Reversed arthroscopic subacromial decompression for symptomatic irreparable rotator cuff tears: mid-term follow-up results in 34 shoulders

Patient-Reported Outcomes After Arthroscopic Superior Capsule Reconstruction With an Acellular Porcine Dermal Xenograft for Irreparable Rotator Cuff Tears

Background

Currently, there is no consensus on the adequate management of irreparable rotator cuff tears. Arthroscopic superior capsule reconstruction (SCR) seems to be an alternative treatment option.

Purpose/Hypothesis

The purpose of this study was to evaluate patient-reported outcomes up to 2 years after the treatment of irreparable rotator cuff tears with SCR using an acellular porcine dermal xenograft. It was hypothesized that SCR treatment with an acellular porcine dermal xenograft would not result in a significant clinical improvement or pain relief in patients with irreparable rotator cuff tears if the xenograft fails.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 26 consecutive patients with irreparable rotator cuff tears were enrolled in the study between 2015 and 2019. All patients underwent SCR with acellular porcine dermal xenograft. Patient-reported outcome measures including visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, the Veterans RAND 12- Item Health Survey (VR-12), and the Single Assessment Numeric Evaluation (SANE) were followed up for 2 years. For statistical analysis, the 1-way analysis of variance was used to compare means for VAS, ASES, VR-12, and SANE results between pre- and posttreatment. Magnetic resonance imaging (MRI) records were obtained at 1 year postoperatively to evaluate graft integrity.

Results

In total, 22 patients were included in the patient-reported outcomes with 4 being lost at final follow-up. The mean VAS score decreased from 4.2 ± 2.5 to 1.0 ± 1.4 (P < .001) from pretreatment to 2 years postoperatively. The mean ASES - index score improved significantly from 47.7 ± 15.3 to 86.4 ± 12.9 (P < .001) and the SANE score improved from 34.0 ± 20.4 to 77.3 ± 20.2 (P < .001). In addition, a clinically important difference in the patients' quality of life was achieved, as shown by the mean changes in the VR-12 physical (+4.3) and mental scores (+9.3). Based on postoperative MRI, the dermal graft on the humeral side was intact in 15 (68.2%) patients after surgery.

Conclusion

Our arthroscopic SCR with an acellular porcine dermal matrix showed significant and continuous improvement in pain and clinical scores up to a 2-year follow-up in patients with irreparable rotator cuff tears, even with structural graft failure. However, further studies and evaluation of larger patient groups are needed to evaluate the long-term effect of this procedure.

Subacromial Balloon Placement Demonstrates No Advantage Over Debridement in the Treatment of Massive Irreparable Rotator Cuff Tears: A Dual-Armed Systematic Review and Meta-analysis of Over 1000 Patients

BACKGROUND

In recent years, the placement of a subacromial balloon (SAB) spacer has emerged as a treatment option for massive irreparable rotator cuff tears (MIRCTs); however, there is significant controversy regarding its utility in comparison with other surgical interventions.

PURPOSE

To compare outcomes after SAB spacer placement versus arthroscopic debridement for MIRCTs.

STUDY DESIGN

Dual-armed systematic review and meta-analysis (level IV evidence).

METHODS

A literature search of PubMed (MEDLINE), Scopus, and CINAHL Complete databases for articles published before May 7, 2022, was conducted to identify patients with MIRCTs undergoing the 2 procedures. For the SAB arm, 14 of 449 studies were considered eligible for inclusion, while 14 of 272 studies were considered eligible for inclusion in the debridement arm.

RESULTS

In total, 528 patients were eligible for inclusion in the SAB arm and 479 patients in the debridement arm, and 69.9% of patients undergoing SAB placement also underwent concomitant debridement. Decreases in the visual analog scale (VAS) pain score and increases in the Constant score were found to be significantly larger after debridement (-0.7 points [P < .001] and +5.5 points [P < .001], respectively), although the Patient Acceptable Symptom State for the VAS was not achieved after either procedure. Both SAB placement and debridement significantly improved range of motion in forward flexion/forward elevation, internal and external rotation, and abduction (P < .001). Rates of general complication were higher after debridement versus SAB placement (5.2% ± 5.6% vs 3.5% ± 6.3%, respectively; P < .001); however, there were no significant differences between SAB placement and debridement in rates of persistent symptoms requiring a reintervention (3.3% ± 6.2% vs 3.8% ± 7.3%, respectively; P = .252) or reoperation rates (5.1% ± 7.6% vs 4.8% ± 8.4%, respectively; P = .552). The mean time to conversion to reverse total shoulder arthroplasty was 11.0 versus 25.4 months, respectively, for the SAB versus debridement arm.

CONCLUSION

While SAB placement was associated with acceptable postoperative outcomes in the treatment of MIRCTs, there was no clear benefit over debridement alone. Shorter operative times coupled with better postoperative outcomes and longer times to conversion to reverse total shoulder arthroplasty rendered debridement a more attractive option. While there may be a role for SAB placement in poor surgical candidates, there is burgeoning evidence to support debridement alone without SAB placement for the treatment of MIRCTs.

Acellular Human Dermal Allograft Tuberoplasty Improved the Biomechanics in Mid-Range and Higher Abduction Angles in a Cadaveric Model of Massive Irreparable Rotator Cuff Tears

Purpose

To evaluate the biomechanical effects of acellular human dermal allograft tuberoplasty (AHDAT) in a cadaveric model of an irreparable supraspinatus + anterior one-half infraspinatus (stage III) rotator cuff tear.

Methods

Eight cadaveric shoulders were tested at 20°, 40°, and 60° of glenohumeral abduction (AB) and 0°, 30°, 60°, and 90° of external rotation (ER). Superior humeral translation, acromiohumeral distance, and subacromial contact were quantified for 4 conditions: (1) intact, (2) stage III tear (entire supraspinatus and anterior one-half infraspinatus), (3) single-layer AHDAT, and (4) double-layer AHDAT.

