Restoration of shoulder biomechanics according to degree of repair completion in a cadaveric model of massive rotator cuff tear: importance of margin convergence and posterior cuff fixation

Outcomes After Superior Capsular Reconstruction With an Achilles Tendon-Bone Allograft Using the Modified Keyhole Technique: A 2-Year Follow-up of a Novel Technique for Irreparable Rotator Cuff Tears

Background

Despite improved outcomes, failure or nonhealing of graft materials has been reported after superior capsular reconstruction (SCR) for massive irreparable rotator cuff tears.

Purpose

To evaluate the short-term clinical and radiological outcomes of a novel technique for SCR using an Achilles tendon-bone allograft.

Study Design

Case series; Level of evidence, 4.

Methods

We performed a retrospective review of patients who underwent SCR using an Achilles tendon-bone allograft with the modified keyhole technique and who had a minimum follow-up of 2 years. The visual analog scale score for pain, American Shoulder and Elbow Surgeons score, and Constant score were evaluated as subjective outcomes, while range of motion of the shoulder joint and isokinetic strength were evaluated as objective outcomes. The acromiohumeral interval (AHI), bone-to-bone healing of the allograft and humeral head on computed tomography, and graft integrity on magnetic resonance imaging were evaluated as radiological outcomes.

Results

This study included 32 patients with a mean age of 56.8 ± 4.2 years and a mean follow-up of 28.4 ± 6.2 months. A significant improvement from preoperatively to the last follow-up was seen in the mean visual analog scale score for pain (from 6.7 to 1.8), American Shoulder and Elbow Surgeons score (from 42.7 to 83.8), Constant score (from 47.2 to 78.5), and AHI (from 4.8 to 8.2 mm) (P < .001 for all) as well as range of motion in forward elevation and internal rotation (P < .001 for both). Medial-to-lateral graft integrity was good in all patients. Nonunion at the fitting zone of the keyhole on the greater tuberosity was diagnosed in 1 case (3.1%), and failure of incorporation between the allograft and remnant tendon at the site of posterior margin convergence was observed in 4 cases (12.5%).

Conclusion

The outcomes after SCR using an Achilles tendon-bone allograft and the keyhole technique improved, with an increased AHI and excellent integrity in the medial and lateral directions compared with preoperatively. This technique is a reasonable option for the surgical treatment of irreparable rotator cuff tears.

Comparison of Outcomes After Arthroscopic Superior Capsule Reconstruction Versus Arthroscopic Partial Repair or Arthroscopic Debridement for Irreparable Rotator Cuff Tears

Background

Arthroscopic superior capsule reconstruction (SCR), arthroscopic partial repair (PR), and arthroscopic debridement (DB) are valid treatment options for irreparable rotator cuff (RC) tears.

Purpose/Hypothesis

The purpose of this study was to compare clinical, functional, and radiological outcomes of arthroscopic SCR with arthroscopic PR and arthroscopic DB in patients with irreparable posterosuperior RC tears. It was hypothesized that SCR would lead to superior clinical and functional outcomes compared with PR or DB.

Study Design

Cohort study; Level of evidence, 3.

Methods

Clinical and functional outcomes of this single-center retrospective study included range of motion, strength, and the age- and sex-adjusted Constant-Murley score. Patient-reported outcome measures (PROMs) involved the quick Disabilities of the Arm, Shoulder and Hand score, the Subjective Shoulder Value, and the visual analog scale for pain. Graft and repaired tendon integrity was evaluated by magnetic resonance imaging (MRI) at 12 months of follow-up.

Results

In total, 57 patients treated with SCR (n = 20), PR (n = 17), and DB (n = 20) were included. The mean clinical follow-up was 33.8 ± 17.9 months. Preoperative clinical and functional characteristics were comparable among the 3 groups. The range of motion and clinical and functional scores of all 3 groups significantly improved from pre- to postoperatively. Postoperative PROMs showed no differences among all 3 study groups. SCR revealed significantly higher postoperative strength compared with PR (P = .001) and DB (P = .004). Postoperative MRI revealed a rerupture in 4 patients with SCR (20%). Postoperative MRI showed a rerupture in 9 patients with PR ( 53%). Fatty muscle infiltration of the supraspinatus and infraspinatus significantly progressed within all 3 study groups in postoperative MRI scans. No clinical and functional differences were observed between intact and reruptured PR.

