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Background: Anterior combined latissimus dorsi and teres major (aLDTM) tendon transfer has shown promise as a treatment for anterior superior irreparable rotator cuff tears (ASIRCTs). Our study aimed to compare aLDTM clinical outcomes for ASIRCTs between young and elderly patients. Methods: This retrospective study reviewed data from patients who underwent aLDTM tendon transfer for ASIRCTs with minimum 2-year follow-up. Clinical evaluations included visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), active range of motion (aROM), strength, and complications. Radiologic assessments included acromiohumeral distance, Hamada classification, and integrity of transferred tendon. Patients were divided into group total (all ages), group old (≥70 years), and group young (≤60 years). Results: A total of 123 patients were enrolled with 39 in group young (mean age, 56.6±4.9 years) and 27 in group old (mean age, 73.6±2.3 years). Postoperatively, both groups showed significant improvements in VAS, ASES, and SANE scores and improved aROM for forward elevation, abduction, and internal rotation. No significant differences in clinical coutcomes were noted between the groups. Furthermore, similar rates of complications, including retears and postoperative infections, were observed across all three groups. Conclusions: Our study highlights the effectiveness of aLDTM transfer for ASIRCTs with minimal glenohumeral arthritis, demonstrating similar outcomes in both group young and group old patients. Moreover, patients in these distinct age groups showed comparable clinical results when compared to group total. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Background Anterior combined latissimus dorsi and teres major (aLDTM) tendon transfer has shown promise as a treatment for anterior superior irreparable rotator cuff tears (ASIRCTs). Our study aimed to compare aLDTM clinical outcomes for ASIRCTs between young and elderly patients. Methods This retrospective study reviewed data from patients who underwent aLDTM tendon transfer for ASIRCTs with minimum 2-year follow-up. Clinical evaluations included visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), active range of motion (aROM), strength, and complications. Radiologic assessments included acromiohumeral distance, Hamada classification, and integrity of transferred tendon. Patients were divided into group total (all ages), group old (≥70 years), and group young (≤60 years). Results A total of 123 patients were enrolled with 39 in group young (mean age, 56.6±4.9 years) and 27 in group old (mean age, 73.6±2.3 years). Postoperatively, both groups showed significant improvements in VAS, ASES, and SANE scores and improved aROM for forward elevation, abduction, and internal rotation. No significant differences in clinical coutcomes were noted between the groups. Furthermore, similar rates of complications, including retears and postoperative infections, were observed across all three groups. Conclusions Our study highlights the effectiveness of aLDTM transfer for ASIRCTs with minimal glenohumeral arthritis, demonstrating similar outcomes in both group young and group old patients. Moreover, patients in these distinct age groups showed comparable clinical results when compared to group total. Level of evidence III.

Margin convergence (MC) and superior capsular reconstruction (SCR) are common treatment options for irreparable rotator cuff tears in younger patients, although they differ in associated costs and operative times. The purpose of this study was to compare range of motion, patient-reported outcomes (PROs), and reoperation rates following MC and SCR. We hypothesized superior outcomes after SCR relative to MC regarding functional outcomes, subjective measures, and reoperation rates. This was a multicenter retrospective review of 59 patients from 3 surgeons treating irreparable rotator cuff tears with either MC (n = 28) or SCR (n = 31) and minimum 1-year follow-up from 2014-2019. Visual analog scale (VAS) for pain, Subjective Shoulder Value (SSV), active forward flexion (FF), external rotation (ER), retear rate, and conversion rate to reverse shoulder arthroplasty were evaluated. t tests and χ2 tests were used for continuous and categorical variables, respectively (P <.05). Baseline demographics, range of motion, and magnetic resonance imaging findings were similar between groups. Average follow-up was 31.5 months and 17.8 months for the MC and SCR groups, respectively (P <.001). The MC and SCR groups had similar postoperative FF (151° ± 26° vs. 142° ± 38°; P =.325) and ER (48° ± 12° vs. 46° ± 11°; P =.284), with both groups not improving significantly from their preoperative baselines. However, both cohorts demonstrated significant improvements in VAS score (MC: 7.3 to 2.5; SCR: 6.4 to 1.0) and SSV (MC: 54% to 82%; SCR: 38% to 87%). There were no significant differences in postoperative VAS scores, SSV, and rates of retear or rates of conversion to arthroplasty between the MC and SCR groups. In patients with preoperative pseudoparesis (FF < 90°), SCR (n = 9) resulted in greater postoperative FF than MC (n = 5) (141° ± 38° vs. 67° ± 24°; P =.002). Both MC and SCR demonstrated excellent postoperative outcomes in the setting of massive irreparable rotator cuff tear, with significant improvements in PROs and no significant differences in range of motion. Specifically for patients with preoperative pseudoparesis, SCR was more effective in restoring forward elevation. Further long-term studies are needed to compare outcomes and establish appropriate indications. [ABSTRACT FROM AUTHOR]

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. 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. 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. 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. [ABSTRACT FROM AUTHOR]

Arthroscopically assisted lower trapezius tendon (aLTT) transfer is one of the treatment options for posterior-superior irreparable rotator cuff tears (PSIRCTs). Although short-term clinical outcomes have shown promising results, there are currently no reported clinical outcomes over a longer follow-up period. This study evaluated the mid-term outcomes of aLTT transfer in patients with a diagnosis of PSIRCT. This retrospective case-series study included patients who underwent aLTT transfer between May 2017 and May 2019. The clinical outcome assessment included the visual analog scale (VAS) pain score, Constant score, American Shoulder and Elbow Surgeons score, University of California–Los Angeles score, Activities of Daily Living Requiring Active External Rotation (ADLER) score, active range of motion, Single Assessment Numeric Evaluation score, and return-to-work rate. The radiographic analysis included the acromiohumeral distance, Hamada grade, and integrity of the transferred tendon at final follow-up. Subgroup analyses were performed based on the integrity of the transferred tendon and the trophicity of the teres minor (Tm). This study enrolled 36 patients with a mean age of 63.4 years who met the inclusion criteria and were followed up for a mean of 58.2 ± 5.3 months. At final follow-up, the patients showed significant improvement in mean VAS score, Constant score, American Shoulder and Elbow Surgeons score, University of California–Los Angeles score, ADLER score, and active range of motion in all directions except internal rotation. A decrease in the acromiohumeral distance and an increase in the Hamada grade were observed at final follow-up (P =.040 and P =.006, respectively). Retears of the transferred tendon occurred in 7 patients, and postoperative infections developed in 2 individuals. An interesting finding was that the retear group still demonstrated improvement in the VAS score but did not show improvement in external rotation at the side by the final follow-up. Compared with the Tm non-hypertrophy group, the Tm hypertrophy group showed significantly better improvement in external rotation at 90° of abduction and at the side, as well as the ADLER score. Of the study patients, 30 (83.3%) were able to successfully resume their previous work. In this study, aLTT transfer in patients with PSIRCTs demonstrated significant improvements in clinical and radiologic outcomes by the final follow-up. These findings provide support for the mid-term safety and effectiveness of aLTT transfer as a viable joint-preserving treatment option for PSIRCTs. However, larger and longer-term studies are still needed to further validate these findings. [ABSTRACT FROM AUTHOR]

