Resultados del tratamiento de roturas irreparables de manguito rotador con el uso del balón subacromial / Results of the treatment of irreparable rotator cuff ruptures with the use of the subacromial balloon

Resumen: Introducción: el tratamiento mediante cirugía artroscópica de las lesiones del manguito rotador ha desplazado a la cirugía abierta como primera opción de tratamiento. Existen diferentes técnicas quirúrgicas descritas para tratar las roturas masivas o no reparables. Desde hace unos años se viene utilizando un nuevo dispositivo que consiste en un balón subacromial biodegradable que actúa como espaciador entre la cabeza humeral y el acromion. Este trabajo pretende analizar los resultados de este implante. Material y métodos: realizamos un estudio observacional y retrospectivo de todos los pacientes a los que se les implantó un balón subacromial en nuestro centro entre 2017 y 2019. Se evaluó a los pacientes pre y postoperatoriamente mediante las escalas de Constant, DASH y EVA. Resultados: un total de 43 pacientes cumplieron los criterios de inclusión y el seguimiento mínimo de 24 meses. La puntuación media de la escala DASH pasó de 53.6 en la evaluación preoperatoria a 27.9 en la postoperatoria (p = 0.026). También se obtuvo una mejoría significativa en la escala de Constant, que pasó de una media de 37.9 a 61.8 (p = 0.037). En cuanto a la evaluación del dolor, la EVA media pasó de 7.44 a 3.38 (p = 0.916). En 90% de los pacientes no se objetivaron complicaciones ni necesidad de nuevas intervenciones. Conclusiones: el balón subacromial ha mostrado resultados favorables en nuestra serie de pacientes, por lo que podría suponer una opción válida de tratamiento en pacientes con roturas no reparables del manguito rotador.

Abstract: Introduction: arthroscopic surgical treatment of rotator cuff tendon injuries has replaced open surgery as the first treatment option. Different surgical techniques have been described for massive or irreparable ruptures, and recently, a new device that consists of a biodegradable subacromial spacer between the humeral head and the acromion has been used. The present study aims to analyse the results of this implant in our experience. Material and methods: we conducted an observational and retrospective study of all patients undergoing subacromial spacer implantation at our centre from 2017 to 2019. Patients were assessed pre- and postoperatively using the Constant, DASH and VAS scales. Results: a total of 43 patients met the inclusion criteria and the minimum follow-up of 24 months. The mean DASH scale score went from 53.6 at preoperative assessment to 27.9 at postoperative assessment (p = 0.026). There was also a significant improvement in the Constant scale from a mean of 37.9 to 61.8 (p = 0.037). In terms of pain assessment, the mean VAS went from a mean of 7.44 to 3.38 (p = 0.916). In 90% of patients no complications or need for further interventions were objectified. Conclusions: the subacromial balloon has shown favorable results in our series of patients, so it could be a valid treatment option in patients with non-repairable rotator cuff tears.

Bridging Graft in Irreparable Massive Rotator Cuff Tears: Autogenic Biceps Graft versus Allogenic Dermal Patch Graft

BACKGROUND: Few comparative studies have reported on the use of biologic grafts for irreparable massive rotator cuff tears. The purpose of this study was to assess the results of arthroscopic bridging graft in irreparable massive rotator cuff tears using an autogenic long head of biceps tendon (LHBT) or an allogenic dermal patch (ADP). METHODS: We retrospectively reviewed 24 patients treated using the LHBT (group I) and eight patients with complete rupture of the LHBT treated using an ADP (group II) since 2011. Preoperative Goutallier's fatty degeneration, range of motion (ROM), visual analogue scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES) score, and Quick Disabilities of the Arm, Shoulder, and Hand (DASH) score were assessed and healing failure was evaluated at 1 year after surgery by ultrasonography or magnetic resonance imaging. RESULTS: The mean fatty degeneration in groups I and II was 3.9 and 3.6 for the supraspinatus (p = 0.288), 2.7 and 2.9 for the infraspinatus (p = 0.685), 0.9 and 1.3 for the subscapularis (p = 0.314), and 1.3 and 3.0 for the teres minor (p = 0.005), respectively. Subscapularis tears were found in 8 patients (33.3%) in group I and in 7 patients (87.5%) in group II (p = 0.023). Mean ROMs and functional scores improved significantly in group I (forward flexion: 121.7° to 153.3°, p = 0.010; external rotation: 32.7° to 52.7°, p = 0.001; external rotation at 90°: 63.3° to 74.5°, p = 0.031; internal rotation: T10.5 to T9.3, p = 0.045; VAS: 7.0 to 1.1, p < 0.001; ASES score: 45.4 to 81.6, p = 0.028; and Quick DASH score: 50.0 to 14.2, p = 0.017), whereas only VAS showed significant improvement in group II (from 5.9 to 2.0, p = 0.025) and ROMs and other functional scores increased without statistical significance in the group. Healing failure was found in 13 patients (54.2%) in group I and in 6 patients (75.0%) in group II (p = 0.404). CONCLUSIONS: The surgeon should prudently choose surgical options for irreparable massive rotator cuff tears, especially in patients with severe fatty degeneration in the teres minor or combined biceps and subscapularis tears.