Results

Stage III tear significantly increased superior translation at 20° and 40° AB and all ER angles and at 60° AB/60° ER (P ≤ .045 vs intact). Compared to the stage III tear, the single-layer AHDAT significantly decreased superior translation at 60° AB/60° ER (P = .003), whereas the double-layer AHDAT significantly decreased superior translation at 40° and 60° AB at all ER angles except 60° AB/0° ER (P ≤ .028). The stage III tear significantly decreased acromiohumeral distance at 20° AB (P ≤ .003); both grafts increased acromiohumeral distance to intact levels (P ≥ .055 vs intact). Stage III tear increased subacromial contact pressure at 20° and 40° AB/0° and 30° ER and at 60° AB/30° and 60° ER (P ≤ .034). Both AHDAT groups decreased contact pressure at 40° AB/30° and 60° ER back to intact, whereas the double-layer AHDAT also decreased contact pressure at 20° AB/0° and 60° ER and 60° AB/30° ER (P ≥ .051 vs intact).

Conclusions

Both single- and double-layer grafts for AHDAT improved superior translation, subacromial contact characteristics, and acromiohumeral distance after a stage III rotator cuff tear, with varying effectiveness due to the position-dependent nature of greater tuberosity to acromial contact with abduction.

Clinical Relevance

The best treatment for massive or irreparable rotator cuff tears is a matter of concern. The results of this study will help determine whether an acellular human dermal allograft tuberoplasty is a potential treatment option worthy of further investigation.

Patient-reported outcome tools and baseline scores vary by country and region for arthroscopic repair of massive rotator cuff tears: a systematic review

Background

Different patient-reported outcome (PRO) tools are used in patients with arthroscopic rotator cuff repair (ARCR) which complicates outcome comparisons. The purpose of this systematic review was to compare PRO usage and baseline scores across world regions and countries in patients with ARCR of massive rotator cuff tears (MRCT).

Methods

A systematic review was performed on ARCR for MRCT. The search was conducted from September to November of 2022 using the MEDLINE database for articles published in the last 15 years. Thirty-seven articles were included after initial screening and full-text review. In each article, PRO usage, baseline scores, and country of origin were collected. PRO usage was reported in percentages and baseline scores were normalized for each region to facilitate comparisons. Normalization was performed using the PRO means from each article. These averages were converted to fractions using the worst and best possible scores. These were combined into a single numerical value, expressed as a decimal from 0 to 1, using the total sample size for each tool per region. Values closer to 0 represent worse functional outcomes.

Results

Thirty-two percent (n = 12) of articles were from Asia, 43.2% (n = 16) from Europe, 5.4% (n = 2) from the Middle East, and 18.9% (n = 7) from North America. The most commonly reported PRO tools were American Shoulder and Elbow Surgeons (ASES) in 19 papers, Constant-Murley Score (CMS) in 26 papers, Visual Analog Scale for pain (VAS) in 19 papers, and University of California in Los Angeles (UCLA) in 11 papers. ASES was reported in 51% of articles with 63% being from Asia (n = 12) compared to 21% from North America (n = 4). CMS was reported in 70% of studies with 58% being from Europe. Upon normalization, the preoperative score ranged from 0.30 to 0.44. Europe (0.39), and North America (0.40) showed similar scores. The lowest and highest scores were seen in the Middle East (0.3) and Asia (0.44) respectively.

Conclusion

There is no standardized method to report outcomes in patients undergoing ARCR for MRCT. Great variation in usage exists in PROs which complicates data comparison between world regions. With normalization, baseline scores where similar among Asia, North America, and Europe, and lowest in the Middle East.

Management of Irreparable Posterosuperior Rotator Cuff Tears-A Current Concepts Review and Proposed Treatment Algorithm by the AGA Shoulder Committee

Posterosuperior rotator cuff tears range among the most common causes of shoulder complaints. While non-operative treatment is typically reserved for the elderly patient with low functional demands, surgical treatment is considered the gold standard for active patients. More precisely, an anatomic rotator cuff repair (RCR) is considered the most desirable treatment option and should be generally attempted during surgery. If an anatomic RCR is impossible, the adequate choice of treatment for irreparable rotator cuff tears remains a matter of debate among shoulder surgeons. Following a critical review of the contemporary literature, the authors suggest the following evidence- and experience-based treatment recommendation. In the non-functional, osteoarthritic shoulder, treatment strategies in the management of irreparable posterosuperior RCT include debridement-based procedures and reverse total shoulder arthroplasty as the treatment of choice. Joint-preserving procedures aimed at restoring glenohumeral biomechanics and function should be reserved for the non-osteoarthritic shoulder. Prior to these procedures, however, patients should be counseled about deteriorating results over time. Recent innovations such as the superior capsule reconstruction and the implantation of a subacromial spacer show promising short-term results, yet future studies with long-term follow-up are required to derive stronger recommendations.

Management of Massive Rotator Cuff Tears Without Arthropathy

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.].

Superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement or balloon spacers for large and massive irreparable rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

Multiple non-arthroplasty surgical techniques are described for the management of large and massive irreparable rotator cuff tears. There is currently no consensus on the best management strategy. Our aim was to compare clinical outcomes following arthroscopic debridement, arthroscopic partial cuff repair, superior capsule reconstruction, balloon spacers or graft interposition for the management of large and massive irreparable rotator cuff tears.

METHODS

A comprehensive search was performed of the following databases: Medline, Embase, CINAHL and Cochrane Database of Systematic Reviews. Data were extracted from relevant studies published since January 2000 according to the pre-specified inclusion criteria. The primary outcome was the post-operative improvement in shoulder scores. Meta-analysis of the primary outcome was performed. Secondary outcomes included retear rates and complications.

RESULTS

Eighty-two studies were included reporting the outcomes of 2790 shoulders. Fifty-one studies were included in the meta-analysis of the primary outcome. The definition of an irreparable tear varied. All procedures resulted in improved shoulder scores at early follow-up. Shoulder scores declined after 2 years following balloon spacers, arthroscopic debridement and partial cuff repair. High retear rates were seen with partial cuff repairs (45%), graft interposition (21%) and superior capsule reconstruction (21%).

CONCLUSIONS

Large initial improvements in shoulder scores were demonstrated for all techniques despite high retear rates for reconstructive procedures. Shoulder scores may decline at mid- to long-term follow-up.

Nonarthroplasty options for massive, irreparable rotator cuff tears have improvement in range of motion and patient-reported outcomes at short-term follow-up: a systematic review

PURPOSE

To compare various nonarthroplasty treatment options for massive, irreparable rotator cuff tears, including allograft bridging/augmentation, debridement, partial repair, superior capsule reconstruction (SCR), subacromial balloon spacer, and tendon transfer.

