Medialized rotator cuff repair for retracted, massive, postero superior tears: Clinical and radiological outcomes

A match-pair analysis of single row vs transosseous equivalent double row in massive posterosuperior rotator cuff tears in patients > 70 years old

INTRODUCTION

The aim of this study was to compare the results of single versus double row (TEO) in massive tears of the posterosuperior rotator cuff in patients older than 70 years old.

METHODS

Between October 2019 and July 2022, 46 patients, older than 70 years old, were operated on, in two centers, by one surgeon (FM), in one center, we performed a single-row repair, while in the other a double row, transosseous equivalent. Patients were paired by age and gender. All patients were studied with a preoperative MRI along with preoperative age and gender adjusted constant score. Postoperative patients were evaluated at the end of the FU. Mean time of FU for single row was 3.2 years (2-4.1) and for TOE was 3.5 years (2.4-3). Mean age for SR patients was 71.15 years (70-82) and for TOE was 74.8 years (70-81). We were able to evaluate 20 pairs of patients (15 pairs of females and five pairs of males).

RESULTS

CS differed in both groups of patients. Patients operated on with TOE had a better, but non-significant CS 81.3 (TOE) versus 75.7 (SR) p > 0.05. The patients operated own with TOE showed statistically significant better arm abduction strength than patients operated on with SR (p < 0.05). There was a trend for patients operated on with TOE to have a better ROM and less pain.

DISCUSSION

The results of our work show that patients older than 70 years old, with repairable RCT operated on with a transosseous equivalent, have a trend to have a better CS and a significantly better strength than patients operated on with SR.

Clinical outcomes of medialized single-row repair with fascia lata graft augmentation for large and massive rotator cuff tears

BACKGROUND

A high postoperative retear rate after arthroscopic rotator cuff repair (ARCR) of large and massive tears remains a problem. This study evaluated rotator cuff integrity after ARCR with fascia lata graft augmentation for large and massive rotator cuff tears and compared clinical outcomes between patients with intact repairs and retears.

METHODS

Forty-five patients with rotator cuff tears who could not undergo primary repair due to tendon retraction underwent arthroscopic medialized single-row repair with fascia lata graft augmentation. The patients' minimum follow-up was 2 (2-9) years. Supraspinatus cuff integrity was evaluated postoperatively by magnetic resonance imaging. We compared the clinical outcomes of patients with intact repairs vs. retears based on the University of California-Los Angeles (UCLA), Constant, and Japanese Orthopaedic Association (JOA) scores. We also evaluated their range of motion (ROM) and muscle strength.

RESULTS

Retears were observed in 11 of 45 patients. UCLA, Constant, and JOA scores significantly improved postoperatively compared to preoperatively in the intact repair (all P < .001) and retear (all P < .036) groups. The intact repair group had significantly higher Constant (75.6 [mean] ± 9.9 [SD] vs. 69.8 ± 7.9; P = .026) and JOA (94.4 ± 6.9 vs. 89.8 ± 5.9; P = .041) scores than the retear group. Forward elevation, abduction, and the strengths of abduction and external rotation significantly improved in the intact repair group (all P < .003) but not in the retear group (all P > .05). The intact repair group had significantly higher postoperative forward flexion (165° ± 15° vs. 154° ± 23°; P = .036), abduction (164° ± 17° vs. 151° ± 26°; P = .029), and abduction strength (3.5 ± 2.2 kg vs. 2.3 ± 1.2 kg; P = .017) than the retear group. In the intact repair group (n = 34), Sugaya type I:II ratio differed significantly between postoperative 3 months (2:32) and 24 months (24:10) (P < .001). Repaired tendon thickness did not decrease significantly between 3 months (7.1 mm) and 2 years (6.9 mm) (P = .543).

CONCLUSIONS

ARCR with fascia lata graft augmentation of large and massive rotator cuff tears showed a 24.4% retear rate but significantly improved the clinical scores, ROMs, and muscle strength with excellent cuff integrity in the intact repair group. However, the differences in the Constant and UCLA scores between the intact repair and retear groups were under the minimal clinically important difference, and their clinical significance is uncertain. Our results confirm that ARCR with fascia lata graft augmentation improves patients' postoperative outcomes if the repair site is maintained postoperatively.

Estimation of the carbon footprint of arthroscopic rotator cuff repairs in France

AIM

The main objective of this study was to estimate the carbon impact of arthroscopic rotator cuff repairs in France. The secondary objective was to assess the effectiveness of the following measures in reducing the carbon footprint associated with this technique: outpatient treatment, arthroscopic water filtration, surgery under locoregional anesthesia.