Mini-Open Suture Bridge Repair with Porcine Dermal Patch Augmentation for Massive Rotator Cuff Tear: Surgical Technique and Preliminary Results

BACKGROUND: The aim of this study was to describe the mini-open suture bridge technique with porcine dermal patch augmentation for massive rotator cuff tear and to assess preliminary clinical and radiological results. METHODS: Five patients with massive rotator cuff tear for which it was not possible to restore the anatomical footprint underwent mini-open suture bridge repair using a porcine dermal patch. The patients' average age was 53.4 years (range, 45 to 57 years), and the average duration of follow-up was 20.6 months (range, 14 to 26 months). Patients were evaluated with preoperative and postoperative outcome measures, including a visual analog scale (VAS) for pain, the University of California Los Angeles (UCLA) score, and the American Shoulder and Elbow Surgeons (ASES) score. The structural integrity of repaired rotator cuffs was assessed by magnetic resonance imaging 6 months postoperatively. RESULTS: The average VAS pain score, UCLA score, and ASES score improved from 6.8, 15.4, and 39.4 preoperatively to 0.8, 31.2, and 86.4 postoperatively (p = 0.041, 0.042, and 0.043, respectively). Magnetic resonance images obtained at an average of 8 months after surgery showed that four patients had intact repair integrity with graft incorporation. One patient had a re-tear with partial healing but still had a satisfactory clinical outcome. There was no intraoperative or postoperative complication in any patient. CONCLUSIONS: Mini-open suture bridge repair with porcine dermal patch augmentation can be an option in young patients with high physical demands and massive rotator cuff tears for which it is not possible to restore the anatomical footprint.

Treatment of Massive Rotator Cuff Tears: Focusing on Arthroscopic Approach / 대한정형외과학회잡지

There are no standard guidelines for treatment of massive rotator cuff tears. In this article, we reviewed the various modalities for treatment of massive rotator cuff tears, especially focusing on arthroscopic treatment. Selection of one of a variety of treatment modalities is essential for understanding pathogenesis, biomechanics and reparability of massive rotator cuff tears. The best clinical results have been reported with arthroscopic complete repair of massive rotator cuff tear. Satisfactory results have also been reported with other various arthroscopic treatment methods, including simple debridement, partial repair, biceps tenotomy or tendesis, and augmentation using a tissue substitution. However few long-term follow up results are available with these salvage options. Treatment of massive rotator cuff tears is difficult due to high incidence of irreparable tears and re-tear rate. Thus, understanding the advantages and disadvantages of various treatment modalities is thought to be helpful to improving the outcome of treatment of massive rotator cuff tears.

Massive Tear of the Rotator Cuff / 대한정형외과학회잡지

Massive rotator cuff tear is defined by either a tear size of more than 5 cm or involvement of more than two rotator cuffs. In reality, among Asians, it is almost impossible to find a tear size larger than 5 cm and the latter definition preferred. Most massive rotator cuff tears are chronic and patients usually complain of gradual aggravation of pain or muscle weakness. Exact evaluation of past history along with an appropriate physical examination is necessary for the exact diagnosis and further treatment. As most massive rotator cuff tears are based on chronic factors, not only the tear site, but whole tendon quality may be poor, making anatomical reconstruction difficult. In addition to primary repair of the torn tendon, many other treatment options are available, such as physical therapy, biceps tenotomy/tenodesis, release of suprascapular nerve, repair with tissue augmentation, tendon transfer, or arthroplasty. These options should be selected carefully according to the symptoms.

