: Minimum 7-Year Follow-up of Fascia Autograft Patch Procedure and Partial Repair

BACKGROUND

In shoulders with irreparable massive rotator cuff tears (RCTs) with high-grade fatty degeneration (Goutallier stage 3 or 4) of the supraspinatus tendon and low-grade fatty degeneration (Goutallier stage 1 or 2) of the infraspinatus tendon (ISP), arthroscopic patch grafting (PG) has been reported as superior to partial repair (PR) regarding the ISP retear rate at short-term to midterm follow-up. However, the longer term outcomes are unclear.

PURPOSE

To compare clinical and structural outcomes in the PG and PR groups at a minimum of 7 years postoperatively.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We evaluated 24 patients in the PG group and 24 patients in the PR group. We primarily used the Constant score for clinical outcomes and performed magnetic resonance imaging for structural outcomes in the PG and PR groups. The risk factors for a retear of the ISP were identified by univariate and multivariate (forward stepwise selection method) logistic regression analyses. We primarily compared values at midterm follow-up (<4 years) with values at the final follow-up (minimum 7 years) for each patient.

RESULTS

The mean midterm and final follow-up times for the PG group were 41.0 and 95.1 months, respectively, compared with 35.7 and 99.3 months, respectively, for the PR group. We found significant differences for the midterm and final follow-up Constant total scores in the PG and PR groups (midterm follow-up: 79.1 vs 69.9, respectively [P = .001]; final follow-up: 76.0 vs 65.3, respectively [P = .006]) and in the Constant strength scores (midterm follow-up: 14.6 vs 8.5, respectively [P < .001]; final follow-up: 13.1 vs 8.3, respectively [P = .001]). Treatment group (PR) was a significant predictor of an ISP retear in the logistic regression analysis (odds ratio, 3.545; P = .043).

CONCLUSION

Patients with low-grade massive RCTs treated with PG or PR improved significantly in terms of clinical outcomes at the midterm and final follow-up time points. However, Constant scores were significantly better in the PG group at the final follow-up.

Medialized repair for retracted rotator cuff tears

BACKGROUND

The purpose of this study was to evaluate the functional outcomes of medialized rotator cuff repair and the continuity of repaired tendon in chronic retracted rotator cuff tears.

METHODS

Thirty-five consecutive patients were selected from 153 cases that underwent arthroscopic rotator cuff repair for more than medium-sized posterosuperior rotator cuff tears between July 2009 and July 2012 performed with the medialized repair. All cases were available for at least 2 years of postoperative follow-up. The visual analog scale of pain, muscle strength, Constant score, American Shoulder and Elbow Surgeons (ASES) score, and University of California-Los Angeles score were evaluated.

RESULTS

At the final follow-up, all clinical outcomes were significantly improved. The visual analog scale score for pain improved from 6 ± 1 preoperatively to 2 ± 1 postoperatively. The range of motion increased from preoperatively to postoperatively: active forward elevation, from 134° ± 49° to 150° ± 16°; active external rotation at the side, from 47° ± 15° to 55° ± 10°; and active internal rotation, from L3 to L1. The shoulder score also improved: Constant score, from 53.5 ± 16.7 to 79 ± 10; American Shoulder and Elbow Surgeons score, from 51 ± 15 to 82 ± 8; and University of California-Los Angeles score, from 14 ± 4 to 28 ± 4. The retear cases at the final follow-up were 6 (17%).

CONCLUSIONS

Medialized repair may be useful in cases in which anatomic bone-to-tendon repair would be difficult because of the excessive tension of the repaired tendon and a torn tendon that does not reach the anatomic insertion.

Impact of rotator cuff tendon reparability on patient satisfaction

Background

The primary purpose of this study was to explore the relationship between patient satisfaction and rotator cuff tendon reparability.