METHODS

A comprehensive search was conducted through the PubMed, MEDLINE, and EMBASE databases for all articles pertaining to nonarthroplasty treatment options for irreparable rotator cuff tears. Inclusion criteria included manuscripts published between 2009 and 2020 with at least 1 year follow-up and Level I-IV evidence. Articles were separated into six groups: debridement, arthroscopic and open repair, allograft bridging/augmentation, SCR, subacromial balloon spacer, and tendon transfer. Data points included range of motion (external rotation, abduction, forward flexion, and internal rotation), visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Constant score, rate of revision surgery, and rate of conversion to arthroplasty.

RESULTS

A total of 83 studies and 3363 patients were included. All treatment options had statistically significant improvements in postoperative range of motion and patient-reported outcomes. Debridement had statistically significantly greater postoperative abduction and forward flexion range of motion, as well as better VAS pain scores, compared to the other treatment options. The SCR subgroup had the greatest improvement in ASES scores postoperatively. The overall revision rate was 7.2% among all surgical options, with the allograft bridging/augmentation group having the lowest rate of revision at 0-8.3%. The overall rate of conversion to arthroplasty was 7.2%, with debridement having the greatest rate of conversion at 15.4%.

CONCLUSION

All six nonarthroplasty treatment options for irreparable rotator cuff tears resulted in statistically significant improvements in range of motion and patient-reported outcomes at 1 year follow-up or more, with low rates of revision and conversion to arthroplasty. Debridement had statistically significantly greater postoperative abduction and forward flexion range of motion, as well as better VAS pain scores, compared to the other treatment options. However, these conclusions should be interpreted with caution due to the heterogeneous nature of the data, lack of prospective randomized control trials, and short-term follow-up. The findings of this study highlight the complexity of irreparable, massive rotator cuff tears, and the need for an individualized approach when treating these patients.

LEVEL OF EVIDENCE

Level IV.

Outcomes of Arthroscopic Tuberoplasty for Symptomatic Irreparable Rotator Cuff Tendon Tear Without Pseudoparalysis

Background

The purpose of this study is to report the outcomes in patients undergoing arthroscopic tuberoplasty for symptomatic irreparable rotator cuff tear (RCT).

Methods

This is a retrospective cohort study comparing preoperative and postoperative data of patients undergoing arthroscopic tuberoplasty for symptomatic irreparable RCT. Exclusion criteria included open tuberoplasty, concomitant partial RCT repair, glenohumeral arthritis, concomitant ipsilateral extremity fractures, <12 months follow-up, or pseudoparalysis. Demographics, shoulder range of motion (ROM), RCT morphology, re-operation rates, satisfaction and outcome scores were collected from medical records and questionnaires. Outcome scores included Patient Reported Outcome Measurement Information System Upper Extremity (PROMIS), American Shoulder and Elbow Surgeons score (ASES), Subjective Shoulder Value (SSV), and pain Visual Analog Score (VAS).

Results

Out of 28 patients identified between 2012 and 2019, 20 (21 shoulders) were available for follow-up at a mean of 43.3 ± 20.9 months. Mean age was 64.6 ± 8.8 years. Mean PROMIS was 37.7 ± 7.3, ASES was 82.9 ± 13.8, and SVV was 67.1 ± 19.4. VAS with activity decreased from 5.0 ± 2.9 preoperatively to 2.3 ± 2.6 (P = .0029). Pre- and post-operative ROM were unchanged. There were 4 failures requiring revision. The remaining 17 patients reported high satisfaction scores (3.4 ± 0.7) and 15 (88.2%) answered “yes” to getting the procedure again, with 3/4 failures stating they would also undergo arthroscopic tuberoplasty again.

Conclusion

Arthroscopic tuberoplasty demonstrates high levels of satisfaction and pain reduction in symptomatic irreparable RCT. In appropriately indicated patients, this treatment should be considered prior to other salvage options.

Arthroscopic debridement for management of massive, irreparable rotator cuff tears: a systematic review of outcomes

Background

Surgical management of massive irreparable rotator cuff tears remains controversial. Arthroscopic debridement (AD) has shown promising results especially in the population older than 65 years; however, there is no consensus on the benefits of various AD procedures. The aim of this systematic review was to evaluate the functional midterm to long-term outcomes in patients treated with AD in combination with subacromial decompression, biceps tenotomy, tuberoplasty, or bursectomy, without repair of the rotator cuff tear.

Methods

A comprehensive search was performed in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane databases for studies reporting clinical outcomes of AD of massive rotator cuff tears. Quality was determined using the Methodological Index for Nonrandomized Studies (MINORS) criteria by two independent reviewers. Pooled frequency-weighted means and standard deviations were calculated for patient-reported outcomes.

Results

Sixteen articles containing 643 patients and 662 shoulders met the eligibility criteria. The mean age at the time of surgery was 65.9 ± 4.4 years with a mean follow-up period of 46.5 ± 27.3 months. There was notable clinically significant improvement across all patient-reported outcome scores postoperatively: Constant 70.4 ± 8.9 (P value = .06), University of California, Los Angeles ultrasonography 26.7 ± 5.2 (P value = .001), American Shoulder and Elbow Surgeons score 71.7 ± 2.1 (P value = .12), Disabilities of the Arm, Shoulder, and Hand score 35.3, and visual analog score 1.7 ± 0.9. Forty-nine patients (7%) required reoperation, which most commonly was a reverse total shoulder arthroplasty for the development of rotator cuff arthropathy.

Conclusion

Arthroscopic debridement with a combination of subacromial decompression, tuberoplasty, subacromial bursectomy, and biceps tenotomy, for treatment of massive irreparable rotator cuff tears, produces good functional outcomes and improvement in pain at mid to long term follow up for the low-demand population greater than 65 years of age looking for pain relief over substantial increase in function.

Long-term outcome of arthroscopic debridement of massive irreparable rotator cuff tears

Objectives

To evaluate the clinical and radiographic outcome of low-demand patients with massive rotator cuff tears undergoing arthroscopic debridement in mid- and long-term follow-up, as well as the rate of conversion to reverse shoulder arthroplasty.

Methods

We performed a retrospective analysis of 19 patients with a mean age at surgery of 68 years (range, 55–80 years) from a previously described consecutive cohort and after a mean follow up of 47 month (FU1) and 145 month (FU2). The functional outcome was evaluated with the VAS score, the American Shoulder and Elbow Surgeons (ASES) score, and the age- and gender-adjusted Constant (aCS) score. The radiographic outcome was classified according to the Hamada classification. Non-parametric analyses were carried out with the Mann-Whitney U for independent samples and the Wilcoxon signed-rank test for related samples.

