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Tokish JM, Brinkman JC. Pseudoparalysis and Pseudoparesis of the Shoulder: Definitions, Management, and Outcomes. J Am Acad Orthop Surg 2024:00124635-990000000-01021. [PMID: 38935855 DOI: 10.5435/jaaos-d-23-00863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 05/19/2024] [Indexed: 06/29/2024] Open
Abstract
Loss of shoulder function can be a complex condition to manage. Specifically, the definition between the terms pseudoparalysis and pseudoparesis remains inconsistent in the literature based on various factors including chronicity, present pathology, and the role of pain in the loss of function. There is also debate as to the optimal management strategies for these challenging conditions. In the setting of advanced glenohumeral arthritis or arthropathy in the correct patient, arthroplasty provides consistent and reliable results. However, in younger patients or the patient without arthritis, arthroplasty may not be the best option. In some cases, addressing pain with biceps procedures, balloon spacer placement, débridement, or others may be appropriate. However, other instances may require attempts at improving shoulder kinematics with procedures such as rotator cuff repair, superior capsular reconstruction, and tendon transfer. In this review, we discuss current definitions for pseudoparalysis and pseudoparesis, in addition to reviewing the indications for the various treatment options and their respective outcomes.
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Affiliation(s)
- John M Tokish
- From the Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, AZ
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Chan E, Remedios S, Wong I. My Approach to Failed Rotator Cuff Repair. Sports Med Arthrosc Rev 2023; 31:120-128. [PMID: 38109164 DOI: 10.1097/jsa.0000000000000370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Failed rotator cuff repairs pose several challenges due to the high incidence rate, complexity, and range of symptoms. We propose an overview for assessing and treating failed rotator cuff repairs. For active young patients, attempt revision repair with patch augmentation if possible. When anatomic revision is not viable, but muscle is retained, consider partial repair with interposition bridging. Isolated, irreparable supraspinatus tears may benefit from superior capsule reconstruction. Tendon transfer is suitable for patients with significant atrophy and multiple irreparable cuff tears. Low-demand elderly patients or those with substantial glenohumeral arthritis may consider reverse total shoulder arthroplasty if conservative management fails. There are a variety of reported outcomes in the literature but long-term studies with larger cohorts are needed to improve the management of failed rotator cuff repair.
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Affiliation(s)
| | - Sarah Remedios
- Faculty of Health, Dalhousie University
- Division of Orthopaedic Surgery, Nova Scotia Health, Halifax, NS
| | - Ivan Wong
- Faculty of Medicine
- Faculty of Health, Dalhousie University
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Campbell RE, Lee D, Day LM, Dixit A, Freedman KB, Tjoumakaris FP. Management of Massive Rotator Cuff Tears Without Arthropathy. Orthopedics 2023; 46:e1-e12. [PMID: 35876782 DOI: 10.3928/01477447-20220719-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Arthroplasty is not an optimal treatment for massive rotator cuff tears in patients who are active and without glenohumeral arthritis. Several surgical techniques have been developed for these patients, including arthroscopic rotator cuff repair with single-/double-row repair (with or without interval slides, margin convergence, graft augmentation), graft bridging, superior capsular reconstruction, tuberoplasty, and tendon transfers. Complete, tension-free, anatomic repair is ideal; however, tendon atrophy and retraction associated with massive tears often complicate repairs. All surgical treatments significantly increase patient-reported functional outcomes 1 year after intervention, with many treatments demonstrating improved mid-term and long-term outcomes. [Orthopedics. 2023;46(1):e1-e12.].
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Concomitant latissimus dorsi tendon transfer during reverse total shoulder arthroplasty does not improve active external rotation or clinical outcomes in patients with external rotation deficit. J Shoulder Elbow Surg 2022; 32:1016-1021. [PMID: 36565740 DOI: 10.1016/j.jse.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 10/25/2022] [Accepted: 11/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND To assess the role of latissimus dorsi tendon transfer (LDT) concomitant with reverse total shoulder arthroplasty in patients with external rotation (ER) deficit secondary to severe rotator cuff deficiency with and without glenohumeral arthritis. METHODS Patients with a positive external lag sign and <10° of active external rotation (aER) treated with reverse shoulder arthroplasty at a single institution with a minimum 12-month follow-up were retrospectively identified from a prospective database. Basic demographic information along with preoperative and postoperative range of motion (ROM) measures, American Shoulder and Elbow Surgeons score (ASES), Visual Analog Scale (VAS) pain, and Subjective Shoulder Value scores were obtained. Statistical analysis was performed to compare ROM and functional outcomes between patients who underwent concomitant LDT and those with no transfer (NT). RESULTS The LDT (n = 31) and NT (n = 33) groups had similar age, sex distributions, and follow-up length average (24 vs. 30 months). No differences were found between groups at baseline, final follow-up, or magnitude of change for ASES, VAS pain, and Subjective Shoulder Value scores. Baseline ROM measures were similar, except for the LDT group having slightly less aER (-8° vs. 0°; P = .004). In addition, all postoperative ROM measures including aER were similar, except for a slight improvement in active internal rotation in the NT group. The majority of patients were satisfied with their outcome (LDT 84% (n = 26); NT 87% (n = 27); P = .72). CONCLUSION Patients with ER deficit secondary to severe rotator cuff deficiency with and without glenohumeral arthritis undergoing reverse total shoulder arthroplasty do not have significantly improved ER or patient-reported outcome measures with LDT.
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Cunningham JG, Ebert JR, Campbell P, Falconer T. Does subscapularis integrity influence outcome following latissimus dorsi tendon transfer for irreparable cuff tears? A comparative series of 48 patients. J Orthop 2022; 31:129-133. [PMID: 35574214 PMCID: PMC9092063 DOI: 10.1016/j.jor.2022.04.017] [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: 01/05/2022] [Revised: 03/01/2022] [Accepted: 04/27/2022] [Indexed: 11/15/2022] Open
Abstract
Background Latissimus dorsi tendon transfer (LDTT) remains a surgical option for massive irreparable rotator cuff tears. Despite a lack of comparative studies, subscapularis insufficiency has been reported as a contraindication. This study investigated the clinical outcome at a minimum 2-years post-surgery, in patients undergoing LDTT with varied subscapularis integrity. Methods This retrospective study included 48 patients, of which 22 underwent LDTT with an intact subscapularis (age 56.9 years, review time 79.6 months, males 68.2%) and 26 with partial (16 patients) or full-thickness (10 patients) subscapularis tearing (age 57.4 years, review time 73.3 months, males 73.1%) between 2004 and 2018. Pre-operative imaging ascertained subscapularis status. Outcomes included the Upper Extremity Functional Index (UEFI), Global Rating of Change (GRC) and patient satisfaction. Results No significant group differences were observed in age (p = 0.617) or review time (p = 0.555), nor the UEFI (intact 69.6, not intact 67.0, p = 0.265) or GRC (intact 3.6, not intact 2.9, p = 0.265). High levels of patient satisfaction were observed in both groups for pain relief, improving the ability to undertake daily and recreational activities, and overall satisfaction (intact 95.5-100.0%, not intact 92.3-96.2%). Conclusion LDTT resulted in encouraging clinical scores and high satisfaction levels, irrespective of the degree of untreated, underlying subscapularis integrity. Level of evidence Therapeutic Level III.
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Affiliation(s)
- James G. Cunningham
- Sir Charles Gairdner Hospital, North Metropolitan Health Service (WA Health), Nedlands, Perth, Western Australia, 6009, Australia
| | - Jay R. Ebert
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Crawley, Perth, Western Australia, 6009, Australia
- Corresponding author. The School Human Sciences (M408), The University of Western Australia, 35 Stirling Highway, Crawley, 6009, Western Australia, Australia.
| | - Peter Campbell
- Western Orthopaedic Clinic, St John of God Hospital, Subiaco, Perth, Western Australia, 6008, Australia
| | - Travis Falconer
- Perth Orthopaedic & Sports Medicine Centre, West Perth, Perth, Western Australia, 6005, Australia
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Broida SE, Sweeney AP, Gottschalk MB, Woodmass JM, Wagner ER. Clinical outcomes of latissimus dorsi tendon transfer and superior capsular reconstruction for irreparable rotator cuff tears: a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1023-1043. [PMID: 34370112 DOI: 10.1007/s00590-021-03046-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/25/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Functionally irreparable rotator cuff tears (FIRCTs) present an ongoing challenge to the orthopedic surgeon. The aim of this systematic review was to critically compare the outcomes of three latissimus dorsi tendon transfer (LDT) techniques and two superior capsular reconstruction (SCR) techniques in treatment of FIRCTs. METHODS A systematic review of studies evaluating the outcome of FIRCT treatment was performed via a search of four databases in April 2020. Each included study was reviewed in duplicate by two reviewers for evaluation of methodological quality. The treatments analyzed were arthroscopic LDT (aLDT), open LDT Gerber technique (oLDTG), open LDT L'Episcopo technique (oLDTL), SCR with allograft (SCR-Allo), and SCR with autograft (SCR-TFL). Demographics, range of motion, patient-reported outcome measures, radiographic acromiohumeral distance (AHD), treatment failures, and revisions were recorded. RESULTS Forty-six studies (1287 shoulders) met criteria for inclusion. Twenty-three studies involved open latissimus transfer, with 445 shoulders undergoing oLDTG with mean follow-up of 63.2 months and 60 patients undergoing oLDTL with mean follow-up of 51.8 months. Ten studies (n = 369, F/U 29.2mo) reported on aLDT. Seven studies (n = 253, F/U 16.9mo) concerned SCR-Allo, and six studies (n = 160, F/U 32.mo) reported on SCR-TFL. Range of motion and subjective outcome scores improved in all techniques with no differences across treatments. Both SCR methods provided greater improvement in AHD than open LDT methods (p < 0.01). The re-tear rates were lower in both oLDT groups compared to the SCR groups (p = 0.03). Clinical failure rates were higher in the SCR-Allo and oLDTG groups, while overall treatment failures were lowest in oLDTL compared to all four other groups. CONCLUSION SCR techniques were associated with improved short-term radiographic acromiohumeral distance, while the open LDT techniques had lower tendon re-tear and treatment failure rates. All techniques resulted in improved clinical outcomes and pain relief compared to preoperative levels with no differences across techniques. LEVEL OF EVIDENCE IV Systematic review of case series and cohort studies.
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Affiliation(s)
- Samuel E Broida
- Department of Orthopaedic Surgery, Emory University, 59 S Executive Park NW, Atlanta, GA, 30329, USA
| | - Aidan P Sweeney
- Department of Orthopaedic Surgery, Emory University, 59 S Executive Park NW, Atlanta, GA, 30329, USA
| | - Michael B Gottschalk
- Department of Orthopaedic Surgery, Emory University, 59 S Executive Park NW, Atlanta, GA, 30329, USA
| | - Jarret M Woodmass
- Department of Orthopaedic Surgery, PanAm Clinic, University of Manitoba, Winnipeg, Canada
| | - Eric R Wagner
- Department of Orthopaedic Surgery, Emory University, 59 S Executive Park NW, Atlanta, GA, 30329, USA.
