Radiologic Comparison of Humeral Position according to the Implant Designs Following Reverse Shoulder Arthroplasty: Analysis between Medial Glenoid/Medial Humerus, Lateral Glenoid/Medial Humerus, and Medial Glenoid/Lateral Humerus Designs

BACKGROUND: The currently available reverse shoulder arthroplasty (RSA) designs can be classified into medial glenoid/medial humerus (MGMH), lateral glenoid/medial humerus (LGMH), and medial glenoid/lateral humerus (MGLH) prosthesis designs. The purpose of this study was to radiologically analyze the effect of different RSA designs on humeral position following RSA. METHODS: A total of 50 patients who underwent primary RSA were retrospectively analyzed. Among 50 patients, 33 patients (group A: MGMH) underwent RSA with Aequalis system (Wright, Inc, Bloomington, MN, USA), 6 (group B: LGMH) with Aequalis system using bony increased offset, and 11 (group C: MGLH) with Aequalis Ascend Flex system. The acromiohumeral distance, acromioepiphyseal distance (AED), lateral humeral offset (LHO), LHO from the center of rotation (LHO(COR)), and deltoid length were radiologically measured to quantify the distalization and lateralization of the humerus. RESULTS: The increment in postoperative AED was 19.92 ± 3.93 mm in group A, 24.52 ± 5.25 mm in group B, and 25.97 ± 5.29 mm in group C, respectively (p=0.001). The increment in postoperative LHO was 0.13 ± 6.30 mm, 8.00 ± 12.14 mm, and 7.42 ± 6.88 mm, respectively (p=0.005). The increment in postoperative LHOCOR was 20.76 ± 6.06 mm, 22.04 ± 5.15 mm, and 28.11 ± 4.14 mm, respectively (p=0.002). CONCLUSIONS: The radiologic analysis of the effect of different RSA designs on humeral position following RSA showed significant differences in the increment in postoperative AED, LHO, and LHO(COR) between the 3 groups. Therefore, MGLH design seems to be more effective for humeral distalization and lateralization compared to original Grammont design.

Treatment Strategy for Irreparable Rotator Cuff Tears

Recently, patients with shoulder pain have increased rapidly. Of all shoulder disorders, rotator cuff tears (RCTs) are most prevalent in the middle-aged and older adults, which is the primary reason for shoulder surgery in the population. Some authors have reported that up to 30% of total RCTs can be classified as irreparable due to the massive tear size and severe muscle atrophy. In this review article, we provide an overview of treatment methods for irreparable massive RCTs and discuss proper surgical strategies for RCTs that require operative management.

Prevalencia de artropatía por desgarro masivo del manguito de los rotadores / Rotator cuff tear athropathy prevalence

Resumen: Introducción: La artropatía por desgarro masivo del manguito de los rotadores (ADMMR) condiciona un desplazamiento de la cabeza humeral acompañada de acetabularización del acromion y femoralización de la glenoides. El objetivo de este estudio fue conocer la prevalencia de la ADMMR en el Instituto Nacional de Rehabilitación (INR). Material y métodos: Se realizó un estudio de prevalencia que incluyó la revisión de 400 expedientes para identificar a 136 pacientes con lesión del manguito de los rotadores. Se integró un subgrupo para pacientes con lesión masiva del manguito de los rotadores (LMMR) y ADMMR. Se estudiaron variables y se estadificaron. Resultados: Se incluyeron 34 pacientes con LMMR (26 mujeres y 8 hombres) con una edad promedio de 60.1 ± 10.26 años. Se registró una prevalencia de 25% de LMMR en el grupo global con lesión del manguito de los rotadores. Asimismo, se buscó la prevalencia de ADMMR en el grupo global y en el subgrupo de lesiones masivas, siendo de 19 y 76%, respectivamente. Los pacientes con LMMR se estadificaron para conocer el grado de ADMMR mediante la clasificación de Seebauer, encontrando 32% con estadios 1a, 11% 1b, 32% 2a, 0% 2b y 23% no presentaban datos de ADMMR. Conclusión: La prevalencia de ADMMR en pacientes del servicio incluido con lesión del manguito de los rotadores y LMMR es mayor a la reportada en la literatura sajona.

