Can Preoperative Magnetic Resonance Imaging Predict the Reparability of Massive Rotator Cuff Tears?

Novel methods to diagnose rotator cuff tear and predict post-operative Re-tear: Radiomics models

Objective

To validated a classifier to distinguish the status of rotator cuff tear and predict post-operative re-tear by utilizing magnetic resonance imaging (MRI) markers.

Methods

This retrospective study included patients with healthy rotator cuff and patients diagnosed as rotator cuff tear (RCT) by MRI. Radiomics features were identified from the pre-operative shoulder MRI and selected by using maximum relevance minimum redundancy (MRMR) methods. A radiomics model for diagnosis of RCT was constructed, based on the 3D volume of interest (VOI) of supraspinatus. Another model for the prediction of rotator re-tear after rotator cuff repair (Re-RCT) was constructed based on VOI of humerus, supraspinatus, infraspinatus and other clinical parameters.

Results

The model for diagnosing the status of RCT produced an area under the receiver operating characteristic curve (AUC) of 0.989 in the training cohort and 0.979 for the validation cohort. The radiomics model for predicting Re-RCT produced an AUC of 0.923 ± 0.017 for the training dataset and 0.790 ± 0.082 for the validation dataset. The nomogram combining radiomics features and clinical factors yielded an AUC of 0.961 ± 0.020 for the training dataset and 0.808 ± 0.081 for the validation dataset, which displayed the best performance among all models.

Conclusion

Radiomics models for the diagnosis of rotator cuff tear and prediction of post-operative Re-RCT yielded a decent prediction accuracy.

Clinical and radiological outcomes between superior capsule reconstruction using allografts or xenografts: a 2-year retrospective comparison study

BACKGROUND

Treating symptomatic, massive, irreparable rotator cuff tears remains challenging and controversial. Superior capsule reconstruction (SCR) using the tensor fascia lata has shown promising clinical results; however, due to donor site morbidity, interest in SCR using other grafts has increased. Yet, no studies have compared allografts with xenografts. In addition, the clinical results of graft tears remain controversial. This study compared the clinical and radiological outcomes of SCR between those with allografts and xenografts.

METHODS

Sixty-seven patients who had undergone SCR with allografts or xenografts between January 2016 and December 2020 were included in this retrospective study. Furthermore, 62 patients were evaluated 2 years postsurgery, with five patients excluded due to loss to follow-up or conversion to reverse shoulder arthroplasty. The Constant, American Shoulder and Elbow Surgeons, and visual analog scale scores, range of motion, and radiological outcomes were evaluated before the surgery and at 6 and 24 months after surgery.

RESULTS

The graft tear rate was 23.08% in the allograft group and 42.86% in the xenograft group at 6 months after surgery; at 2 years postsurgery, the gap further widened to 32.43% and 64%, respectively, showing a significant difference. The graft in the allograft group was thicker than that in the xenograft group, and there were significant differences on the humeral side and in the midsubstance area. The allograft group showed significantly better visual analog scale, Constant, and American Shoulder and Elbow Surgeons scores than the xenograft group 2 years postsurgery. However, the difference in clinical outcomes between the two groups did not surpass minimal clinically important differences.

CONCLUSION

Although arthroscopic SCR using xenografts had significantly lower clinical outcome than allografts, this difference did not reach minimal clinically important differences. Arthroscopic SCR using xenografts showed higher graft tear rates than allografts. Even with partial tears, better results were obtained if the graft continuity was maintained. Additionally, after surgery, the xenograft showed less thickness than the allograft and resulted in more tears, specifically in the midsubstance area.

A modified Patte classification system for rotator cuff tendon retraction to predict reparability and tendon healing in arthroscopic rotator cuff repair

PURPOSE

The purpose of this study was to propose a modified Patte classification system for tendon retraction, including the cut-off points for predicting reparability and rotator cuff healing after arthroscopic rotator cuff repair (ARCR) and assess its prediction accuracy and measurement reliability.

METHODS

This retrospective study included 463 consecutive patients scheduled to undergo ARCR for full-thickness supraspinatus tears. Receiver operating characteristic (ROC) curve analysis was used to determine the cut-off points for predicting reparability and tendon healing. The modified Patte classification system, in which these cut-off points were combined with the original Patte classification, classified the tendon retraction as stages I-V. The prediction accuracy of reparability and tendon healing was assessed using the area under the curve (AUC). Measurement reliability was determined using Cohen's κ statistics.

RESULTS

Of the 402 included patients, 32 rotator cuff tears were irreparable and 71 of the remaining 370 were diagnosed with healing failure. ROC analysis determined the cut-off point of reparability at the medial one-fifth and that of tendon healing at the medial one-third of the humeral head. The AUC of the modified Patte classification for predicting reparability and tendon healing was 0.897 (excellent) and 0.768 (acceptable), respectively. Intra-rater reliability was almost perfect (mean κ value: 0.875), and inter-rater reliability was substantial (0.797).

CONCLUSION

Diagnostic performance of the modified Patte classification system was excellent for reparability and acceptable for rotator cuff healing, with high measurement reliability. The modified Patte classification system can be easily implemented in clinical practice for planning surgical procedures and counselling patients in the day-by-day clinical work.

LEVEL OF EVIDENCE

Level III.

Factors associated with reparability of rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

To identify and quantify the factors associated with the reparability of rotator cuff tears (RCTs).

METHODS

PubMed, Scopus, and Web of Science databases were searched for clinical studies published in English focusing on RCT reparability by using the keywords "rotator cuff tear" and "reparability". A meta-analysis was conducted if ≥3 studies examined the same factor and provided enough data to assess RCT reparability. Quality assessment was completed using the quality assessment of diagnostic accuracy studies tool.

RESULTS

Eighteen studies (2700 patients) were enrolled and 26 factors were included in the meta-analysis. The dichotomous variables associated with irreparability were Patte stage 3 (odds ratio (OR): 8.0, 95% confidence interval [CI]: 4.3-14.9), massive tear vs. large tear (OR: 3.1, 95% CI: 1.3-7.2), Goutallier stage for each tendon, and tangent sign (OR: 11.1, 95% CI: 4.3-28.4). The continuous variables associated with irreparability were age (mean difference (MD): 3.25, 95% CI: 1.4-5.1), mediolateral tear size (MD: 12.3, 95% CI: 5.8-18.9), anteroposterior tear size (MD: 10.4, 95% CI: 5.2-15.6), acromiohumeral distance on X-ray (MD: -2.3, 95% CI: -3.0 to -1.6) and magnetic resonance imaging (MD: -1.8, 95% CI: -2.8 to -0.9), and inferior glenohumeral distance on magnetic resonance imaging (MD: 2.2, 95% CI: 1.4-3.0).

CONCLUSION

This study revealed that older age, larger tear size, severe fatty infiltration, muscle atrophy, and advanced superior migration of the humeral head were strongly associated with irreparable RCTs. Conversely, clinical symptoms provided limited information for predicting reparability. Additionally, the tangent sign emerged as a powerful and simple tool for individual prediction, and several quantitative scoring systems also proved useful.

Reliability of Magnetic Resonance Imaging Criteria for the Preoperative Assessment of Rotator Cuff Tears: A Systematic Review

BACKGROUND

Magnetic resonance (MR) imaging is the most common modality for assessment of the rotator cuff before and after surgery. Several classifications have been described aiming to define main tear characteristics. However, there is still confusion when it comes to the reliability of those classifications.

PURPOSE

(1) To identify all MR classifications available in the literature for preoperative assessment of rotator cuff tears, (2) to summarize available data on the reliability of identified classifications, and (3) to assess the methodological quality of reliability studies.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies reporting MR assessment in patients with a superior or posterosuperior rotator cuff tear were included. After identification of the available MR criteria, reliability studies were analyzed. Descriptive statistics were used to summarize findings. Methodological quality was assessed using the Quality Appraisal of Reliability Studies checklist.

RESULTS

A total of 75 studies were included in this review. Eight categories of outcomes could be identified. Of the total, 62 studies reported interobserver reliability whereas 32 reported intraobserver reliability of some of the identified criteria. Each category reflected a variety of reliability, ranging from poor to excellent agreement. MR proved to be a reliable imaging modality to detect the structural integrity of the posterosuperior cuff, especially in cases of full-thickness tear; it was also reliable in terms of tear width and length and muscle atrophy based on a tangent sign or Thomazeau classification. All other classifications did not prove acceptable reliability. Methodological quality was high for 23 articles and moderate for 14.

CONCLUSION

Preoperative MR is a reliable imaging modality to identify full-thickness tears, measure tear size and morphology, and identify muscle atrophy with tangent sign or Thomazeau classification. All other outcomes and classifications did not show acceptable reliability; therefore, caution is needed when using them for preoperative evaluation of a rotator cuff tear.

Definition of irreparable rotator cuff tear: a scoping review of prospective surgical therapeutic trials to evaluate current practice

BACKGROUND

The definition of irreparable rotator cuff tear (IRCT) is controversial. This scoping review provides definitions used to describe IRCT in the literature. This scoping review (1) identified criteria used in the definition of IRCT and (2) investigated the current state of those criteria in prospective surgical therapeutic trials.

METHODS

This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. PubMed, Scopus, and Web of Science were searched in March 2023. Studies were screened against predetermined inclusion and exclusion criteria. Criteria regarding clinical symptoms, preoperative images, and intraoperative findings were captured respectively.

RESULTS

A total of 41 prospective studies were eligible for inclusion, and 35 studies (85.4%) defined IRCT. IRCT was defined on the basis of the following main criteria: preoperative image findings (28/35), intraoperative findings (24/35), and symptoms (16/35). With regard to preoperative images, IRCT was mainly defined on the basis of retraction of the tendon in the coronal plane (22/28), the severity of fatty degeneration (19/28), and ruptured tendon number or width of the defect in the sagittal plane (17/28).