Conclusion

Patients who underwent SCR had better postoperative strength recovery than patients who underwent PR or DB.

Effect of intraarticular pressure on glenohumeral kinematics during a simulated abduction motion: a cadaveric study

BACKGROUND

The current understanding of glenohumeral joint stability is defined by active restrictions and passive stabilizers including naturally-occurring negative intraarticular pressure. Cadaveric specimens have been used to evaluate the role of intraarticular pressure on joint stability, although, while the shoulder's negative intraarticular pressure is universally acknowledged, it has been inconsistently accounted for.

HYPOTHESIS

During continuous, passive humeral abduction, releasing the native intraarticular pressure increases joint translation, and restoring this pressure decreases joint translations.

STUDY DESIGN

Descriptive Laboratory Study.

METHODS

A validated shoulder testing system was used to passively abduct the humerus in the scapular plane and measure joint translations for seven (n = 7) cadaveric specimens. The pressure within the glenohumeral joint was measured via a 25-gauge needle during passive abduction of the arm, which was released and subsequently restored. During motion, the rotator cuff muscles were loaded using stepper motors in a force feedback loop and electromagnetic sensors were used to continuously measure the position of the humerus and scapula. Joint translation was defined according to the instant center of rotation of the glenohumeral head according to the recommendations by the International Society of Biomechanics.

RESULTS

Area under the translation versus abduction angle curve suggests that releasing the pressure within the capsule results in significantly less posterior translation of the glenohumeral head as compared to intact (85-90˚, p < 0.05). Posterior and superior translations were reduced after 70˚ of abduction when the pressure within the joint was restored.

CONCLUSION

With our testing system employing a smooth continuous passive motion, we were able to show that releasing intraarticular pressure does not have a major effect on the path of humeral head motion during glenohumeral abduction. However, both violating the capsule and restoring intraarticular pressure after releasing alter glenohumeral translations. Future studies should study the effect of simultaneous external rotation and abduction on the relationship between joint motion and IAP, especially in higher degrees of abduction.

CLINICAL RELEVANCE

Thoroughly simulating the glenohumeral joint environment in the cadaveric setting may strengthen the conclusions that can be translated from this setting to the clinic.

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.

Infraspinatus shift for massive, posterosuperior tears yields good clinical outcome

AIM

To evaluate the functional outcome of partial reconstruction margin convergence in the treatment of massive, irreparable posterosuperior rotator cuff tear (RCT).

METHODS

This retrospective, single-center study included all patients that were operated by means of a partial repair and infraspinatus shift for a massive, posterosuperior cuff tear between 2009 and 2016, either in arthroscopic or mini-open technique. Outcome measures included sex- and age-adapted Constant Score (saCS), Western Ontario Rotator Cuff (WORC) Index, Disabilities of Arm, Shoulder and Hand Scores (DASH), and relative effect per patient (REPP).

RESULTS

Fifty-six shoulders in 54 patients (mean age: 66 ± 7 years) were evaluated at a mean follow-up of 40 ± 9 months. The mean tear size was Bateman 3.1 ± 0.7 and Patte 2.3 ± 0.4. All clinical scores showed improvement. The saCS improved from 64.1 ± 13.4 to 90.4 ± 13.7 (p < 0.0001), the DASH score from 51.8 ± 9.4 to 10.2 ± 13.4 (p < 0.0001) and the WORC index from 47.1% ± 8.6 to 87.9% ± 13.7 (p < 0.0001). The abduction strength of the affected side (1.7 ± 1.6 kg) was not restored to the same level as the contralateral side (5.4 ± 2.7 kg, p < 0.0001).