Abstract: Introduction: Glenohumeral arthritis secondary to massive rotator cuff tear presents with a superior displacement and femoralization of the humeral head with coracoacromial arch acetabularization. The purpose of this study was to establish prevalence of rotator cuff tear artropathy (CTA) at our institution. Material and methods: Four hundred electronic records were reviewed from which we identified 136 patients with rotator cuff tears. A second group was composed with patients with massive cuff tears that were analized and staged by the Seebauer cuff tear arthropathy classification. Results: Thirty four patients with massive rotator cuff tears were identified, 8 male and 26 female (age 60.1 ± 10.26 years). Massive rotator cuff tear prevalence was 25%. CTA prevalence found in the rotator cuff group was 19 and 76% in the massive cuff tears group. Patients were staged according to the classification with 32% in stage 1a, 11% 1b, 32% 2a and 0% 2b. Conclusion: CTA prevalence in patients with rotator cuff tears and massive cuff tears is higher than the one reported in American population. We consider that a revision of the Seebauer classification to be appropriate to determine its reliability.

Effect of Preoperative Fatty Degeneration of the Deltoid and the Teres Minor Muscles on the Clinical Outcome after Reverse Total Shoulder Arthroplasty

BACKGROUND: To evaluate the effect of preoperative fatty degeneration of deltoid and teres minor muscles on the clinical outcome in patient with reverse total shoulder arthroplasty (RTSA). METHODS: Nineteen patients with RTSA were enrolled. The mean follow-up period was 16.1 months. The fatty degeneration of three distinct parts in each deltoid and the teres minor muscle was measured using a preoperative magnetic resonance imaging. Postoperatively, the muscle strengths for forward elevation (FE), abduction (Abd), and external rotation (ER) were measured using a myometer at the last follow-up. The parameters for clinical outcome were Constant Score (CS) and Korean Shoulder Score (KSS). RESULTS: The number of cases was 10 in group 1 and 9 in group 2. The strength of FE and Abd were significantly higher in group 1 (p<0.001 and p<0.001, respectively), and the strength of ER was not different significantly between two groups (p=0.065). For the clinical outcome, both CS and KSS were higher in group 1 (p=0.002 and p=0.002, respectively). The number of patients in group A was 11, and group B was 8. Although there was not a significant difference in terms of FE and Abd between group A and B (p=0.091, p=0.238), ER was significantly higher in group A (p=0.012). We did not find a significant difference in the clinical scores (CS, p=0.177 and KSS, p=0.238). CONCLUSIONS: These findings suggest the importance of a preoperative evaluation of the fatty degeneration of deltoid and teres minor muscles for predicting postoperative strength and clinical outcome.

Effect of Preoperative Fatty Degeneration of the Deltoid and the Teres Minor Muscles on the Clinical Outcome after Reverse Total Shoulder Arthroplasty

BACKGROUND: To evaluate the effect of preoperative fatty degeneration of deltoid and teres minor muscles on the clinical outcome in patient with reverse total shoulder arthroplasty (RTSA). METHODS: Nineteen patients with RTSA were enrolled. The mean follow-up period was 16.1 months. The fatty degeneration of three distinct parts in each deltoid and the teres minor muscle was measured using a preoperative magnetic resonance imaging. Postoperatively, the muscle strengths for forward elevation (FE), abduction (Abd), and external rotation (ER) were measured using a myometer at the last follow-up. The parameters for clinical outcome were Constant Score (CS) and Korean Shoulder Score (KSS). RESULTS: The number of cases was 10 in group 1 and 9 in group 2. The strength of FE and Abd were significantly higher in group 1 (p<0.001 and p<0.001, respectively), and the strength of ER was not different significantly between two groups (p=0.065). For the clinical outcome, both CS and KSS were higher in group 1 (p=0.002 and p=0.002, respectively). The number of patients in group A was 11, and group B was 8. Although there was not a significant difference in terms of FE and Abd between group A and B (p=0.091, p=0.238), ER was significantly higher in group A (p=0.012). We did not find a significant difference in the clinical scores (CS, p=0.177 and KSS, p=0.238). CONCLUSIONS: These findings suggest the importance of a preoperative evaluation of the fatty degeneration of deltoid and teres minor muscles for predicting postoperative strength and clinical outcome.

Reverse Shoulder Arthroplasty with Tendon Transfer Using Single Incision for Massive Rotator Cuff Tear with Loss of External Rotation / 대한정형외과학회잡지

In patients with massive rotator cuff tears, operative treatment is considered if there is no improvement after conservative treatment. Reverse shoulder arthroplasty is an option among several treatments. However, in cases of massive rotator cuff tears that extend to the teres minor with combined loss of active elevation and external rotation, reverse shoulder arthroplasty alone might not restore the active external rotation. As a consequence, patients continue to feel inconvenienced in performing activities of daily living. Reverse shoulder arthroplasty, with latissimus dorsi and teres major transfer, can restore functional range of motion in forward flexion and in external rotation. Herein, we report a case of massive rotator cuff tear with literature review.