Introduction: Treating global irreparable rotator cuff tears (GIRCTs) that involve both antero-and postero-superior cuff tendon tears could be a challenging problem. There has been limited joint-preserving treatment options in high-demand patients with minimal glenohumeral arthritis. The study aims to assess the clinical outcome of combined anterior latissimus dorsi and teres major tendon (aLDTM) transfer for patients with both GIRCTs and minimal glenohumeral arthritis. Materials and methods: This retrospective study included patients who underwent combined aLDTM transfer for GIRCTs between 2018 May and 2020 October. Clinical outcomes include pain VAS, Constant, American Shoulder and Elbow Society (ASES), University of California Los Angeles (UCLA), activities of daily living requiring active internal rotation (ADLIR) score, active range of motion (aROM), strength, rates of pseudoparalysis or pseudoparesis reversal and return to work. Radiographic assessment included the acromiohumeral distance (AHD), Hamada grade, and transferred tendon integrity at final follow-up. Results: 23 patients (mean age: 64.7 ± 5.9 years [55–74]) were included and the mean follow-up period was 28.2 ± 4.3 [24‒36] months. Postoperatively, VAS, Constant, ASES, UCLA, and ADLIR scores significantly improved at final follow-up (P <.001). Postoperative aROM was significantly improved in forward elevation (FE) to 129° ± 29°, abduction (ABD) to 105° ± t3°, and internal rotation (IR) at back to 5.9 ± 2.5. Strength of both FE and IR were also significantly improved (P <.001). Patients with preoperative pseudoparalysis (2 of 4 patients) and pseudoparesis (6 of 6 patients) experienced a reversal. No significant change in AHD and hamada grade was confirmed at final follow-up. 3 patients experienced partial tear of the transferred tendon. Conclusions: In this study, we found significant improvement in clinical outcomes with no significant progression of arthritis by final follow-up. The aLDTM transfer could be an alternative choice of joint-preserving treatment option for young and active patients with GIRCTs and minimal glenohumeral arthritis. However, large and long-term studies should be conducted to establish its adequacy. Study design: Case series. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Introduction: While the well-established correlation between increased muscle volume and enhanced muscle strength is widely recognized, there have been no studies assessing volumetric muscle changes in transfer surgery in the shoulder. This study aimed to evaluate changes in transferred muscle volume and their clinical implications in anterior latissimus dorsi and teres major (aLDTM) tendon transfer in patients with anterior superior irreparable rotator cuff tears (ASIRCTs). Materials and methods: The study retrospectively examined 40 patients who underwent aLDTM tendon transfers for ASIRCTs between August 2018 and January 2022. Using ImageJ software, the LDTM muscle was segmented in T2-weighted oblique axial images, and total muscle volume (tLDTMV) of both immediate and postoperative 1-year were calculated. Pearson correlation analysis was used to determine the correlation between ΔtLDTMV and ΔASES scores, Δactive-ROM, and Δstrength. Results: The current study revealed an 11.4% increase in tLDTMV at 1-year postoperative. Patients were grouped based on postoperative ASES score: Group 1 (Optimal, n = 17) and Group 2 (Suboptimal, n = 23). Although tLDTMVimmediate postoperative values were similar between groups (P = 0.954), tLDTMV1-year postoperative value was significantly higher in Group 1 compared to Group 2 (P = 0.021). In correlation analysis, ΔtLDTMV showed significant correlations with ΔASES score (r = 0.525, P < 0.001), ΔaROM of forward elevation (FE) (r = 0.476, P = 0.002), ΔaROM of internal rotation (IR) at back (r = 0.398, P = 0.011), Δstrength of FE (r = 0.328, P = 0.039), Δ strength of IR at 90° abduction (r = 0.331, P = 0.037), and IR at side (r = 0.346, P = 0.029). Conclusions: Significant increase in tLDTMV was observed at 1-year postoperative for ASIRCT patients. Notably, greater ΔtLDTMV exhibited a correlation with better ASES scores, increased aROM and strength in both FE and IR. Nevertheless, further research is required by employing more robust standardized measurement tools and a larger sample size. [ABSTRACT FROM AUTHOR]

An irreparable rotator cuff tear refers to a situation where the tear in the rotator cuff is large, and there is significant fatty degeneration and atrophy, making it impossible to suture the torn ends back to the humeral head. Various treatment options, including tendon transfer procedures, can be considered in such cases. Tendon transfer may be chosen for younger and active patients, and the selection should consider the advantages and disadvantages, the characteristics of different tendon transfer techniques and the condition of the rotator cuff. The lack of established standard treatment guidelines highlights the need for, further research and clinical experience. Future studies will be needed to establish the effectiveness and safety of treatments, and efforts should be made to improve treatment methods and ensure appropriate patient selection. [ABSTRACT FROM AUTHOR]

Background: Excellent short-term outcomes after reverse shoulder arthroplasty (RSA) have been reported, but longer term outcomes in the existing literature are sparse and vary widely. The purpose of this study is to systematically assess the existing literature to quantify functional outcomes and complication rates after RSA at a minimum of five years of follow-up. Methods: A Preferred Reporting Items for Systematic Reviews and Meta-analyses-compliant systematic literature search of the PubMed and Embase databases was undertaken. Studies reporting outcomes after primary RSA for nontrauma-related indications with a minimum of 5-year follow-up were included. Results: Overall, 20 studies satisfied all inclusion criteria. This represented 1591 shoulders in 1556 patients (32.1% males), with a mean age of 70.2 ± 5.0 years and mean follow-up of 8.8 years, or 106.2 ± 30.1 months (60-243). At final follow-up, the mean reported Constant Murley score was 62.1 ± 5.0 (49.0-83.0). The mean adjusted Constant Murley score was 83.5 ± 12.5 (58-111.9). The mean American Shoulder and Elbow Surgeons score was 81.8 ± 4.6, while the mean subjective shoulder value was 74.6 ± 6.4. Overall, 88% of patients rated their satisfaction as either good or very good. The range of active forward flexion, abduction, external, and internal rotation were respectively, 126° ± 13°, 106° ± 11°, 22° ± 11°, and 6° ± 2°. The overall rate of revision surgery was 4.9% (0%-45.5%). Regarding complications, the rate of prosthetic joint infection was 4.3% (0%-26.7%), shoulder dislocation was 3.7% (0%-20.4%), and acromial fracture was 2.0% (0%-8.8%). At final follow-up, 30.9% of shoulders had some degree of scapular notching. Conclusion: This systematic review shows that RSA results in high satisfaction rates, good clinical outcomes, as well as modest complication and revision rates at minimum 5-year follow-up.

Abstract 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.