CONCLUSION

Partial cuff repair for posterosuperior, massive cuff tears yields good clinical outcome with a low rate of complications and high proportion of good and excellent responders.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Rotator cuff tear reaching the superior half portion of the humeral head causes shoulder abduction malfunction

PURPOSE

To examine the biomechanical properties governing posterosuperior rotator cuff (RC) tear progression and dynamic shoulder abduction function, in the absence of excess loading.

METHODS

Twelve freshly frozen cadaveric shoulders were evaluated via an established dynamic shoulder abduction stimulator. The shoulder abduction functions were primarily evaluated using subacromial contact pressure (SACP) during an abduction procedure, and subsequent middle deltoid force (MDF) under 5 conditions: (1) intact, (2) anterior 1/3 posterosuperior rotator cuff (PSRC) tear, (3) anterior 2/3 PSRC tear, (4) entire PSRC tear, and (5) global RC tear (tear involving the entire superior RC).

RESULTS

No obvious differences were observed in the peak MDF required for abduction, and in the peak SACP among the four PSRC tear statuses (49.8 ± 9.2 N, 0.39 ± 0.05 mPa [1/3 PSRC tear]; 49.3 ± 6.8 N, 0.40 ± 0.06 mPa [2/3 PSRC tear]; 51.6 ± 7.0 N, 0.44 ± 0.08 mPa [entire PSRC tear]), as well as intact statuses (48.3 ± 9.8 N, 0.40 ± 0.05 mPa). However, significant elevations in the peak MDF and peak SACP levels were observed among the four PSRC tear statuses and global RC tear (68.1 ± 9.3 N; 4.12 ± 1.50 mPa, P < 0.01).

CONCLUSION

In the absence of excess loading, the biomechanical function of the shoulder was not impaired by a simple PSRC tear. However, once the tear size reached the half superior portion of the humeral head, the humeral head migrated to the surface of the subacromion, and this action markedly decreased shoulder abduction function.

Traumatic rotator cuff tears - Current concepts in diagnosis and management

Rotator cuff tears represent one of common shoulder pathologies presenting over a wide spectrum of age groups and varying presentation. Typically, rotator cuff tears occur more frequently in elderly than in younger patients, following a chronic or acute-on-chronic course and usually secondary to due to tendon degeneration. Though there has been a considerable debate in the literature of the terms "acute" and "traumatic" used in the classification of rotator cuff tears, there appears to be consensus about the need for early diagnosis to facilitate prompt surgical treatment and the improve patient outcome. Significant differences in rotator cuff tears between those occurring in younger and older patients could be due to mechanism of injury, presentation, severity of the tear, biological healing potential and rehabilitation. Acute traumatic rotator cuff tears especially in younger age group represent a distinct entity from other patterns of rotator cuff tears. Consequently, a high index of suspicion, focused clinical examination, complementary imaging is a pre-requisite for an early diagnosis and effective management. We analyze the biomechanical consequences of acute rotator cuff tears along with characteristic mechanism of injury and spectrum of tendon involvement. The evolving concepts in the diagnosis and management of these distinct injuries are discussed with review of current literature.

Midterm Functional and Structural Outcomes of Large/Massive Cuff Tears Treated by Arthroscopic Partial Repair

Background:

Previous studies have shown good clinical outcomes in patients with irreparable large or massive rotator cuff tears treated using arthroscopic partial repair (APR); however, few studies have evaluated both functional and structural outcomes in these patients.

Purpose:

To evaluate both functional and structural outcomes in patients with large or massive rotator cuff tears treated using APR.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between March 2009 and November 2016, a total of 30 patients underwent APR because of the irreparability of their large or massive rotator cuff tears during surgery. Of these patients, 24 completed the minimum 24-month follow-up (mean, 61.8 ± 27.1 months; range, 24-112 months) and were included in this study. Functional outcome measures included the Japanese Orthopaedic Association (JOA) and University of California Los Angeles (UCLA) scores and the visual analog scale for pain. Structural outcome measures comprised preoperative fatty degeneration, mediolateral tear size, residual tendon attachment area, and glenohumeral (GH) arthritic changes evaluated on magnetic resonance imaging scans or plain radiographs before and after surgery. Functional and structural outcomes were evaluated preoperatively, at 3 months postoperatively, and at the final follow-up.