CONCLUSION

This scoping review highlights the lack of a standardized definition for IRCT in clinical practice, with common predictive criteria including a duration of over 6 months, retraction beyond 5 cm, Goutallier grade 3 fatty infiltration, and the rupture of two or more tendons. However, surgeons should apply more than one criterion when examining preoperative images and confirm reparability during surgery. A more objective manner of evaluating intraoperative reparability is necessary.

The Posterosuperior Tetralogy Scoring System as a Practical Tool to Predict Shoulder Function After Posterosuperior Large-to-Massive Rotator Cuff Repairs

Background

Fatty infiltration (FI) or atrophy alone has been found to be inaccurate in predicting shoulder function after repair of large-to-massive rotator cuff tears (L/MRCTs), especially when a diverse extent of FI and atrophy presents in multiple rotator cuff muscles.

Purpose/Hypothesis

The Posterosuperior Tetralogy Scoring System (PS-Tetra Score), which integrates FI and atrophy, was proposed to predict shoulder function after surgery. It was hypothesized was that a PS-Tetra Score ≥3 would be a risk factor for poor shoulder function after repair of posterosuperior L/MRCTs and would possess greater diagnostic value than using isolated FI or atrophy of the supraspinatus (SSP) or infraspinatus (ISP).

Study Design

Case-control study; Level of evidence, 3.

Methods

A total of 187 arthroscopic repairs of posterosuperior L/MRCTs were reviewed. Magnetic resonance imaging evaluations were performed of FI and atrophy of the SSP and ISP, teres minor hypertrophy, tendon retraction, and acromiohumeral distance. A postoperative American Shoulder and Elbow Surgeons (ASES) score of 70 was used to subgroup patients according to shoulder function. Univariate and multivariate analyses were performed to determine the risk factors of poor shoulder function (ASES ≤70). The diagnostic values of different indicators for predicting shoulder function were evaluated.

Results

In univariate analysis, female sex, higher Goutallier grade of the SSP and ISP, positive SSP tangent sign, and PS-Tetra Score ≥3 was significantly associated with ASES score ≤70, whereas in binary logistic regression analysis, a PS-Tetra Score ≥3 was the only significant risk factor for poor shoulder function. The occurrence rate of poor function in shoulders with a PS-Tetra Score of 0, 1, 2, 3, and 4 was 0% (0/52), 0% (0/52), 19.57% (9/46), 58.06% (18/31), and 83.33% (5/6), respectively. PS-Tetra Score ≥3 possessed higher crude agreement (87.70%), specificity (90.97%), positive predictive value (62.16%), and area under the receiver operating characteristic curve (0.814) than the other 3 indicators, with relatively high negative predictive value (94.00%) and moderate sensitivity (71.88%).

Conclusion

PS-Tetra Score ≥3 was a risk factor of poor shoulder function after repair of posterosuperior L/MRCTs and possessed greater diagnostic value than using isolated FI or atrophy of SSP or ISP alone for predicting shoulder function.

An objective assessment of the impact of tendon retraction on sleep efficiency in patients with full-thickness rotator cuff tears: a prospective cohort study

BACKGROUND

Sleep quality, quantity, and efficiency have all been demonstrated to be adversely affected by rotator cuff pathology. Previous measures of assessing the impact of rotator cuff pathology on sleep have been largely subjective in nature. This study was undertaken to objectively analyze this relationship through the use of activity monitors.

METHODS

Patients with full-thickness rotator cuff tears at a single institution were prospectively enrolled between 2018 and 2020. Waistworn accelerometers were provided for the patients to use each night for 14 days. Sleep efficiency was calculated using the ratio of the time spent sleeping to the total amount of time that was spent in bed. Retraction of the rotator cuff tear was classified using the Patte staging system.

RESULTS

This study included 36 patients: 18 with Patte stage 1 disease, 14 with Patte stage 2 disease, and 4 patients with Patte stage 3 disease. During the study, 25 participants wore the monitor on multiple nights, and ultimately their data was used for the analysis. No difference in the median sleep efficiency was appreciated amongst these groups (P>0.1), with each cohort of patients demonstrating a generally high sleep efficiency.

CONCLUSIONS

The severity of retraction of the rotator cuff tear did not appear to correlate with changes in sleep efficiency for patients (P>0.1). These findings can better inform providers on how to counsel their patients who present with complaints of poor sleep in the setting of full-thickness rotator cuff tears. Level of evidence: Level II.

ACR Appropriateness Criteria® Chronic Shoulder Pain: 2022 Update

Chronic shoulder pain is an extremely common presenting complaint. Potential pain generators include the rotator cuff tendons, biceps tendon, labrum, glenohumeral articular cartilage, acromioclavicular joint, bones, suprascapular and axillary nerves, and the joint capsule/synovium. Radiographs are typically the initial imaging study obtained in patients with chronic shoulder pain. Further imaging may often be required, with modality chosen based on patient symptoms and physical examination findings, which may lead the clinician to suspect a specific pain generator. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Early postoperative recovery comparisons of superior capsule reconstruction to tendon transfers

BACKGROUND

The management of massive posterosuperior rotator cuff tears is controversial, with no gold standard. Two recently developed techniques that have shown promising initial results include arthroscopic superior capsular reconstruction (SCR) and tendon transfers (latissimus or lower trapezius). However, there remains a scarcity of studies examining each procedure's early postoperative clinical outcomes individually or in comparison to each other. The purpose of this study is to compare the early postoperative recovery outcomes of tendon transfers (TTs) to SCR.

METHODS

Using the surgical outcomes system global database (Arthrex Inc.), we assessed the postoperative recovery outcomes for all patients who had outcomes recorded at least 6 months after SCR or TT. The time points analyzed included preoperative and postoperative (2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years). The outcomes analyzed included pain visual analog scale (VAS) score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, VR-12 physical, and Single Assessment Numeric Evaluation (SANE).

RESULTS

Overall, 163 patients underwent SCR and 24 arthroscopically assisted TT. The mean age for SCR and TT was 60 and 56 years, respectively. Postoperative recovery curves demonstrate that both procedures produced improved outcomes at each postoperative time point compared to preoperative. The pain and functional outcomes measures, including VAS, ASES, SANE, and VR-12 physical, were comparable for TT and SCRs, with similar recovery curves between the 2 techniques. Ultimately at 2 years postoperatively, there were no significant differences between the 2 techniques.

CONCLUSIONS

Analysis of the early outcomes associated with arthroscopic treatment of massive posterosuperior rotator cuff tears demonstrated that the arthroscopically assisted tendon transfers and arthroscopic superior capsular reconstruction had similar pain and functional outcomes throughout the 2-year postoperative recovery period. Overall, the process of recovery appears equivalent between the 2 techniques. Future studies are needed to assess the outcomes of each technique and specific indications in an attempt to delineate an algorithm for the treatment of irreparable rotator cuff tears.

Three-Dimensional Software- and MR-Imaging-Based Muscle Volumetry Reveals Overestimation of Supraspinatus Muscle Atrophy Using Occupation Ratios in Full-Thickness Tendon Tears

Supraspinatus muscle atrophy is widely determined from oblique-sagittal MRI by calculating the occupation ratio. This ex vivo and clinical study aimed to validate the accuracy of 3D software- and MR-imaging-based muscle volumetry, as well as to assess the influence of the tear pattern on the occupation ratio. Ten porcine muscle specimens were volumetrized using the physical water displacement volumetry as a standard of reference. A total of 149 individuals with intact supraspinatus tendons, partial tears, and full-thickness tears had 3T MRI. Two radiologists independently determined occupation ratio values. An excellent correlation with a Pearson’s r of 0.95 for the variables physical volumetry using the water displacement method and MR-imaging-based muscle volumetry using the software was found and formed the standard of reference for the patient study. The inter-reader reliability was 0.92 for occupation ratios. The correlation between occupation ratios and software-based muscle volumes was good in patients with intact tendons (0.84) and partial tears (0.93) but considerably lower in patients with full-thickness tears (0.68). Three-dimensional-software- and MR-imaging-based muscle volumetry is reliable and accurate. Compared to 3D muscle volumetry, the occupation ratio method overestimates supraspinatus muscle atrophy in full-thickness tears, which is most likely due to the medial retraction of the myotendinous unit.

Partial Rotator Cuff Repair Provides Improved Patient-Reported Outcome Measures Following Superior Capsule Reconstruction (SCR)

Purpose

To evaluate the role of concomitant partial rotator cuff repair (RCR) (i.e., infraspinatus) on patient-reported clinical outcomes following superior capsule reconstruction (SCR).

Methods

Postoperative recovery outcomes of SCR alone were compared with SCR with concomitant infraspinatus rotator cuff repair (SCR+RCR) at 3, 6, 12, and 24 months. Patients were included if they had an SCR surgery with or without a concomitant infraspinatus repair. Patients were excluded if they did not have a minimum of 6 months’ follow-up or if a preoperative baseline questionnaire was not performed. Outcome measures included pain visual analog scale, American Shoulder and Elbow Surgeons (ASES) Shoulder Function, ASES Shoulder Index, and Single Assessment Numeric Evaluation (SANE) score.

Results

Overall, 180 patients were evaluated, including 163 patients who underwent SCR alone and 17 patients who underwent concomitant infraspinatus repair (SCR+RCR). There was no difference in demographic data including age, sex, and body mass index. The postoperative recovery curves demonstrated SCR alone and SCR+RCR both provide significantly improved pain and functional scores at 2 years postoperatively (P < .001). When we compared the 2 groups, SCR+RCR provided significantly improved ASES Index (87.6 vs 78.2, P = .048) and ASES Function (25.5 vs 21.7, P = .02). There was no statistically significant difference in SANE scores (75.5 vs 64.2, P = .07) at 24 months’ follow-up.

Conclusions

SCR provides modest improvements in pain and function at 2 years postoperatively in patients with irreparable rotator cuff tears. Patients who underwent SCR and concomitant infraspinatus repair demonstrated significantly improved ASES Index and ASES Function scores and statistically nonsignificant improvement in SANE scores at 24 months postoperatively when compared with SCR alone.

Level of Evidence

III, retrospective cohort study.