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Inui H, Yamada J, Nobuhara K. Does Margin Convergence Reverse Pseudoparalysis in Patients with Irreparable Rotator Cuff Tears? Clin Orthop Relat Res 2021; 479:1275-1281. [PMID: 33394763 PMCID: PMC8133065 DOI: 10.1097/corr.0000000000001617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/02/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Margin convergence has been shown to restore muscle tension in a cadaveric model of a rotator cuff tear. However, the clinical utility of this technique remains uncertain for patients with pseudoparalysis caused by an irreparable rotator cuff tear. QUESTIONS/PURPOSES (1) For patients with massive irreparable rotator cuff tears, in what proportion of patients does margin convergence reverse pseudoparalysis? (2) In patients with massive irreparable rotator cuff tears, does margin convergence improve American Shoulder and Elbow Surgeons (ASES) scores? (3) What is the survivorship free from MRI evidence of retear after margin convergence? METHODS Between 2000 and 2015, we treated 203 patients for pseudoparalysis with a rotator cuff tear. Pseudoparalysis was defined as active elevation less than 90° with no stiffness, which a physical therapist evaluated in the sitting position using a goniometer after subacromial injection of 10 cc lidocaine to eliminate pain. Of those, we considered patients who underwent at least 3 weeks of unsuccessful nonoperative treatment in our hospital as potentially eligible. Twenty-one percent (43 of 203) who either improved or were lost to follow-up within 3 weeks of nonoperative treatment were excluded. A further 12% (25 of 203) were excluded because of cervical palsy, axillary nerve palsy after dislocation or subluxation, and development of severe shoulder stiffness (passive shoulder elevation < 90°). Repair was the first-line treatment, but if tears were considered irreparable with the torn tendon unable to reach the original footprint after mobilizing the cuff during surgery, margin convergence was used. When margin convergence failed, the procedure was converted to hemiarthroplasty using a small humeral head to help complete the repair. Therefore, 21% (42 of 203) of patients treated with regular repair (18% [36 of 203]) or hemiarthroplasty (3% [6 of 203]) were excluded. That left 93 patients eligible for consideration. Of those, 13 patients were lost before the minimum study follow-up of 2 years or had incomplete datasets, and 86% (80 of 93) were analyzed (49 men and 31 women; mean age 68 ± 9 years; mean follow-up 26 ± 4 months). Seventy-six percent (61 of 80) were not evaluated in the last 5 years. We considered reversal of pseudoparalysis as our primary study outcome of interest; we defined this as greater than 90° active forward elevation; physical therapists in care measured this in the sitting position by using goniometers. Clinical outcomes were evaluated based on the ASES score from chart review, active ROM in the shoulder measured by the physical therapists, and the 8-month Kaplan-Meier survivorship free from MRI evidence of retear graded by the first author. RESULTS Pseudoparalysis was reversed in 93% (74 of 80) patients, and improvement in ASES scores was observed at the final follow-up (preoperative 22 ± 10 to postoperative 62 ± 21, mean difference 40 [95% CI 35 to 45]; p < 0.01). The 8-month Kaplan-Meier survivorship free from MRI evidence of retear after surgery was 72% (95% CI 63% to 81%). There were no differences in clinical scores between patients with and without retears (intact ASES 64 ± 24, re-tear ASES 59 ± 10, mean difference 6 [95% CI -5 to 16]; p = 0.27). CONCLUSION Margin convergence can be a good option for treating patients with pseudoparalysis and irreparable rotator cuff tears despite the relatively high retear rates. The proportion of pseudoparalysis reversal was lower in patients with three-tendon involvement. Further studies will be needed to define the appropriate procedure in this group. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Hiroaki Inui
- H. Inui, J. Yamada, K. Nobuhara, Nobuhara Hospital & Institute of Biomechanics, Hyogo, Japan
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Johns WL, Ailaney N, Lacy K, Golladay GJ, Vanderbeck J, Kalore NV. Implantable Subacromial Balloon Spacers in Patients With Massive Irreparable Rotator Cuff Tears: A Systematic Review of Clinical, Biomechanical, and Financial Implications. Arthrosc Sports Med Rehabil 2020; 2:e855-e872. [PMID: 33364617 PMCID: PMC7754516 DOI: 10.1016/j.asmr.2020.06.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/21/2020] [Indexed: 01/26/2023] Open
Abstract
Purpose To determine the clinical, biomechanical, and financial impact of the use of subacromial balloon spacers in the surgical management of massive, irreparable rotator cuff tears (RCTs). Methods All studies assessing the use of implantable subacromial balloon spacers for management of massive, irreparable RCTs were systematically searched. Risk of bias was assessed using Methodological Index for Non-Randomized Studies criteria. Data extraction and analysis was performed for pain and function scores, shoulder range of motion (ROM), glenohumeral contact pressure and vertical migration of humeral head, and cost. Subjective synthesis was performed with forest plots when outcomes were reported in 3 or more studies. Results In total, 19 studies met inclusion criteria for analysis; 337 patients (mean age 68 years) had 343 subacromial balloon spacer implantations. Throughout a mean follow-up of 33 months, there was significant improvement in the Total Constant Score (preoperative: 22.5-41.8; postoperative: 51.4-72.3), Oxford Shoulder Score (preoperative: 21.3-26; postoperative: 34.39-48.2), American Shoulder and Elbow Surgeons score (preoperative: 24.5-59.1; postoperative: 72.5-85.7), and shoulder ROM parameters. Subacromial balloon spacer placement resisted superior humeral head migration (range of preoperative to postoperative difference: 2.8-6.2 mm) and decreased peak subacromial pressure during shoulder ROM. Conclusions Existing literature of subacromial balloon spacers has a high risk of bias, lack of appropriate control, and low levels of evidence. A qualitative synthesis indicates that subacromial balloon spacer implantation in patients with massive irreparable RCTs is cost-effective and leads to improved function (Total Constant Score and Oxford Shoulder Score) and ROM. In cadaveric studies, subacromial balloon spacers resist superior humeral head migration and reduce subacromial pressure. The theoretical risk of biodegradation of the balloon spacer has not been substantiated in study of up to 5-years follow-up, and the risk of complications from this procedure appears to be minimal. Level of Evidence IV; Systematic review of level III-IV studies.
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Affiliation(s)
- William L Johns
- School of Medicine, Virginia Commonwealth University Health, Richmond, Virginia, USA
| | - Nikhil Ailaney
- School of Medicine, Virginia Commonwealth University Health, Richmond, Virginia, USA
| | - Kevin Lacy
- School of Medicine, Virginia Commonwealth University Health, Richmond, Virginia, USA
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, Richmond, Virginia, USA
| | - Jennifer Vanderbeck
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, Richmond, Virginia, USA
| | - Niraj V Kalore
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, Richmond, Virginia, USA
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Kia C, Muench LN, Williams AA, Avery DM, Cote MP, Reed N, Arciero RA, Chandawarkar R, Mazzocca AD. Author Reply to "Regarding 'High Clinical Failure Following Latissimus Dorsi Transfer for Revision Massive Rotator Cuff Tears'". Arthroscopy 2020; 36:2350-2351. [PMID: 32891238 DOI: 10.1016/j.arthro.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/06/2020] [Indexed: 02/02/2023]
Affiliation(s)
- Cameron Kia
- Department of Orthopaedic Surgery, UConn Health Center, Farmington, Connecticut, U.S.A
| | - Lukas N Muench
- Department of Orthopaedic Surgery, UConn Health Center, Farmington, Connecticut, U.S.A.; Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Ariel A Williams
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | | | - Mark P Cote
- Department of Orthopaedic Surgery, UConn Health Center, Farmington, Connecticut, U.S.A
| | - Nicholas Reed
- Associates in Orthopedics and Sports Medicine, Dalton, Georgia, U.S.A
| | - Robert A Arciero
- Department of Orthopaedic Surgery, UConn Health Center, Farmington, Connecticut, U.S.A
| | | | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, UConn Health Center, Farmington, Connecticut, U.S.A
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Neviaser RJ. Regarding "High Clinical Failure Rate After Latissimus Dorsi Transfer for Revision Massive Rotator Cuff Tears". Arthroscopy 2020; 36:2350. [PMID: 32891239 DOI: 10.1016/j.arthro.2020.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/06/2020] [Indexed: 02/02/2023]
Affiliation(s)
- Robert J Neviaser
- Professor Emeritus of Orthopaedic Surgery, George Washington University School of Medicine, Washington, DC, U.S.A
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Osti L, Milani L, Gerace E, Padovani S, Massari L, Maffulli N. Arthroscopic superior capsular reconstruction versus latissimus dorsi transfer for irreparable rotator cuff lesions: a systematic review. Br Med Bull 2020; 134:85-96. [PMID: 32507891 DOI: 10.1093/bmb/ldaa014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/19/2020] [Accepted: 04/21/2020] [Indexed: 11/13/2022]
Abstract
INTRODUCTION The present systematic review compared arthroscopic superior capsular reconstruction (ASCR) and latissimus dorsi transfer (ALDT) for the management of massive irreparable rotator cuff lesions. SOURCES OF DATA We performed a systematic review searching the literature on Medline, Cochrane and Scopus databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. AREAS OF AGREEMENT We included a total of 20 articles, 10 on ASCR and 10 on ALDT (12 retrospective and 8 prospective studies), all published between 2013 and 2019. AREAS OF CONTROVERSY ASCR and ALDT are technical demanding procedures. When compared to each other, they do not produce significantly different improvements in clinical outcome. GROWING POINTS Both ASCR and ALDT are valid options for surgical management of MIRCLs. Although ALDT has shown a greater complication rate and a less improvement in acromion-humeral distance, its clinical outcomes overlap those obtained with ASCR. AREAS TIMELY FOR DEVELOPING RESEARCH Further comparative prospective and retrospective studies with longer follow-up could confirm which surgical procedure can lead to better outcomes with a lower complication rate.