Background: Both superior capsular reconstruction (SCR) and middle trapezius tendon (MTT) transfer can be performed in nonarthritic young and active patients with isolated irreparable supraspinatus tendon tears (IISTTs). However, to our knowledge, no comparative clinical studies have been conducted on these procedures. Purpose: To evaluate and compare the clinical and radiological outcomes of SCR and arthroscopic-assisted MTT transfer in patients with IISTTs. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 60 patients with IISTTs were categorized into 2 groups according to the surgical procedure—Group S underwent SCR (n = 34); Group M underwent MTT transfer (n = 26). The clinical outcomes included the visual analog scale score for pain, active shoulder range of motion, American Shoulder and Elbow Surgeons score, and University of California, Los Angeles, shoulder score. Radiological outcomes included the assessment of the acromiohumeral distance, progression of cuff tear arthropathy (Hamada grade), subacromial bone erosion, and graft failure. Results: The mean follow-up time was 39.3 ± 5.2 months (range, 26-59 months) and 37.6 ± 9.8 months (range, 27-54 months) in Group S and Group M, respectively. Significant improvements in clinical outcomes were observed in both groups, while the active forward flexion (148.2°± 24.1° vs 165.9°± 8.7°; P =.003) and abduction (131°± 37.3° vs 152.5°± 17.9°; P =.035) were significantly higher in Group M at the final follow-up. No significant differences were found in the postoperative Constant, American Shoulder and Elbow Surgeons, and University of California, Los Angeles, shoulder scores between the 2 groups. Radiologically, although no difference was found in the Hamada grade at the final follow-up between the 2 groups (P =.143), the rates of acromial wear (58.8% vs 15.4%; P <.001) and graft retear (47.1% vs 7.7%; P <.001) were significantly higher in Group S than in Group M. Conclusion: Both SCR and MTT transfer improved the overall clinical outcomes of IISTTs postoperatively, whereas MTT transfer was superior to SCR in terms of active forward flexion and abduction range of motion. Although higher rates of graft failure and subacromial bone erosion were observed in Group S, no difference was found in the clinical scores between the 2 groups at the short-term follow-up. However, further well-structured, prolonged comparative trials should be conducted in the future. [ABSTRACT FROM AUTHOR]

Purpose of Review: The purpose of the review is to provide an updated overview of a relatively novel but controversial surgical device (InSpace subacromial balloon, Stryker, Kalamazoo, MI) that can be readily incorporated into the armamentarium of the shoulder surgeon. The authors review the critical clinical and surgical decision-making aspects of InSpace. A recommended surgical technique and rehabilitation protocol are outlined. The authors present a nuanced view of the balloon spacer in the continuum of care of the irreparable rotator cuff tear. Recent Findings: Within the last year, two Level I clinical trials have been published, and the data from these studies offer conflicting evidence regarding the utility of the subacromial balloon spacer. The current review contrasts these two recent studies and offers a framework by which the available evidence can be practically understood with respect to clinical decision-making. The literature currently supports a limited indication for use of InSpace: the elderly, low-demand patient with preserved active range of motion with an operatively irreparable, posterosuperior rotator cuff tear with an intact subscapularis. Summary: The InSpace subacromial balloon spacer is a simple device that can yield substantial improvements in clinical outcomes among a subset of patients with irreparable rotator cuff tears. InSpace is not a panacea for the complex, irreparable rotator cuff tear. Individualized decision-making is necessary in this diverse and challening patient population. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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Purpose of reviewMassive irreparable rotator cuff tears present a significant challenge to the orthopedic surgeon. No single treatment, particularly among joint-preserving options, has been shown to be superior. The purpose of this review is to discuss recent advances in the treatment of massive irreparable rotator cuff tears, including partial repair with and without graft augmentation, interposition grafts, superior capsule reconstruction, subacromial balloon spacers, tendon transfer, and reverse total shoulder arthroplasty. We will also offer guidance on surgical indications based on our clinical experience.Recent findingsPartial repair may offer reasonable clinical improvement for patients with lower preoperative function despite high re-tear rates. Additionally, several types of interposition grafts have shown promising short-term results and may outperform repair alone. Subacromial balloon spacers may lead to clinical improvement, especially in patients without glenohumeral osteoarthritis or pseudoparalysis, and recently received FDA approval for use in the USA. Superior capsule reconstruction is a technically demanding procedure that appears to produce excellent short-term results particularly when performed at high volume, but long-term studies in heterogeneous study groups are needed. Tendon transfers improve function by restoring force coupling in the shoulder, offering a promising option for younger patients. Reverse total shoulder arthroplasty (RTSA) is a reliable option for treatment of irreparable cuff tears in elderly patients with lower functional demands. Irreparable cuff tears remain a difficult condition to treat. Recommended treatment for younger patients without glenohumeral osteoarthritis is particularly controversial. For older patients with low-demand lifestyles and glenohumeral osteoarthritis, RTSA is an effective treatment option. For all discussed procedures, patient selection appears to play a critical role in clinical outcomes.

Massive irreparable rotator cuff tears (RCTs) are a commonly encountered orthopedic condition that can be difficult to treat. Several techniques have been described to manage these tears, with the implantable subacromial balloon spacer being one of the most recent. The device, which has only been approved for clinical use in the United States since 2021, functions by resisting the superior humeral head migration seen in the setting of massive RCTs and restoring normal shoulder biomechanics, as corroborated by cadaveric studies. However, results regarding clinical outcomes have been mixed to date, and further high-quality studies are needed to define the optimal use of the subacromial balloon spacer in the treatment of massive irreparable RCTs.

Background: Irreparable rotator cuff tears represent approximately 12% of all presenting cuff tears, and multiple surgical techniques have been described for treatment, including allograft/bridge augmentation, debridement, partial repair, subacromial balloon, tendon transfer, and superior capsule reconstruction (SCR). SCR has demonstrated durable improvement in range of motion (ROM) and outcome scores at 2 and 5 years. Indications: Surgical indications for SCR include an irreparable tear of the supraspinatus and/or infraspinatus with a preserved or reparable subscapularis and preserved glenohumeral joint cartilage. Technique Description: Diagnostic arthroscopy is performed to identify and characterize the rotator cuff tear. Thorough debridement of the greater tuberosity is performed. Two all-suture FiberTak anchors are placed in the superior aspect of the glenoid. Two 2.6-mm FiberTak suture anchors are placed in the humeral head at the chondral margin. After measuring, the dermal allograft is cut to size with 15-mm overhang left on the far lateral edge. A 12-mm passport cannula is inserted laterally and the sutures from the glenoid and humeral head anchors are brought out through the cannula maintaining their position and orientation. The sutures are passed through the graft outside the cannula. The graft is introduced into the shoulder via the passport cannula with a back grasper. A cannula-in-cannula technique is used to tie the glenoid anchors first and then the medial row anchors. Two lateral row swivel lock anchors are used to complete a standard double row repair. Margin convergence is performed between the dermal allograft and remaining rotator cuff anterior and posterior. Postoperatively, patients are kept in a sling for 6 weeks, with no shoulder ROM. From weeks 6 to 12, patients discontinue sling and begin passive progression to active ROM. Strengthening is initiated at 12 weeks, and return-to-sport or work is at approximately 6 months. Results: Irreparable rotator cuff tears treated with arthroscopic rotator cuff repair and SCR show durable improvement in patient-reported outcomes at 2 and 5 years. Re-tear rates did not differ between athletes and non-athletes. Discussion/Conclusion: Arthroscopic rotator cuff repair with SCR is a durable and reliable surgical option for patients presenting with preserved glenohumeral joint and irreparable supraspinatus and/or infraspinatus tear. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication. [ABSTRACT FROM AUTHOR]