Histologic Differences in Human Rotator Cuff Muscle Based on Tear Characteristics

BACKGROUND

Fatty accumulation in the rotator cuff is associated with shoulder dysfunction and a risk of failure of rotator cuff repair. The aims of this study were to (1) describe cellular findings in rotator cuff muscles in patients presenting with varying degrees of rotator cuff tendon pathology by examining fat content and myofiber cross-sectional area of rotator cuff muscles and (2) correlate histologic features to magnetic resonance imaging (MRI) grades derived with the Goutallier classification.

METHODS

Rotator cuff muscle biopsies were performed in a consecutive series of patients undergoing arthroscopic shoulder surgery. Rotator cuffs were graded according to the Goutallier classification and labeled as either partial-thickness or full-thickness. Patients without a rotator cuff tear undergoing arthroscopic surgery served as controls. The biopsy specimens were examined using LipidTOX to visualize lipid accumulation. Laminin was used to quantify myofiber cross-sectional area.

RESULTS

Twenty-seven patients with a rotator cuff tear and 12 without a tear (controls) were included. There were 24 males (62%). The mean age was 55 years. Patients in the control cohort were younger (mean, 46 years) than those in the treatment group (mean, 60 years, p < 0.01). Within the treatment group, 12 and 15 patients were recorded as having partial and full-thickness rotator cuff tears, respectively. Lipid accumulation visualized at the cellular level was fairly-to-moderately correlated with the Goutallier classification on MRI (R s = 0.705, 95% confidence interval [CI] = 0.513, 0.829). Muscle biopsy specimens with a Goutallier grade of 2+ had significantly more lipid accumulation than those with grade-0 (p < 0.01) or grade-1 (p < 0.01) fatty accumulation. Muscle biopsies at the sites of full-thickness tears showed significantly greater lipid accumulation than those associated with either partial (p < 0.01) or no (p < 0.01) tears. Partial-thickness rotator cuff tears had no difference in lipid accumulation in comparison to the control group. Muscle biopsy specimens from full-thickness tears had significantly smaller myofiber cross-sectional area when compared with partial-thickness tears (p = 0.02) and controls (p < 0.01).

CONCLUSIONS

Cellular lipid accumulation correlates with the MRI Goutallier grade of fatty accumulation, thus verifying the Goutallier classification at the cellular level. Muscle biopsy specimens from partial-thickness tears are more similar to controls than to those from full-thickness tears, whereas full-thickness tears of all sizes showed significantly greater lipid content and smaller myofiber cross-sectional area compared with partial-thickness tears and controls.

CLINICAL RELEVANCE

Our research confirms the utility of using the Goutallier classification to predict rotator cuff muscle quality and shows that tendon attachment, even if partially torn, protects the muscle from fatty accumulation.

Shoulder kinematics and muscle activity following latissimus dorsi transfer for massive irreparable posterosuperior rotator cuff tears in shoulders with pseudoparalysis

BACKGROUND

The aim of this study was to evaluate the thoracohumeral (TH) and glenohumeral (GH) motion with muscle activity after latissimus dorsi transfer (LDT) in a shoulder with a massive irreparable posterosuperior rotator cuff tear (MIRT) and pseudoparalysis compared with the asymptomatic contralateral shoulder (ACS).

METHODS

We recruited and evaluated 13 patients after LDT in a shoulder with preoperative clinical pseudoparalysis and an MIRT on magnetic resonance imaging, with a minimum follow-up period of 1 year, and with a Hamada stage of 3 or less. Three-dimensional electromagnetic tracking was used to assess shoulder active range of motion in both the LDT shoulder and the ACS. The maximal active elevation of the shoulder (MAES) was assessed and consisted of forward flexion, scapular abduction, and abduction in the coronal plane. Maximal active internal rotation and external rotation were assessed separately. Surface electromyography (EMG) was performed to track activation of the latissimus dorsi (LD) and deltoid muscles during shoulder motion. EMG was scaled to its maximal isometric voluntary contraction recorded in specified strength tests.

RESULTS

In MAES, TH motion of the LDT shoulder was not significantly different from that of the ACS (F_1,12 = 1.174, P = .300) but the GH contribution was significantly lower in the LDT shoulder for all motions (F_1,12 = 11.230, P = .006). External rotation was significantly greater in the ACS (26° ± 10° in LDT shoulder vs. 42° ± 11° in ACS, P < .001). The LD percentage EMG maximum showed no significant difference between the LDT shoulder and ACS during MAES (F_1,11 = 0.005, P = .946). During maximal active external rotation of the shoulder, the LDT shoulder showed a higher percentage EMG maximum than the ACS (3.0% ± 2.9% for LDT shoulder vs. 1.2% ± 2.0% for ACS, P = .006).

CONCLUSIONS

TH motion improved after LDT in an MIRT with pseudoparalysis and was not different from the ACS except for external rotation. However, GH motion was significantly lower after LDT than in the ACS in active-elevation range of motion. The LD was active after LDT but not more than in the ACS except for active external rotation, which we did not consider relevant as the activity did not rise above 3% EMG maximum. The favorable clinical results of LDT do not seem to be related to a change in LD activation and might be explained by its effect in preventing proximal migration of the humeral head in active elevation.

Ultrasound shear wave elastography-derived tissue stiffness is positively correlated with rotator cuff tear size and muscular degeneration

PURPOSE

The purpose of this study is to describe rotator cuff muscle stiffness in patients with different degrees of rotator cuff tear (RCT) severity and to assess its predictive ability for RCT reparability.

METHODS

One hundred and thirty-three consecutive patients who were scheduled to undergo arthroscopic shoulder surgery were prospectively enrolled. Tendon retraction, fatty infiltration, and muscle atrophy were evaluated using magnetic resonance imaging. Shear modulus of supraspinatus (SSP) and infraspinatus (ISP) muscles were measured by ultrasound shear wave elastography (SWE). The tear size and reparability were determined intraoperatively.

RESULTS

There were 97 patients in RCT group and 36 patients in control group. Bilateral shear modulus discrepancy (Δshear modulus) was used to represent rotator cuff stiffness. Severely fatty-infiltrated rotator cuff muscles possessed a significantly higher stiffness compared with their counterparts (SSP: CI 27.8-31.8 vs. 13.5-15.6 kPa, ISP: CI 33.2-38.1 vs. 8.8-11.2 kPa, p < 0.001). The same trend applied to muscles with distinct tendon retraction (SSP: CI 27.7-32.3 vs. 10.9-14.9 kPa, ISP: CI 33.2-38.6 vs. 6.5-11.0 kPa, p < 0.001) and obvious muscle atrophy (SSP: CI 27.9-32.1 vs. 13.6-15.8 kPa, ISP: CI 32.9-38.2 vs. 9.0-11.7 kPa, p < 0.001). Irreparable massive RCT (MRCT) patients had significantly stiffer SSP (CI 27.7-31.9 vs. 13.5-16.5 kPa, p < 0.001) and ISP (CI 33.5-37.8 vs. 10.3-14.8 kPa, p < 0.001) than reparable MRCT. The Δshear modulus of the ISP was a highly accurate predictor of RCT reparability. A cutoff value of 18.0 kPa had a sensitivity of 100% and specificity of 98.8% for irreparable MRCT.

CONCLUSION

Ultrasound SWE-derived rotator cuff muscle stiffness is closely correlated with RCT size and severity.

LEVEL OF EVIDENCE

I.

Preoperative rotator cuff tendon integrity, tear size, and muscle atrophy and fatty infiltration are associated with structural outcomes of arthroscopic revision rotator cuff repair

PURPOSE

A few studies have focused on factors predisposing to retear after arthroscopic revision rotator cuff repair (ARRCR). This study aimed to retrospectively evaluate (1) the structural and clinical outcomes of ARRCR and (2) pre- and intraoperative factors affecting the integrity of the rotator cuff (RC) tendon by focusing on preoperative RC tendon integrity, tear size, muscle hypotrophy and fatty infiltration.

METHODS

Patients who underwent ARRCR between 2006 and 2016 were reviewed. Preoperative variables included demographic data, RC tendon integrity, tear size, and muscle hypotrophy and fatty infiltration on preoperative magnetic resonance imaging (MRI). Intraoperative variables included repair technique and completeness of repair. The visual analog scale for pain (PVAS), functional VAS (FVAS), American Shoulder and Elbow Surgeons scores, and shoulder range of motion (ROM) were assessed. Postoperative tendon integrity was evaluated using over 6-month follow-up MRI. Patients were classified into groups A (healed) and B (retear), and their variables were compared.

RESULTS

Overall 65 patients with a mean follow-up of 49.5 ± 30.2 (range, 24.0-148.9) months were analyzed. Fifty-six of 65 (86.2%) patients underwent MRI at 9.1 ± 9.7 (range, 4.4-40.2) months after ARRCR, and 20 of 56 (35.7%) patients (group B) exhibited retear. Group A (36/56, 64.3%) showed higher functional scores and ROMs than group B at the final follow-up, with significant differences in the FVAS scores (Group A versus B: FVAS, 7.6 ± 1.8 versus 6.4 ± 1.9, p = 0.036). Intraoperative variables, including preoperative tendon integrity (p = 0.021), tear size (p = 0.007), supraspinatus and infraspinatus muscle hypotrophy and fatty infiltration (p < 0.001 and p = 0.046), and completeness of repair (p = 0.030), differed significantly between the groups. Multivariate analysis revealed that preoperative supraspinatus muscle hypotrophy and fatty infiltration were independent predisposing factors for retear after ARRCR [odds ratio = 7.5, 95% confidence interval (CI) 1.1-55.8, p = 0.048].

CONCLUSION

The retear was found in 20/56 patients (35.7%) after ARRCR for less than massive rotator cuff tears in this limited study population. Preoperative tendon integrity, tear size, supraspinatus and infraspinatus muscle hypotrophy and fatty infiltration, and completeness of repair was revealed to be associated with tendon integrity following ARRCR. Among them, preoperative supraspinatus muscle atrophy and fatty infiltration were the independent factors for retear after ARRCR, although generalization is limited.