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Affiliation(s)
- Leonardo Osti
- Department of Orthopaedic Surgery, Arthroscopy and Sport Medicine, Hesperia Hospital, Arqua' Street, 41125 Modena, Italy
| | - Lorenzo Milani
- Department of Biomedical and Speciality Surgical Sciences, Unit of Orthopaedic and Traumatology, S. Anna Hospital, Aldo Moro Street, 8, 41121 Ferrara, Italy
| | - Emanuele Gerace
- Department of Biomedical and Speciality Surgical Sciences, Unit of Orthopaedic and Traumatology, S. Anna Hospital, Aldo Moro Street, 8, 41121 Ferrara, Italy
| | - Sara Padovani
- Department of Biomedical and Speciality Surgical Sciences, Unit of Orthopaedic and Traumatology, S. Anna Hospital, Aldo Moro Street, 8, 41121 Ferrara, Italy
| | - Leo Massari
- Department of Biomedical and Speciality Surgical Sciences, Unit of Orthopaedic and Traumatology, S. Anna Hospital, Aldo Moro Street, 8, 41121 Ferrara, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, University of Salerno, 84081 Salerno, Italy.,Institute of Science and Technology in Medicine, Keele University School of Medicine, Stoke on Trent ST4 7QB, UK.,Centre for Sport and Exercise Medicine, Barts and the London School of Medicine, Queen Mary University of London, London E1 4NS, UK
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Long-term outcomes of latissimus dorsi transfer for irreparable rotator cuff tears. INTERNATIONAL ORTHOPAEDICS 2020; 44:905-910. [PMID: 32222787 DOI: 10.1007/s00264-020-04540-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 03/18/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The primary objective of this retrospective study was to validate electrophysiological results of latissimus dorsi tendon transfer (LDTT) to determine if this transfer is active for different daily living tasks, and the secondary objective was to correlate these clinical results. METHODS With a mean follow-up of 4.7 years, 14 latissimus dorsi tendon transfers were retrospectively reviewed. Patients were clinically evaluated with the constant score and the SSV. Healing of the tendon on the greater tuberosity and atrophy of the LDTT muscle was determined by ultrasound and compared with the contralateral side. Electrical activity was analyzed by electromyography in active elevation, abduction, and external rotation. RESULTS Twelve patients are satisfied (SSV). At the last follow-up, the EMG found a significant electrical activity in the abduction and external rotation and a lower activity in adduction and internal rotation. The mean constant score increased from 29 to 51, the mean forward elevation increased from 89° to 135°, the mean abduction from 92° to 105°, and the external rotation from 12° to 24°. The ultrasound found 12 healed tendons and two ruptures at the myotendinous junction. CONCLUSION Electrical activity in abduction and external rotation testifies that the LDT transfer acts as an active muscle transfer and acts not only a muscle tenodesis that covers the humeral head.
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Ebert-Fillmer S, Bloos UT, El Masri S, Stangl R. [Transfer of latissimus dorsi muscle for irreparable posterosuperior rotator cuff defects in older patients : Medium term results]. Unfallchirurg 2019; 122:544-554. [PMID: 30382285 DOI: 10.1007/s00113-018-0557-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Is transfer of the latissimus dorsi muscle (LDT) a good option in older patients with irreparable posterosuperior rotator cuff tears? MATERIAL AND METHOD In 2010-2016 a total of 25 patients without glenohumeral arthritis and non-reconstructable supraspinatus and infraspinatus tendons, a recentered glenohumeral joint with remaining function in anteversion and irreparable posterosuperior rotator cuff defects were treated using LDT at the Rummelsberg Hospital. Of the patients 9 (36%) had in the past 1 or more attempts at reconstruction of the rotator cuff. All other patients (64%) underwent a primary reconstruction using LDT. The patients had an average age of 61 years and average follow up of 32 months. Of the 25 patients 24 (96%) were clinically followed up with the constant score (CS) and the visual analogue scale (VAS). The operation was performed in the technique described by Gerber to raise the latissimus dorsi but in the beach-chair position. Follow-up treatment was performed for 6 weeks using the ACRO-Assist splint (shoulder brace) in 90 ° abduction with daily limited external rotation exercises, followed by a regular regular rehabilitation on an outpatient basis. RESULTS The average operating time was 112 min (68-199 min). Postoperatively the only complication was an tightly sutured drainage. The preoperative Constantpoint averaged 25 (2-59). The postoperative Constantpoint was 60. The average gain of improvement was 35 points. The age-corrected relative CS was 74 after surgery. Pain perception improved significantly from preoperatively severe to very severe pain to postoperatively minor to no pain. In the VAS score there was a reduction from preoperatively 6 to postoperatively 3 VAS points. The external rotation improved from average 3 points in the CS to 6 points in the CS. The preoperative Constantpoint in patients <60 years (n = 12) was 20, the postoperative 51. The gain was 31 Constantpoints. In patients ≥60 years (n = 12), the preoperative Constantpoint was 31, the postoperative 60. The gain was 29 points. The difference between the age groups was not significant. Previously operatively treated patients (arthroscopic or mini-open reconstruction) all showed an improvement in Constantpoints (26 vs. 32 in primarily non-reconstructed patients); however, on a lower level (45 points in previously operated patients vs. 69 CS points). CONCLUSION With appropriate patient selection, a high gain in CS can be achieved even in older patients using latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears. The VAS score and external rotation significantly improved. Previously attempts in rotator cuff reconstruction demonstrated a negative influence on the clinical outcome.
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Affiliation(s)
- S Ebert-Fillmer
- Klinik für Unfall‑, Schulter- und Wiederherstellungschirurgie, Sportmedizin und Sporttraumatologie, Sana Krankenhaus Rummelsberg, Rummelsberg 71, 90592, Schwarzenbruck, Deutschland.
| | - U T Bloos
- Klinik für Unfall‑, Schulter- und Wiederherstellungschirurgie, Sportmedizin und Sporttraumatologie, Sana Krankenhaus Rummelsberg, Rummelsberg 71, 90592, Schwarzenbruck, Deutschland
| | - S El Masri
- Klinik für Unfall‑, Schulter- und Wiederherstellungschirurgie, Sportmedizin und Sporttraumatologie, Sana Krankenhaus Rummelsberg, Rummelsberg 71, 90592, Schwarzenbruck, Deutschland
| | - R Stangl
- Klinik für Unfall‑, Schulter- und Wiederherstellungschirurgie, Sportmedizin und Sporttraumatologie, Sana Krankenhaus Rummelsberg, Rummelsberg 71, 90592, Schwarzenbruck, Deutschland
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Sidler-Maier CC, Mutch JA, Sidler M, Leivadiotou D, Payandeh JB, Nam D. Augmented latissimus dorsi transfer: initial results in patients with massive irreparable posterosuperior rotator cuff tears. Shoulder Elbow 2019; 11:59-67. [PMID: 31019564 PMCID: PMC6463378 DOI: 10.1177/1758573217750832] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 11/23/2017] [Accepted: 11/25/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The surgical treatment of irreparable massive rotator cuff tears is challenging. The purpose of the present study was to report the initial outcomes after a modified latissimus dorsi transfer (LDT) augmented by acellular dermal allograft (ADA). METHODS This retrospective study includes 24 patients managed with LDT using ADA augmentation as a bursal-sided onlay between March 2009 and December 2015. RESULTS All patients were men with a mean age of 57 years (range 48 years to 70 years). Seven patients had a previously failed rotator cuff repair and ten patients presented with a deficient subscapularis tendon. At last follow-up (mean 27 months), there was a significant improvement in active forward flexion (mean increase 31°; p = 0.016), and abduction by 25° (p = 0.059). The acromiohumeral distance remained stable and the failure rate was low (4%). Neither a history of previous rotator cuff surgery, nor the presence of a subscapularis tear had a negative impact on functional outcome. CONCLUSIONS In our cohort of patients, LDT augmented with ADA was a reasonable option for patients with previously failed rotator cuff repair, as well as in the subgroup of patients with a deficient subscapularis tendon. LEVEL OF EVIDENCE Level IV: Therapeutic study (case series).
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Affiliation(s)
- Claudia C. Sidler-Maier
- Upper Limb Surgery, Ashford and St Peter's Hospital, NHS Foundation Trust, Chertsey, Surrey, UK,Claudia C. Sidler-Maier Ashford and St Peter's Hospital, Upper Limb Surgery Guildford Road, Chertsey KT16 0PZ, UK. E-mail:
| | - Jennifer A. Mutch
- Department of Orthopaedic Surgery, St-Mary's Hospital Center, Montreal, Canada
| | - Martin Sidler
- Department of Paediatric and Neonatal Surgery, Great Ormond Street Hospital, London, UK
| | | | - Jubin B. Payandeh
- Department of Orthopaedic Surgery, Thunder Bay Regional Health Sciences Centre, Thunder Bay, Canada
| | - Diane Nam
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada
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15
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Moon AS, Patel HA, Ithurburn MP, Brabston EW, Ponce BA, Momaya AM. Subacromial Spacer Implantation for the Treatment of Massive Irreparable Rotator Cuff Tears: A Systematic Review. Arthroscopy 2019; 35:607-614. [PMID: 30545609 DOI: 10.1016/j.arthro.2018.08.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 08/02/2018] [Accepted: 08/02/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To synthesize and report the early clinical and radiographic outcomes associated with subacromial spacer use in patients with massive irreparable rotator cuff tears. METHODS A systematic search on MEDLINE, Embase, and Cochrane Library databases was performed during February 2018. Included studies were evaluated regarding the level of evidence and quality using the methodological index for nonrandomized studies. Patient demographics, intraoperative findings, clinical and radiographic outcomes, and complications were recorded for each of the included studies. RESULTS Seven eligible studies including 204 shoulders from 200 patients with subacromial spacer implantation were identified (6 Level IV studies and 1 Level III study). The mean methodological index for nonrandomized studies score for noncomparative studies was 11, whereas that of comparative studies was 15. The mean age of patients was 67.6 years, and the mean reported follow-up time was 19.4 months. All patients had Goutallier stage 3 and 4 fatty infiltration on magnetic resonance imaging. All studies reported consistent improvement in the total Constant score or American Shoulder and Elbow Surgeons score over the duration of follow-up. A total of 6 (3%) complications were reported in the included studies. Two studies detailed radiographic outcomes, with discrepant changes in the acromiohumeral interval. CONCLUSIONS Patients undergoing subacromial spacer implantation for the treatment of massive irreparable rotator cuff tears have satisfactory outcomes at the 2- to 3-year follow-up with a low rate of complications. LEVEL OF EVIDENCE Level IV, systematic review of 1 Level III and 6 Level IV studies.
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Affiliation(s)
- Andrew S Moon
- Tufts University School of Medicine, Boston, Massachusetts, U.S.A.; Department of Orthopaedics, The University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Harshadkumar A Patel
- Department of Orthopaedics, The University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Matthew P Ithurburn
- Department of Orthopaedics, The University of Alabama at Birmingham, Birmingham, Alabama, U.S.A.; Department of Physical Therapy, The University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Eugene W Brabston
- Department of Orthopaedics, The University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Brent A Ponce
- Department of Orthopaedics, The University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Amit M Momaya
- Department of Orthopaedics, The University of Alabama at Birmingham, Birmingham, Alabama, U.S.A..