Results

Five patients (26%) developed symptomatic cuff tear arthropathy and underwent reverse shoulder arthroplasty after a mean time of 63 months (range, 45–97 months). These patients were excluded from further analyses. The mean VAS score of the remaining 14 patients at FU1 was significantly lower compared to preoperatively (P = .041), while there were no significant differences between the VAS score at FU1 and FU2 (P = 1.0). The ASES score of the affected shoulder at FU1 was significantly higher compared to prior to surgery (P = .028), while there were no significant differences between the scores of the affected shoulder between FU1 and FU2 (P = .878). While the ASES score of the contralateral shoulder at FU1 was significantly higher than the score of the affected shoulder (P = .038), there were no significant differences in the ASES scores of the affected and the healthy shoulder at FU2 (P = .575). The evaluation of the aCS produced similar results. A progression of the Hamada grade was documented in 6 patients.

Conclusions

Arthroscopic debridement is a safe and valid option for low-demand middle-age or elderly patients with symptomatic massive rotator cuff tears, leading to a significant pain relief and significantly improved functional outcome at mid- and long-term follow up. However, about a quarter of the patients in our cohort had to undergo reverse shoulder arthroplasty due to symptomatic cuff tear arthropathy. Furthermore, some of the remaining patients continued to undergo radiographic progression. This might be due to the natural history of their disease and/or the surgical procedure, and the clinical relevance of this finding should be evaluated in further studies.

The role of Superior Capsule Reconstruction in the irreparable rotator cuff tear - A systematic review

BACKGROUND

Irreparable rotator cuff tears in active patients provide a significant challenge and a consensus on the gold standard treatment is currently lacking. Superior capsule reconstruction (SCR) has recently been advocated and functions by providing a passive biological constraint to superior humeral head migration. The aim of this study is to systematically review the literature to evaluate the role of SCR in terms of functional outcome scores and failure rates.

PATIENTS AND METHODS

A review of the online databases Medline and EMBASE was conducted in accordance with the PRISMA guidelines on the 28th January 2019. Clinical studies reporting SCR using any type of graft or surgical technique were included if reporting either functional outcome scores or rate of secondary surgery. The studies were appraised using the Methodological index for non-randomised studies tool.

RESULTS

The search strategy identified nine studies eligible for inclusion; five reported on fascia lata autografts and four studies reported on dermal allografts. All nine studies reported significant improvement in functional scores after SCR. Rates of secondary surgery were only provided in the dermal allograft studies at short-term follow-up (mean 10.9 to 32.4months) and ranged from 0 to 18.6%. Radiological assessment revealed graft failure in 5.5 to 55% of dermal allografts and 4.2 to 36.1% of fascia lata autografts.

CONCLUSION

This review demonstrates that SCR is a useful treatment modality for patients with irreparable rotator cuff tears. SCR was associated with significantly improved functional outcome scores in all studies. All studies reported a preserved or increased mean AHD. The radiological graft failure rate ranged from 4.2 to 55% and the short duration of follow-up in most studies means that this remains an important concern that requires longer-term evaluation.

LEVEL OF EVIDENCE

IV, systematic review.

Failed Dermal Allograft Procedures for Irreparable Rotator Cuff Tears Can Still Improve Pain and Function: The "Biologic Tuberoplasty Effect"

Background:

Acellular dermal matrices (ADMs) have been used in the treatment of shoulders with massive rotator cuff tears (MRCTs). Despite clinical improvement, correlation of clinical findings with ADM integrity on imaging has not been investigated.

Hypothesis:

The pain in shoulders with MRCTs is partially due to bone-to-bone contact between the tuberosity and acromion. Coverage of the tuberosity with an intact graft or a graft that is torn in a way that the tuberosity remains covered will act as an interpositional tissue, preventing bone-to-bone contact and leading to clinical improvement.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between 2006 and 2016, a total of 25 shoulders with MRCTs underwent a procedure with an ADM. Pre- and postoperative visual analog scale (VAS) results, American Shoulder and Elbow Surgeons (ASES) score, Hamada grade, and Goutallier classification were reviewed. A postoperative magnetic resonance imaging (MRI) was obtained in 22 (88%) shoulders. The status of the graft was divided into the following categories: type I, intact graft; type II, graft tear with tuberosity covered; and type III, graft tear with tuberosity uncovered (bare).

Results:

The mean patient age was 61 years (range, 49-73 years), and the mean follow-up was 25.6 months (range, 10-80 months). Mean length from surgery to postoperative MRI was 13.9 months (range, 6-80 months). The graft was torn in 59% (13/22 shoulders). Significant improvements were found in VAS and ASES scores (7 vs 0.7 and 32.6 vs 91.2, respectively; P < .01) for type I grafts and in VAS and ASES scores (8.1 vs 1.3 and 26.3 vs 84.6, respectively; P < .01) for type II grafts. No difference was found in postoperative VAS and ASES (0.7 vs 1.3 and 91.2 vs 84.6, respectively; P = .8) between type I and type II grafts. No improvement was seen in VAS (7.3 vs 5.7; P = .2) or ASES (30.6 vs 37.2; P = .5) for type III grafts.

Conclusion:

MRI appearance of the graft has a significant impact on functional outcomes. Patients with an intact graft or a graft tear leaving the tuberosity covered have lower pain and higher functional scores than those in whom the torn graft leaves the tuberosity uncovered.

Significant improvement in patient self-assessed comfort and function at six weeks after the smooth and move procedure for shoulders with irreparable rotator cuff tears and retained active elevation

BACKGROUND

It has been documented that the smooth and move procedure-smoothing the proximal humeral surface while maintaining the coracoacromial arch-can provide clinically significant long-term improvement in function for patients having irreparable rotator cuff tears with retained active elevation. This study sought to demonstrate that clinically significant gains in comfort, function, and active motion can be realized as early as 6 weeks after this procedure.

METHODS

We conducted a prospective cohort study of the 6-week clinical outcomes for 48 patients enrolled prior to a smooth and move procedure for irreparable rotator cuff tears. Prior rotator cuff repair had been attempted in 28 (70%).