Results:

The JOA scores for all patients significantly improved from 67.9 ± 11.3 preoperatively to 85.4 ± 15.6 postoperatively (P < .0001). Similarly, the UCLA scores significantly improved from 15.8 ± 4.20 preoperatively to 29 ± 6.69 at final follow-up postoperatively (P < .0001). The mediolateral tear size were significantly decreased at 3 months postoperatively (P < .001) and at the final follow-up (P < .001). Compared with preoperative scores, the novel score evaluating the residual tendon attachment area improved from 3.08 ± 0.46 to 3.54 ± 0.41 (P < .001) after surgery overall, although it significantly deteriorated from 3 months postoperatively to the final follow-up. GH osteoarthritis progressed in 6 patients (25%). Patients who developed osteoarthritis had lower JOA and UCLA scores than did those who did not (JOA, P = .010; UCLA, P = .037).

Conclusion:

In irreparable large or massive rotator cuff tears treated using APR, functional outcome improved after surgery. Although the residual tendon attachment area improved, functional outcome after APR corresponded to the GH alterations at the midterm follow-up. Longer-term follow-up is needed to further elucidate the effect of APR on clinical outcomes in these patients.

Consider Long Head of Biceps Tendon for Reconstruction of Massive, Irreparable Rotator Cuff Tear

Despite the different treatment options for irreparable and massive rotator cuff tears (RCTs), there is no optimal treatment. Thirty percent of total RCTs can be classified as irreparable because of the massive tear size and severe muscle atrophy. The reported treatment failure rate is approximately 40% for massive RCTs. RCTs may be treated conservatively or surgically depending on pain, disability, and functional demands. The surgical treatment options are many, but decision making is a challenge; the real challenge is to apply the correct procedure for the correct indication in each patient. The long head of the biceps tendon (LHBT) was used for augmentation to bridge the gap in immobile, massive RCTs. An arthroscopic biceps-incorporating technique was used for repair of large and massive RCTs, avoiding undue tension on the rotator cuff (RC). Recently, the LHBT was used for superior capsular reconstruction. This article describes the use of the LHBT for reconstruction of massive and irreparable RCTs through the following steps: (1) open exposure of the RCT, (2) debridement and subacromial decompression, (3) biceps tenotomy at the LHBT's origin on the glenoid, (4) LHBT and RC cuff mobilization, (5) passage of the LHBT through the mobilized RC and reflection onto itself, (6) tuberoplasty, and (7) fixation of the RC complex at the RC footprint.

[Research progress of treatment for massive rotator cuff tears]

Objective

To review the research progress of treatment for massive rotator cuff tears.

Methods

The domestic and foreign literature about the treatment of massive rotator cuff tears was reviewed. The methods and effectiveness were extensively summarized.

Results

The treatment of massive rotator cuff tears still needs long-term research to promote its continuous improvement. The main goal of treatment is to relieve the symptoms and improve the shoulder joint function. With the development of arthroscopic technique, arthroscopic repair of rotator cuff tears has become a mature surgical protocol. Among these techniques, superior capsule reconstruction and patch augmentation for massive rotator cuff tears acquire more attention in recent years. As for rotator cuff arthropathy, reverse shoulder arthroplasty is considered to be a final choice.

Conclusion

Surgical treatment is the main choice for massive rotator cuff tears. Patients' age and muscle condition should be taken into consideration to decide the surgical technique.

Biomechanics in an Incomplete Versus Complete Supraspinatus Tear: A Cadaveric Study

Background:

Degenerative and traumatic changes to the rotator cuff can result in massive and irreparable rotator cuff tears (RCTs).

Purpose/Hypothesis:

The study objective was to conduct a biomechanical comparison between a small, incomplete RCT and a large, complete RCT. We hypothesized that the incomplete supraspinatus (SS) tear would lead to an incremental loss of abduction force and preserve vertical position of the humeral head, while a complete SS tear would cause superior humeral migration, decrease functional deltoid abduction force, and increase passive range of motion (ROM).

Study Design:

Controlled laboratory study.

