Rotator cuff tears treated with a modified deltoid flap repair technique

Vascularized dermal autograft for the treatment of irreparable rotator cuff tears

BACKGROUND

Irreparable rotator cuff tears (IRCTs) are a challenging problem with diverse treatment modalities. We propose a technique for the treatment of IRCTs in which a vascularized dermal autograft is transferred to the posterosuperior region of the rotator cuff using the supraclavicular artery (SCA) island flap.

MATERIALS AND METHODS

Dissection of 11 fresh cadavers (19 shoulders) was performed, and the SCA island flap was harvested in all specimens. A full-thickness posterosuperior rotator cuff defect was created, and the flap was tunneled under the acromion and secured into position over the defect using multiple suture anchors. Simulated flap perfusion was then assessed, and flap measurements were recorded.

RESULTS

There were 4 male and 7 female cadavers (19 shoulders). Flap perfusion was assessed in 10 shoulders. On average, the flap thickness was 4.7 mm (range, 3.5-7.1 mm); width, 32.6 mm (range, 25.5-38.0 mm); and length, 169.2 mm (range, 132.0-235.0 mm). The average distance from the flap tip to the Neviaser portal was 76.2 mm (range, 48.0-99.6 mm), and that from the flap tip to the anterolateral acromial edge was 54.1 mm (range, 29.5-75.1 mm). The pedicle-to-footprint distance was 113.7 mm (range, 88.5-147.0 mm). The average flap length exceeded the pedicle-to-footprint distance by 55.5 mm (range, 43.5-88.0 mm), indicating adequate excursion of the flap. All flaps demonstrated adequate simulated perfusion after fixation.

CONCLUSION

The SCA island flap may be an option for a vascularized dermal autograft for IRCTs, as shown in this cadaveric study. This illustrates a possible technique with vascular viability.

Long-term follow-up after latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears

BACKGROUND

Irreparable posterosuperior rotator cuff tears are treated in several ways. Transfer of the latissimus dorsi is an alternative with acceptable mid-term results, but long-term results have rarely been published.

METHODS

The cases of 108 consecutive patients with 115 shoulders treated with latissimus dorsi transfer between 2000 and 2005 were reviewed clinically and radiographically. Ninety-three shoulders in eighty-six patients were included in the follow-up analysis. The mean duration of follow-up was 9.3 years (range, 6.6 to 11.7 years), and the mean age at the operation was fifty-six years (range, forty to seventy-two years). Outcome measures included the Constant-Murley score (Constant score), American Shoulder and Elbow Surgeons (ASES) index, and visual analog scale (VAS) for pain. The progress of cuff tear arthropathy was determined with radiographic evaluation according to the system described by Hamada et al.

RESULTS

The mean relative Constant score improved from 44% preoperatively to 71% at the time of follow-up (p < 0.0001, effect size = 0.6), excluding the clinical failures. Similarly, the mean ASES index improved from 30 to 70 (p < 0.0001, effect size = 0.7), and the mean VAS score decreased from 7.8 to 2.4 (p < 0.0001, effect size = 0.8). A pain-free outcome was reported in only eighteen shoulders (19%). Active shoulder movement improved significantly (p < 0.05). The mean Hamada radiographic grade of cuff tear arthropathy increased from 1.7 (range, 0 to 2) preoperatively to 2.2 (range, 1 to 5) (p < 0.0001, effect size = 0.2). The rate of clinical failure of latissimus dorsi transfer was 10%, and the rate of shoulder prosthetic replacement after latissimus dorsi transfer was 4%.

CONCLUSIONS

Pain relief and improvement of shoulder function were maintained a mean of 9.3 years after latissimus dorsi transfer for irreparable posterosuperior cuff defects. The younger the patient, the better the outcome.

Reverse total shoulder arthroplasty after failed deltoid flap reconstruction

HYPOTHESIS

Reverse shoulder arthroplasty (RSA) yields unsatisfactory results after deltoid flap reconstruction due to defect of the deltoid muscle.

METHODS

We retrospectively reviewed the outcome of 19 patients after failed deltoid flap reconstruction treated with RSA. Follow-up was after a mean of 4.5 years.

RESULTS

Seven patients (37 %) had nine postoperative complications requiring totally 16 revision surgeries. Nonetheless, at latest follow-up, 17 patients had no or mild, two had moderate, and none had severe pain. Before RSA; 13 patients had a pseudoparesis. At latest follow-up, none of the patients had a pseudoparesis. Mean flexion was 121° (90°-160°). Abduction strength averaged 2.3 kg (range 0-5.4 kg). The mean constant score was 70 % (range 28-98 %). Of the 19 patients, 15 were very satisfied with the outcome, four were satisfied, and none was dissatisfied. The mean overall subjective shoulder value was 73 % (30-95 %) of the value of a normal shoulder.

CONCLUSIONS

Despite of a localized defect of the deltoid muscle after deltoid flap repair, RSA can reliably be associated with a satisfactory outcome.

Rotator cuff: biology and current arthroscopic techniques

The present article summarizes current trends in arthroscopic rotator cuff repairs focusing on the used repair technique, potential influencing factors on the results, and long-term outcome after reconstruction of the rotator cuff. Moreover, different treatment options for the treatment for irreparable rotator cuff ruptures were described, and the results of additional augmentation of the repairs with platelet-rich plasma were critically analyzed. Based on the current literature, double-row repairs did not achieve superior clinical results compared to single-row repairs neither in the clinical results nor in the re-rupture rate. Multiple factors such as age, fatty infiltration, and initial rupture size might influence the results. If the rupture is not repairable, various options were described including cuff debridement, partial repair, tuberoplasty, or tendon transfers. The additional augmentation with platelet-rich plasma did not reveal any significant differences in the healing rate compared to conventional rotator cuff repairs.

LEVEL OF EVIDENCE

IV.