RESULTS

In 40 patients with preoperative and 6-week postoperative measurements, the Simple Shoulder Test scores improved from an average of 3.4 ± 2.8 preoperatively to 5.7 ± 3.5 at 6 weeks (p < 0.001), an improvement that exceeded the published values for the minimal clinically important difference (MCID). The clinical outcomes were not worse for the 18 shoulders with irreparable tears of both the supraspinatus and infraspinatus. In 30 patients with preoperative and 6-week postoperative objective measurements of active motion, the average abduction improved from 93(± 43) to 123(± 47)° (p = 0.005) and the average flexion improved from 102(± 46) to 126(± 44)° (p = 0.023).

CONCLUSIONS

In addition to its previously documented long-term effectiveness for shoulders with irreparable rotator cuff tears and retained active elevation, this study demonstrates that the smooth and move procedure provides clinically significant improvement as early as 6 weeks after surgery.

The absorbable subacromial spacer for irreparable posterosuperior cuff tears has inconsistent results

PURPOSE

To evaluate the 2-year results of an absorbable subacromial spacer in patients with irreparable posterosuperior rotator cuff tears.

METHODS

Prospective longitudinal study of a consecutive case series of 16 subjects with irreparable tears of the posterosuperior rotator cuff in which the InSpace^® subacromial spacer was arthroscopically implanted. A full clinical evaluation that included the Constant test, Simple Shoulder Test (SST) and the QuickDash questionnaire was performed preoperatively and at 12 and 24 months follow-up. The primary outcome for assessing the success of the procedure was a variable composed of a clinically relevant variation of the Constant (established in an improvement greater than 10 points) and the absence of surgical reintervention.

RESULTS

Fifteen subjects (11 women/4 men, median age = 69.4 years [interquartile range 7.50], range 60-80 years) completed the 2-year of follow-up. According to the main evaluation criteria, only 6 patients (40%) had a successful outcome. Five subjects required reconversion to a reverse shoulder arthroplasty (at a median of 9.8 months postoperatively) due to absence of clinical improvement or worsening of symptoms. Of the ten remaining subjects, only 6 had improvements greater than 10 points in the Constant score. Despite of this, these 10 subjects had, on average, some improvement in the Constant test (preoperative Constant: median 35.0 [27.0-52.5] vs Constant at 24 months: 53.5 [55.0-84.0], significant differences p = 0.02), in the SST (3.0 [2.0-4.0] vs 6.0 [3.25-7.75], p = 0.039) and in the QuickDASH test (37.0 [33.25-40.0] vs 27.5 [20.5-32.75], p = 0.012).

CONCLUSIONS

The outcomes of the implantation of the subacromial biodegradable spacer at 2-year follow-up are not satisfactory. In this small case series only 40% of patients seem to clearly benefit from surgery. One in three required revision to a reverse shoulder arthroplasty. The described technique does not seem a reasonable alternative for the management of the majority of patients with irreparable ruptures of the rotator cuff. The indications of this device should be more clearly defined.

LEVEL OF EVIDENCE

IV.

Computational optimization of graft tension in simulated superior capsule reconstructions

Superior capsular reconstruction has received increased attention as a surgical technique to address massive "irreparable" rotator cuff tears; however, the functional limitations and surgical techniques associated with this repair have yet to be sufficiently explored. The goal of this study was to utilize a multidisciplinary approach to characterize the biomechanics of this repair by: (i) identifying activities of daily living that may overburden the graft; and (ii) optimizing surgical techniques used during implantation. This experiment was completed in three phases. First, graft failure mechanics were characterized by performing an in vitro experiment. Second, in vivo shoulder kinematics associated with various activities were recorded with 3-D motion capture techniques. Finally, an in silico model was used to assess graft strains. Results show that motions involving posterior shoulder rotation, such as back washing, lead to graft strains that may cause failure. Output from the optimization suggests that orienting the humerus in approximately 25° abduction, and 20° internal rotation during implantation will result in optimal graft performance. Clinical Significance: The novel paradigm used in this study demonstrates the utility of coupling in vitro, in vivo, and in silico modeling techniques in one cohesive experiment. This paradigm presents an additional tool, aside from clinical studies and cadaveric experimentation, to better predict and understand the strengths and limitations of superior capsular reconstruction. This approach has potential to be translated to other soft tissue repairs and may provide valuable information to clinicians and rehabilitative specialists to manage patient expectations and guide rehabilitation. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2789-2796, 2018.

The use of a subacromial spacer-inspace balloon in managing patients with irreparable rotator cuff tears

Aim

The objective of this prospective non-randomized study was to establish the role of biodegradable sub-acromial spacer (InSpace™) insertion in the management of patients with massive irreparable rotator cuff tear by reporting beneficial effects on the pain relief and functional outcomes in these patients.

Methods

This is a prospective non-randomized study of patients treated for irreparable cuff tears during a period between January 2014 and November 2016.14 patients with symptomatic massive irreparable rotator cuff tears were managed with arthroscopic debridement and implantation of a biodegradable subacromial spacer and were followed up for at least one year (8-16 m). Inclusion criteria were patients with irreparable rotator cuff tears that failed the conservative management, with muscle retraction (Patte > stage 2), muscle atrophy, and fatty infiltration (Goutalier type 3). Patients with osteoarthritis grade 3 in the Hamada classification and/or without preserved passive motion were excluded from our study. Outcome measures included pre and postoperative, the range of motion, Constant and Oxford shoulder scores. The decision to perform surgery was made after failure of nonoperative treatment and rehabilitation (massive rotator cuff tear protocol, reading shoulder unit)for at least six months.

Results

Fourteen shoulders (14 patients, ten male four female) met the inclusion criteria. The mean age of patients was 76.2 (70-85) years. During the last follow-up (8-16 months mean 12.6 months), the range of motion was significantly increased in all patients with anterior elevation (from 80 to 105°), abduction (from 70 to 110°), and external rotation (from 25 to 35°). The mean Constant score was also significantly (P < 0.001) improved from 22.5 (13-33) preoperatively to 51.4 (30-64) at the last follow-up. The Oxford shoulder score improved from 26 preoperatively (21-28) to 48.2 postoperatively (34-56). No night pain following surgery and ADL increased by 40%, which is significant in these patients. No significant perioperative complications were found except for one patient who had a spacer migration. However, no action was required in that case.

Conclusions

Arthroscopic implantation of a subacromial spacer for irreparable rotator cuff tear resulted in a noticeable improvement in pain relief and shoulder function at a mean 12.6 months follow up. It is a quick, safe and a minimally invasive procedure that is suitable for elderly patients with irreparable cuff tears and medical co-morbidities.