Background: Arthroscopic superior capsule reconstruction (SCR), arthroscopic partial repair (PR), and arthroscopic debridement (DB) are valid treatment options for irreparable rotator cuff (RC) tears. Purpose/Hypothesis: The purpose of this study was to compare clinical, functional, and radiological outcomes of arthroscopic SCR with arthroscopic PR and arthroscopic DB in patients with irreparable posterosuperior RC tears. It was hypothesized that SCR would lead to superior clinical and functional outcomes compared with PR or DB. Study Design: Cohort study; Level of evidence, 3. Methods: Clinical and functional outcomes of this single-center retrospective study included range of motion, strength, and the age- and sex-adjusted Constant-Murley score. Patient-reported outcome measures (PROMs) involved the quick Disabilities of the Arm, Shoulder and Hand score, the Subjective Shoulder Value, and the visual analog scale for pain. Graft and repaired tendon integrity was evaluated by magnetic resonance imaging (MRI) at 12 months of follow-up. Results: In total, 57 patients treated with SCR (n = 20), PR (n = 17), and DB (n = 20) were included. The mean clinical follow-up was 33.8 ± 17.9 months. Preoperative clinical and functional characteristics were comparable among the 3 groups. The range of motion and clinical and functional scores of all 3 groups significantly improved from pre- to postoperatively. Postoperative PROMs showed no differences among all 3 study groups. SCR revealed significantly higher postoperative strength compared with PR (P =.001) and DB (P =.004). Postoperative MRI revealed a rerupture in 4 patients with SCR (20%). Postoperative MRI showed a rerupture in 9 patients with PR (53%). Fatty muscle infiltration of the supraspinatus and infraspinatus significantly progressed within all 3 study groups in postoperative MRI scans. No clinical and functional differences were observed between intact and reruptured PR. Conclusion: Patients who underwent SCR had better postoperative strength recovery than patients who underwent PR or DB. [ABSTRACT FROM AUTHOR]

Background: Massive rotator cuff tears can be difficult to manage and consensus regarding treatment is debated. The purpose of this questionnaire study was to examine surgeon techniques and considerations for treatment of massive rotator cuff tears including how they implement superior capsule reconstruction (SCR), when indicated. Methods: A 21-item questionnaire was sent to members of the American Shoulder and Elbow Surgeons and the American Orthopedic Society for Sports Medicine. Questions covered management preferences for massive rotator cuff tears, rotator cuff repair and SCR techniques, beliefs about SCR, implant choices, use of augments, demographics, and patient management scenarios. Results: The questionnaire had 230 respondents. In rotator cuff repair of massive rotator cuff tears, preferred responses were long head biceps tendon preservation (when asymptomatic, 45.3%), routine subacromial decompression (62.1%), solid threaded anchors (71.1%), double row configuration (65.1%), and bone marrow stimulation of the footprint (55.6%). For providers that perform SCR (n = 166), preferred strategies included long head biceps tenodesis (55.4%), human dermal allograft tissue (93.2%), glenoid fixation with 3 implants (71.2%) using solid threaded anchors (42.3%), and humeral fixation with 2 solid threaded anchors medially (71.0%), and 2 solid threaded anchors laterally (46.9%). Other highly recommended strategies were side-to-side repair to the posterior rotator cuff if able (97.6%) and to use the thickest graft available (62.2%). Conclusion: Despite improved techniques and growing interest in SCR, many questions still remain. This study identifies the significant variability in repair constructs and methodology with SCR; further investigation into these variables could be analyzed to identify best practice guidelines.

Background: Superior capsular reconstruction (SCR) for massive, irreparable rotator cuff tears involves anchoring a graft between the superior glenoid and the greater tuberosity of the humerus. Optimizing the graft size is important. We aimed (1) to evaluate the reliability of plain film radiography in determining graft size for SCR and (2) to create a database to help predict future graft sizes. Methods: An inter- and intra-rater reliability trial was conducted on 10 and 6 subjects with healthy shoulders, respectively, using plain film radiography to measure the distance between the superior glenoid and the supraspinatus footprint. The subjects were positioned upright with an abduction pillow modified to hold the shoulder at 30° abduction and 45° external rotation, afterwhich a true antero-posterior shoulder radiograph was captured. Thirty subjects were recruited for the database and grouped using the aforementioned protocol. Results: The inter-rater and intra-rater trial agreement was excellent, with intraclass correlation coefficients of 0.94 (95% CI) and 0.76 (95% CI), respectively. Three medio-lateral patch sizes, of 33 mm, 38 mm, and 47 mm, were proposed based on the protocol in 30 subjects. Conclusions: Plain film radiography demonstrated excellent reliability in measuring the distance between the superior glenoid and the supraspinatus footprint. Three ordinal patch sizes are proposed. [ABSTRACT FROM AUTHOR]

Background: Recently, a polypropylene mesh has been introduced and reported to improve clinical outcomes after superior capsular reconstruction (SCR) using a fascia lata autograft (FLA). However, mesh-related events such as a foreign body response may trigger inflammation, which might affect graft healing and remodeling. Purpose/Hypothesis: The aim was to investigate whether the healing and remodeling of an FLA were affected by the use of a mesh by comparing the signal intensity of an FLA-alone group vs an FLA + Mesh group on postoperative magnetic resonance imaging (MRI). The hypothesis was that the use of a mesh would decrease the MRI signal intensity of FLA during the early postoperative phase. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who had undergone SCR using an FLA with or without a mesh between March 2013 and August 2021 were retrospectively analyzed. Follow-up MRI was performed at 3 months. A total of 78 patients (24 in the FLA group and 54 in the FLA + Mesh group) with intact grafts were included. Graft remodeling was evaluated by analyzing the signal-to-noise quotient (SNQ) at the humeral, mid-substance, and glenoid sites. Theoretically, lower SNQ ratios indicate higher strength and better healing of the graft. Results: The mean SNQ was 30.603 (range, 11.790-72.710) in the FLA group and 18.367 (range, 4.464-69.500) in the FLA + Mesh group (P <.001). Furthermore, significant differences were found between the 2 groups at the humeral and mid-substance sites (37.863 [range, 5.092-81.187] vs 15.512 [range, 1.814-80.869], P <.001; and 29.168 [range, 6.103-73.900] vs 16.878 [range, 2.454-92.416], P =.003; respectively). However, there was no difference between the 2 groups at the glenoid site (25.346 [range, 7.565-86.353] vs 20.354 [range, 3.732-88.468], P =.057). Conclusion: At the 3-month follow-up, the FLA + Mesh group showed a lower MRI signal intensity than the FLA group. The healing and remodeling of an FLA may be enhanced when a mesh is used. [ABSTRACT FROM AUTHOR]