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16
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Anatomic study of pedicled bipolar teres major transfer for irreparable posterosuperior rotator cuff tears. J Shoulder Elbow Surg 2018; 27:1740-1747. [PMID: 29941305 DOI: 10.1016/j.jse.2018.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 04/15/2018] [Accepted: 04/18/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Treatment of rotator cuff (RC) tears has not included bipolar muscle-tendon transfers to date. The objective of this study was to verify the feasibility of pedicled bipolar teres major (TM) transfer over and under the long head of the triceps brachii (LHT) and compare its versatility with monopolar transfer in a model of supraspinatus (SS) tears in cadavers. METHODS In 6 shoulders of cryopreserved cadavers, we re-created complete SS tears, conducting monopolar and bipolar TM transfers over and under LHT. We compared the morphology of the SS and TM, defect coverage, angle between the transferred TM and major SS axis, and axillary nerve overlap with each technique. RESULTS The TM and SS were morphologically similar. Defect coverage was significantly lower with monopolar transfer (12 ± 4 mm) than with bipolar transfer (39 ± 9 mm under the LHT, P = .003, and 38 ± 8 mm over the LHT, P = .004). The bipolar transfer course over the LHT was the nearest to the SS axis (39° ± 11°, P = .005). We found a greater axillary nerve overlap with bipolar transfer under the LHT (27 ± 8 mm) than with bipolar transfer over the LHT (1 ± 2 mm, P = .005) or monopolar transfer (0 mm, P < .001). CONCLUSION Bipolar TM transfer is possible without neurovascular pedicle interference, obtaining greater RC defect coverage and the closest path to the SS axis when conducted over the LHT compared with monopolar or bipolar transfer under the LHT. Accordingly, it can be considered an alternative option for the treatment of posterosuperior RC defects.
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17
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Kany J, Grimberg J, Amaravathi RS, Sekaran P, Scorpie D, Werthel JD. Arthroscopically-Assisted Latissimus Dorsi Transfer for Irreparable Rotator Cuff Insufficiency: Modes of Failure and Clinical Correlation. Arthroscopy 2018; 34:1139-1150. [PMID: 29361422 DOI: 10.1016/j.arthro.2017.10.052] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 10/17/2017] [Accepted: 10/21/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE The main objective of this retrospective study was to analyze the rate and modes of failure of latissimus dorsi transfer (LDT). The secondary objective was to evaluate whether a rupture of the transfer was associated with a worse outcome. METHODS During a 2-year period, we performed consecutive LDTs either for irreparable posterior-superior rotator cuff tears (RCTs) or for failed prior repair. All the LDTs were performed by a single surgeon. All transfers were arthroscopically assisted and fixed as a tubularized LD tendon in a bone tunnel inside the humeral head. Three metal clips were placed systematically intraoperatively in the tubularized tendon at a fixed distance of 2, 4, and 6 cm from the tip of the tendon. Immediate postoperative standard anteroposterior radiographs were performed and the position of the metal clips was compared with their position on radiographs performed at 6 weeks and 3 and 24 months postoperatively. Constant, Subjective Shoulder Value (SSV), Simple Shoulder Test (SST), Activities of daily living requiring active external rotation (ADLER), visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) scores and patient's subjective satisfaction (assessed by self-questionnaire) at last follow-up were compared between patients who had a rupture of the transfer and those who did not. RESULTS Sixty-six patients were included. Six of 66 patients (9%) were lost to follow-up. There were 11 complications (18.3%) in the global series (10 hematoma and 1 subscapularis retear). At a mean 35.2 months (range 24-50 months), there were 23/60 cases of rupture (38%). The 7 scores and the satisfaction reported were significantly lower for patients who had a rupture of the transfer versus those who had an intact transfer: Constant score, 42.8 versus 68.7 (P = .001); SSV, 48.9 versus 71.6 (P = .001); SST, 4.8 versus 8.4 (P = .012); ADLER, 19.7 versus 26.7 (P = .005); VAS, 3.7 versus 2.3 (P = .082); ASES, 55.4 versus 74.8 (P = .056); and 13% of either satisfied or very satisfied patients versus 78% (P < .001). CONCLUSIONS The rate of rupture of LDT is high (38%). With complete healing of LDT, the outcome is significantly lower in those with rupture compared with those without rupture, showing that LDT can efficiently treat massive and irreparable RCT. LEVEL OF EVIDENCE Level IV, case series treatment study.
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Affiliation(s)
- Jean Kany
- Clinique de l'Union, Saint Jean, France.
| | | | - Rajkumar S Amaravathi
- Department of Orthopedics, Arthroscopy and Sports Medicine, St John's Medical College Hospital, Bangalore, India
| | - Padmanaban Sekaran
- Department of Physiotherapy and Rehabilitation, Sparsh Hospital for Advanced Surgeries, Bangalore, India
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18
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Piekaar RSM, Bouman ICE, van Kampen PM, van Eijk F, Huijsmans PE. Early promising outcome following arthroscopic implantation of the subacromial balloon spacer for treating massive rotator cuff tear. Musculoskelet Surg 2017; 102:247-255. [PMID: 29151232 DOI: 10.1007/s12306-017-0525-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 11/08/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Massive rotator cuff tear (RCT) can result in disability and severe pain. When conservative treatment fails, surgical treatment should be considered, as various surgical options can provide relatively satisfactory results. However, choosing an optimal treatment remains controversial. A relatively new treatment for irreparable RCT is the arthroscopic implantation of a biodegradable balloon spacer into the subacromial space. Here, we examined whether placement of this balloon spacer reduces pain and improves functional outcome in patients with an irreparable RCT. Patients were followed for 1 year following implantation. METHODS In this prospective single-arm study, a biodegradable balloon spacer was implanted into the subacromial space of patients with a massive RCT. Pain was evaluated using a numeric rating scale (NRS), and functional outcome was evaluated using the Oxford shoulder score (OSS) and the Constant-Murley shoulder score (CMS). Five follow-up visits were performed during the first postoperative year. RESULTS Forty-six shoulders in 44 patients with massive RCT were treated by surgical implantation of the subacromial balloon spacer. The mean reduction in NRS score was 3.5 points (95% CI 2.5-4.4), and 74% of patients achieved the minimal clinically important difference of 2 points by the 1-year follow-up visit. Functional outcome improved significantly based on OSS and CMS scores, and 80% of patients reported that they were satisfied with their outcome. No surgical or postoperative medical complications due to implantation of the balloon spacer were reported. CONCLUSIONS Our results suggest that arthroscopic implantation of a biodegradable balloon spacer in the subacromial space significantly reduces pain and improves activities of daily living in patients with massive RCT during 1 year of follow-up. The specific contribution of the balloon with respect to improved clinical outcome needs further study, ideally in a randomized controlled trial.
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Affiliation(s)
- R S M Piekaar
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, The Netherlands.
| | - I C E Bouman
- Department of Orthopaedic Surgery, Haga Hospital The Hague, Sportlaan 600, 2566 MJ, The Hague, The Netherlands
| | - P M van Kampen
- Department of Orthopaedic Surgery, Bergman Clinics, Laan van Oversteen 20, 2289 CX, Rijswijk, The Netherlands
| | - F van Eijk
- Department of Orthopaedic Surgery, Bergman Clinics, Laan van Oversteen 20, 2289 CX, Rijswijk, The Netherlands
| | - P E Huijsmans
- Department of Orthopaedic Surgery, Bergman Clinics, Laan van Oversteen 20, 2289 CX, Rijswijk, The Netherlands
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Arthroscopic Subacromial Spacer Implantation in Patients With Massive Irreparable Rotator Cuff Tears: Clinical and Radiographic Results of 39 Retrospectives Cases. Arthroscopy 2017; 33:1639-1644. [PMID: 28602388 DOI: 10.1016/j.arthro.2017.03.029] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 03/14/2017] [Accepted: 03/31/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the clinical and radiographic outcome of a biodegradable subacromial spacer in the treatment of massive irreparable rotator cuff tear. METHODS Between January 2011 and December 2014, all shoulders with symptomatic massive irreparable rotator cuff tears treated at our institution with arthroscopic implantation of a biodegradable subacromial spacer followed for at least 1 year were included in our series. Patients with osteoarthritis ≥ grade 3 in the Hamada classification were excluded. Outcome measures included pre- and postoperative, range of motion, Constant score, acromiohumeral distance, and Hamada classification on anteroposterior and lateral radiographs. RESULTS Thirty-nine consecutive shoulders (37 patients) met the inclusion criteria. The mean age of patients was 69.8 (53-84) years. At the last follow-up (mean 32.8 ± 12.4 months), range of motion was significantly increased for all patients in anterior elevation (from 130° to 160°, P = .02), abduction (from 100° to 160°, P = .01), and external rotation (from 30° to 45°, P = .0001). The mean Constant score was also significantly (P < .001) improved from 44.8 (±15.2) preoperatively to 76.0 (±17.1) at the last follow-up. The mean acromiohumeral distance significantly (P = .002) decreased from 8.2 mm (±3.4) to 6.2 mm (±3.1) at the last follow-up. The Hamada score progressed of 1 radiographic stage in 4 shoulders (15%) and progressed of 3 stages in 2 (4%), whereas the other 32 shoulders remained stable. No intra- or postoperative complications were found except for 1 patient who required a revision for spacer migration. CONCLUSIONS Arthroscopic implantation of a subacromial spacer for irreparable rotator cuff tear leads to significant improvement in shoulder function at a minimum of 1 year postoperatively. LEVEL OF EVIDENCE Level IV, therapeutic case series; treatment study.
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20
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Tokish JM, Alexander TC, Kissenberth MJ, Hawkins RJ. Pseudoparalysis: a systematic review of term definitions, treatment approaches, and outcomes of management techniques. J Shoulder Elbow Surg 2017; 26:e177-e187. [PMID: 28526423 DOI: 10.1016/j.jse.2017.02.024] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 02/08/2017] [Accepted: 02/13/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pseudoparalysis remains one of the most challenging conditions in shoulder surgery. Long thought of as an unsolvable problem, recent advances in surgical techniques offer potential return of overhead motion in the setting of massive irreparable rotator cuff tears. This article summarizes the available literature including existing definitions and the results of different treatment approaches regarding range of motion, outcome scores, and reversal. METHODS In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of the MEDLINE database, Cochrane database, Physiotherapy Evidence Database, and Google Scholar database was performed for studies that defined a preoperative shoulder group as having pseudoparalysis. A secondary search included preoperative active forward elevation less than 90°. RESULTS In 16 studies, the most consistent definition was a massive rotator cuff tear with active elevation less than 90°, but studies inconsistently included stiffness, external rotation loss, arthritic changes, neurologic status, and pain. There were 6 different techniques: nonoperative rehabilitation, rotator cuff repair, muscle transfer, hemiarthroplasty, reverse total shoulder arthroplasty, and reverse total shoulder arthroplasty with muscle transfer. Postoperatively, all approaches showed improvement. CONCLUSION Pseudoparalysis of the shoulder has a variable definition in the literature without consideration of degree or substratification of other confounders such as the presence of arthritis or pain. Thus the literature supports treating this condition with any variety of treatment. We propose that pseudoparalysis be more restrictively defined to allow comparisons. In addition, we propose an algorithm to serve as a treatment guideline to aid in surgical decision making for this condition.