Options for Failed Rotator Cuff Repair

Failed rotator cuff repairs can pose a clinical challenge to the treating orthopedic surgeon. There are many nonsurgical and surgical options available to address the failed rotator cuff repair. Surgical options include revising the primary repair, partial or nonanatomic repair, tendon transfer, biological augmentation or use of tissue-engineered grafts for reconstruction, or total joint arthroplasty (typically with a modern reverse total shoulder arthroplasty system). The treating surgeon must assess the patient's functional status, health status, and expectations in order to customize the appropriate treatment plan for addressing the failed rotator cuff repair. With the abundance of treatment options available, there is typically an adequate solution to help the patient regain function and experience less pain.

Treatment Strategy for Irreparable Rotator Cuff Tears

Recently, patients with shoulder pain have increased rapidly. Of all shoulder disorders, rotator cuff tears (RCTs) are most prevalent in the middle-aged and older adults, which is the primary reason for shoulder surgery in the population. Some authors have reported that up to 30% of total RCTs can be classified as irreparable due to the massive tear size and severe muscle atrophy. In this review article, we provide an overview of treatment methods for irreparable massive RCTs and discuss proper surgical strategies for RCTs that require operative management.

Arthroscopic Subacromial Spacer Implantation in Patients With Massive Irreparable Rotator Cuff Tears: Clinical and Radiographic Results of 39 Retrospectives Cases

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.

Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty

PURPOSE

We sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation can be durably improved using a conservative surgical procedure that smoothes the interface between the proximal humeral convexity and the concave undersurface of the coracoacromial arch followed by immediate range of motion exercises.

METHODS

We reviewed 151 patients with a mean age of 63.4 (range 40-90) years at a mean of 7.3 (range 2-19) years after this surgery.

RESULTS

In 77 shoulders with previously unrepaired irreparable tears, simple shoulder test (SST) scores improved from an average of 4.6 (range 0-12) to 8.5 (range 1-12) (p < 0.001). Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points. For 74 shoulders with irreparable failed prior repairs, SST scores improved from 4.0 (range 0-11) to 7.5 (range 0-12) (p < 0.001). Fifty-four patients (73%) improved by the MCID of 2 SST points.

CONCLUSION

Smoothing of the humeroscapular interface can improve symptomatic shoulders with irreparable cuff tears and retained active elevation. This conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears.

LEVEL OF EVIDENCE

Level IV.

Arthroscopic Debridement for Irreparable Rotator Cuff Tears

Background:

Arthroscopic debridement represents a salvage procedure for irreparable rotator cuff tears. It is important to accurately diagnose the patient for irreparable rotator cuff tears. The diagnosis and the therapeutic options must be explained to the patient. It is mandatory that the patient understands the primary goal of the arthroscopic debridement being reduction of pain, not improving strength or function.

Methods:

The procedure consists of 7 distinct steps to debride the soft tissues and alleviate pain.

Results:

Even though there is a lack of evidence that this procedure is superior to other therapeutic options, it has shown good results in patients with the main complaint of pain.

Conclusion:

The results reported in some studies should, however, be interpreted with caution, taking into consideration the substantial structural damage in irreparable defects.

The Incidence of Subsequent Surgery After Outpatient Arthroscopic Rotator Cuff Repair

PURPOSE

To quantify the incidence and risk factors associated with subsequent shoulder procedures in individuals undergoing outpatient arthroscopic rotator cuff repair (ARCR).

METHODS

We examined the New York Statewide Planning and Research Cooperative Systems outpatient database from 2003 through 2014 to identify patients undergoing isolated ARCR with or without concomitant acromioplasty. Patients were longitudinally followed up for a minimum of 2 years to determine the incidence of subsequent ipsilateral shoulder surgery. The impact of age, sex, insurance, concomitant acromioplasty, and tobacco use on reoperation was explored.

RESULTS

Between 2003 and 2012, 30,430 patients underwent isolated ARCR. The mean age was 56.6 ± 11.5 years, and 55.1% were male patients. A total of 1,826 patients (6.0%) underwent subsequent ipsilateral outpatient shoulder surgery a mean of 24.3 ± 27.1 months after the initial ARCR. Of patients who underwent repeat surgery, 57.3% underwent a revision cuff repair. Patients who underwent additional outpatient shoulder surgery were significantly younger (53.7 ± 10.9 years v 56.8 ± 11.5 years, P < .001). Tobacco use was associated with an increased rate of subsequent surgery (7.3% v 5.9%, P = .044) and accelerated time to reoperation (16.9 months v 24.7 months, P < .001). Independent risk factors for subsequent ipsilateral surgery after initial ARCR were presence of a Workers' Compensation claim (odds ratio, 2.11; 95% confidence interval, 1.89-2.36; P < .001) and initial ARCR without acromioplasty (odds ratio, 1.20; 95% confidence interval, 1.09-1.34; P < .001).

CONCLUSIONS

We identified a 6.0% incidence of repeat ipsilateral surgery after isolated ARCR. Although reasons for reoperation are likely multifactorial, younger age, Workers' Compensation claim, and absence of acromioplasty at the time of initial ARCR remained independent predictors of subsequent outpatient procedures, whereas a history of tobacco use was associated with accelerated time to subsequent surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Massive Rotator Cuff Tears: Trends in Surgical Management

Compared with smaller tears, massive rotator cuff tears present significant clinical management dilemmas for the treating surgeon because they are often fraught with structural failure and poor outcomes. To optimize healing, current surgical methods look to optimize footprint coverage and enhance the biological environment for healing. Double-row techniques have demonstrated clear biomechanical advantages in controlled cadaveric studies, but have yet to demonstrate clear clinical efficacy over more simple repair techniques. When repairs for massive rotator cuff tears fail, options include revision repair or superior capsular reconstruction, an option to bridge the tissue gap with human dermal allograft or fascia lata autograft in hopes of containing the humeral head from superior migration and precluding rotator cuff arthropathy. Although latissimus transfers remain a reasonable option for massive, irreparable rotator cuff tears in appropriately indicated patients, clinical results are often unpredictable. Older patients with chronic, massive rotator cuff tears with pseudoparalysis can achieve predictable, often excellent clinical results with a reverse total shoulder arthroplasty. [Orthopedics. 2016; 39(3):145-151.].