Background: Superior capsule reconstruction (SCR) is an option for the treatment of massive, irreparable rotator cuff tears. However, which materials yield the strongest constructs remains undetermined. Purposes: We sought to investigate whether SCR with polytetrafluoroethylene (PTFE) or human dermal allograft (HDA), 2 or 3 glenoid anchors, and suture or minitape resulted in better failure load properties at the patch-glenoid interface. Methods: We conducted a biomechanical study in 30 glenoid-sided SCR repairs in Sawbones models divided into 5 groups. Each was pulled to failure to assess mode of failure, peak load (N), stiffness (N/mm), yield load (N), peak energy (N m), and ultimate energy (N m). The 5 groups were as follows: group 1—PTFE, 2 anchors, and suture; group 2—PTFE, 2 anchors, and minitape; group 3—HDA, 2 anchors, and suture; group 4—HDA, 2 anchors, and minitape; group 5—PTFE, 3 anchors, and minitape. Results: Repairs failed by button-holing of suture/minitape. Group 5 had greater peak load, stiffness, yield load, and peak energy (384 ± 62 N; 24 ± 3 N/mm; 343 ± 42 N; 4 ± 2 N m) than group 3 (226 ± 67 N; 16 ± 4 N/mm; 194 ± 74 N; 2 ± 1 N m) or group 4 (274 ± 62 N; 17 ± 4 N/mm; 244 ± 50 N; 2 ± 1 N m) and greater ultimate energy (8 ± 3 N m) than all other groups. Conclusions: This biomechanical study of SCR repairs in Sawbones models found that yield load was greater in PTFE than HDA, 3 anchors were better than 2, and minitape was no better than suture. [ABSTRACT FROM AUTHOR]

Background: Middle trapezius tendon (MTT) transfer has been described for dynamic reproduction of supraspinatus function. For management of irreparable rotator cuff (RC) tears, this procedure can be coupled with in situ (long head of the biceps tendon–based) superior capsular reconstruction (SCR) and partial RC repair. Purpose: To investigate the functional outcomes of augmentation of in situ SCR–reinforced partial RC repair with MTT transfer for the management of irreparable posterosuperior RC tears. Study Design: Cohort study; Level of evidence, 3. Methods: Conducted between September 2014 and March 2022, this study included 24 patients with irreparable posterosuperior RC tears who were allocated into 2 groups: patients managed with 2-layer tendon construct (in situ SCR–reinforced partial RC repair) (group A; n = 15) and patients managed with 3-layer tendon construct (MTT transfer–augmented, in situ SCR–reinforced partial RC repair) (group B; n = 9). Outcome measures included 2-year postoperative pain, range of motion (ROM) in forward flexion and external rotation, and the American Shoulder and Elbow Surgeons (ASES) and the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores. For data comparison, independent and paired t tests were used for parametric quantitative variables, and Mann-Whitney and Wilcoxon signed-rank tests were used for nonparametric quantitative variables; Fisher exact and McNemar tests were used for qualitative variables. Results: The mean age of the patients was 58.40 ± 4.54 years in group A and 59.22 ± 4.46 years in group B; there were no between-group differences in baseline patient characteristics. Patients in both groups had significant preoperative to postoperative improvement on all outcome measures (P <.05 for all). Group B had a significantly higher magnitude of postoperative improvement compared with group A in forward flexion ROM (88.88° ± 29.34° vs 46.66° ± 20.93°; P =.001), external rotation ROM (32.22° ± 14.81° vs 16.0° ± 9.10°; P =.002), ASES score (71.07 ± 8.26 vs 57.87 ± 8.39; P =.001), and QuickDASH score (–70.20 ± 6.95 vs –58.34 ± 12.52; P =.007). Conclusion: Augmentation of in situ SCR–reinforced partial RC repair with MTT transfer in a 3-layer tendon construct led to significantly greater improvement in postoperative ROM and functional scores compared with a 2-layer construct. [ABSTRACT FROM AUTHOR]

Arthroscopic augmentation of massive and irreparable rotator cuff tears proves to be a valid and evidence-based treatment option to maximize healing and patient outcomes following rotator cuff repair. Integration of acellular dermal allografts as augment or interposition grafts demonstrates definitive benefit in patients with high risk of retear or individuals with severely retracted tears, respectively. Furthermore, these allografts have demonstrated benefit when used for superior capsular repair for chronic, atrophied tears in young, active patients who do not want to proceed with a reverse total shoulder replacement. [ABSTRACT FROM AUTHOR]

Superior capsular reconstruction (SCR) was developed as a minimally invasive, innovate technique to restore normal shoulder biomechanics for patients who present with massive, irreparable rotator cuff tear (MIRCTs) that preclude shoulder arthroplasty. Current studies have shown that SCR for MIRCTs result in excellent short-term clinical outcomes, adequate pain relief, and functional improvement with low graft failure and complication rates. This article aims to critically evaluate the biomechanics, indications, procedural considerations, clinical outcomes, rehabilitation program, and complications associated with the SCR procedure. [ABSTRACT FROM AUTHOR]

Background: Superior capsule reconstruction (SCR) was developed as an alternative treatment for irreparable rotator cuff tears to restore superior stability of the glenohumeral joint. Although fatty infiltration (FI) of the rotator cuff muscles, especially the infraspinatus, has been implicated as a predictor of outcomes and graft integrity after rotator cuff repair, it has not been fully investigated in cases of SCR. Purpose: To evaluate the effect of FI of the infraspinatus muscle on clinical and radiological outcomes after SCR. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 55 consecutive patients with irreparable posterosuperior rotator cuff tears who underwent SCR between January 2013 and August 2020 were included retrospectively. Preoperative and postoperative clinical and radiological findings (median follow-up of >2 years), including magnetic resonance imaging results, were thoroughly reviewed. The patients were divided into 2 groups: group 1 with mild FI of the infraspinatus (Goutallier grades 0-2) and group 2 with severe FI of the infraspinatus (Goutallier grades 3-4). The American Shoulder and Elbow Surgeons score, Constant score, visual analog scale score for pain, and range of motion were evaluated. Acromiohumeral distance and rotator cuff tear arthropathy using the Hamada classification were assessed on plain radiography. Postoperative graft integrity was evaluated by magnetic resonance imaging. Graft failure was defined as complete discontinuity. Univariate and multivariable logistic regression analyses were performed to evaluate clinical and radiological findings that might be associated with successful SCR. Results: Clinical and radiological outcomes significantly improved after SCR. Graft failure was noted in 15 (27.3%) patients and was more frequent in group 2 than in group 1 (50.0% vs 14.3%, respectively; P =.004). Univariate analysis indicated a significant association between severe FI in the infraspinatus (group 2) and graft failure after SCR (odds ratio, 6.00 [95% CI, 1.65-21.80]; P =.006). Multivariable analysis indicated that FI of the infraspinatus was the only factor associated with graft failure (odds ratio, 6.37 [95% CI, 1.63-24.90]; P =.008). Conclusion: Severe FI of the infraspinatus muscle was a factor indicating a poor prognosis for graft integrity after SCR. Preoperative evaluation of FI in the rotator cuff muscles can help predict postoperative outcomes and may help guide therapeutic options. [ABSTRACT FROM AUTHOR]