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Affiliation(s)
- John M Tokish
- Steadman Hawkins Clinic of the Carolinas, Greenville Health Systems, Greenville, SC, USA.
| | | | - Michael J Kissenberth
- Steadman Hawkins Clinic of the Carolinas, Greenville Health Systems, Greenville, SC, USA
| | - Richard J Hawkins
- Steadman Hawkins Clinic of the Carolinas, Greenville Health Systems, Greenville, SC, USA
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21
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Bargoin K, Boissard M, Kany J, Grimberg J. Influence of fixation point of latissimus dorsi tendon transfer for irreparable rotator cuff tear on glenohumeral external rotation: A cadaver study. Orthop Traumatol Surg Res 2016; 102:971-975. [PMID: 28341266 DOI: 10.1016/j.otsr.2016.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 08/20/2016] [Accepted: 09/05/2016] [Indexed: 02/02/2023]
Abstract
UNLABELLED Latissimus dorsi tendon transfer is a surgical option for treating irreparable posterosuperior rotator cuff tears, notably when attempting to reconstruct active external rotation. We hypothesized that the positioning of the transfer's point of fixation would differ depending on the desired elbow-to-body external rotation or external rotation with the elbow abducted. MATERIAL AND METHODS Seven shoulders from four whole frozen cadavers were used. We created two systems to install the subject in a semi-seated position to allow external rotation elbow to body and the arm abducted 90°. Traction sutures were positioned on the latissimus dorsi muscle and a massive tear of the rotator cuff was created. We tested six different transfer positions. Muscle contraction of the latissimus dorsi was stimulated using 10-N and 20-N suspended weights. RESULTS The point of fixation of the latissimus dorsi on the humeral head had an influence on the elbow-to-body external rotation and with 90° abduction (P<0.001). The fixation point for a maximum external rotation with the elbow to the body was the anterolateral position (P<0.016). The fixation point for a maximum external rotation at 90° abduction was the position centered on the infraspinatus footprint (P<0.078). CONCLUSION The optimal point of fixation differs depending on whether external rotation is restored at 0° or 90° abduction. LEVEL OF EVIDENCE Fundamental study, anatomic study.
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Affiliation(s)
- K Bargoin
- Le Confluent-Nouvelles Cliniques Nantaises, Nantes, France.
| | - M Boissard
- Centre Hospitalier Universitaire, Nantes, France
| | - J Kany
- Clinique de l'Union, Saint Jean, France
| | - J Grimberg
- Institut de recherche en chirurgie orthopédique et sportive, Paris, France
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22
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Ippolito G, Serrao M, Napoli F, Conte C, Miscusi M, Coppola G, Pierelli F, Costanzo G, De Cupis V. Three-dimensional analysis of the shoulder motion in patients with massive irreparable cuff tears after latissimus dorsi tendon transfer (LDT). Arch Orthop Trauma Surg 2016; 136:1363-70. [PMID: 27498105 DOI: 10.1007/s00402-016-2547-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Latissimus dorsi tendon transfer (LDT) is a recent method for surgical treatment of massive, irreparable posterosuperior cuff tears (MIPCT). So far, there are no studies on the quantitative motion analysis of the shoulder and latissimus dorsi (LD) muscle activation after LDT. The changes in shoulder movements after LDT can be objectively assessed by the 3-D motion analysis. These changes may not be due to an increased activity of the LD muscle as external rotator. MATERIALS AND METHODS The shoulder kinematics of nine patients with MIPCT were recorded through a 3-D motion analysis system, before LTD (T0), and after 3 (T1) and 6 (T2) months post-LDT. Maximal shoulder flexion-extension, abduction-adduction, and horizontal abduction-adduction, and the internal and external circumduction of the shoulder joint were measured during upright standing posture. Surface EMG activity of the LD muscle was recorded during both internal rotation (IR) and external rotation (ER) tasks in three different postures. RESULTS A significant increase of shoulder movements was observed at T2 compared with T0 for almost all motor tasks. A significant effect of LDT was also found on LD-IR/ER ratio in posture 1 at T2 compared with T0 and T1. No significant effects were found for the LD-IR/ER ratio in the other postures. CONCLUSIONS Our study indicates that LDT is effective in shoulder motion recovery. Such improvement is not associated with a change in function of the LD muscle, which may be induced by a depression of the humeral head into the glenoid cavity instead.
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Affiliation(s)
- Giorgio Ippolito
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 40100, Latina, Italy
| | - Mariano Serrao
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 40100, Latina, Italy. .,Movement Analysis LAB, Rehabilitation Centre Policlinico Italia, Piazza del Campidano 6, 00162, Rome, Italy.
| | - Francesco Napoli
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 40100, Latina, Italy
| | | | - Massimo Miscusi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 40100, Latina, Italy
| | - Gianluca Coppola
- Department of Neurophysiology of Vision and Neurophthalmology, G.B. Bietti Foundation-IRCCS, Via Livenza 3, 00198, Rome, Italy
| | - Francesco Pierelli
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 40100, Latina, Italy.,IRCCS Neuromed, Pozzilli, IS, Italy
| | - Giuseppe Costanzo
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 40100, Latina, Italy
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Petriccioli D, Bertone C, Marchi G. Recovery of active external rotation and elevation in young active men with irreparable posterosuperior rotator cuff tear using arthroscopically assisted latissimus dorsi transfer. J Shoulder Elbow Surg 2016; 25:e265-75. [PMID: 26952287 DOI: 10.1016/j.jse.2015.12.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 12/09/2015] [Accepted: 12/14/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Massive irreparable posterosuperior rotator cuff tears represent a serious functional disablement for young and active patients in their daily activities. Latissimus dorsi (LD) muscle-tendon transfer can restore elevation and external rotation where supraspinatus and infraspinatus function is lost. MATERIALS AND METHODS Between 2009 and 2013, 45 consecutive patients underwent arthroscopically assisted LD transfer for an irreparable posterosuperior rotator cuff tear. Thirty-three patients agreed to participate in this retrospective study. For 8 patients, we used a standard passage of the LD through the plane between the infraspinatus-teres minor and the deltoid muscles. For the remaining 25 patients, we transferred the LD tendon in front of the triceps muscle according to a personal described technique. The follow-up period was 35.7 months. Final follow-up included assessment by standard radiographs, bipolar surface electromyography, pain score by visual analog scale, Constant-Murley shoulder score, and Disabilities of the Arm, Shoulder, and Hand score. For quantitative strength evaluation measurements, a Biodex dynamometer was used. RESULTS Overall clinical outcomes improved at the final follow-up and were significantly age related. We found similar results for revision and primary patients with mean increase in Constant-Murley scores of 29.5 and 30.5 points, respectively. In our series, we recorded osteoarthritis progression in 33.3% of patients. CONCLUSION Arthroscopic LD tendon transfer for irreparable posterosuperior rotator cuff tears can achieve good clinical outcomes at a midterm follow-up, especially in active men 60 years of age or younger and in patients with low preoperative elevation (<80°) but an intact or reparable subscapularis tendon.
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Affiliation(s)
- Dario Petriccioli
- Department of Orthopedics, Istituto Clinico Città di Brescia, Brescia, Italy
| | - Celeste Bertone
- Department of Orthopedics, Istituto Clinico Città di Brescia, Brescia, Italy.
| | - Giacomo Marchi
- Department of Orthopedics, Istituto Clinico Città di Brescia, Brescia, Italy
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Cutbush K, Peter NA, Hirpara K. All-Arthroscopic Latissimus Dorsi Transfer. Arthrosc Tech 2016; 5:e607-13. [PMID: 27656385 PMCID: PMC5021352 DOI: 10.1016/j.eats.2016.02.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 02/04/2016] [Indexed: 02/03/2023] Open
Abstract
Massive irreparable rotator cuff tears are often associated with severe functional impairment and disabling pain. One viable treatment option is a latissimus dorsi tendon transfer. We propose an all-arthroscopic technique that we believe avoids insult to the deltoid musculature while reducing morbidity from open harvest of the tendon. The operation is performed with the patient in the lateral decubitus position, by use of a combination of viewing and working portals in the axilla. The initial viewing portal is placed along the anterior belly of the latissimus muscle in the axilla. The latissimus and teres major are identified, as is the thoracodorsal neurovascular pedicle. The tendons are carefully separated, and the inferior and superior borders of the latissimus are whipstitched using a suture passer, which helps facilitate subsequent mobilization of the muscle. The interval deep to the deltoid and superficial to the teres minor is developed into a subdeltoid tunnel for arthroscopic tendon transfer. The latissimus tendon is then transferred and stabilized arthroscopically to the supraspinatus footprint with suture anchors. Our preliminary data suggest that this surgical technique results in improvement in pain, range of motion, and function.
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Affiliation(s)
- Kenneth Cutbush
- University of Queensland, Brisbane, Australia,Brisbane Hand and Upper Limb Clinic, Brisbane, Australia,Orthopaedic Department, Princess Alexandra Hospital, Woolloongabba, Australia,Address correspondence to Kenneth Cutbush, M.B.B.S., F.R.A.C.S., F.A.Orth.A., 9/259 Wickham Terrace, Brisbane, 4000, Queensland, Australia.9/259 Wickham TerraceBrisbane4000, QueenslandAustralia
| | - Noel A. Peter
- Orthopaedic Department, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Kieran Hirpara
- Orthopaedic Department, Prince Charles Hospital, Chermside, Queensland, Australia
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25
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Oliva F, Piccirilli E, Bossa M, Via AG, Colombo A, Chillemi C, Gasparre G, Pellicciari L, Franceschetti E, Rugiero C, Scialdoni A, Vittadini F, Brancaccio P, Creta D, Buono AD, Garofalo R, Franceschi F, Frizziero A, Mahmoud A, Merolla G, Nicoletti S, Spoliti M, Osti L, Padulo J, Portinaro N, Tajana G, Castagna A, Foti C, Masiero S, Porcellini G, Tarantino U, Maffulli N. I.S.Mu.L.T - Rotator Cuff Tears Guidelines. Muscles Ligaments Tendons J 2016; 5:227-63. [PMID: 26958532 DOI: 10.11138/mltj/2015.5.4.227] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Despite the high level achieved in the field of shoulder surgery, a global consensus on rotator cuff tears management is lacking. This work is divided into two main sessions: in the first, we set questions about hot topics involved in the rotator cuff tears, from the etiopathogenesis to the surgical treatment. In the second, we answered these questions by mentioning Evidence Based Medicine. The aim of the present work is to provide easily accessible guidelines: they could be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, in order to improve the quality of care and rationalize the use of resources.