Functional status and failed rotator cuff repair predict outcomes after arthroscopic-assisted latissimus dorsi transfer for irreparable massive rotator cuff tears

BACKGROUND

Arthroscopic-assisted latissimus dorsi tendon transfer (LDTT) has been recently introduced for treatment of irreparable, posterosuperior massive rotator cuff tears. We sought to evaluate the functional outcomes of this technique and to check for possible outcome predictors.

METHODS

The study reviewed 86 patients (aged 59.8 ± 5.9 years) who underwent an arthroscopic-assisted latissimus dorsi tendon transfer after 36.4 ± 9 months of follow-up. Of these, 14 patients (16.3%) sustained an irreparable massive rotator cuff tear after a failed arthroscopic rotator cuff repair. The Constant and Murley score (CMS) was used to assess patients' functionality preoperatively and at follow-up.

RESULTS

As a group, the CMS improved with surgery from 35.5 ± 6.1 to 69.5 ± 12.3 (P < .001). A lower preoperative CMS and a previous failed rotator cuff repair resulted in lower postoperative range of motion (P = .044 and P = .007, respectively) and CMS (P = .042 and P = .018, respectively). A previous rotator cuff repair resulted in lower satisfaction with surgery (P = .009). Gender and age did not affect the clinical outcomes.

CONCLUSIONS

Our results support the effectiveness of arthroscopic-assisted LDTT in the treatment of patients with an irreparable, posterosuperior massive rotator cuff tears in pain relief, functional recovery, and postoperative satisfaction. Patients with lower preoperative CMS and a history of failed rotator cuff repair have a greater likelihood of having a lower clinical result. However, the favorable values of summary postoperative scores do not exclude these patients as candidates for arthroscopic-assisted LDTT.

Long-term outcome of tuberoplasty for irreparable massive rotator cuff tears: is tuberoplasty really applicable?

BACKGROUND

Tuberoplasty is a therapeutic option for irreparable massive rotator cuff tear (RCT). However, no study has reported long-term outcomes after arthroscopic tuberoplasty.

METHODS

We evaluated 16 patients who underwent arthroscopic tuberoplasty for symptomatic irreparable massive RCT without pseudoparalysis. Patients were a mean age of 64 years (range, 43-80 years) at the time of the operation, and the mean duration of follow-up was 98 months (range, 84-126 months).

RESULTS

At the last follow-up, the visual analog scale score for pain during motion had decreased to 2.3 from a preoperative mean of 6.9 (P < .001). The mean University of California at Los Angeles and Constant scores improved from 10.3 and 37.9 preoperatively to 27.2 and 59.2, respectively, at the last follow-up (P < .001 for both). The best University of California at Los Angeles (UCLA) and Constant scores during the follow-up duration were 28.3 and 60.3, respectively, at 5 years. The mean acromiohumeral interval changed from 5 mm preoperatively to 4 mm at the last follow-up. The rate of continuity in the inferior scapulohumeral line decreased significantly from 69% (11 shoulders) preoperatively to 19% (3 shoulders) at the last follow-up (P = .011). Only 1 patient underwent revision surgery.

CONCLUSIONS

Arthroscopic tuberoplasty yielded satisfactory outcomes during a mean 8-year follow-up period. Although superior migration of the humeral head progressed with time, the clinical outcomes were not affected. Arthroscopic tuberoplasty is a good option for relieving pain and improving functionality in nonpseudoparalytic patients with painful irreparable massive RCT.

Massive rotator cuff tears: pathomechanics, current treatment options, and clinical outcomes

Rotator cuff tear size has an important effect on clinical outcomes after repair. Management options for massive rotator cuff tears are numerous, and selection of the most appropriate treatment method for individual patients can be a challenge. An understanding of the pathomechanics, treatment, and clinical outcomes in patients with massive rotator cuff tears can serve as a guide for clinical decision-making. The purpose of this article was to review treatment options and clinical outcomes for the management of massive rotator cuff tears.

Decision-making in massive rotator cuff tear

Treatment of massive rotator cuff tears has developed over many years ranging from conservative treatment to open and arthroscopic repair, muscle transfers and reversed arthroplasty. The evolution of more advanced techniques in arthroscopic repair has changed the treatment approach and improved the prognosis for functional outcome despite low healing rates. Due to this rapid development, our evidence-based knowledge today is mainly founded in Level 3 and Level 4 studies. Based on the literature, the current knowledge on treatment of symptomatic massive rotator cuff tears is proposed in an algorithm. Level of evidence V.

Arthroscopic treatment options for irreparable rotator cuff tears of the shoulder

The management of patients with irreparable rotator cuff tears remains a challenge for orthopaedic surgeons with the final treatment option in many algorithms being either a reverse shoulder arthroplasty or a tendon transfer. The long term results of these procedures are however still widely debated, especially in younger patients. A variety of arthroscopic treatment options have been proposed for patients with an irreparable rotator cuff tear without the presence of arthritis of the glenohumeral joint. These include a simple debridement with or without a biceps tenotomy, partial rotator cuff repair with or without an interval slide, tuberplasty, graft interposition of the rotator cuff, suprascapular nerve ablation, superior capsule reconstruction and insertion of a biodegradable spacer (Inspace) to depress the humeral head. These options should be considered as part of the treatment algorithm in patients with an irreparable rotator cuff and could be used as either as an interim procedure, delaying the need for more invasive surgery in the physiologically young and active, or as potential definitive procedures in the medically unfit. The aim of this review is to highlight and summarise arthroscopic procedures and the results thereof currently utilised in the management of these challenging patients.

Reliability of the posterolateral corner of the acromion as a landmark for the posterior arthroscopic portal of the shoulder

HYPOTHESIS

The present study aimed to evaluate the variability of the posterolateral corner of the acromion (PCA) position in relation to the glenohumeral joint, in a craniocaudal direction, to assess whether the universal use of a certain distance from that point will always lead to a consistent placement of the posterior arthroscopic portal of the shoulder.

METHODS

The study used 140 dried scapulae (36 women and 34 men). Measurements included the glenoid height and the perpendicular distance between the PCA and the most superior point of the glenoid. The percentage of coverage of the glenoid by the acromion was defined as the ratio between the 2 measurements. The Student t test was used to examine for significant differences between the sexes and the Student paired t test between sides (P < .05).

RESULTS

The average glenoid height was 3.37 ± 0.29 cm (range, 2.69-4.00 cm). The perpendicular distance between the PCA and the most superior point of the glenoid was 0.82 ± 0.69 cm (range, -0.35 to 2.27 cm). The percentage of coverage of the glenoid by the acromion was 24% ± 20% (range, -10% to 64%).