LEVEL OF EVIDENCE

IV.

Medialized vs. lateralized humeral implant in reverse total shoulder arthroplasty: the comparison of outcomes in pseudoparalysis with massive rotator cuff tear

BACKGROUND

With the increasing use of lateralized humeral implants in reverse total shoulder arthroplasty (RTSA), it is still unclear whether this design will be as advantageous as the medialized humeral implants in the setting of pseudoparalysis (PP).

METHODS

A total of 51 eligible RTSA cases for PP signs due to massive rotator cuff deficiency were selected for the retrospective review. Twenty-five patients were allocated to group L in which the isolated humeral side lateralization was performed (neck-shaft angle of 145°), and 26 patients were allocated to group M (neck-shaft angle of 155°). Pre- and postoperative radiologic measurements including critical shoulder angle, acromiohumeral distance (AHD), lateral humeral offset (LHO), and deltoid wrapping offset (DWO), as well as range of motion (ROM) and clinical outcome scores, were compared. The mean age was 71.0 ± 6.5 years for group L and 70.3 ± 7.0 years for group M, and the overall mean follow-up period was 49.0 ± 13.5 months (range, 25.7-68.9).

RESULTS

The preoperative radiologic measurements were similar, but the postoperative LHO and DWO were significantly larger for group L, whereas the postoperative AHD was larger for group M compared with group L, with the values being 39.8 ± 9.7 mm and 33.6 ± 10.4 mm, respectively (P = .034). For the ROM, active forward elevation did improve significantly for both, starting preoperatively with the active ranges of 39° ± 19° (passively 153° ± 24°) for group L and 42° ± 18° (passively 156° ± 11°) for group M-the final postoperative active ranges being 142° ± 16° and 133° ± 33°, respectively, without significant difference between the groups (P = .426). The postoperative recovery of PP for group L was 100% (25 of 25), whereas for group M, it was 96.2% (25 of 26). The final visual analog scale (VAS) scores and University of California Los Angeles (UCLA) shoulder scores improved significantly for both groups, but the differences between the groups at the final assessments were insignificant. The 4 complications were periprosthetic fracture, acromial stress fracture, periprosthetic joint infection, and neuropraxia, all of which were in group M, and scapular notching with higher grades were more prevalent for group M (26.9%, 7 of 26).

CONCLUSIONS

With RTSA, good outcomes and recovery were achieved in most cases of PP. The postoperative active elevation range and functional outcomes were not affected by medialization or lateralization of the humeral implant. Earlier recovery of motion was observed with the lateralized group, but no significant differences were seen in the final ROM between the groups.

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.

Does the Interval Slide Procedure Reduce Supraspinatus Tendon Repair Tension?: A Biomechanical Cadaveric Study

Background

The benefits of the interval slide (IS) procedure in retracted rotator cuff tears remain controversial.

Purpose

The purpose was to evaluate the effect of the IS procedure on repair tension (RT). It was hypothesized that the IS procedure (anterior IS [AIS], posterior IS [PIS], and intra-articular capsular release [CR]) would reduce the RT of a supraspinatus tendon.

Study Design

Controlled laboratory study.

Methods

A total of 31 Thiel-embalmed human cadaveric shoulders (mean age, 74 years; range, 68-84 years) were tested. Full-thickness supraspinatus tendon tears were created, and 1 cm of tendon was resected to simulate a retracted defect. Shoulders were randomized into intervention (n = 16) and control (n = 15) groups. In all shoulders, the load during tendon reduction to footprint was measured, an endpoint was defined as maximum tendon lateralization before 50 N was reached, and the RT (load during lateralization to endpoint) of the native tendon (t₁) was evaluated. In the intervention group, AIS (t₂), PIS (t₃), and CR (t₄) were performed in order, with RT measurement after each step. In the control group, RT was assessed at the same time points without the intervention.

Results

A complete reduction of the tendon was not achieved in any of the shoulders. Mean maximum lateralization was 6.7 ± 1.30 mm, with no significant differences between groups. In the intervention group, the overall IS procedure reduced RT about 47.0% (t₁ vs t₄: 38.7 ± 3.9 vs 20.5 ± 12.3 N; P < .001). AIS reduced RT significantly (t₁ vs t₂: 38.7 ± 3.9 vs 27.4 ± 10.5 N; P < .001), whereas subsequent PIS (t₂ vs t₃: 27.4 ± 10.5 vs 23.2 ± 12.4 N; P = .27) and CR (t₃ vs t₄: 23.2 ± 12.4 vs 20.5 ± 12.3 N; P = .655) did not additionally reduce tension. Comparison between groups at t₄ revealed a reduction of RT of about 47.8% (control vs intervention: 39.3 ± 4.0 vs 20.5 ± 12.3 N; P < .001).

Conclusion

The IS procedure reduces RT of the supraspinatus tendon in human cadaveric shoulders. However, performing PIS and CR subsequent to AIS does not reduce tension additionally.

Clinical Relevance

These findings provide surgeons with a biomechanical rationale regarding the efficacy of the IS procedure.

Can magnetic resonance imaging accurately and reliably measure humeral cortical thickness?

Background

Historically, imaging osseous detail in three dimensions required a computed tomography (CT) scan with ionizing radiation that poorly visualizes the soft tissues. The purpose of this study was to determine the accuracy and reliability of ultrashort echo time (UTE) magnetic resonance imaging (MRI) in measuring humeral cortical thickness and cancellous density as compared with CT.

Methods

This was a comparative radiographic study in nine cadavers, each of which underwent CT and UTE MRI. On images aligned to the center of the humeral shaft, anterior, posterior, medial, and lateral humeral cortical thickness was measured 5, 10, and 15 cm distal to the top of the head. Cancellous density was measured as signal within a 1-cm diameter region of interest in the center of the head, the subtuberosity head, the subarticular head, and the subarticular glenoid vault. Glenoid cortical thickness was measured at the center of the glenoid. Cortical measurements were compared using mean differences and 95% confidence intervals, paired Student’s t-tests, and intraclass correlation coefficients (ICCs). We compared cancellous measurements using Pearson’s correlation coefficients. For all measurements, we calculated interobserver and intraobserver reliability using ICCs with 0.75 as the lower limit for acceptability.

Results

With regard to accuracy, for humeral cortical thickness measurements, there were no significant differences between MRI and CT measures, and ICCs were >0.75. The glenoid cortical thickness ICC was <0.75. There was no significant correlation between the cancellous signal on MRI and on CT in any region. For both MRI and CT, interobserver reliability and intraobserver reliability were acceptable (ie, >0.75) for almost all humeral cortical thickness measures.

Conclusion

UTE MRI can reliably and accurately measure humeral cortical thickness, but cannot accurately measure cancellous density or accurately and reliably measure glenoid cortical thickness.

[Image and report quality of outpatient MRI examinations : Evaluation of organizational, technical and report-related parameters in patients with arthroscopically secured rotator cuff rupture]

BACKGROUND

MRI is commonly used to diagnose and assess prognosis for rotator cuff (RM) pathology in addition to history and clinical examination.

AIM

This study investigates the image and report quality of shoulder MRIs with regard to prognosis-relevant parameters in outpatients who subsequently underwent surgical treatment for RM rupture.

MATERIALS AND METHODS

Using a defined questionnaire, both the MR images and the original reports of 94 patients were evaluated by an experienced radiologist with regard to referral information, MRI technology and quality of the MRI reports.

RESULTS

Questions or comments on RC were noted in 39% (general practitioners) and 48% (orthopaedics/UCH) of referrals. In MRI reports with the diagnosis "complete rupture of the RC", no information on the size of the defect was available in 47% of cases. In 18 and 30% of the reports, respectively, a fatty infiltration of the RM musculature or atrophy of the musculature was mentioned. When a partial RC rupture (n = 25) was diagnosed; the depth diameter (< or > 50% of the tendon thickness) was determined in only one case. The protocol recommendations valid today for MRI diagnostics of the shoulder were implemented in 60% of the examinations. According to the evaluating radiologist, 93-97% of the available MRI examinations were able to answer prognostic-relevant questions of an RC rupture.

DISCUSSION

The questions by physicians referring to the MRI examination of a shoulder with a subsequently arthroscopically verified RC rupture were predominantly unspecific or insufficient. In the radiological reports of these MRI examinations, prognosis-relevant parameters could not be extracted in sufficient form and number, although the MRI technique would have allowed this.

Progression of long head of the biceps brachii tendon abnormality on magnetic resonance imaging after rotator cuff repair

OBJECTIVES

To correlate the deterioration of preserved long head of biceps tendon (LHB) after rotator cuff repair with preoperative and postoperative MRI factors.

METHODS

Total of 209 shoulder joints (F:M = 145:64; mean age 57.4 years) which underwent rotator cuff repair and at least two postoperative MRI scans over 10 months after surgery were included. LHB integrity was graded with a five point severity scale. LHB deterioration was defined by increased composite score of integrity and extent score between the preoperative and second postoperative MRI. For preoperative and postoperative MRI factors, size and location of superior cuff -supraspinatus and infraspinatus- and subscapularis tears, fatty degeneration of rotator cuff, preoperative LHB status, subluxation of LHB, superior labral tear, acromion type, repaired rotator cuff status, postoperative capsulitis and acromioplasty state were assessed. Logistic regression was used to evaluate the association between LHB deterioration and aforementioned factors. Same analysis was conducted for 62 shoulder joints with a long-term follow-up MRI.

RESULTS

Of the 209 shoulders, 49.3% (n = 103) showed LHB deterioration on short-term follow-up MRI. In long-term follow-up subgroup, 32 LHBs were further deteriorated. In multivariate analysis, fatty degeneration of superior cuff showed significant association with LHB deterioration in both short-term (p = .04, p = .007) and long-term subgroups (p = .004, p = .005) among preoperative and postoperative factors, respectively.

CONCLUSIONS

Degree of fatty degeneration in superior cuff is associated with LHB deterioration on postoperative MRI.