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Affiliation(s)
- Francesco Oliva
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Italy
| | - Eleonora Piccirilli
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Italy
| | - Michela Bossa
- Department of Physical and Rehabilitation medicine, School of Medicine, University of Rome "Tor Vergata", Italy
| | - Alessio Giai Via
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Italy
| | | | - Claudio Chillemi
- Department of Orthopaedic and Traumatology, Istituto Chirurgico Ortopedico Traumatologico (ICOT), Latina, Italy
| | - Giuseppe Gasparre
- Department of Physical and Rehabilitation Medicine, University of Padua, Italy
| | - Leonardo Pellicciari
- Department of Physical and Rehabilitation medicine, School of Medicine, University of Rome "Tor Vergata", Italy
| | - Edoardo Franceschetti
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Italy
| | - Clelia Rugiero
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Italy
| | - Alessandro Scialdoni
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Italy
| | - Filippo Vittadini
- Department of Physical and Rehabilitation Medicine, University of Padua, Italy
| | | | - Domenico Creta
- Physical Therapy and Rehabilitation Service, Private Hospital "Madre Fortunata Toniolo", Bologna, Italy
| | - Angelo Del Buono
- Orthopaedics and Traumatology, Ospedale Sant'Anna, Sanfermo della Battaglia, Como, Italy
| | - Raffaele Garofalo
- Shoulder Service, Miulli Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Francesco Franceschi
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Italy
| | - Antonio Frizziero
- Department of Physical and Rehabilitation Medicine, University of Padua, Italy
| | - Asmaa Mahmoud
- Department of Physical and Rehabilitation medicine, School of Medicine, University of Rome "Tor Vergata", Italy
| | - Giovanni Merolla
- Shoulder and Elbow Unit Biomechanics Laboratory "M. Simoncelli" D. Cervesi Hospital, Cattolica, Italy
| | - Simone Nicoletti
- Department of Orthopaedics and Traumatology, San Jacopo Hospital, Italy
| | - Marco Spoliti
- Department of Orthopaedics and Traumatology, San Camillo Hospital, Rome, Italy
| | - Leonardo Osti
- Unit of Arthroscopic and Sports Medicine, Hesperia Hospital, Modena, Italy
| | - Johnny Padulo
- Sport Science, University e-Campus, Novedrate, Italy; Tunisian Research Laboratory "Sports Performance Optimization", National Center of Medicine and Science in Sport, Tunis, Tunisia
| | - Nicola Portinaro
- UO Pediatric Orthopaedics, Humanitas Research Hospital, Milano, Italy
| | | | - Alex Castagna
- Shoulder and Elbow Unit, IRCCS Humanitas Institute, Rozzano, Milano, Italy
| | - Calogero Foti
- Department of Physical and Rehabilitation medicine, School of Medicine, University of Rome "Tor Vergata", Italy
| | - Stefano Masiero
- Department of Physical and Rehabilitation Medicine, University of Padua, Italy
| | - Giuseppe Porcellini
- Shoulder and Elbow Unit Biomechanics Laboratory "M. Simoncelli" D. Cervesi Hospital, Cattolica, Italy
| | - Umberto Tarantino
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Italy
| | - Nicola Maffulli
- Head of Department of Orthopaedics and Traumatology, Azienda Ospedaliera San Giovanni di Dio e Ruggi d'Aragona, University of Salerno, Italy; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, London, UK
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26
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Petri M, Greenspoon JA, Bhatia S, Millett PJ. Patch-Augmented Latissimus Dorsi Transfer and Open Reduction-Internal Fixation of Unstable Os Acromiale for Irreparable Massive Posterosuperior Rotator Cuff Tear. Arthrosc Tech 2015; 4:e487-92. [PMID: 26697309 PMCID: PMC4662244 DOI: 10.1016/j.eats.2015.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 05/18/2015] [Indexed: 02/03/2023] Open
Abstract
Latissimus dorsi transfer is a reasonable treatment option for massive posterosuperior rotator cuff tears that can substantially improve chronically painful and dysfunctional shoulders. This report and accompanying video describe the treatment of an active 43-year-old man with severe pain and weakness in the right shoulder after 3 failed rotator cuff repairs. Preoperative imaging showed a massive posterosuperior rotator cuff tear retracted to the glenoid as well as a hypermobile os acromiale likely causing dynamic impingement and recurrent rotator cuff tears. After diagnostic arthroscopy, the latissimus tendon is harvested and augmented with a 3-mm human acellular dermal patch (ArthroFlex; Arthrex, Naples, FL). The native rotator cuff tissue is repaired as much as possible, and the latissimus tendon is passed underneath the deltoid and posterior to the teres minor. The patch-augmented tendon is then integrated into a double-row SpeedBridge repair of eight 4.75-mm BioComposite SwiveLock anchors (Arthrex). The bony surface of the os acromiale is prepared and then fixed to the acromion with 2 cannulated partially threaded screws and additional tension-band wiring. Postoperative rehabilitation initially focuses on early passive range of motion, followed by active and active-assisted motion and a biofeedback program starting at 6 weeks postoperatively.
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Affiliation(s)
- Maximilian Petri
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,The Steadman Clinic, Vail, Colorado, U.S.A
| | | | - Sanjeev Bhatia
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,The Steadman Clinic, Vail, Colorado, U.S.A
| | - Peter J. Millett
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,The Steadman Clinic, Vail, Colorado, U.S.A.,Address correspondence to Peter J. Millett, M.D., M.Sc., Steadman Philippon Research Institute, 181 W Meadow Dr, Ste 1000, Vail, CO 81657, U.S.A.
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27
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Grimberg J, Kany J, Valenti P, Amaravathi R, Ramalingam AT. Arthroscopic-assisted latissimus dorsi tendon transfer for irreparable posterosuperior cuff tears. Arthroscopy 2015; 31:599-607.e1. [PMID: 25498458 DOI: 10.1016/j.arthro.2014.10.005] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 09/30/2014] [Accepted: 10/03/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate, in a multicenter, prospective study, the clinical, magnetic resonance imaging (MRI), and radiologic results of arthroscopic-assisted latissimus dorsi (LD) tendon transfer for irreparable posterosuperior rotator cuff tears; and to assess the influence of perioperative data on clinical results. METHODS Fifty-five patients with irreparable tears of at least the supraspinatus and infraspinatus tendons were managed with arthroscopic-assisted LD tendon transfer and reviewed clinically, with standardized radiographs and MRI, after a mean of 29 months. Outcome measures included the Constant score and the Subjective Shoulder Value. The osteoarthritic stage and acromiohumeral distance were measured on standardized radiographs, and the transferred tendon aspect was evaluated on MRI. RESULTS Thirty patients had already undergone 1 or more previous surgical procedures. The mean Subjective Shoulder Value increased from 26% preoperatively to 71% postoperatively. The Constant score improved from 37 preoperatively to 65.4 postoperatively. The pain score increased from 1.7 preoperatively to 12.6 postoperatively; the activity score, from 6.4 to 13.8; active forward flexion, from 134° to 157°; active abduction, from 67° to 92.5°; active external rotation, from 29° to 41.5°; and abduction strength, from 1.4 kg to 4.8 kg. The only statistically significant factor negatively influencing the Constant score was previous surgery. Four patients had a ruptured LD tendon on MRI follow-up at 1 year. There was no statistical difference between preoperative and final follow-up acromiohumeral distance. There was no increase in osteoarthritic stage. CONCLUSIONS Arthroscopic-assisted LD tendon transfer improves shoulder pain and function in patients with irreparable posterosuperior cuff tears, with similar clinical and radiologic results compared with results of published series using open techniques. Patients with a history of surgery had lower Constant scores compared with non-previously operated patients. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Jean Grimberg
- L'Institut de Recherché en Chirurgie Orthopédique et Sportive, Paris, France.
| | - Jean Kany
- Clinique de l'Union, Saint Jean, France
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28
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Gracitelli MEC, Assunção JH, Malavolta EA, Sakane DT, Rezende MRD, Ferreira Neto AA. Trapezius muscle transfer for external shoulder rotation: anatomical study. ACTA ORTOPEDICA BRASILEIRA 2014; 22:304-7. [PMID: 25538475 PMCID: PMC4273954 DOI: 10.1590/1413-78522014220600931] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 08/13/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE: To compare the viability of transferring the lower and transverse trapezius to the greater tuberosity using three different techniques. METHODS: Twelve shoulders from six cadavers were used. The primary outcome was to assess the suture viability of the trapezius muscle transfer to the greater tuberosity in the insertion topography of the infraspinatus, with the arm adducted during internal rotation (hand on the abdomen) and maximum scapular retraction. Three transfers were applied to each shoulder: the lower and transverse trapezius distal insertion (Group 1); lower trapezius alone (Group 2); and lower trapezius insertion and origin (Group 3). Accessory nerve integrity was assessed before and after transfers. RESULTS: Sutures were viable in 42% (5/12) and 58% (7/12) on Groups 1 and 3, respectively, with no statistically significant difference (Fisher's test, p=0.558); Group 3 exhibited frequent neurologic injury (11/12). Group 2 was the least successful; the tendon did not reach the greater tuberosity, and no sutures were viable. CONCLUSION: Groups 1 and 3 exhibited the best nongrafting suture viability to the greater tuberosity; however, Group 3 was associated to frequent spinal accessory nerve injury. Level of Evidence IV, Anatomical Study
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29
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Abstract
BACKGROUND Transfer of the latissimus dorsi tendon to the posterosuperior part of the rotator cuff is an option in active patients with massive rotator cuff tears to restore shoulder elevation and external rotation. However, it is unknown whether this treatment prevents progression of cuff tear arthropathy. QUESTIONS/PURPOSES The purpose of this study was to determine whether the observed improvement in shoulder function in the early postoperative period with latissimus dorsi tendon transfer for irreparable rotator cuff tears will be permanent or will deteriorate in the midterm period (at 1-5 years after surgery). METHODS During a 6-year period, we performed 11 latissimus dorsi tendon transfers in 11 patients for patients with massive, irreparable, chronic tears of the posterosuperior part of the rotator cuff (defined as > 5 cm supraspinatus and infraspinatus tendon tears with Goutallier Grade 3 to 4 fatty infiltration on MRI), for patients who were younger than 65 years of age, and had high functional demands and intact subscapularis function. No patients were lost to followup; minimum followup was 12 months (median, 33 months; range, 12-62 months). The mean patient age was 55 years (median, 53 years; range, 47-65 years). Shoulder forward elevation, external rotation, and Constant-Murley and American Shoulder and Elbow Surgeons scores were assessed. Pain was assessed by a 0- to 10-point visual analog scale. Acromiohumeral distance and cuff tear arthropathy (staged according to the Hamada classification) were evaluated on radiographs. RESULTS Shoulder forward elevation, external rotation, Constant-Murley scores, and American Shoulder and Elbow Surgeons scores improved at 6 months. However, although shoulder motion values and Constant-Murley scores remained unchanged between the 6-month and latest evaluations, American Shoulder and Elbow Surgeons scores decreased in this period (median, 71; range, 33-88 versus median, 68; range, 33-85; p = 0.009). Visual analog scale scores improved between the preoperative and 6-month evaluations but then worsened (representing worse pain) between the 6-month and latest evaluations (median, 2; range, 0-5 versus median, 2; range, 1-6; p = 0.034), but scores at latest followup were still lower than preoperative values (median, 7; range, 4-8; p = 0.003). Although acromiohumeral distance values were increased at 6 months (median, 8 mm; range, 6-10 mm; p = 0.023), the values at latest followup (median, 8 mm; range, 5-10 mm) were no different from the preoperative ones (mean, 7 mm; range, 6-9 mm; p > 0.05). According to Hamada classification, all patients were Grade 1 both pre- and postoperatively, except one who was Grade 3 at latest followup. CONCLUSIONS The latissimus dorsi tendon transfer may improve shoulder function in irreparable massive rotator cuff tears. However, because the tenodesis effect loses its strength with time, progression of the arthropathy should be expected over time. Nevertheless, latissimus dorsi tendon transfer may help to delay the need for reverse shoulder arthroplasty for these patients. LEVEL OF EVIDENCE Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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30
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De Casas R, Lois M, Cidoncha M, Valadron M. Clinic and electromyographic results of latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears. J Orthop Surg Res 2014; 9:83. [PMID: 25380558 PMCID: PMC4237752 DOI: 10.1186/s13018-014-0083-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/09/2014] [Indexed: 02/03/2023] Open
Abstract
Background This study examines the clinical and electromyographic results of latissimus dorsi transfer (LDT) using a combined open and arthroscopic technique for the treatment of symptomatic irreparable posterosuperior rotator cuff tears. Methods Between 2006 and 2009, LDT was performed in 14 patients (mean age 59 years) with massive and symptomatic irreparable posterosuperior rotator cuff tear. The patients were examined preoperatively and postoperatively with mean follow-up of 52 months using the Constant score, and the integrity of the latissimus dorsi (LD) transfer was assessed by ultrasound in all cases and by MRI in ten cases. The functional activity of the LD transfer was compared to the non-operated side using surface electromyography. Results All patients demonstrated a significant improvement in the Constant score (p = 0.001), from a preoperative score of 33 points (range 10–55 points) to a postoperative score of 59 points (range 13–80 points). The subjective assessment score was good to excellent in 12 patients (85%), and 11 patients (78%) would be willing to undergo surgery again. Integrity of the transferred tissue was confirmed in 13 of the 14 cases using ultrasound and MRI. Surface electromyographic signal showed increased activation of the transferred latissimus dorsi when performing active movements of external rotation (p = 0.002) and abduction-elevation (p = 0.009). Conclusions Our results indicate that LDT significantly improves function and diminishes pain in patients with a massive posterosuperior rotator cuff tear. The combined open and arthroscopic technique preserves the deltoid muscle and controls the LD tendon reinsertion. Surface electromyographic signal confirms the active function of the transferred muscle. Electronic supplementary material The online version of this article (doi:10.1186/s13018-014-0083-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ricardo De Casas
- Department of Orthopedic Surgery, Clinica Traumacor, Ronda de Nelle 72, 15005, A Coruna, Spain.