HYPOTHESIS

The hypothesis was that the carbon footprint could be significantly improved with the implementation of these three procedures.

METHODS

A continuous series of 26 patients who underwent surgery for a rotator cuff tear involving only one tendon between November 2020 and April 2021 were included. The evaluation protocol consisted of three parts: 1/ use of volatile anesthetic agents; 2/ electrical consumption linked to the procedure; 3/ emissions related to patient and staff travel, delivery of implants and waste management. Another series of 26 patients operated between November 2018 and April 2019 who had none of these three factors were matched.

RESULTS

The carbon impact of arthroscopic repair of the rotator cuff was estimated at 334.61±18.82kgCO2eq. The implementation of the three methods for improvement made it possible to significantly reduce emissions by 40.9±1.71kgCO2eq (12.2%) (p<0.001).

CONCLUSION

Performing surgery under locoregional anesthesia, on an outpatient basis with water purification, reduces the carbon impact of arthroscopic rotator cuff repair by more than 12%.

LEVEL OF EVIDENCE

III, retrospective case control.

Superior capsular reconstruction for irreparable posterosuperior rotator cuff tears

Although the superior portion of the shoulder joint capsule is a clearly distinct structure, its ability to prevent vertical humeral head translation in irreparable rotator cuff tears remains controversial. The clinical results of superior capsule reconstruction (SCR) in this context are satisfactory but the radiological outcomes are poor in up to two-thirds of patients. Moreover, there is no proof that SCR is more beneficial than simply doing a subacromial debridement, a partial repair or a tenotomy of the long head of biceps. Furthermore, graft healing is not predictive of success. Given the lack of comparative studies with high level of evidence (level 1 or 2), we cannot conclude that this surgical technique (and its many variants) has a place in our treatment paradigm. Also, it seems that xenografts are no longer being used given the high rate of structural failure seen on MRI and the large number of complications. If the long head of biceps tendon is still intact at the time of surgery, it is a feasible option for SCR given the reasonable cost and minimal complications. If it is not - but the subscapularis tendon is intact or repairable - an allograft or a non-local autograft should be considered, despite its unpredictable clinical results. Surgeons should inform patients of the high rate of radiological repair failure and the worse results if a reverse shoulder arthroplasty should be needed subsequently. Level of evidence: 4.

Repair of Massive Rotator Cuff Tear With Medialization and Balloon Spacer Insertion

Retracted massive rotator cuff tears can be challenging to repair. Reduction of the retracted tendon to the native footprint may result in a repair with excessive tension. Repair under excessive tension predisposes to increased tendon retear rates. Footprint medialization involves securing the tendon medial to the anatomic footprint, resulting in decreased tension during repair. Several surgical adjuncts can also be employed to reinforce such tears so as to reduce the risk of retear. The aim of this Technical Note is to describe a surgical technique of rotator cuff repair with medialization of the footprint combined with a balloon spacer insertion.

Editorial Commentary: Extreme Medial Repair of Massive Rotator Cuff Tears With Atrophy Warrants Caution: Robbing Peter to Pay Paul

Medialization of the rotator cuff insertion as a technique to manage massive rotator cuff tears has been described for decades. However, "extreme medialization" as a means to manage massive rotator cuff tears with significant atrophy warrants caution. Nonanatomic reconstruction almost always carries a price. Biomechanical studies show extreme medialization results in significant and obligate restriction of motion, and it is difficult to imagine how extreme medialization would allow normal clinical motion without substantial scapulothoracic compensation. Similarly, obligatory loss of strength could be expected. Based on the current evidence, I will not indicate this technique for my own patients at the present time.

Medialized Rip-Stop Convergence Technique for Retracted Rotator Cuff Tears

Attempts to restore the anatomical footprint during rotator cuff repair for retracted, relatively immobile tears can be difficult. In some cases, it can lead to excessive tension of the repair. Previous studies have noted improved clinical outcomes when repair tension is not excessive, and medialization of the anatomical footprint has been suggested as a technique that can help surgeons repair large, retracted tears without excessive tension and achieve improved clinical outcomes. Of note, excessive tension when restoring the rotator cuff tendon to the anatomical footprint is not limited to large, retracted tears. In some cases, restoring small- and medium-sized tears to the anatomical footprint also can lead to excessive tension. Therefore, it is not uncommon for the authors to employ some degree of footprint medialization even for repair of small- or medium-sized tears if repair to the anatomical footprint will lead to excess tension. The purpose of this article and video demonstration is to provide instruction for a reproducible rotator cuff technique using a medialized single-row rip-stop construct combined with convergence.