Background: History of prior rotator cuff repair (RCR) may adversely affect the outcomes of reverse total shoulder arthroplasty (RTSA), but there is no information regarding the influence of prior superior capsular reconstruction (SCR) surgery on the outcomes of RTSA. The purpose of this study is to evaluate the outcomes of RTSA following failed arthroscopic SCR. Methods: All patients who underwent RTSA for failed SCR (SCR cohort) at our institution were identified from our institutional database. A comparative cohort of patients who had RTSA with a history of failed RCR (Control cohort) was also reviewed. Demographic information, 90-day complication rate, 90-day emergency department visits, length of stay, and outcome scores (patient-reported outcomes measurement information system [PROMIS] physical function upper extremity, Visual Analog Scale score, and range of motion) were compared. Results: From 2015 to 2020, 87 arthroscopic SCRs were performed at our institution and of these, 13 patients underwent RTSA at a mean time of 14.6 months (5.8-32.4) after SCR and were followed up for an average of 17.9 months (1.6-44.6). The average number of shoulder surgeries prior to RTSA was 2.8 (1-7), with the last surgery being SCR. During the same period, we identified 15 patients who underwent an RTSA after a failed RCR (control cohort). The RTSA in the control cohort was performed on average at 12.8 months (1.5-39.5) following the last RCR, and patients were followed up for an average of 27.7 months (2.8-53.9). The average number of shoulder surgeries before the RTSA in the control cohort was 1.4 (1-3). Although the SCR cohort had significant improvements in pain scores and forward flexion (FF), there was only a modest functional improvement with PROMIS scores and no meaningful improvement with external rotation. Complications (23%) in the SCR cohort included 1 periprosthetic joint infection requiring 2-stage revision, 1 acromion stress fracture, and 1 ulnar neuritis. Overall, compared to the SCR cohort, patients in the control cohort had better function (PROMIS physical function upper extremity), lower Visual Analog Scale score, and greater range of motion (FF and external rotation) preoperatively and at last follow-up, but there were no differences in the length of stay and 90-day emergency department visits, infection, and complication rate between the 2 cohorts. Conclusion: RTSA after failed SCR improves pain and FF but is associated with modest functional improvements and high complication rates. However, these findings will require confirmation in a larger cohort with longer follow-up.

Irreparable anterosuperior rotator cuff tears (IASRCTs) can result in loss of active elevation, loss of internal rotation, and pseudoparalysis. Joint-preserving treatment options for IASRCTs in young and high-demand elderly patients are limited. The purpose of this study was to evaluate the clinical and radiologic outcomes of combined anterior latissimus dorsi and teres major (aLDTM) tendon transfer in patients with IASRCTs without reconstruction of the superior rotator cuff and capsular portion. This retrospective study was conducted between 2015 and 2018. We included patients who underwent combined aLDTM tendon transfer for IASRCTs. Clinical outcomes included visual analog scale for pain, Constant score, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder scores, activities of daily living requiring active internal rotation score, active range of motion, subscapularis-specific physical examination, and rate of return to work. Radiographic analyses included the assessment of acromiohumeral distance, Hamada grade for cuff tear arthropathy, rate of anterior glenohumeral subluxation reduction, and transferred tendon integrity at 2 years postoperatively. The mean follow-up period was 38.1 ± 13.7 (range: 24-63) months. Of the patients, 30 (mean age: 64.1 years) met the study criteria. Postoperatively, mean Constant, American Shoulder and Elbow Surgeons, University of California Los Angeles, and activities of daily living requiring active internal rotation scores improved from 47.4 to 69.9 (P <.001), 44.9 to 79.2 (P <.001), 20.0 to 28.7 (P <.001), and 13.2 to 26.9 (P <.001), respectively. The mean active range of motion was significantly increased postoperatively for both forward elevation (P <.001) and internal rotation at the back (P <.001). Of the patients, 24 (83%) returned to their previous work. No significant progression of cuff tear arthropathy was observed at final follow-up (Hamada grade: preoperative 1.3 ± 0.5 to postoperative 1.5 ± 0.7; p=0.155). Fifteen of 30 patients (50%) restored the anterior glenohumeral subluxation that was apparent preoperatively. One patient presented with transient axillary nerve palsy after surgery. Two patients presented with partial nonretracted tears of the transferred tendon. This minimum 2-year follow-up study demonstrated that combined aLDTM tendon transfer without reconstruction of the superior rotator cuff and capsular portion was a viable treatment option with favorable clinical and radiologic outcomes for patients with IASRCTs. [ABSTRACT FROM AUTHOR]

The optimal management for massive rotator cuff tears (MRCTs) without osteoarthritis (OA) remains controversial. The purpose of this study was to evaluate and compare the clinical outcomes of reverse shoulder arthroplasty (RSA) vs. rotator cuff repair (RCR) in patients with MRCTs without OA. We conducted a retrospective data analysis of 68 patients treated for MRCTs via RSA and 215 patients treated for MRCTs via arthroscopic RCR between January 2014 and April 2019. Through propensity score matching, patients were matched for sex, age, tear size, and global fatty degeneration index. Thirty-nine patients in each group were included, and all patients had completed minimal 2-year follow-up. Postoperative radiologic evaluations of healing failure were performed. The visual analog scale score for pain, range of motion, and functional outcome measures including the American Shoulder and Elbow Surgeons score, QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score, Simple Shoulder Test score, and Constant score were assessed and compared between the 2 groups. Healing failure was observed in 10 patients in the RCR group (32.3%). No statistically significant differences in preoperative range of motion and functional scores were found between the RCR and RSA groups. Both groups showed significant pain relief and functional improvement at final follow-up. Patients in the RCR group showed significantly greater forward elevation (156.4° ± 23.8° vs. 139.7° ± 22.4°, P <.001) and internal rotation (thoracic vertebra, T8.2 ± 1.2 vs. T9.7 ± 2.6, P =.001). The average American Shoulder and Elbow Surgeons score was 88.3 ± 12.2 in the RCR group and 81.8 ± 16.1 in the RSA group (P =.045). The QuickDASH score was significantly higher in the RCR group (P =.019). A significantly higher Simple Shoulder Test score (9.7 ± 2.8 vs. 8.1 ± 3.0, P =.01) and a significantly higher Constant score (67.2 ± 6.5 vs. 63.2 ± 7.1, P =.011) were seen in the RCR group. Both RSA and RCR are effective and reliable treatment options for MRCTs without OA. However, the RCR group showed better shoulder function improvement than the RSA group. Considering the possible implications of RSA, RCR should be referred to as a first-line treatment option for patients with MRCTs without OA with proper indications. [ABSTRACT FROM AUTHOR]