ADVANCES IN KNOWLEDGE

Our results support that tenotomy or tenodesis of LHB should be considered during rotator cuff repair, especially in patients with advanced fatty degeneration of rotator cuff.

Influence of fat infiltration, tear size, and post-operative tendon integrity on muscle contractility of repaired supraspinatus muscle

Background

The purpose of this study was to evaluate the effect of fat infiltration, tear size, and post-operative tendon integrity, on post-operative contractility.

Methods

Thirty-five patients who underwent rotator cuff repair were included. The fat infiltration, tear size, and post-operative tendon integrity were evaluated by Goutallier stage, Cofield classification, and Sugaya classification, respectively. The muscle elasticity at rest and at contraction was assessed by real-time tissue elastography pre- and one-year post-operatively. We defined the difference in elasticity between at rest and at contraction as the activity value which reflects muscle contractility.

Results

The activity value in patients with Sugaya Type I tended to increase regardless of Cofield classification, whereas those with Sugaya Type III and IV tended to decrease. While the activity value in the patients classified as stage 1 and Type I tended to increase, patients classified as stage 2 showed decreased or constant in contractility even in those subjects classified as Type I. Stepwise multiple regression analysis showed both pre- (p = 0.004, r = -0.47) and post-operative activity values (p = 0.022, r = -0.39) to be significantly correlated only with the Goutallier stage.

Conclusion

Multiple regression analysis indicated only the Goutallier stage was a significant independent factor for contractility of the supraspinatus muscle. Supraspinatus muscle contractility in patients classified as Types III and IV based on the Sugaya classification tended to decrease post-operatively, while patients whose contractility increased post-operatively were characterized by having a Type I tendon integrity.

Predicting the surgical reparability of large-to-massive rotator cuff tears by B-mode ultrasonography: a cross-sectional study

PURPOSE

This study aimed to compare the ability of B-mode ultrasonography and magnetic resonance imaging (MRI) to predict the repairability of large-to-massive rotator cuff tears (RCTs).

METHODS

This cross-sectional study included participants with large-to-massive RCTs who underwent arthroscopic repair. B-mode ultrasonography and MRI were conducted prior to arthroscopic repair. B-mode ultrasonography was used to evaluate the echogenicity of the rotator cuff muscle using the Heckmatt scale. Intra-rater and inter-rater reliabilities were examined for two independent physicians. MRI was used to evaluate the degrees of tendon retraction, fatty infiltration of rotator cuff muscles, and muscle atrophy. Finally, two experienced orthopedic surgeons performed surgery and decided whether the torn stump could be completely repaired intraoperatively.

RESULTS

Fifty participants were included, and 32 complete repairs and 18 partial repairs were performed. B-mode ultrasonography showed good intra-rater reliability and inter-rater reliability for assessment of the muscle echogenicity of the supraspinatus and infraspinatus muscles. The correlation coefficients between B-mode ultrasound findings and MRI findings showed medium to large effect sizes (r=0.4-0.8). The Goutallier classification of the infraspinatus muscles was the MRI predictor with the best discriminative power for surgical reparability (area under the curve [AUC], 0.89; 95% confidence interval [CI], 0.81 to 0.98), while the Heckmatt scale for infraspinatus muscles was the most accurate ultrasound predictor (AUC, 0.85; 95% CI, 0.74 to 0.96). No significant differences in AUCs among the MRI and ultrasound predictors were found.

CONCLUSION

B-mode ultrasonography was a reliable examination tool and had a similar ability to predict surgical reparability to that of MRI among patients with large-to-massive RCTs.

Incomplete footprint coverage under tension in repair of isolated supraspinatus full-thickness tear

Although it is well known that repairing large or massive tears under tension may have an adverse effect on healing of the repaired tendons, only few studies have addressed this issue in medium-sized isolated supraspinatus full-thickness tear. The purpose of this study was to compare the clinical outcomes and structural integrity of arthroscopic rotator cuff repair with tension versus without it. This study retrospectively investigated 90 patients who underwent arthroscopic repair in a single-row for medium-sized isolated supraspinatus full-thickness tear. The patients were assigned to either repaired under tension (Group A, n = 38) or repaired without tension (Group B, n = 52) groups. Functional outcomes were assessed using the patient reported subjective values and the active range of motion (ROM). Postoperative radiographic evaluation was performed 6 months after the surgery to assess the structural integrity of the repaired tendons. Changes in the subjective shoulder scores from initial to 2 years after surgery showed no statistical significance between the two groups. The ROMs measured at initial and 2 years after surgery also showed no statistical difference between the two groups. Postoperative radiological evaluations found a significantly higher re-tear rate in Group A (28.9%, 11/38) than in Group B (9.6%, 5/52). The torn cuff tendons that were repaired under tension as retraction with limited mobility had significantly higher re-tear rate despite having immobilized for 6 weeks after surgery, but their clinical outcomes showed no significant difference from the outcomes of repaired tendons without tension.

Clinical Outcomes for Isolated Subscapularis Tears With Advanced Fatty Infiltration: Nonoperative Treatment Versus Arthroscopic Single-Row Repair

Background:

No study has investigated the treatment outcomes of isolated subscapularis tears with advanced fatty infiltration and tear progression to the supraspinatus tendon.

Purpose:

To assess the natural progression of isolated subscapularis tears with advanced fatty infiltration and compare clinical outcomes between nonoperative and operative treatment.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This study included 52 patients who received either operative (group A) or nonoperative (group B) treatment at our institution for isolated subscapularis full-thickness tears with grade 3 or 4 advanced fatty infiltration. All study patients had a minimum 2-year follow-up. The following 4 functional measures were used: visual analog scale for pain, Subjective Shoulder Value, American Shoulder and Elbow Surgeons score, and University of California Los Angeles score. The modified belly-press test was used to assess subscapularis muscle strength. In group A, structural integrity was evaluated using magnetic resonance imaging at 6 months after surgery. In addition, ultrasonographic evaluation was performed on both groups during the follow-up period to assess tear progression into the supraspinatus tendon.

Results:

At initial presentation, all functional assessment scores were significantly worse in group A versus group B (P ≤ .05 for all 4 scores). When we compared the mean change in scores before treatment versus after treatment, the group A patients were found to have significantly greater improvement than group B patients (P < .001 for all 4 scores); however, no significant difference was seen in final outcome scores between the groups. Although a high retear rate of 78.6% (22/28) was identified in group A, both groups showed no further tear progression to the supraspinatus tendon at the final ultrasonographic evaluation.

Conclusion:

For isolated subscapularis tears with advanced fatty infiltration, clinical improvement was seen with both nonoperative and operative treatment. Although the operatively treated group started with lower baseline scores, there were no significant differences in outcomes at final follow-up. Considering the high retear rate even after repair, surgical treatment of these lesions may not be warranted. Early detection and prompt repair of subscapularis tears, before the lesion becomes advanced with grade 3 or 4 fatty infiltration, are important for better outcomes.

Clinical and radiological outcomes with PEEK suture anchors used in rotator cuff repair: our experience confirm that a perianchor fluid signal on RM does not affect clinical outcome at one year of follow up

Introduction / objectives:

Osteolytic-type reactions of the perianchor bone which in magnetic resonance are manifested as hyperintensity of the signal in T2 images are reported in many studies. The doubt that this reaction of the bone could result in a loss of pull-out in the short and medium term and that it could therefore negatively affect tendon healing is the subject of an increasing number of studies. An osteolytic type signal around absorbable anchors can be explained by the metabilic processes in progress foreseen by the very nature of the material used, however this type of signal is also recognized around sutured implants or made of notoriously inert material. The objective of the present study is to evaluate and compare to the literature data the clinical and radiological results of a group of patients who underwent arthroscopic suture of a rotator cuff tear using polyetherketone (PEEK) suture anchors.

Materials and methods:

Twenty patients, aged between 44 and 73 years, who underwent arthroscopic repair of the rotator cuff for lesions smaller than 4 cm considered reparaible between August 2017 and January 2019, were enrolled in the present study. Patients were evaluated clinically with clinical examination, Constant scale and ASES scale pre and post surgery. MRI either pre and post operation at one year were evaluated to obtain data about tendon healing and evaluate bone reaction to PEEK anchors.

Results:

The mean lesion size was 16.8 mm +/- 7.8 mm and the mean tendon retraction was 15.6 mm +/- 14.9 mm. The mean increase in Constant and ASES scores at the one year-follow up was respectively 36.8 (p<0.01) and 47.2 (p<0.01). MRI analysis showed a tendon signal according to Sugaya classification of type 1 in the 25% of patients, type 2 in the 60% of cases and type 3 in the remaining 15% . Osteolysis was grade 0 in 65%, grade 1 in 30 % and grade 2 in 5% of cases. No anchors pull out or mobilization were reported.

Conclusions:

The presence of a T2 hyperintense signal osteolysis like on MRI control using PEEK anchors for the sutur of rotator cuff lesions does not find correlation whit the final clinical result of the procedure. Indeed, both patients with a major degree of osteolysis and those with degree 0 had an improvement both in terms of clinical and scores evaluation and in termsof tendon healing according to Sugaya’s score found in our cohort. (www.actabiomedica.it)

Radiographic greater tuberosity spurs and narrow acromiohumeral intervals are associated with advanced retraction of the supraspinatus tendon in patients with symptomatic rotator cuff tears

Background

Degenerative signs on shoulder radiographs, including spur formation and narrow acromiohumeral intervals (AHIs), have been recognized as indicative of atrophic and fat-infiltrated rotator cuff muscles. Past studies have demonstrated that patients with poor quality muscles are prone to retraction of the supraspinatus tendon and failure to repair. However, the association between radiographic signs and tendon retraction has never been elucidated in previous literature. The present study aimed to investigate the association between the degenerative signs on shoulder radiographs and the severity of supraspinatus retraction.