Methods:

Six cadaveric shoulders were evaluated using a custom testing apparatus. Each shoulder was subjected to 3 conditions: (1) intact/control, (2) 50%, full-thickness, incomplete SS tear, and (3) 100%, complete SS tear. Deltoid abduction force, superior humeral head migration, and passive ROM were measured in static conditions at 0°, 30°, and 60° of glenohumeral abduction, respectively.

Results:

The intact SS resulted in a mean deltoid abduction force of 2.5, 3.3, and 3.8 N at 0°, 30°, and 60° of abduction, respectively. Compared with the intact shoulder, there was no significant difference in mean abduction force seen in the incomplete tear, while the force was significantly decreased by 52% at 30° of abduction in the complete tear (P = .009). Compared with the incomplete tear, there were significant decreases in abduction force seen in the complete tear, by 33% and 48% (0.9 N and 1.1 N) at 0° and 30° of abduction, respectively (P = .04 and .004). The intact configuration experienced a mean superior humeral head migration of 1.5, 1.4, and 1.1 mm at 0°, 30°, and 60° of abduction, respectively. The complete tear resulted in a superior migration of 3.0 and 4.4 mm greater than the intact configuration at 0° and 30° of abduction, respectively (P = .001). There was a 5° and 10° increase in abduction ROM with 50% and 100% tears, respectively (P = .003 and .03).

Conclusion:

An incomplete SS tear does not significantly alter the biomechanics of the shoulder, while a large, complete SS tear leads to a significant superior humeral migration, a decreased deltoid abduction force, and a mild increase in passive ROM.

Clinical Relevance:

Our findings demonstrate the effects of large SS tears on key biomechanical parameters, as they progress from partial tears.

Patient-Determined Outcomes After Arthroscopic Margin Convergence Rotator Cuff Repair

Purpose

To determine whether patients who require margin convergence would have equivalent postsurgical patient-determined scores compared with patients with standard rotator cuff repair. The secondary purpose of this study was to determine whether the short-term results found for patients with margin convergence repairs would be durable through medium-term follow-up.

Methods

A retrospective analysis of patients undergoing arthroscopic rotator cuff repair was performed to examine the effects of marginal convergence on patient-determined outcomes (Western Ontario Rotator Cuff Index, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, Single Assessment Numeric Evaluation, and Shoulder Activity Level). Patient-determined outcomes in patients who had margin convergence repairs were compared with patients who had standard rotator cuff repair. Prospective follow-up of patients that had margin convergence repairs was performed to determine whether patient-determined outcomes deteriorated over time.

Results

Two-hundred-seventy-two patients had standard rotator cuff repairs and 9 patients had margin convergence rotator cuff repair (3.2%). All patients had significant improvements in their Western Ontario Rotator Cuff Index, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and Single Assessment Numeric Evaluation. Patients requiring margin convergence rotator cuff repair had similar preoperative and postoperative scores compared with patients with a standard rotator cuff repair. At a mean follow-up of 7.5 years, there was no change in outcome scores compared with the early follow-up time point (mean 3.3 years) for patients undergoing margin convergence.

Conclusions

Arthroscopic margin convergence repair techniques along with the treatment of concomitant pathologies result in similar patient-determined outcomes compared with standard rotator cuff repair techniques. These results appear to be durable and do not deteriorate from short-term to medium-term follow-up.

Level of evidence

III: Retrospective comparative study.

Biomechanical effects of superior capsular reconstruction in a rotator cuff-deficient shoulder: a cadaveric study

BACKGROUND

Superior capsular reconstruction (SCR) has been gaining popularity as a treatment for irreparable rotator cuff tears (RCTs), especially in younger patients. This biomechanical study aimed to investigate how SCR affects functional abduction force, humeral head migration, and passive range of motion following an irreparable RCT. We hypothesized that SCR will restore these parameters to nearly intact shoulder levels.