Background: Arthroscopically-assisted lower trapezius tendon (aLTT) transfer has emerged as an effective surgical option for patients with posterior superior irreparable rotator cuff tears (PSIRCTs) who primarily complain of external rotation weakness and lag signs, in the absence of arthritis. The purpose of this study is to compare the clinical and structural outcome among different age groups in aLTT transfer for PSIRCTs., Methods: We retrospectively reviewed patients who underwent aLTT transfer for PSIRCTs between May 2017 and September 2021. We included patients with PSIRCTs, minimal glenohumeral arthritis (Hamada grade ≤ 2), poor muscle quality (Goutallier grades ≥ 3), and a minimum follow-up of 2 years. Patients lacking a minimum of 2-year follow-up data and a postoperative MRI were excluded. For the purpose of the study, three groups were created: Group Total includes all ages, Group A consists of patients aged 60 and below, and Group B consists of patients aged 70 and above. We compared patient-reported outcome scores (VAS, Constant, UCLA, ASES, ADLER), pre- and postoperative range of motion (ROM), acromiohumeral distance (AHD), Hamada grade, graft integrity on postoperative MRI, and complications among the groups., Results: Eighty-four patients underwent aLTT transfer (51 with Achilles tendon allografts and 33 with fascia lata autografts), with a mean follow-up of 43.7 ± 14.6 months. There was significant improvement in VAS, Constant, UCLA, ASES, ADLER scores, and ROM in the entire cohort. When comparing Group A (n=23) and Group B (n=19), there were no significant differences in patient-reported outcomes, ROM, AHD, and Hamada grade. Additionally, we observed comparable clinical results, with similar rates of complications such as re-tear, postoperative stiff shoulder, and revision surgery between the groups., Conclusion: The current study demonstrates that aLTT transfer for PSIRCTs with minimal glenohumeral arthritis yields similar results between Group A and Group B. Additionally, the two different age groups did not show significantly different clinical results when compared to the entire cohort. Our findings contribute to a more comprehensive understanding of the applicability of aLTT transfer across different age groups, emphasizing its potential as a viable treatment option for a broader patient population., (Copyright © 2024. Published by Elsevier Inc.)

Background: Among emerging options, Middle Trapezius Tendon (MTT) transfer has shown promise, particularly in isolated supraspinatus irreparable rotator cuff tears (ISIRCTs) and nonarthritic shoulders unsuitable for reverse total shoulder arthroplasty. This study aims to assess clinical and radiological results of MTT transfer utilizing an Achilles tendon allograft for ISIRCTs., Methods: We retrospectively reviewed patients who received MTT transfer using Achilles tendon allograft for ISIRCTs between May 2020 and August 2021. Clinical assessments using pain VAS, Constant, ASES, UCLA, and SANE score were assessed pre- and postoperatively. Active Range of Motion (aROM) were obtained, and radiologic assessments included AHD, Hamada grade, and MTT integrity., Results: 18 patients were involved with mean age of 63.8 ± 7.1, followed for an average of 25.4 ± 4.4 months. Significant improvements were observed in pain relief (VAS:4.7±1.5 to 1.6±0.9, P<.001), shoulder function (Constant: 53.1±11.1 to 70.0±15.1, ASES: 57.7±13.5 to 78.2±17.0, UCLA: 13.6±4.5 to 22.0±6.4; all P<.001), and patient satisfaction (SANE: 51.3±14.1 to 73.7±15.0, P<.001). Active range of motion significantly improved in Forward elevation (FE) and abduction (ABD). Radiologic assessments showed no significant change in AHD and Hamada grade, with p-values of 0.503 and 0.260, respectively., Conclusion: MTT transfer using Achilles tendon allograft showed improvement in pain relief, clinical scores, and active FE and ABD in patients with ISIRCTs. However, the validation of its effectiveness necessitates multicenter and long-term studies., (Copyright © 2024. Published by Elsevier Inc.)

Background: Functionally irreparable rotator cuff tears (FIRCTs) present an ongoing challenge to the orthopedic surgeon. The aim of this systematic review was to critically compare the outcomes of three latissimus dorsi tendon transfer (LDT) techniques and two superior capsular reconstruction (SCR) techniques in treatment of FIRCTs. Methods: A systematic review of studies evaluating the outcome of FIRCT treatment was performed via a search of four databases in April 2020. Each included study was reviewed in duplicate by two reviewers for evaluation of methodological quality. The treatments analyzed were arthroscopic LDT (aLDT), open LDT Gerber technique (oLDTG), open LDT L'Episcopo technique (oLDTL), SCR with allograft (SCR-Allo), and SCR with autograft (SCR-TFL). Demographics, range of motion, patient-reported outcome measures, radiographic acromiohumeral distance (AHD), treatment failures, and revisions were recorded. Results: Forty-six studies (1287 shoulders) met criteria for inclusion. Twenty-three studies involved open latissimus transfer, with 445 shoulders undergoing oLDTG with mean follow-up of 63.2 months and 60 patients undergoing oLDTL with mean follow-up of 51.8 months. Ten studies (n = 369, F/U 29.2mo) reported on aLDT. Seven studies (n = 253, F/U 16.9mo) concerned SCR-Allo, and six studies (n = 160, F/U 32.mo) reported on SCR-TFL. Range of motion and subjective outcome scores improved in all techniques with no differences across treatments. Both SCR methods provided greater improvement in AHD than open LDT methods (p < 0.01). The re-tear rates were lower in both oLDT groups compared to the SCR groups (p = 0.03). Clinical failure rates were higher in the SCR-Allo and oLDTG groups, while overall treatment failures were lowest in oLDTL compared to all four other groups. Conclusion: SCR techniques were associated with improved short-term radiographic acromiohumeral distance, while the open LDT techniques had lower tendon re-tear and treatment failure rates. All techniques resulted in improved clinical outcomes and pain relief compared to preoperative levels with no differences across techniques. Level of evidence IV: Systematic review of case series and cohort studies. [ABSTRACT FROM AUTHOR]

Small, preliminary studies and the systematic reviews on superior capsular reconstruction (SCR) that collate data are at increased risk spin. This study's primary objective was to identify, describe, and account for the incidence of spin in systematic reviews of SCR. This study's secondary objective was to characterize the studies in which spin was identified to determine whether identifiable patterns of characteristics exist among studies with spin. This study was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using a predetermined protocol. A search was conducted on the PubMed and Embase databases for systematic reviews and meta-analyses on SCR. Screening and data extraction were conducted independently by 2 authors. Each included study's abstract was assessed for the presence of the 15 most common types of spin, with full texts reviewed during cases of disagreement or for clarification. General data that were extracted included study title, authors, publication year, journal, level of evidence, study design, funding source, reported adherence to PRISMA guidelines, preregistration of the study protocol, and primary and secondary outcome measures. Full texts were used in the assessment of study quality per AMSTAR 2. We identified 53 studies during our search, of which 17 met the inclusion criteria. At least 1 form of spin was observed in all 17 studies. The most common types of spin were type 5 ("The conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies") and type 9 ("Conclusion claims the beneficial effect of the experimental treatment despite reporting bias"), both of which were observed in 11 studies (11 of 17, 65%). A statistically significant association between lower level of evidence and type 5 ("The conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies") was observed (P =.0175). A statistically significant association was also found between more recent year of publication and the spin category misleading interpretation (P =.0398), and between lower AMSTAR 2 score and type 13 ("Failure to specify the direction of the effect when it favors the control intervention") (P =.0260). No other statistical associations between other study characteristics were observed. Spin is highly prevalent in abstracts of SCR systematic reviews and meta-analyses. An association was found between the presence of spin and lower level of evidence, year of publication, and AMSTAR 2 ratings. [ABSTRACT FROM AUTHOR]