CONCLUSIONS

The position of the PCA in relation to the glenohumeral joint is quite variable. Therefore, the use of a universal distance from the PCA will not always lead to a consistent placement of the posterior arthroscopic portal of the shoulder. Future research is needed in this area to develop techniques to individualize placement of the posterior portal.

Indications for reverse shoulder replacement: a systematic review

The outcome of an anatomical shoulder replacement depends on an intact rotator cuff. In 1981 Grammont designed a novel large-head reverse shoulder replacement for patients with cuff deficiency. Such has been the success of this replacement that it has led to a rapid expansion of the indications. We performed a systematic review of the literature to evaluate the functional outcome of each indication for the reverse shoulder replacement. Secondary outcome measures of range of movement, pain scores and complication rates are also presented.

Results of arthroscopic decompression and tuberoplasty for irreparable massive rotator cuff tears

PURPOSE

The purpose of this study was to evaluate the clinical and radiologic results of arthroscopic tuberoplasty for symptomatic irreparable massive rotator cuff tears.

METHODS

This study enrolled 32 patients (32 shoulders) who underwent arthroscopic tuberoplasty for irreparable massive rotator cuff tears and were followed up for at least 24 months. The mean patient age at the time of surgery was 62.4 years (range, 43 to 76 years), and the mean duration of follow-up was 40 months (range, 24 to 63 months). The Constant score and the University of California, Los Angeles score were used for clinical evaluation. The acromiohumeral interval and inferior scapulohumeral line continuity were used for radiologic evaluation.

RESULTS

Twenty-six shoulders underwent arthroscopic tuberoplasty with concomitant acromioplasty, and 6 shoulders had only arthroscopic tuberoplasty. The Constant score increased from a preoperative mean of 47.6 points to 70.4 points at the last follow-up (P < .001). The University of California, Los Angeles score also improved from a preoperative mean of 15.4 points to 27.1 points at the last follow-up (P < .001), with 3 shoulders (9%) rated as excellent, 23 (72%) as good, and 6 (19%) as poor. The active range of forward flexion improved from 115.9° to 142.7° (P = .024). The final outcomes were not statistically affected by sex, age, preoperative mobility, and existence of a lesion of the long head of the biceps tendon. However, preoperative acromiohumeral interval and inferior scapulohumeral line continuity were statistically correlated with the final results (P < .001 and P = .047, respectively).

CONCLUSIONS

Arthroscopic tuberoplasty with concomitant acromioplasty, as well as treatment of the biceps tendon when indicated, would be an option for diminishing pain and improving active forward elevation for irreparable massive rotator cuff tears. In particular, satisfactory results during the minimum follow-up period of 24 months can be achieved in the cases with good preservation of the preoperative and postoperative acromiohumeral interval and continuity in the inferior scapulohumeral line, regardless of preoperative mobility.

Arthroscopic treatment of rotator cuff disease

The goal of this article is to summarize the current concepts on rotator cuff disease with an emphasis on arthroscopic treatment. Most rotator cuff tears are the result of an ongoing attritional process. Once present, a tear is likely to gradually increase in size. Partial-thickness and subscapularis tears can both be successfully treated arthroscopically if conservative management fails. Partial tears involving greater than 50% of tendon thickness should be repaired. Articular-sided partial tears involving less than 50% of the rotator cuff can reliably be treated with debridement. A more aggressive approach should be considered for low-grade tears (<50%) if they occur on the bursal side. Biomechanical and anatomic studies have shown clear superiority with dual-row fixation compared with single-row techniques. However, current studies have yet to show clear clinical advantage with dual-row over single-row repairs. Biceps tenotomy or tenodesis can reliably provide symptomatic improvement in patients with irreparable massive tears. True pseudoparalysis of the shoulder is a contraindication to this procedure alone and other alternatives should be considered.

Outcome of rotator cuff repair in large-to-massive tear with pseudoparalysis: a comparative study with propensity score matching

BACKGROUND

Active range of motion deficit is one of the alleged negative influencing factors of rotator cuff repair. Recently, with the popularity of reverse total shoulder arthroplasty (RTSA), there is a tendency toward performing RTSA in cases of nonarthritic large-to-massive tears with pseudoparalysis.

HYPOTHESIS

Rotator cuff repair in patients with active motion deficit may yield inferior outcome.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Among 195 complete repairs of large-to-massive rotator cuff tears, 35 patients experienced painful pseudoparalysis preoperatively. Propensity score matching (1-to-1) was performed between pseudoparalytic and nonpseudoparalytic groups. Finally, 29 patients in each group were matched using the following variables: age, gender, dominance, onset period, aggravation period, number of tendons involved, retraction, operation method (arthroscopic or mini-open), rows of repair (single or double), number of anchors, and fatty degeneration of the supraspinatus, infraspinatus, and subscapularis. At least 1 year after surgery (mean, 30.5 months), range of motion, visual analog scale for pain and satisfaction, Constant score, Simple Shoulder Test, American Shoulder and Elbow Surgeons (ASES) score, and University of California, Los Angeles shoulder rating scale (UCLA score) were evaluated. Healing of repaired cuffs was evaluated by computed tomography arthrography.

RESULTS

Range of motion was improved in both groups after rotator cuff repair. Active forward elevation had significantly improved postoperatively in the pseudoparalytic group (P < .001). All functional outcome scores improved at the final follow-up visit compared with preoperative values (all P < .05). Preoperative Constant, ASES, and UCLA scores were significantly inferior in the pseudoparalytic group, but all except the Constant score showed no differences between the 2 groups at the final follow-up (P = .04). Postoperatively, 7 patients (24.1%) in the pseudoparalytic and 1 (3.4%) in the nonpseudoparalytic group showed pseudoparalysis (P = .03). Among 37 patients who underwent postoperative computed tomography arthrography, cuff healing was achieved in 6 of 18 (33.3%) in the pseudoparalytic and 9 of 19 (47.4%) in the nonpseudoparalytic group (P = .385).

CONCLUSION

Recovery from pseudoparalysis after rotator cuff repair was evident in a large portion of the study group, and postoperative function and cuff healing were not different according to the presence of pseudoparalysis. Considering possible complications and longevity of RTSA, rotator cuff repair should be the first-line treatment option for large-to-massive tears.