Materials and methods

This was a secondary analysis of prospectively collected data of consecutive patients who underwent arthroscopic repair of full-thickness rotator cuff tear and were followed up for 2 years. The satisfaction level was rated on a 6-point Likert scale. Patient-oriented disability measures included the American Shoulder and Elbow Surgeons score, the short version of the Western Ontario Rotator Cuff index, the Constant-Murley score, and the Quick Disabilities of the Arm, Shoulder, and Hand. Partial repair was defined as repair with >1 cm residual gap.

Results

There were 145 patients (65 women, 80 men; mean age, 62 years) who met the inclusion criteria. There were 12 massive, 31 large, and 102 small or moderate rotator cuff tears. Of 43 large or massive tears, 23 had a partial repair. There was a statistically significant relationship between satisfaction and tendon reparability (P = .01). Patients with work-related shoulder injury reported less satisfaction with surgery (P = .005). Age, gender, or tear size did not affect satisfaction with surgery. Satisfaction was a predictor of all postoperative outcome scores after being adjusted for preoperative scores (P = .001 to P < .0001).

Conclusion

In this study, patients with partial repair and those with an active compensable injury were less satisfied with surgery than their counterparts were. Older age, female sex, or a larger tear was not a negative predictor of patient satisfaction.

Evaluation of Repair Tension in Arthroscopic Rotator Cuff Repair: Does It Really Matter to the Integrity of the Rotator Cuff?

BACKGROUND

Repair tension of a torn rotator cuff can affect healing after repair. However, a measurement of the actual tension during arthroscopic rotator cuff repair is not feasible. The relationship between repair tension and healing of a rotator cuff repair remains unclear.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate the effect of repair tension on healing at the repair site. The hypothesis was that repair tension would be a major factor in determining the anatomic outcome of rotator cuff repair.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Arthroscopic rotator cuff repairs (132 patients) for full-thickness rotator cuff tears were analyzed. An intraoperative model was designed for the estimation of repair tension using a tensiometer. Magnetic resonance imaging (MRI) was performed approximately 1 year (mean [±SD], 12.7 ± 3.2 months) postoperatively for the evaluation of healing at the repair site. Multivariable analysis was performed for tear size, amount of retraction, and fatty degeneration (FD) of rotator cuff muscles.

RESULTS

The mean repair tension measured during the arthroscopic procedure was 28.5 ± 23.1 N. There was a statistically significant correlation between tension and tear size (Pearson correlation coefficient [PCC], 0.529; P < .001), amount of retraction (PCC, 0.619; P < .001), and FD of the supraspinatus (Spearman correlation coefficient [SCC], 0.308; P < .001) and infraspinatus (SCC, 0.332; P < .001). At the final follow-up (12.7 ± 3.2 months), healing failure was observed in 18.2% (24/132), and repair tension also showed a significant inverse correlation with healing at the repair site (SCC, 0.195; P = .025). However, when sex, age, tear size, amount of retraction, tendon quality, and FD of rotator cuff muscles were included for multivariable logistic regression analysis, only FD of the infraspinatus showed an association with the anatomic outcome of repair (Exp(B) = 0.596; P = .010).

CONCLUSION

Our intraoperative model for the estimation of rotator cuff repair tension showed an inverse correlation of repair tension with healing at the repair site, suggesting that complete healing is less likely with high-tension repairs. A significant association was observed on MRI between a high level of FD of the infraspinatus and repaired tendon integrity.

Rotator cuff repair using a decellularized tendon slices graft: an in vivo study in a rabbit model

PURPOSE

Although varieties of surgical repair techniques and materials have been used to repair rotator cuff defects, re-tearing frequently occurs. The purpose of this study is to evaluate the postoperative outcomes of rotator cuff repairs with a decellularized tendon slices (DTSs) graft in a rabbit model.

METHODS

Large defects in the infraspinatus tendons were created bilaterally in 21 rabbits. The graft group underwent reconstruction of the defects with the DTSs grafts, while the defect group did not undergo any treatment. The specimens underwent histological observation, biomechanical testing, and magnetic resonance imaging (MRI) detection at 4, 8, and 12 weeks after surgery. In addition, 2 rabbits that were not operated on were used for MRI detection as a normal reference.