Background: The irreparability of rotator cuff repair is generally determined during surgery. We have been performing partial repairs for rotator cuff tears that are deemed irreparable with primary repair. The aim of this study is to report, for the first time, the long-term postoperative outcome of our partial repair method and to clarify the criteria for the irreparability of primary repair. Methods: The UCLA score, radiographic findings, and magnetic resonance imaging findings of 156 shoulders that underwent rotator cuff repair (primary repair, 126 shoulders; partial repair, 30 shoulders) were retrospectively evaluated at preoperative and >10-year postoperative follow-up (mean evaluation time, 11.5 ± 1.0 years). Osteoarthritic (OA) changes were evaluated by radiographic findings, and the cuff integrity (Sugaya classification) and fatty infiltration (Goutallier classification) were evaluated by magnetic resonance imaging findings. These evaluations were compared between a primary repair group and partial repair group. Results: Although no significant difference was observed between preoperative and postoperative findings for the UCLA score, the strength of forward flexion was significantly lower at 10 years postoperatively in the partial repair group. Preoperative image evaluation showed no significant difference in OA changes between the 2 groups; however, fatty infiltration showed significantly greater progression in the partial repair group than the primary repair group. At >10-year postoperative follow-up, the OA changes, cuff integrity, and fatty infiltration showed significantly greater progression in the partial repair group compared to the primary repair group. Although the long-term outcome of the partial repair group was inferior to that of the primary repair group in imaging evaluations, good functional outcome of the shoulder joint was maintained. Conclusion: Our results suggested that partial repair could be an effective treatment option for irreparable rotator cuff tear. In terms of the feasibility of primary repair, the cutoff value for preoperative fatty infiltration was stage 2; thus, we believe that primary repair should be performed for cases with stage 2 fatty infiltration or lower, and partial repair should be performed for cases with stage 3 fatty infiltration or higher. However, manual workers and athletes with stage 3 fatty infiltration or higher should be advised in advance that mild muscle weakness may remain after surgery.

Background: The proximal fascia lata (FL) graft construct used for arthroscopic superior capsule reconstruction (ASCR) is openly harvested, whereas the mid-thigh FL graft construct is minimally invasively harvested. The purpose of the current study was to compare the biomechanical properties of proximal thigh and mid-thigh-harvested FL graft constructs used for ASCR. The hypothesis was that, despite the different morphological characteristics of the proximal thigh and mid-thigh FL graft constructs used for ASCR, their biomechanical properties would not significantly differ. This information may assist orthopedic surgeons in the choice of the harvest location, technique, and type of graft construct for ASCR. Methods: Forty FL specimens, 20 proximal thigh and 20 mid-thigh, were harvested from the lateral thighs of 10 fresh human cadavers (6 male, 4 female; average age, 58.60 ± 17.20 years). The thickness of each 2-layered proximal thigh and 6-layered mid-thigh FL graft construct was measured. Each construct was mechanically tested in the longitudinal direction, and the stiffness and Young’s modulus were computed. Data were compared by Welch’s independent t-test and analysis of variance, and statistical significance was set at P

Abstract Background Irreparable rotator cuff tears are common and difficult to treat. Techniques for “filling the loss of substance” require fixation to the rotator cuff stump (tendon augmentation) or to the glenoid (superior capsular reconstruction), which are complicated by the narrow working zone of the subacromial space. The main objective of this study was to determine whether a braided graft of gracilis (GR) and semitendinosus (ST) could fill a loss of tendon substance from an irreparable rupture of the supra- and infraspinatus, by fixing the graft to the greater tuberosity and the spine of the scapula. Methods This was a cadaveric study with the use of ten specimens. The GRA and ST tendons were harvested, braided and reinforced with suture. An experimental tear of the supraspinatus (SS) and upper infraspinatus (IS) retracted at the glenoid was made. The GRAST transplant was positioned over the tear. The transplant was attached to the greater tuberosity by two anchors and then attached to the medial third of the scapular spine by trans-osseous stitching. The percentage of filling obtained was then measured and passive mobility of the shoulder was assessed. We proceeded to the same technique under arthroscopy for a 73 years old patient whom we treated for a painful shoulder with irreparable cuff tear. We inserted a GRAST graft using arthroscopy. Results The Braided-GRAST allowed a 100% filling of the loss of tendon substance. Mobility was complete in all cases. Conclusion This technique simplifies the medial fixation and restores the musculo-tendinous chain where current grafting techniques only fill a tendinous defect. The transplant could have a subacromial “spacer” effect and lower the humeral head. The donor site morbidity and the fate of the transplant in-vivo are two limits to be discussed. This anatomical study paves the way for clinical experimentation.

Repairing massive rotator cuff tears (MRCTs) can often be technically challenging due to tendon retraction, bursal fibrosis, and muscular fatty infiltration that usually occurs, often resulting in poor outcomes and an unpredictable prognosis. Although some other surgical management options have been reported, there is a lack of literature supporting tendon transfers in the presence of combined anterior and posterior-superior irreparable rotator cuff tears. We describe a case where a combined transfer of the latissimus dorsi and lower trapezius tendons was employed to treat an MRCT affecting the anterior and posterior superior portions of the rotator cuff. A 64-year-old male presented significant pain and limited range of motion in the right shoulder following a traumatic anterior shoulder dislocation seven months prior. MRI showed retracted tears (> 5 cm) of the supraspinatus, infraspinatus, and subscapularis tendons with significant fatty infiltration (Goutallier IV). The patient underwent an open transfer of the lower trapezius tendon to the greater tuberosity and the latissimus dorsi to the lesser tuberosity. At the final follow-up, 2.5 years postoperatively, the patient exhibited a painless functional range of motion and could resume daily activities. Although there are alternative surgical options available, the positive outcomes observed in the presented case may be attributed to the restoration of rotational strength and the re-establishment of force coupling across the shoulder. This report describes the successful implementation of a surgical treatment option for managing MRCT affecting the anterior and posterior superior portions of the rotator cuff. • Combined transfer of latissimus dorsi and lower trapezius tendons for massive rotator cuff tears • Non-arthroplasty surgical option for tears involving anterior and posterior-superior regions • At 2.5 years post-op, patient achieved painless functional range of motion • Addresses literature gap on tendon transfers for combined irreparable rotator cuff tears [ABSTRACT FROM AUTHOR]