Reverse Shoulder Arthroplasty for Humeral Head Fracture with Massive Rotator Cuff Tear in Elderly Patient / 대한정형외과학회잡지

There are several methods to treat anatomic neck fracture of humerus in elderly patients. It is not easy to obtain optimal clinical or radiological results because of unstable fixaton of fractured site attributed to multifractured osteoporotic tuberosities and combined massive rotator cuff tears in these patients. These factors often lead to high failure rate of implantation. Alternative methods of treatment have been proposed to reduce complications and improve shoulder functions. Reverse shoulder prosthesis was originally designed for patients with cuff tear arthropathy. Indications for reverse shoulder arthroplasty have expanded with initial success. However, there are few reports to perform reverse shoulder prosthesis in proximal humerus fracture. We performed reverse shoulder arthroplasty in a 74-year-old man with right anatomic neck fracture of humerus and concomitant massive rotator cuff tear.

Massive Rotator Cuff Tears: Arthroplasty

PURPOSE: Surgical treatment of massive rotator cuff tear is challenging and there are various surgical options. The purpose of this article is to describe arthroplasty for the treatment of massive rotator cuff tear. MATERIALS AND METHODS: We reviewed all publications that focused on and/or mentioned arthroplasty as a treatment option for massive rotator cuff tear. RESULTS: Arthroplasty can be used as primary treatment and represents a salvage option for irreparable rotator cuff tear. Hemi-arthroplasty can provide satisfactory results by Neer's limited goals criteria in patients with intact coracoacromial arch. In addition, reverse total shoulder arthroplasty can be a salvage option for pain relief and restoration of active flexion in elderly patients with pseudoparalysis. CONCLUSION: In patients with massive rotator cuff tear, proper selection of arthroplasty can provide pain relief and restoration of functional range of motion in shoulder joints.

Massive Rotator Cuff Tear Repair

PURPOSE: Anatomical repair of massive rotator cuff tear has been technically challenging because of medial retraction, muscle atrophy and fatty degeneration. Among several treatment options for massive rotator cuff tear, we reviewed rotator cuff repairs and investigated modalities for improvement of clinical outcomes, decreasing the re-tear rate, and increasing healing. MATERIALS AND METHODS: Patient-related factors and rotator cuff-related factors were the two major groups of factors we considered when choosing a treatment plan. RESULTS: Mobilization of a massive rotator cuff tear was increased by soft tissue release and by the interval slide technique. After meticulous soft tissue release, anatomical repair could be achieved. If the injury was not amenable to anatomical repair, alternative treatment options such as partial repair, the margin convergence technique and augmentation with a tenotomized biceps tendon were considered. Many reports of massive rotator cuff repair demonstrated satisfactory clinical outcomes, decreased pain, recovery of shoulder functions, and increases in muscle strength. However, the re-tear rate had been reported to be relatively high in long-term follow-up. CONCLUSION: Despite a high re-tear rate after massive rotator cuff repair, a better understanding of the pathogenesis, progression and clinical symptoms of massive rotator cuff tear and improved surgical materials and techniques will lead to satisfactory clinical outcomes.

The Outcome after Arthroscopic Massive Rotator Cuff Repair according to the Repair Technique - Comparison of Tendon to Tendon Repair versus Tendon to Tendon and Bone to Tendon Repair - / 대한정형외과학회잡지

PURPOSE: We evaluated the functional outcomes after arthroscopic repair of a massive tear between the tendon to tendon (TT) repair technique and the tendon to tendon and bone to tendon (TTBT) repair technique. MATERIALS AND METHODS: From March, 2002 to January, 2007, 43 cases of arthroscopic massive rotator cuff repair were evaluated. 12 were repaired by TT repair and 31 were repaired by TTBT repair. At 1year follow-up, the functional results were assessed by the KSS, ASES, UCLA and Constant scoring system and the P-VAS (Pain visual analogue score). Post-operative integrity was evaluated by an ultrasound examination 6 months after the operation. RESULTS: In TTBT repair group, the improvement of the KSS, ASES, UCLA and Constant scores were 15.4 (50.5 to 65.9), 28 (55.6 to 83.6), 9.6 (21.1 to 30.7) and 11 (40.7 to 51.7), respectively. The pain improvement was 2.7 (VAS, 3.8 to 1.1) and the retear rate was 62%. In the TT repair group, the functional improvements were 29.2 (33.7 to 62.9), 42.7 (38.6 to 81.3), 13.4 (16.4 to 29.8) and 19.7 (29.6 to 49.3), respectively. The pain improvement was 4.2 (VAS, 5.5 to 1.3) and the retear rate was 75%. CONCLUSION: Arthroscopic repair of a massive tear could afford good functional results and pain relief in spite of a high retear rate. The TT repair technique was comparable to the TTBT repair technique.