METHODS

Six fresh-frozen cadaveric shoulders were evaluated using a custom biomechanical testing apparatus. Each shoulder was taken through 3 conditions: (1) intact (control); (2) irreparable, complete supraspinatus (SS) tear; and (3) SCR. Functional abduction force, superior humeral head migration, and passive range of motion, including axial shoulder rotation, were measured in static condition at 0°, 30°, and 60° of glenohumeral abduction. Data were analyzed using the paired Student t test or Wilcoxon signed rank test, depending on the results of normality testing.

RESULTS

The irreparable SS tear resulted in significantly lower functional abduction force at 30° of abduction (P = .01) and a trend toward a decrease (P = .17) at 60° compared with the intact configuration. SCR shoulders produced greater functional force at 0° compared with the tear configuration (P = .046). Humeral head migration was significantly increased by 4.4 and 3.0 mm at 0° and 30° of abduction, respectively, when comparing the intact vs. SS tear configurations (P = .001). SCR decreased superior migration down to levels of intact shoulders at 0° and 30° of abduction (P = .008 and P = .013, respectively) and was not significantly different from the intact configuration at any angle. SCR decreased passive shoulder extension compared with the tear configuration and increased abduction compared with the intact configuration (P = .007 and P = .03, respectively). The overall arc of axial rotation was not significantly different between SCR and the intact configuration at any angle.

CONCLUSIONS

In the setting of an irreparable SS tear, SCR restores key biomechanical parameters of the shoulder to intact levels. SCR should be considered for qualifying patients with irreparable RCTs.

Irreparable rotator cuff tears: Current treatment options

Rotator cuff disease is one of the most common causes of shoulder pain, yet controversy still exists regarding treatment of "irreparable" tears. Nonoperative management, including physical therapy and steroid injections, should be reserved for those without significant pain or functional impairment. Debridement may be used for low-demand patients, and should be performed with partial cuff repair, subacromial decompression, and/or acromioplasty to maximize outcomes. Biceps tenotomy and/or tenodesis have been shown to reduce postoperative pain and improve satisfaction when performed in conjunction with rotator cuff repairs, with no difference in functional outcome comparatively. Tendon transfers have been advocated with the potential benefit to improve function and decrease pain. More recently, extracellular matrix and human-derived dermal allografts have been used off-label as patch grafts in irreparable tears. Superior capsular reconstructive techniques and subacromial balloon spacers serve a similar function by acting to depress the humeral head in a cuff-deficient shoulder, however long-term data is needed before widespread adoption of these procedures. Finally, reverse shoulder arthroplasty serves as a salvage option for low demand elderly patients.

Sources, Quality, and Reported Outcomes of Superior Capsular Reconstruction: a Systematic Review

PURPOSE

Superior capsular reconstruction (SCR) has gained attention as a potential treatment option for those with massive irreparable rotator cuff tears without significant arthritis. The aim of this systematic review is to review and evaluate the current sources and quality of SCR literature as well as reported outcomes.

METHODS

Three databases (PubMed, Ovid [MEDLINE], and EMBASE) were searched independently and in duplicate to systematically screen the literature. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist guided the reporting and data abstraction. The results are presented in a narrative summary fashion using descriptive statistics.

RESULTS

Overall, 58 studies were identified, including 304 different patients. There was a rapid increase in the number of publications observed over the past 3 years, with the most dramatic single-year increase noted from 2017 to 2018 (175% increase). There are no level 1 studies, and 95% of the included studies were level 4 and 5 evidence. Comparing pre-operative to post-operative pooled-weighted mean outcome scores, the American Shoulder and Elbow Surgeons score improved from 44.2 to 84.8, the Visual Analogue Scale from 5.0 to 1.5, and acromiohumeral distance from 6.5 to 8.4 mm, respectively. Range of motion in forward elevation also improved from 111° to 152°. Among studies reporting, the complication rate was 13.4% with a revision surgery rate of 4.3%.

CONCLUSION

Over the past 3 years there has been considerable growth in the number of publications of publications related to SCR. Despite a lack of high-quality clinical evidence, preliminary available evidence does suggest promising results both functionally and radiographically. There is a need for future higher-quality research such as large randomized controlled trials to improve our current understanding of the benefits of SCR.