| | - Matías Lois
- Department of Orthopedic Surgery, Centro Gallego de Buenos Aires, Avenida Belgrano 2199, 1094, Buenos Aires, Argentina.
| | - Myriam Cidoncha
- Department of Physical Medicine, Clinica Traumacor, Ronda de Nelle 72, 15005, A Coruna, Spain.
| | - Miguel Valadron
- Department of Orthopedic Surgery, Clinica Traumacor, Ronda de Nelle 72, 15005, A Coruna, Spain.
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31
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Black EM, Paxton ES, Williams GR, Song HS. Arthroscopic repair of an avulsed latissimus dorsi tendon transfer for massive, irreparable rotator cuff tear: a report of two cases. J Shoulder Elbow Surg 2014; 23:e217-20. [PMID: 25127912 DOI: 10.1016/j.jse.2014.05.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 05/08/2014] [Accepted: 05/15/2014] [Indexed: 02/01/2023]
Affiliation(s)
- Eric M Black
- Department of Orthopedic Surgery, The Summit Medical Group, Berkeley Heights, NJ, USA
| | - E Scott Paxton
- Department of Orthopedic Surgery, Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Gerald R Williams
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Hyun-Seok Song
- Department of Orthopedic Surgery, St. Paul's Hospital, The Catholic University of Korea, Seoul, South Korea.
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32
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Grimberg J, Kany J. Latissimus dorsi tendon transfer for irreparable postero-superior cuff tears: current concepts, indications, and recent advances. Curr Rev Musculoskelet Med 2014; 7:22-32. [PMID: 24458942 DOI: 10.1007/s12178-013-9196-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Latissimus dorsi tendon transfer is a method for surgical treatment of massive irreparable posterosuperior cuff tears. It partially restores active anteflexion, external rotation, and function of the shoulder but does not significantly increase strength of the shoulder. It is contraindicated in case of pseudoparalytic shoulder; associated irreparable subscapularis tear, deltoid palsy, and in case of associated osteoarthritis, as an isolated procedure. Results are inferior when performed as a secondary procedure compared with a primary procedure. However, latissimus dorsi tendon transfer is an attractive solution to improve shoulder mobility and function of young and non osteoarthritic patients whose previous surgical treatment of massive postero-superior irreparable rotator cuff tear failed. As a primary procedure, latissimus dorsi tendon transfer competes with debridement, biceps tenotomy, and partial cuff repair. In association with reverse shoulder arthroplasty, it restores active external rotation in osteoarthritic patients with active external rotation deficit. New arthroscopic assisted techniques might improve results in the future.
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Affiliation(s)
- Jean Grimberg
- IRCOS (Institut de Recherche en Chirurgie Osseuse et Sportive), 6 avenue Alphonse XIII, 75016, Paris, France,
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33
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Does the latissimus dorsi tendon transfer for massive rotator cuff tears remain active postoperatively and restore active external rotation? J Shoulder Elbow Surg 2014; 23:553-60. [PMID: 24135419 DOI: 10.1016/j.jse.2013.07.055] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 07/17/2013] [Accepted: 07/28/2013] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS The purpose of this study is to evaluate the muscle activity with surface electromyography (EMG) and the clinical outcome of the latissimus dorsi transfer. It remains unclear whether the clinical results of the latissimus dorsi transfer for massive posterosuperior rotator cuff tears are achieved either by active muscle contractions or by a passive tenodesis effect of the transfer. METHODS Eight patients were evaluated preoperatively and at 1 year (SD, 0.1) after the latissimus dorsi transfer. Clinical evaluation of outcomes included active range of motion, Constant score, and visual analog scale (VAS) for pain and activities of daily living (ADL). Muscle activity was recorded with EMG during directional isometric abduction and adduction tasks. RESULTS The external rotation in adduction improved from 23° to 51° (P = .03). The external rotation in abduction improved from 10° to 70° (P = .02). The mean Constant score improved from 39 to 62 postoperatively (P = .01). The VAS for pain at rest improved from 3.3 preoperatively to 0.1 (P = .02). The VAS for ADL improved from 4.9 to 2.3 (P = .05). The transferred latissimus dorsi remained active in all cases, as reflected by increased latissimus dorsi EMG activity during abduction tasks. In addition, the latissimus dorsi EMG activity shifted from preoperative antagonistic co-activation in adduction to synergistic activation in abduction. CONCLUSION The latissimus dorsi has synergistic muscle activity after transfer. Apart from a tenodesis effect, directional muscle activity seems relevant for improved clinical outcome and pain relief. A specific gain was observed for external rotation in elevated arm positions, a motion essential for ADL tasks.
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34
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Henseler JF, Nagels J, van der Zwaal P, Nelissen RGHH. Teres major tendon transfer for patients with massive irreparable posterosuperior rotator cuff tears: Short-term clinical results. Bone Joint J 2013; 95-B:523-9. [PMID: 23539705 DOI: 10.1302/0301-620x.95b4.30390] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Surgical repair of posterosuperior rotator cuff tears has a poorer outcome and a higher rate of failure compared with repairs of supraspinatus tears. In this prospective cohort study 28 consecutive patients with an irreparable posterosuperior rotator cuff tear after failed conservative or surgical treatment underwent teres major tendon transfer. Their mean age was 60 years (48 to 71) and the mean follow-up was 25 months (12 to 80). The mean active abduction improved from 79° (0° to 150°) pre-operatively to 105° (20° to 180°) post-operatively (p = 0.011). The mean active external rotation in 90° abduction improved from 25° (0° to 70°) pre-operatively to 55° (0° to 90°) post-operatively (p < 0.001). The mean Constant score improved from 43 (18 to 78) pre-operatively to 65 (30 to 86) post-operatively (p < 0.001). The median post-operative VAS (0 to 100) for pain decreased from 63 (0 to 96) pre-operatively to 5 (0 to 56) post-operatively (p < 0.001). In conclusion, teres major transfer effectively restores function and relieves pain in patients with irreparable posterosuperior rotator cuff tears and leads to an overall clinical improvement in a relatively young and active patient group with limited treatment options.
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Affiliation(s)
- J F Henseler
- Leiden University Medical Center, Department of Orthopaedics, Postzone J-11-R, Postbus 9600, 2300 RC Leiden, the Netherlands.
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35
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Henry PDG, Dwyer T, McKee MD, Schemitsch EH. Latissimus dorsi tendon transfer for irreparable tears of the rotator cuff: An anatomical study to assess the neurovascular hazards and ways of improving tendon excursion. Bone Joint J 2013; 95-B:517-22. [PMID: 23539704 DOI: 10.1302/0301-620x.95b4.30839] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Latissimus dorsi tendon transfer (LDTT) is technically challenging. In order to clarify the local structural anatomy, we undertook a morphometric study using six complete cadavers (12 shoulders). Measurements were made from the tendon to the nearby neurovascular structures with the arm in two positions: flexed and internally rotated, and adducted in neutral rotation. The tendon was then transferred and measurements were taken from the edge of the tendon to a reference point on the humeral head in order to assess the effect of a novel two-stage release on the excursion of the tendon. With the shoulder flexed and internally rotated, the mean distances between the superior tendon edge and the radial nerve, brachial artery, axillary nerve and posterior circumflex artery were 30 mm (26 to 34), 28 mm (17 to 39), 21 mm (12 to 28) and 15 mm (10 to 21), respectively. The mean distance between the inferior tendon edge and the radial nerve, brachial artery and profunda brachii artery was 18 mm (8 to 27), 22 mm (15 to 32) and 14 mm (7 to 21), respectively. Moving the arm to a neutral position reduced these distances. A mean of 15 mm (8 to 21) was gained from a standard soft-tissue release, and 32 mm (20 to 45) from an extensile release. These figures help to define further the structural anatomy of this region and the potential for transfer of the latissimus dorsi tendon.