RESULTS

Histological analysis revealed that the graft promoted host cell ingrowth and tissue integration, and a tendon-like structure developed at 12 weeks. The ultimate tensile load had a significant difference between specimens at 4 and 12 weeks in the graft group, but there was no significant difference between the graft group and the defect group. In the graft group, the stiffness at 12 weeks was significantly greater than that at 4 or 8 weeks, and it was also greater than the stiffness in the defect group at 12 weeks. MRI demonstrated that the signal strength of the regenerative tissue from the graft group at 12 weeks was similar to that of normal infraspinatus tendon.

CONCLUSION

The DTSs graft allowed for incorporation of host tendon and improved the biomechanical performance of the regenerative tendon. Therefore, the graft could be a promising bioscaffold to enhance the surgical repair of large rotator cuff defects and consequently improve the clinical outcome of rotator cuff tears.

Relationship between clinical and surgical findings and reparability of large and massive rotator cuff tears: a longitudinal study

Background

The literature has shown good results with partial repairs of large and massive tears of rotator cuff but the role of factors that affect reparability is less clear. The purpose of this study was twofold, 1) to examine clinical outcomes following complete or partial repair of large or massive full-thickness rotator cuff tear, and 2) to explore the value of clinical and surgical factors in predicting reparability.

Methods

This was a secondary data analysis of consecutive patients with large or massive rotator cuff tear who required surgical treatment (arthroscopic complete or partial repair) and were followed up for two years. Disability measures included the American Shoulder and Elbow Surgeons (ASES), the relative Constant-Murley score (CMS) and the shortened version of the Western Ontario Rotator Cuff Index (ShortWORC). The relationship between predictors and reparability was examined through logistic regressions and chi-square statistics as appropriate. Within group change over time and between group differences in disability outcomes, range of motion and strength were examined by student’s T-tests and non-parametric statistics.

Results

One hundred and twenty two patients (41 women, 81 men, mean age 64, SD = 9) were included in the analysis. There were 86 large (39 fully reparable, 47 partially reparable) and 36 (10 fully reparable, 26 partially reparable) massive tears. Reparability was not associated with age, sex, or pre-operative active flexion or abduction (p > 0.05) but the fully reparable tear group showed a better pre-operative ASES score (p = 0.01) and better active external rotation in neutral (p = 0.01). Reparability was associated with tear shape (p < 0.0001), size (p = 0.002), and tendon quality (p < 0.0001).

Conclusions

Reparability of large or massive tears is affected by a number of clinical and surgical factors. Patients whose tears could not be fully repaired showed a statistically significant improvement in range of motion, strength and disability at 2 years, although they had slightly inferior results compared to those with complete repairs.

Transfer of teres minor with bone pedicle for irreparable posterior-superior rotator cuff tears

BACKGROUND

The objectives of this study are to evaluate the clinical and radiographic mid- to long-term outcomes of patients treated by teres minor with bone pedicle transfer for irreparable massive rotator cuff tear and to investigate the limitations of this procedure.

METHODS

Clinical outcomes were assessed by quantifying: the range of shoulder motion; a visual analog pain scale; the University of California, Los Angeles Shoulder Score (UCLA score); and the Disability of the Arm, Shoulder, and Hand (DASH) score. Radiographs were assessed for deterioration of the glenohumeral joint and upper migration of the humeral head.

RESULTS

Eighteen patients with mean age of 66.9 years and mean follow-up of 74.4 months were included. The technique resulted in significant decrease in shoulder pain. The mean UCLA score improved from 10.3 points initially to 24.1 points at time of final follow-up. However, the postoperative results were classified as poor in 11 shoulders. The mean postoperative DASH score was 27.6 points. The mean active forward elevation significantly improved from 75.9° initially to 121.6° at time of final follow-up. In radiographic assessment, osteoarthritis of the glenohumeral joint progressed in 15 shoulders, and the upper migration of humeral head progressed in 14 shoulders.