The pathogenesis and management of cuff tear arthropathy

Massive rotator cuff tears may lead to the development of cuff tear arthropathy (CTA). Although this pathology has been recognized for more than 150 years, treatment strategies have continued to evolve. During the last decade, there has been increased understanding of the molecular and cellular changes that govern rotator cuff tear outcomes and development of new treatment strategies to repair or reconstruct the rotator cuff. These have included an expansion of the use of arthroscopic double-row transosseous-equivalent repairs and the development of superior capsule reconstruction. However, the greatest change in the management of CTA has been the expansion of the use of reverse total shoulder arthroplasty, which has become the standard of care for patients who do not have a repair option and when nonoperative management has failed. This review article summarizes the current literature on the management of CTA, including nonoperative, repair, reconstruction, and replacement options, with a focus on literature in the last 5 years.

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.

[Irreparable rotator cuff tears. Debridement, partial reconstruction, tendon transfer or reversed shoulder arthroplasty]

Therapeutic options for the treatment of irreparable rotator cuff tears are fluent, are dependent on the patients' claims and demands and on the grade of the ongoing cuff tear arthropathy.A partial rotator cuff reconstruction with sufficient tenolysis combined with interval slide techniques to restore the anterior and posterior force couple may be indicated if there is no fatty degeneration > grade 3 of the rotator cuff muscles in a well-centered joint. The margin convergence technique with side-by-side adaptation of the tendon limbs may reduce the load on the reconstructed tendons.The role of the suprascapular nerve, which can probably be constricted by the retracted rotator cuff, and its therapy has not been completely clarified. When distinct symptoms are present neurolysis may be reasonable.Tendon transfers can be indicated in a cooperative patient < 65 years with a higher grade of muscular atrophy but without degenerative changes > grade II according to Hamada with the loss of active external rotation but performable active flexion. For posterosuperior tears the latissimus dorsi or recently the teres major tendon transfer to the rotator cuff footprint may be appropriate. For nonreconstructable anterosuperior tears a partial transfer of the pectoralis major tendon is possible.Careful subacromial debridement combined with biceps tenotomy and a cautious or reversed decompression may reduce the pain temporarily without having an influence on active motion until with the loss of active elevation the indication for a reversed shoulder arthroplasty is reached.In the mean time, absorbable subacromial spacers may re-center the humeral head, but the effectiveness of this therapy on clinical outcome should be analyzed in further studies.

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.

Arthroscopic Partial Repair of Irreparable Rotator Cuff Tears: Preoperative Factors Associated With Outcome Deterioration Over 2 Years

BACKGROUND

Arthroscopic partial repair is a treatment option in irreparable large-to-massive rotator cuff tears without arthritic changes. However, there are indications that arthroscopic partial repair does not yield satisfactory outcomes.

PURPOSE

To report the clinical and radiographic results of arthroscopic partial repairs in patients with irreparable large-to-massive cuff tears. In addition, an analysis was performed regarding preoperative factors that may influence patient outcomes and patient-rated satisfaction over time.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From 2005 to 2011, a total of 31 patients who underwent arthroscopic partial repair for irreparable large-to-massive cuff tears were retrospectively evaluated. Partial repair was defined as posterior cuff tissue repair with or without subscapularis tendon repair to restore the transverse force couple of the cuff. Pain visual analog scale (PVAS), questionnaire results (American Shoulder and Elbow Surgeons [ASES] and Simple Shoulder Test [SST]), and radiographic changes (acromiohumeral distance and degenerative change) were assessed preoperatively, at first follow-up (roughly 1 year postoperatively), and at final follow-up (>2 years postoperatively). Patients rated their satisfaction level at each postoperative follow-up as well. Preoperative factors that might influence outcomes, such as patient demographics, tear size, and fatty infiltration, were investigated.