Methods

Images of 67 individuals, who had undergone an arthroscopic rotator cuff repair, were retrospectively reviewed. The greater tuberosity (GT) morphology, subacromial spur, AHI, and acromial thickness were evaluated on the radiographs, whereas the retraction of the supraspinatus tendon was assessed via an MRI in accordance with the Patte classification. Simple regression analyses between the radiographic signs and Patte stages were performed, and factors reaching statistical significance were then included in the multiple ordinal logistic regression. Statistically significant predictors from the multiple regression analysis were constructed into combinations, for which the sensitivity and specificity were calculated.

Results

The GT morphology (P = .004), AHI (P = .083), subacromial spur (P = .008), and age (P = .004) were associated with supraspinatus retraction in the simple regression analyses. These four parameters were incorporated into the multiple ordinal logistic regression, where the GT spur (adjusted odds ratio 8.63, 95% confidence interval 2.16-34.53, P = .002) and AHI (AOR 0.79, 95% CI 0.63-0.98, P = .032) were demonstrated to be predictive of the Patte stage of supraspinatus retraction. The acromial spur implied a higher risk of severe retraction although this finding was not statistically significant (AOR 2.89, 95% CI 0.90-9.29, P = .075). The presence of concurrent GT spur and narrow AHI was highly specific (sensitivity 27.3% / specificity 91.1%) for advanced supraspinatus retraction.

Conclusion

The presence of a radiographic GT spur, narrow AHI, and subacromial spur indicated advanced retraction of the supraspinatus tendon. When patients with clinical suspicion of rotator cuff tear present with combinations of these radiographic signs, a prompt MRI examination and a referral to a shoulder specialist are recommended.

Diagnostic value of the axial view of magnetic resonance imaging to identify two-dimensional shapes of full-thickness rotator cuff tears

BACKGROUND

Coronal and sagittal views of magnetic resonance imaging (MRI) were used to determine rotator cuff tear size and fatty infiltration, but these images were not enough to identify the tear shape.

PURPOSE

To correlate the preoperative axial MRI views and arthroscopic surgical findings to identify the two-dimensional shapes in rotator cuff tears.

MATERIAL AND METHODS

This study included 166 patients who underwent arthroscopic repair between 2015 and 2018. Preoperative coronal, sagittal, and axial MRI views were evaluated for tear size and geographic configuration in axial sections, and the length and the width were measured and were matched with arthroscopic surgical views by lateral portals.

RESULTS

The agreement of axial MRI views with the arthroscopic view was 88.0% in crescent, 97.2% in longitudinal, 78.6% in massive, and 100% in rotator cuff tear arthropathy. The mean agreement rate of axial MRI views with arthroscopic view was 81.9%. Mean mediolateral and anteroposterior tear sizes on axial MRI were 16.68 mm and 19.33 mm, respectively. Mean mediolateral and anteroposterior tear sizes by arthroscopic view were 21.49 mm and 21.04 mm, respectively. Tear sizes by MRI axial images were 71.3% of arthroscopic view. SST/IST degenerative changes were noted in most patients with massive tears and rotator cuff arthropathy (P = 0.001).

CONCLUSION

Rotator cuff tear shape on preoperative axial MRI view had close agreement (81.9%) with arthroscopic findings by lateral portal, and tear size by preoperative axial MRI views was 71.3% of that of arthroscopic view. Axial MRI views helped to predict the geometric tear shape of rotator cuff tears.

Outcome of arthroscopically assisted lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tears

BACKGROUND

The purpose of this study is to report the outcome of arthroscopically assisted lower trapezius transfer to reconstruct irreparable posterior-superior rotator cuff tear.

METHODS

Forty-one consecutive patients with irreparable posterior-superior rotator cuff tears who underwent an arthroscopically assisted transfer of the lower trapezius transfer were included in this study. The patients' average age was 52 years (range 37-71), and average follow-up was 14 months (range 6-19 months). Nineteen patients had true pseudoparalysis preoperatively, whereas 66% had a prior failed rotator cuff repair. Outcome measures included visual analog scale (VAS) pain score, range of motion, Subjective Shoulder Value (SSV), and Disabilities of the Arm, Shoulder, and Hand (DASH) score.

RESULTS

Thirty-seven (90%) patients had significant improvement of all outcome scores: VAS, SSV, and DASH. The presence of a subscapularis tear did not affect the outcome. However, 3 patients who had preoperative rotator cuff arthropathy changes of the shoulder had persistent pain and limited range of motion of the shoulder after surgery, and 2 of them underwent reverse shoulder arthroplasty. Two additional patients had a traumatic rupture of the transfer as a result of fall (at 5 and 8 months postop). One underwent revision arthroscopic repair and did well after surgery, and the other had good pain relief but recurrent weakness and limited range of motion, and elected not to have a revision surgery.

CONCLUSIONS

Arthroscopic-assisted lower trapezius transfer may lead to a good outcome in patients with massive irreparable posterior-superior rotator cuff tears, including patients with pseudoparalysis. The presence of an associated reparable subscapularis tear did not affect the outcome.

A Novel Reparability Assessment Scoring System for Full-Thickness Rotator Cuff Tears

Background:

It is difficult to predict the arthroscopic reparability of rotator cuff tears preoperatively when the repair is challenging. This can result in unsatisfactory outcomes and a high retear rate.

Purpose:

To develop an assessment score reflecting factors in rotator cuff tears that can predict reparability before surgery.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We retrospectively enrolled 170 patients with rotator cuff tears larger than 2 cm who underwent arthroscopic repair. Patients were categorized into “complete repair” and “partial repair” groups based on the area of the exposed footprint after arthroscopic rotator cuff repair. In each group, preoperative magnetic resonance imaging factors (tear size, fatty infiltration, remnant tendon length, atrophy), clinical factors (range of motion, American Shoulder and Elbow Surgeons score, Constant score), and patient demographics were evaluated. Receiver operating characteristic curve analysis was used to choose the optimal cutoff value. A reparability assessment score was formulated through stepwise selection using variables that showed significant between-group differences on univariate analysis. We selected 4 variables and assigned a relative score for each variable based on estimated coefficient values. The sum of the scores for each factor ranged from 0 to 5.

Results:

The average rotator cuff tear size was 28 × 26 mm. The torn rotator cuff was repaired completely in 74 patients (43.5%) and partially in 96 patients (56.5%). The following factors were chosen for the reparability assessment score: positive tangent sign (odds ratio [OR], 5.969; P = .001), fatty infiltration of the infraspinatus of grade ≤2 (OR, 3.537; P = .001), coronal tear size ≥26 mm (OR, 3.315; P = .002), and remnant tendon length <15 mm (OR, 2.584; P = .017). Complete repair was possible if the sum of the scores was <3 (area under curve, 0.803; 95% CI, 0.739-0.867; sensitivity, 51.0%; specificity, 95.9%).

Conclusion:

In patients with a score of <3 on the novel reparability assessment score, complete repair was obtainable, whereas in patients with a score of ≥3, complete repair was difficult and other methods such as biologic grafts or arthroplasty had to be considered for a favorable prognosis.

Surgical Management of Massive Irreparable Posterosuperior Rotator Cuff Tears: Arthroscopic-Assisted Lower Trapezius Transfer

PURPOSE OF THE REVIEW

Functionally irreparable rotator cuff tears (FIRCTs) remain one of the most challenging pathologies treated in the shoulder. The lower trapezius transfer represents a very promising treatment option for posterosuperior FIRCT. This article reviews the role for the lower trapezius transfer in the treatment of patient with FIRCTs and highlights the tips and tricks to performing this arthroscopic-assisted procedure.

RECENT FINDINGS

The treatment of posterosuperior FIRCTs contemplates a wide array of surgical options, including partial repair, biceps tenodesis/tenotomy, superior capsule reconstruction, subacromial balloon, reverse shoulder arthroplasty, and open-/arthroscopic-assisted tendon transfers. Tendon transfers have emerged as very promising reconstructive options to rebalance the anterior-posterior force couple. Controversy remains regarding the relative indications of latissimus dorsi transfer (LDT) and lower trapezius transfer (LTT). Initially used with very good success in patients with brachial plexus injuries, the open LTT has shown excellent clinical and radiographic outcomes in a recent series of patients with FIRCTs. However, this technique should be reserved for patients with an intact or reparable subscapularis tendon and no advanced glenohumeral arthritis or humeral head femoralization. With advancements in surgical technique, the arthroscopic-assisted LTT has shown similar promising results. However, studies on arthroscopically assisted LTT are limited to short-term follow-up, and future comparative trials with large patient numbers and longer follow-up are needed to better understand the indications for this novel tendon transfer in the treatment of FIRCT. The arthroscopic-assisted LTT is a novel, promising option for the treatment of patients with functional irreparable posterosuperior rotator cuff tears. Careful attention to indications and technical pearls are paramount when performing this procedure to optimize postoperative clinical outcomes.

Use sonoelastography to predict the reparability of large-to-massive rotator cuff tears

INTRODUCTION

Most symptomatic large-to-massive rotator cuff tears (RCTs) should be operated, but the surgical reparability depended on the degree of rotator cuff muscle atrophy or fatty infiltration. The orthopedic surgeons will decide whether the teared stump is reparable during the surgery, but preoperative evaluation can be done by some assessment tools. Magnetic resonance imaging (MRI) was used in recent studies to predict the reparability of large-to-massive RCTs, but the clinical availability was not as good as ultrasound. We hypothesize that the ultrasound elastography can predict the reparability of large-to-massive RCTs.

METHODS

This is a prospective observational study and participants with large-to-massive RCTs who are going to have surgeries will be included. Out investigators will evaluate the shoulder passive range of motion (ROM) and strength of all participants. Participants' degree of shoulder pain and activities of daily living (ADLs) will be assessed by American Shoulder and Elbow Surgeons (ASES) score. The ultrasound elastography will be used to evaluate the tissue quality of supraspinatus muscle and infraspinatus muscle. To test the reliability of the ultrasound elastography, two physicians will perform the ultrasound elastography independently and twenty participants will be selected for the reliability test. Besides, MRI will be used to evaluate the size of tear, the degree of tendon retraction, fatty infiltration of rotator cuff muscles, and muscle atrophy. Finally, the orthopedic surgeons will perform surgeries and decide whether the teared stump can be completely repaired intraoperatively. The primary analysis is the predictive validity of ultrasound elastography for the reparability of large-to-massive RCTs. Before the predictive validity of ultrasound elastography is measured, our investigators will assess the reliability of ultrasound elastography when administered to cases with large-to-massive RCTs, and we will check the correlations between the findings of ultrasound elastography and MRI.