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Affiliation(s)
- P D G Henry
- St. Michael's Orthopaedic Associates, 155 Queen St. E, Suite 800, Toronto, Ontario M5C 1R6, Canada
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36
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Scheibel M. Redefekte der Rotatorenmanschette. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2012; 24:458-67. [DOI: 10.1007/s00064-012-0179-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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37
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Delaney RA, Lin A, Warner JJ. Nonarthroplasty Options for the Management of Massive and Irreparable Rotator Cuff Tears. Clin Sports Med 2012; 31:727-48. [DOI: 10.1016/j.csm.2012.07.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
The management of patients with a failed rotator cuff repair is challenging. Revision arthroscopic repairs can be entertained in select patients when realistic outcomes are understood. Complete evaluation of the shoulder is needed to identify and treat potential confounding pain generators. The ability to determine if a recurrent tear is repairable is difficult, because there are no established criteria to make this determination. If a recurrent tear is found to be repairable, the results of the surgery are encouraging, although persistent limitations in shoulder function are common. Strategies to improve the rates of tendon healing should be used and include the use of stronger repair constructs, when possible, and implementation of a slower rehabilitation progression.
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Affiliation(s)
- Jay D Keener
- Shoulder and Elbow Service, Department of Orthopaedic Surgery, Washington University, Campus Box #8233, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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39
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Latissimus dorsi tendon transfer for massive irreparable rotator cuff tears: a systematic review. Sports Med Arthrosc Rev 2012; 19:428-37. [PMID: 22089293 DOI: 10.1097/jsa.0b013e3182390639] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Tendon transfers have been proposed as a possible solution to restore pain-free functions, strength, and range of motion in patients with massive and irreparable cuff tears. The aim of this review is to establish the outcomes of (1) latissimus dorsi tendon transfer (LDT-T) surgery performed as a single procedure or in combination with other muscle-tendon transfer procedures, replacement, or both; (2) LDT-T in primary and revision surgery for massive irreparable rotator cuff tears; (3) the LDT-T procedure in relation to subscapularis and teres minor integrity; (4) the LDT-T procedure in relation to the reattachment position on the humeral head of the transferred tendon; (5) the LDT-T procedure performed as a single or a double incision; (6) arthroscopic, open, or combined approach: and (7) the LDT-T procedure in patients with preoperative osteoarthritis and a nonosteoarthritic condition with the evaluation of osteoarthritis progression. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Studies of levels of evidence I-IV were included. The LDT-T surgical procedure, outcomes, and complications were evaluated. Twenty-two studies describing 493 shoulders in 487 patients were included in our study. There were no prospective randomized, controlled studies. LDT-T is a promising strategy for the management of massive and irreparable rotator cuff tears, even though no agreement was found on several aspects and options of LDT-T. Randomized prospective control studies are still awaited on this subject.
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Schneeberger AG, Schuler L, Rikli D, Thür C. Rotator cuff tears treated with a modified deltoid flap repair technique. J Shoulder Elbow Surg 2012; 21:310-8. [PMID: 21885299 DOI: 10.1016/j.jse.2011.05.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Revised: 05/17/2011] [Accepted: 05/26/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND Few options exist in the treatment of irreparable rotator cuff tears, especially in younger patients. The purpose of this study was to present our experience with deltoid flap repairs combined with acromion elevation osteotomy increasing the space for the flap. METHODS We retrospectively reviewed the outcome of 57 patients with a mean age of 60 years who had undergone the modified anterolateral deltoid flap technique for the treatment of large and massive rotator cuff tears. Follow-up was performed after a mean of 6 years. RESULTS At follow-up, 84% of patients considered the condition of their shoulder as better or much better compared with before surgery. The mean Constant score was 88% (range, 45-122). Before surgery, all shoulders were significantly painful. At latest follow-up, 91% of the patients had no or mild pain. Elevation of the arm above 90° was possible in 38 patients before surgery and in 53 patients at latest follow-up. Tears involving 3 tendons were associated with inferior results. Retears of the deltoid flap occurred in 8 patients (14%); 1 of them was successfully treated with a reverse total shoulder replacement, and 6 had a repair of the flap, with only 1 satisfactory outcome. CONCLUSIONS The modified deltoid flap yielded reliable pain relief and a high rate of patient satisfaction, as well as satisfactory function in the majority of the patients. Especially in younger patients, this technique might be considered a viable alternative for the treatment of irreparable rotator cuff tears.
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Abstract
Irreparable rotator cuff tears are a challenging problem for patients and surgeons. There are several treatment options, but deciding the correct one for each patient can be difficult. Treatment options include physical therapy, arthroscopy, muscle transfers, reverse shoulder arthroplasty, and hemiarthroplasty. An understanding of the patient's chief complaint and their functional ability to elevate their arm above horizontal should guide the treatment. This article reviews the current literature on various treatment options for irreparable rotator cuff tears, then outlines an algorithm for determining treatment.
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Affiliation(s)
- M Michael Khair
- Resident in Orthopedic Surgery, Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
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Diop A, Maurel N, Chang VK, Kany J, Duranthon LD, Grimberg J. Tendon fixation in arthroscopic latissimus dorsi transfer for irreparable posterosuperior cuff tears: an in vitro biomechanical comparison of interference screw and suture anchors. Clin Biomech (Bristol, Avon) 2011; 26:904-9. [PMID: 21689873 DOI: 10.1016/j.clinbiomech.2011.05.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 05/20/2011] [Accepted: 05/23/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND The fixation of the tendon to the bone remains a challenging problem in the latissimus dorsi tendon transfer for irreparable cuff tears and can lead to unsatisfactory results. A new arthroscopic method of tendon to bone fixation using an interference screw has been developed and the purpose of this study was to compare its biomechanical properties to the ones of a standard fixation technique with anchors. METHODS Six paired fresh frozen cadaveric human humeri were used. The freed latissimus dorsi tendon was randomly fixed to the humeral head with anchors or with interference screw after a tubularization procedure. Testing consisted to apply 200 cycles of tensile load on the latissimus dorsi tendon with maximal loads of 30 N and 60 N, followed by a load to failure test. The stiffness, displacements after cyclic loadings, ultimate load to failure, and site of failure were analysed. FINDINGS The stiffness was statistically higher for the tendons fixed with interference screws than for the ones fixed with anchors for both 30 N and 60 N loadings. Likewise, the relative bone/tendon displacements after cyclic loadings were lower with interference screws compared to anchors. Load to failure revealed no statistical difference between the two techniques. INTERPRETATION Compared to the standard anchor fixation, the interference screw fixation technique presents higher or similar biomechanical performance. These results should be completed by further biomechanical and clinical trials to confirm the interest of this new technique as an alternative in clinical use.
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Affiliation(s)
- Amadou Diop
- Equipe Biomécanique et Remodelage Osseux, Arts et Métiers ParisTech, France.
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Abstract
Repair of massive rotator cuff tears is technically difficult but often feasible. Technical and biological challenges to a successful repair include inelastic poor-quality tendon tissue, scarring, muscle atrophy, and fatty infiltration. Fatty infiltration of the involved rotator cuff muscles has been identified as an important negative prognostic factor for the outcome after repair of massive rotator cuff tears. Tendon transfer is a good option for young patients and manual laborers with an irreparable massive rotator cuff tear. Arthroplasty can be considered for the treatment of symptomatic massive rotator cuff tears in patients who have glenohumeral arthritis.
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Affiliation(s)
- Asheesh Bedi
- Hospital for Special Surgery, New York, NY 10021, USA.
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Yum JK, Lee HS, Park SB. Tendon Transfer for Irreparable Massive Rotator Cuff Tear. Clin Shoulder Elb 2010. [DOI: 10.5397/cise.2010.13.1.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Cho CH, Song KS, Kim SK. Antegrade Interlocking Intramedullary Nailing in Humeral Shaft Fractures. Clin Shoulder Elb 2010. [DOI: 10.5397/cise.2010.13.1.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Steenbrink F, Nelissen RGHH, Meskers CGM, van de Sande MAJ, Rozing PM, de Groot JH. Teres major muscle activation relates to clinical outcome in tendon transfer surgery. Clin Biomech (Bristol, Avon) 2010; 25:187-93. [PMID: 20004504 DOI: 10.1016/j.clinbiomech.2009.11.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Revised: 10/29/2009] [Accepted: 11/03/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND In massive rotator cuff tears a teres major (TMj) tendon transfer to the insertion of the supraspinatus (SSp) reverses its adduction moment arm into abduction which is supposed to be an adequate salvage procedure. Analysis of muscle function to find biomechanical ground of such success is scarce. METHODS We compared pre- and postoperative clinical outcome of TMj transfer, i.e. Range of Motion, pain, Constant Shoulder scores and arm force. TMj activation was evaluated in 14 patients suffering massive cuff tears using activation ratios to describe the desired 'in-phase' and undesired 'out-of-phase' contribution to the external arm moment. Additionally, we analyzed activation of the latissimus dorsi (LD) and the medial part of the deltoids (DE). The activation ratios were compared to controls and TMj activation ratios were related to clinical outcome. FINDINGS TMj tendon transfer improved arm function. Pre-operatively, we observed 'out-of-phase'abduction activation of TMj and LD. After transfer patients activated TMj according to its new anatomical position. 'Out-of-phase' LD abduction activation persisted. The clinical improvements coincided with changes in activation ratio of TMj. INTERPRETATION 'Out-of-phase' TMj adductor activation is associated with compromised arm function in patients with irreparable cuff tears. After transfer, TMj is activated in correspondence with its new anatomical function, which was supportive for the improved arm function.
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Affiliation(s)
- Frans Steenbrink
- Laboratory for Kinematics and Neuromechanics, Leiden University Medical Center, Leiden, The Netherlands
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Latissimus dorsi transfer for treatment of irreparable rotator cuff tears. INTERNATIONAL ORTHOPAEDICS 2010; 34:1239-44. [PMID: 20155494 DOI: 10.1007/s00264-010-0970-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Revised: 01/18/2010] [Accepted: 01/19/2010] [Indexed: 10/19/2022]
Abstract
Massive rotator cuff tendon ruptures are not uncommon in older patients. We propose the transfer of the latissimus dorsi muscle for treatment of irreparable ruptures associated with functional impairment and chronic pain. Five women and 11 men were so treated and reviewed with an average follow-up of 26 months. The mean age was 60 years. Four patients also had subscapularis deficiency. Results were assessed with the Constant score and the Oxford shoulder score. Humeral head position was analysed. Statistical analysis was performed by the Wilcoxon non-parametrical test. The Constant score increased by 24.2% (p = 0.001) with all parameters showing improvement. Nine patients showed improved humeral head positioning in internal rotation. Three of four patients with a deficient subscapularis had unfavourable results. Latissimus dorsi transfer for the treatment of irreparable massive rotator cuff tears leads to a substantial clinical improvement. An intact subscapularis tendon is mandatory.
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