RESULTS

The preoperative, first follow-up, and final follow-up results for mean PVAS (5.13, 2.13, and 3.16, respectively) and questionnaires (ASES: 41.97, 76.37, and 73.78; SST: 3.61, 6.33, and 6.07, respectively) improved significantly (all P < .05). Radiographic evaluation showed no difference compared with preoperative status. Nevertheless, patient-rated satisfaction at final evaluation was inferior: 16 good responses ("very satisfied" and "satisfied") and 15 poor responses ("rather the same" and "dissatisfied"). Despite initial improvements in both groups (P < .05), patients with poor satisfaction demonstrated statistically significant deterioration in mean PVAS (from 2.07 to 4.67), questionnaire scores (ASES: from 74.56 to 59.80; SST: from 5.11 to 3.81), and acromiohumeral distance (from 7.19 to 5.06 mm) between the first and final follow-up (all P < .05). Patients with good satisfaction showed no significant difference or they improved (P > .05) from the first to the final follow-up. Among preoperative factors, fatty infiltration of the teres minor was identified as the only statistically significant factor affecting patient-rated satisfaction (P = .007).

CONCLUSION

This study showed that arthroscopic partial repair may produce initial improvement in selected outcomes at 2-year follow-up. However, about half of the patients in the study were not satisfied with their outcomes, which had deteriorated over time. Preoperative fatty infiltration of the teres minor was the only factor that correlated with worse final outcomes and poor satisfaction after arthroscopic partial repair.

The role of pectoralis major and latissimus dorsi muscles in a biomechanical model of massive rotator cuff tear

BACKGROUND

Superior migration of the humeral head after massive rotator cuff tear (mRCT) is thought to lead to cuff tear arthropathy. Previous biomechanical studies have demonstrated the ability of the pectoralis major and latissimus dorsi (PM/LD) muscles to resist this migration. This study examined the role of PM/LD muscles on glenohumeral joint forces and acromiohumeral contact pressures in a mRCT model.

METHODS

Six cadaveric shoulders were tested using a custom shoulder-testing system. Muscle insertions of the rotator cuff, deltoid, and PM/LD were preserved and used for muscle loading. Specimens were tested in 3 different humeral rotation positions at 0° abduction and 2 rotation positions at 60° abduction. Testing was performed for intact specimens, after supraspinatus removal, and after supraspinatus/infraspinatus/teres minor removal. PM/LD were loaded or unloaded to determine their effect. Humeral head kinematics, glenohumeral joint forces, and acromiohumeral contact area and pressure were measured.

RESULTS

For the mRCT condition at 0° abduction, unloading the PM/LD resulted in superior shift of the humeral head. Acromiohumeral contact pressures were undetectable when the PM/LD were loaded but increased significantly after PM/LD unloading. After mRCT, superior joint forces were increased and compressive forces were decreased compared with intact; loading the PM/LD resolved these abnormal forces in some testing conditions.

CONCLUSION

In mRCT, the PM and LD muscles are effective in improving glenohumeral kinematics and reducing acromiohumeral pressures. Strengthening or neuromuscular training of this musculature, or both, may delay the progression to cuff tear arthropathy.

No prosthetic management of massive and irreparable rotator cuff tears

A massive rotator cuff tear is not necessarily irreparable. Number of tendons involved, muscle-tendon unit quality, and decreased acromionhumeral distance (AHD) are as important as tear size in determining reparability of lesion. Massive and irreparable rotator cuff tears cannot be anatomically repaired to the bone and are a common source of pain and disability even in middle-aged patients. In these patients when conservative management has failed, it is possible to perform different surgical techniques. A functional repair can help to restore the horizontal force couple of the cuff on the humeral head and to increase the AHD. Debridement of irreparable tears and biceps tenotomy or tenodesis can have a role in low functional demand patients but results deteriorate over time. Recently, several commercially available tissue-engineered biological and synthetic scaffolds have been developed to augment rotator cuff repairs. The aim is to provide a mechanical improvement in case of poor quality tissue at time zero and give a support to have a better cuff healing. In selected cases, the scaffold can be used also to bridge tendon defect. Patients who not have pseudoparalysis, cuff tear arthropathy and with intact deltoid function can benefit from tendon transfers with satisfactory outcomes. These different procedures should be chosen for each patient with selected criteria and after a satisfactory explanation about the really possible expectation after surgery.