Clinical Result of Arthroscopic Partial Repairs in Massive Rotator Cuff Tears

PURPOSE: With the better understanding of cuff function, partial repair or "force couple repair" for treating massive irreparable rotator cuff tear has gained some popularity. However, there were few reports on the results of partial repair. The purpose of this study was to report the clinical outcome of massive irreparable rotator cuff tears who received arthroscopic force-couple repair or partial repair. MATERIALS AND METHODS: From June 2005 to Feb 2008, arthroscopic partial repairs were performed for 16 irreparable rotator cuff tears among the 101 large to massive rotator cuff tears that were operated on. Clinical and radiographic evaluation were done at the final follow-up RESULTS: There were 7 men and 9 women with a mean age of 66.6 years. The mean follow-up period was 27.3 month (range: 15-46). The pain VAS improved from 4.4 (+/-2.50) to 2.1 (+/-2.26) and the functional VAS improved from 46.9 (+/-16.64) to 70.0 (+/-22.80). The ASES score improved from 39.0 (+/-10.80) to 80.3 (+/-16.78) and the KSS score was 81.9 (+/-16.74) at the final follow-up. The acromio-humeral distance was 6.6 cm (+/-1.74) preoperatively and 6.2 cm (+/-1.69) postoperatively without significant change (p=0.3874). The degenerative changes had no statistically progressed (p=0.2663). CONCLUSION: Partial repair for massive rotator cuff injury patients showed improvement in the clinical score without progression of arthritic change at a mean of 2.3 years follow-up.

The Radiologic and Clinical Changes after Open Complete Repair of Massive Rotator Cuff Tears

PURPOSE: This study evaluated the preoperative and postoperative radiologic findings of patients with complete repairs after massive rotator cuff tears along with the incidence of re-tear and the clinical outcomes. MATERIALS AND METHODS: This study evaluated 33 cases who had open complete repairs for massive rotator cuff tears and these patients were followed up for more than 24 months. The clinical evaluation was performed according to the shoulder joint function test of the American Shoulder and Elbow Surgeons (ASES), and the degree of arthritis related to the massive rotator cuff tears was evaluated using the Hamada classification. RESULTS: The ASES scores improved from 37.6 preoperatively to 85.6 postoperatively. The mean preoperative acromio-humeral interval (AHI) score was 6.5 mm, which increased to 9.3 mm immediately after surgery, and there was a decreased to 6.5 mm noted at the last follow up. The lower radiology stages of arthritis according to the classification showed better preoperative and postoperative results. CONCLUSION: An open complete repair as the surgical treatment for a massive rotator cuff tear showed satisfactory results for pain relief and an improvement in the shoulder joint function though re-tear after surgery.

Massive Rotator Cuff Tear / 대한정형외과학회잡지

PURPOSE: To report our experience of massive rotator cuff tear and evaluate the final outcome and factors influencing the final results. MATERIALS AND METHODS: We have performed 25 repairs (24 patients) of the massive rotator cuff tear. The average age 58 years old, mean follow-up was 22 months. Acromioplasty alone was performed in 7 cases and acromioplasty with direct repair was performed in 18 cases. We statistically analyzed the results by Student's T-test. RESULTS: Postoperative pain and UCLA score improved 2.2, 32 from 7.4, 14 respectively. The gain of 32 degrees in forward flexion, 8 degrees in external rotation could be obtained. Six (24%) was excellent, sixteen (64%) was good and three (12%) was poor and eigthy-four percent of our series was satisfied. Preoperative range of motion (P=0.040) , the degree of degeneration and the magnitude of tendon retraction (P=0.013) influenced the final results, but age (P=0.232) , duration and severity of pain (P=0.370) did not. There was a significant difference between acromioplasty only and acromioplasty with direct repair even though this discrepancy is very small (P=0.046) . Retear was revealed in 8 cases (44%) among repaired rotator cuff. CONCLUSION: Acromioplasty by itself could get a pain relief and functional improvement and a patient satisfaction in the treatment of massive rotator cuff tear regardless a reparability, but a more favorable result could be expected when a torn rotator cuff was repaired if possible.