DISCUSSION

The outcome will provide the evidence of ultrasound elastography for preoperative evaluation of large-to-massive RCTs. The relationships between the findings of ultrasound elastography and MRI will also be examined for further analysis.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03682679. Date of Registration: 25 September 2018, https://clinicaltrials.gov/ct2/show/NCT03682679?cond=rotator+cuff&cntry=TW&draw=2&rank=1.

Reliability of open architecture anchors in biocomposite material: medium term clinical and MRI evaluation. Our experience

OBJECTIVES

Comparing radiologic bone ingrowth and the clinical outcomes of an open-construct (PEEK) (polyether ether ketone) suture anchor with those of a bio-composite suture anchor (glycolic polylactic acid anchors, beta-tricalcium phosphate and calcium sulphate) in patients with arthroscopic rotator cuff repair.

METHODS

From August 2017 to January 2019, 33 patients of both sexes, aged between 44 and 78 years underwent arthroscopic rotator cuff repair for tears considered repairable with an extension not exceeding4 cm. The bioabsorbable anchors used comprised glycolic polylactic acid/beta-tricalcium phosphate/ calcium sulphate, and the non-absorbable anchors in polyetheretherketone (PEEK). All patients underwent MRI evaluation at 12 months postoperatively to determine complications and identify any re-tear.

RESULTS

Clinical scores showed an improvement from both clinical and functional point of view. There were no statistically significant changes compared to the physical examination. On radiographs, mobilizations, anchor pull-outs or other complications did not occur in each group.

CONCLUSIONS

Shoulder function improved after complete repair of the rotator cuff and similar clinical results were achieved regardless of the material and shape of the suture anchor. The bioabsorbable anchors in innovative open architecture material seem to have results comparable to peek anchors. Unfortunately, further studies are needed to define the advantages in using one material compared to the other. (www.actabiomedica.it).

Contrast-Enhanced Ultrasound (CEUS) as Predictor for Early Retear and Functional Outcome After Supraspinatus Tendon Repair

Supraspinatus (SSP) tendon tears represent a common indication for shoulder surgery. Yet, prediction of postoperative function and tendon retear remains challenging and primarily relies on morphologic magnetic resonance imaging (MRI)-based parameters, supported by patients' demographic data like age, gender, and comorbidities. Considering continuously high retear rates, especially in patients with larger tears and negative prognostic factors, improved outcome prediction could be of high clinical value. Contrast-enhanced ultrasound (CEUS) enables an assessment of dynamic perfusion of the SSP muscle. As a potential surrogate for muscle vitality, CEUS might reflect functional properties of the SSP and support improved outcome prediction after tendon repair. Fifty patients with isolated SSP tendon tears were prospectively enrolled. Preoperatively, SSP muscle perfusion was quantified by CEUS and conventional morphologic parameters like tear size, fatty infiltration, and tendon retraction were assessed by MRI. At six months follow-up, shoulder function, tendon integrity, and muscle perfusion were reassessed. The predictive value of preoperative CEUS for postoperative shoulder function and tendon integrity was evaluated. 35 patients entered the statistical analysis. Preoperative CEUS-based assessment of SSP perfusion significantly correlated with early postoperative shoulder function (Constant, r = 0.48, p < 0.018) and tendon retear (r = 0.67, p < 0.001). CEUS-based subgroup analysis identified patients with exceptionally high, respectively low risk for tendon retear. CEUS-based assessment of the SSP seemed to predict early shoulder function and tendon retear after SSP repair and allowed to identify patient subgroups with exceptionally high or low risk for tendon retear. © 2019 The Authors. Journal of Orthopaedic Research® published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 38:1150-1158, 2020.

What can the radiological parameters of superior migration of the humeral head tell us about the reparability of massive rotator cuff tears?

Objective

The interrelation and clinical utility of the parameters for superior migration of the humeral head, such as the acromiohumeral interval (AHI), inferior glenohumeral distance (IGHD), and upward migration index (UMI), in the management of massive rotator cuff tears are not clear. The objectives of this study were to identify the relation between AHI, IGHD, and UMI when measured with radiography and MRI and to determine whether superior migration can predict the irreparability of massive rotator cuff tears.

Methods

We retrospectively reviewed the files of 64 consecutive patients who underwent arthroscopic partial or complete repair for massive rotator cuff tears at our institution between August 2015 and August 2018. We recorded both radiography and MRI measurements of AHI, IGHD, and UMI, and further the tangent sign, fatty infiltration of the rotator cuff muscles, and the Patte grade. We performed correlation assessments and multiple logistic regression analysis to identify potential predictors of the reparability of massive rotator cuff tears.

Results

Thirty-five patients had partially reparable and 29 had completely reparable tears. Parameters measured with either radiography or MRI were highly correlated with each other. The radiographic measurements showed a moderate or low correlation with the MRI measurements. All parameters of superior migration of the humeral head on radiography and MRI, the tangent sign, fatty infiltration of the infraspinatus muscle, and the Patte grade showed significant differences between patients with partially and completely repaired tears. Among these, the independent predictors for irreparability was Patte grade = 3.

Conclusion

The AHI, IGHD, and UMI were highly correlated when measured with either radiography or MRI, but not when comparing their radiographic with their MRI values. Furthermore, they were not independent indicators of reparability in massive rotator cuff tears.

Nerve and Muscle Abnormalities

Muscle atrophy in shoulders with rotator cuff tendon tears is a negative prognosticator, associated with decreased function, decreased reparability, increased retears after repair, and poorer outcomes after surgery. Muscle edema or atrophy within a neurologic distribution characterizes denervation. Because most nerve entrapments around the shoulder are not caused by mass lesions and show no nerve findings on routine MR imaging sequences, pattern of muscle denervation is often the best clue to predicting location of nerve dysfunction, which narrows the differential diagnosis and guides clinical management. The exception is suprascapular nerve compression in the spinoglenoid notch caused by a compressing cyst.

The Chinese Knot Stitch Technique Using a Footprint Ultrasuture Anchor for Rotator Cuff Repair

Management of the rotator cuff presents specific challenges to orthopaedic surgeons. Several locking suture methods have been reported but often fail for a number of reasons. We describe a different technique that is easy to perform and inspired by the Chinese knot, an arthroscopic double-locking suture using a footprint ultrasuture anchor. This technique is similar to the suture-bridge structure on the bursal side of the tendon in that it increases tissue grip and stabilizes initial tendon-to-bone fixation. This technique is especially suitable for the patients who have bursal-side partial-thickness or degenerative small- and medium-sized rotator cuff tears.

Management of the Irreparable Rotator Cuff Tear

When evaluating patients with irreparable rotator cuff tears, orthopaedic surgeons have an increasingly wide array of surgical options, including both established techniques and emerging technologies. However, significant variability exists in the clinical evaluation and surgical indications in this subset, and definitions for pseudoparalysis and tear irreparability are inconsistent. In older patients with symptomatic rotator cuff arthropathy and relatively sedentary demands, the reverse total shoulder arthroplasty has been established as the preferred treatment option, producing reliable improvements in both pain and function. In younger patients without glenohumeral arthritis or pseudoparalysis, joint-preserving options are preferred, with recent literature highlighting alternative options including partial repair, bridging or interpositional graft placement, tendon transfers (ie, latissimus, trapezius, and pectoralis major), superior capsular reconstruction, and subacromial spacer placement. In this review article, we address the topic of irreparable rotator cuff tears, emphasizing the workup, indications for various treatment options, and clinical outcomes.

Low level of evidence for all treatment modalities for irreparable posterosuperior rotator cuff tears

PURPOSE

This systematic review assesses evidence for improvements in outcome for all reported types of treatment modalities [physical therapy, tenotomy or tenodesis of the long head of the biceps, debridement, partial repair, subacromial spacer, deltoid flap, muscle transfer, rotator cuff advancement, graft interposition, superior capsular reconstruction (SCR), and reversed shoulder arthroplasty (RSA)] used for irreparable posterosuperior rotator cuff tears without glenohumeral osteoarthritis. The primary aim was to be able to inform patients about expectations of the amount of clinical improvement after these treatments.

METHODS

A systematic search was conducted in MEDLINE, EMBASE, CINAHL, and Cochrane databases for studies on irreparable posterosuperior rotator cuff lesions without glenohumeral osteoarthritis, published from January 2007 until January 2019, with minimum 2-year follow-up. Studies with pre-operative and/or intra-operative determination of cuff tear irreparability were included. We defined the non-adjusted Constant Score as the primary outcome.

RESULTS

Sixty studies (2000 patients) were included with a fair mean quality score, according to the Modified Coleman Methodology Score. The employed definitions of 'irreparable' were mainly based on MRI criteria and were highly variable among studies. The smallest weighted mean preoperative to post-operative improvements in Constant Score were reported for biceps tenotomy/tenodesis (10.7 points) and physical therapy (13.0). These were followed by debridement (21.8) and muscle transfer (27.8), whereas the largest increases were reported for partial repair (32.0), subacromial spacer (32.5), rotator cuff advancement (33.2), RSA (34.4), graft reconstruction (35.0), deltoid flap (39.8), and SCR (47.4). Treatment using deltoid flap showed highest mean weighted improvement in Constant Score among studies with available medium-term (4-5-year) follow-up. Treatments deltoid flap, muscle transfer, and debridement were the only treatments with available long-term (8-10-year) follow-up and showed similar improvements in Constant Score at this time point.