CONCLUSIONS

Aggravation of the glenohumeral joint and upper migration of the humeral head both progressed postoperatively at a high rate. Therefore, we conclude that this procedure should no longer be performed despite its relative simplicity.

Will preoperative atrophy and Fatty degeneration of the shoulder muscles improve after rotator cuff repair in patients with massive rotator cuff tears?

Recently, retear rate after repair for massive cuff tear have been improved through devised suture techniques. However, reported retear rate is relevant to preoperative atrophy and fatty degeneration. The purpose of this study was to investigate whether preoperative atrophy and fatty degeneration of rotator cuff muscles improve by successful repair. Twenty-four patients with massive rotator cuff tear were evaluated on the recovery of atrophy and fatty degeneration of supraspinatus and infraspinatus muscle after surgery. Atrophy was classified by the occupation ratio and fatty degeneration by modified Goutallier's classification. Both were assessed on magnetic resonance imaging (MRI) before and after the operation. When the cuff was well repaired, improvement of the atrophy and fatty degeneration were observed in a half and a one-fourth of the cases, respectively. In retear cases, however, atrophy and fatty degeneration became worse. Improvement of atrophy and fatty degeneration of the rotator cuff muscles may be expected in the cases with successful achievement of rotator cuff repair for large and massive tear.

Radiological classification of glenoid deformity in rheumatoid arthritis

We report a classification system based on the changes in shape of the glenoid fossa and on an evaluation of the upward migration of the humeral head, because a simple classification based on X-ray evaluation would be of great assistance to physicians dealing with the diagnosis and treatment of RA. We evaluated 150 shoulders of 118 RA patients who showed changes in the glenoid fossa after radiological examinations. The morphology of the glenoid fossa of the RA shoulder was classified into 3 types and we were able to classify a total of six types of deformities by adding the problem of upward migration of the humeral head. An additional investigation on the difference in the type of deformity between the right and left shoulder, the changes in type during the course of the study, and the relationship between this particular classification and certain patient characteristics was also included.

Open repair for massive rotator cuff tear with a modified transosseous-equivalent procedure: preliminary results at short-term follow-up

BACKGROUND

Many surgical procedures have been reported for rotator cuff tears. We adopted the modified transosseous-equivalent procedure, also termed "surface-holding repair with transosseous sutures," and demonstrated that this procedure has a biomechanical advantage regarding the concentration of stress on the tendon stump. This study aimed to evaluate the clinical and structural outcomes of this technique, which has been demonstrated by postoperative magnetic resonance imaging (MRI) to produce high intact rates.

METHODS

Twenty-nine massive rotator cuff tears involving at least two tendons were treated by open repair using this procedure. Twenty-four patients were evaluated at an average of 43.2 months (range 24-71) postoperatively (the follow-up rate was 83.8%). The pre- and postoperative clinical outcomes were examined using the scoring system of the Japanese Orthopedic Association (JOA score). In an A-P radiograph, the presence of osteoarthritis (OA) of the glenohumeral joint and upward migration of the humeral head were compared pre- and postoperatively. The repair integrity of the cuff tendon was evaluated by applying Sugaya's classification to the postoperative MRIs.

RESULTS

The JOA score improved from 42.8 points preoperatively to 89.3 points at final follow-up. Radiographic examination showed that OA progressed in 16.7% and upward migration of the humeral head progressed in 20.8%. Postoperative MRI scans revealed 14 shoulders with type 1 repair based on Sugaya's classification, 4 shoulders with type 2, 4 shoulders with type 3, 2 shoulders with type 4, and no shoulders with a type 5 repair.

CONCLUSIONS

Although osteoarthritis of the glenohumeral joint and upward migration of the humeral head had both progressed postoperatively in some cases, postoperative MRI scans revealed that 91.7% of the repairs resulted in a continuous rotator cuff. Therefore, this technique produces a high healing rate.