CONCLUSION

The variability in patient characteristics, co-interventions, outcome reporting, and length of follow-up in studies on irreparable rotator cuff tears without osteoarthritis complicates sound comparison of treatments. Clinically important treatment effects were seen for all 11 different treatment modalities.

LEVEL OF EVIDENCE

IV.

Development of an automatic muscle atrophy measuring algorithm to calculate the ratio of supraspinatus in supraspinous fossa using deep learning

BACKGROUND AND OBJECTIVE

Rotator cuff muscle tear is one of the most frequent reason of operations in orthopedic surgery. There are several clinical indicators such as Goutallier grade and occupation ratio in the diagnosis and surgery of these diseases, but subjective intervention of the diagnosis is an obstacle in accurately detecting the correct region.

METHODS

Therefore, in this paper, we propose a fully convolutional deep learning algorithm to quantitatively detect the fossa and muscle region by measuring the occupation ratio of supraspinatus in the supraspinous fossa. In the development and performance evaluation of the algorithm, 240 patients MRI dataset with various disease severities were included.

RESULTS

As a result, the pixel-wise accuracy of the developed algorithm is 0.9984 ± 0.073 in the fossa region and 0.9988 ± 0.065 in the muscle region. The dice coefficient is 0.9718 ± 0.012 in the fossa region and 0.9463 ± 0.047 in the muscle region.

CONCLUSIONS

We expect that the proposed convolutional neural network can improve the efficiency and objectiveness of diagnosis by quantifying the index used in the orthopedic rotator cuff tear.

Analysis of Greater Tuberosity from the Center of the Humeral Head: Progression to Femoralization

Background

Progression of the tear size and erosion of the greater tuberosity (femoralization) in the supraspinatus tear makes it difficult to repair or increases the risk of a re-tear. This study examined the proximal articular surface and greater tuberosity of the humeral head in plain radiography.

Methods

Two-hundred forty-seven cases, whose anteroposterior (AP) radiographs were taken correctly, were included from 288 cases, in whom the status of the supraspinatus had been confirmed by surgery. After downloading the plain AP radiograph as DICOM, the radius of the circle apposed at the superior half of the articular surface of the head, and the distance between the circle and the farthest point of the greater tuberosity (‘height’ of the greater tuberosity) were calculated using the software (TechHime, Korea). MRI checked the number of torn tendons and degree of muscular atrophy.

Results

The following were encountered: 93 intact supraspinatus, 50 partial-thickness tears, and 104 full-thickness tears. In the analysis using the 93 intact cases, the average radius of the rotation center was 25.3 mm in male and 22.3 mm in female. The average height of the greater tuberosity from the circle with the same rotation center was 4.3 mm in male and 4.2 mm in female with no statistical significance. The correlation between the reparability of supraspinatus and height of the greater tuberosity, fatty infiltration, and muscular atrophy was confirmed.

Conclusions

The height of the greater tuberosity from the circle with the same rotation center was 4.3 mm in male and 4.2 mm in female. This height was strongly correlated with muscular atrophy and fatty infiltration of the supraspinatus tendon.

An intact subscapularis tendon and compensatory teres minor hypertrophy yield lower failure rates for non-operative treatment of irreparable, massive rotator cuff tears

PURPOSE

To investigate whether subscapularis integrity and compensatory teres, minor hypertrophy is associated with maintaining relatively good function and tolerable pain levels during non-operative treatment.

METHODS

This study included 108 patients with irreparable, massive rotator cuff tears involving at least two tendons and stage III or IV muscle hypotrophy and fatty infiltration on oblique sagittal magnetic resonance imaging, in which even a partial repair does not seem feasible. All supraspinatus and infraspinatus muscles were grade IV; if the subscapularis was involved, only stage III or IV was included. Patients were divided into two groups: group A consisted of 67 patients with both an intact subscapularis and teres minor hypertrophy; group B consisted of 41 patients lacking either one or both. The Visual Analogue Scale pain score, the American Shoulder and Elbow Surgeons score, the University of California at Los Angeles shoulder score, and active range of motion (ROM) were assessed.

RESULTS

During the follow-up period, failure of non-operative treatment was found in 29 (43%) patients in group A and 28 (68%) in group B (p = 0.012). Conversion to surgery was noted in 26 (39%) patients in group A and 27 (66%) in group B (p = 0.006). Among the remaining nonsurgical patients, there were no significant differences in clinical outcomes between the groups except ROM in internal rotation at final follow-up.

CONCLUSIONS

Although conservative treatment was not always successful in patients with irreparable, massive cuff tears, patients with both an intact subscapularis tendon, and teres minor hypertrophy experienced significantly lower incidences of failure and conversion to surgery, since force couple is maintained in the setting of minimal arthritis.

LEVEL OF EVIDENCE

III.

Long-term Results of Arthroscopic Rotator Cuff Repair: Initial Tear Size Matters: A Prospective Study on Clinical and Radiological Results at a Minimum Follow-up of 10 Years

BACKGROUND

Arthroscopic techniques are now considered the gold standard for treatment of most rotator cuff (RC) tears; however, no consensus exists on the maintenance of results over time, and long-term follow-up data have been reported for few cohorts of patients.

PURPOSE

To present the long-term results associated with the arthroscopic treatment of RC tears and to evaluate associations between preoperative factors and RC integrity at final follow-up.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 169 patients were contacted at least 10 years after arthroscopic RC surgery and were invited to a clinical evaluation. Information on preoperative conditions, tear size, subjective satisfaction, and functional scores was collected; isometric strength and range of motion were also measured; and each patient underwent an ultrasound examination to evaluate supraspinatus integrity and a shoulder radiograph to evaluate osteoarthritis.

RESULTS

A total of 149 patients (88.2% of the eligible patients) were available for a complete telephonic interview, and 102 patients were available for the final evaluation. Ultrasound revealed an intact supraspinatus in 54 patients (53.47%). By adding the 10 patients who underwent revision surgery to the nonintact group, this percentage would drop to 48.65%. Tear size was associated with supraspinatus integrity in univariate analysis (hazard ratio, 3.04; 95% CI, 1.63-5.69; P = .001) and multivariable analysis (hazard ratio, 2.18; 95% CI, 1.03-4.62; P = .04). However, no significant differences were encountered in the subjective and functional scores collected, with the exception of the Constant-Murley Score, which was significantly higher in patients with smaller tears at the index procedure. Strength testing also revealed significantly superior abduction and flexion strength in this group, and radiographs showed a significantly higher acromion-humeral distance and lower grades of osteoarthritis. Patients with an intact supraspinatus at final follow-up showed superior results in all functional scores, greater satisfaction, superior abduction and flexion strength, higher acromion-humeral distance, and lower grades of osteoarthritis.

CONCLUSION

RC tear size at the time of surgery significantly affects supraspinatus integrity at a minimum follow-up of 10 years. However, a larger tear is not associated with an inferior subjective result, although it negatively influences abduction and flexion strength, range of motion, and osteoarthritis progression. Intraoperative efforts to obtain a durable RC repair are encouraged, since supraspinatus integrity at final follow-up influences clinical and functional outcomes, patient satisfaction, and osteoarthritis progression.

Lower Trapezius Tendon Transfer for Massive Irreparable Rotator Cuff Tears

The treatment of the massive irreparable rotator cuff tear poses a challenging problem. Tendon transfers offer a solution for irreparable posterosuperior rotator cuff tears. The lower trapezius tendon transfer with incorporation of an Achilles tendon allograft has emerged as an effective way to restore strength and function in select patients. Both open and arthroscopic-assisted techniques have been described.

Superior capsule reconstruction using dermal allograft: early outcomes and survival

BACKGROUND

Superior capsule reconstruction (SCR) has shown promising outcomes in its initial description, but lacks additional reports analyzing outcomes. This study analyzes early outcomes of SCRs in patients with massive irreparable rotator cuff tears.

METHODS

A retrospective analysis of all SCRs at our institution from January 1, 2015, to August 31, 2017, was performed with a minimum 6-months follow-up. A total of 34 patients were included with a mean age of 60 years. SCR was performed by 1 of 6 fellowship trained surgeons.

RESULTS

At an average follow-up of 12 months, 22 patients were identified as failures after modified Neer classification. Furthermore, 8 of these patients have undergone a reoperation, whereas an additional 14 patients were considered clinical failures experiencing continued pain and a lack of shoulder function. Of note, 2 of the 3 patients with a subscapularis tear had a failure. In addition, revision cases, female gender, increased fatty infiltration in the infraspinatus and low surgeon volume were associated with a higher rate of failure. There was no significant improvement in range of motion or functional scores.

CONCLUSION

SCR performed for large-to-massive irreparable rotator cuff tears has a high rate of persistent pain and poor function leading to clinical failure in 65% of patients. Risk factors predicting clinical failure included revision cases, female gender, increased Goutallier fatty infiltration of the infraspinatus, and low surgeon volume (n ≤ 10).

The grade of preoperative subscapularis muscle atrophy as a prognostic factor for postoperative retears: A double-center retrospective series

The aim of the study was to investigate whether subscapularis muscle atrophy is a negative prognostic factor leading to increased risk of retears in patients treated with an arthroscopic subscapularis tendon repair. We hypothesized that fatty infiltration of the subscapularis muscle deteriorates the clinical and sonographic outcome of the arthroscopic repair and inhibits reparability of the ruptured tendons. A double- center, multinational, retrospective, blind (in the follow-up) clinical study regarding 32 patients who underwent an arthroscopic subscapularis repair was conducted. Patients were divided into two groups according to the preoparative fatty infiltration grade of subscapularis muscle (group A: grade<II, group B: grade II or higher). Reparability was not influenced by the grade of preoperative fatty infiltration of subscapularis muscle. The preoperative MRI scans showed significantly higher grades of fatty infiltration (group B) in the subscapularis muscle of patients with clinical evidence of retear after the arthroscopic repair. Low grades of preoperative subscapularis muscle atrophy are significantly correlated with low clinical and sonographic retear’s rate after subscapularis arthroscopic repair, while high grades were a clear negative prognostic factor for the clinical outcome of the aforementioned patients.