Reverse Total Shoulder Arthroplasty for Massive Cuff Tear and Cuff Tear Arthropathy in Elderly Patients / 대한정형외과학회잡지

PURPOSE: We wanted to assess the short term clinical outcomes and the effectiveness of reverse total shoulder replacement for massive rotator cuff tears with cuff tear arthropathy in elderly patients. MATERIALS AND METHODS: Between September 2007 and January 2009, 17 reverse total shoulder arthroplasties were performed on patients with an average age of 69.3 (58-80) years. The follow up period was an average of 17.9 (12-32) months. The outcomes were evaluated using the visual analogue scale, the range of motion, the muscle strength, the Constant score, the UCLA score and the Korea shoulder score. We performed radiological measurements of medialization of the center of rotation, distalization of the humerus, and tilting of the inferior glenoid on the preoperative and postoperative radiographs. RESULTS: The VAS improved from 7.2+/-3.6 preoperatively to 1.6+/-1.0 postoperatively. The average preoperative active forward fl exion was 51.5+/-28.4 degrees, which improved to 131.5+/-20.7 degrees at the final follow-up. The internal rotation was deteriorated from L2 to L5 (p<0.001, 0.001, 0.011). The average Constant score improved from 23.9+/-5.1 points before surgery to 62.2+/-9.1 points at the time of follow-up and the UCLA score and KSS score also rose from 7.6+/-2.4 and 27.0+/-7.5 points to 26.3+/-3.6 and 69.2+/-10.4 points respectively, which were statistically significant. For the radiological measurements, the medialization of rotation of the center was a mean of 20.6 mm+/-4.3 and the distalization of the humerus was a mean 22.8 mm+/-5.56. The glenoid inferior tilting increased a mean of 12.1+/-4.3 degrees. Inferior scapular notching was observed in two cases. CONCLUSION: The reverse total shoulder arthroplasty produced good results when used for the treatment of massive rotator cuff tear and cuff tear arthropathy. Forward fl exion was significantly improved, but on the contrary internal rotation was deteriorated. Considering the technical difficulties and the possibility of complications, the reverse total shoulder arthroplasty should be judiciously used by expert surgeons.

Debridement or Tuberoplasty for Massive Rotator Cuff Tear

PURPOSE: The purpose of this article was to review the effectiveness of arthroscopic debridement and tuberoplasty, and to evaluate the clinical and radiologic results of our series for irreparable massive rotator cuff tears in the elderly. MATERIALS AND METHODS: We reviewed articles that focused on the treatment options and decision making for irreparable massive rotator cuff tears. In particular, we summarized the reported results of arthroscopic debridement and tuberoplasty for irreparable massive rotator cuff tears in the elderly. Among consecutive patients who had arthroscopic tuberoplasty for irreparable massive rotator cuff tears in our series, thirty-two patients available for clinical and radiological evaluation at a mean follow-up of 29 months (range, 13-52 months) were enrolled and reviewed for the analysis. RESULTS: At the last follow-up, the range of active forward flexion increased significantly with excellent pain relief and improvement in the ability to perform the activities of daily living. However, the group with less than 2 mm in preoperative acromiohumeral distance showed inferior postoperative results. CONCLUSION: Arthroscopic tuberoplasty may be an alternative option in irreparable massive rotator cuff tears for pain relief and improvement of range of motion. However, good results can not be expected if the acromiohumeral distance is less than 2 mm preoperatively and decreases postoperatively, or when the preoperative range of motion is less than 90degrees on flexion and abduction.

Mid-term Results of Biceps Incorporating Suture Without Deteaching the Biceps Tendon from the Flenoid in the Large or Massive Cuff Tear

PURPOSE: The aim of this study is to analyze the clinical results of using the technique of rotator cuff repair without parting the biceps long head from the glenoid for large or massive tear of the rotator cuff. MATERIAL AND METHODS: Form January 2005 to January 2007, we performed the arthroscopic biceps repair with incorporating suture to the rotator cuff for 21 patients with large or massive rotator cuff tear. The mean follow up period was 23 months (range: 6-48months). The number of males and females was 9 and 13, respectively. The age distribution ranged from 47 to 73 years with a mean age of 60.3 years. We compared the preoperative score with the postoperative scores using the University of California Los Angeles (UCLA) score, the shoulder index of the American Shoulder and Elbow Surgeons (ASES) and a simple shoulder test (SST). RESULTS: The improvement in the VAS, ASES and the UCLA and SST scores was statistically significant at the final follow up (average follow-up 23 months) (p>0.05). Two of nine cases were found to have partial tear with continuity but seven cases were found to have complete tear according to the ultrasonography and MRI. CONCLUSION: The technique of rotator cuff repair without parting the biceps long head from the glenoid for large or massive tear of the rotator cuff is considered to be recommendable.

Anatomical Repair of Massive Rotator Cuff Tear / 대한정형외과학회잡지

PURPOSE: We evaluate the possibility of the anatomical repair of massive rotator cuff tear and review the clinical results. MATERIALS AND METHODS: From March 1995 to June 1999, twenty-six cases of massive rotaor cuff tear were reviewed with minimal followup of one year. The clinical results were evaluated using ASES (American Shoulder and Elbow Surgeons) score. RESULTS: Twenty two cases (85%) showed satisfactory results, 8 excellent results (31%) and 14 good results (54%). There were four cases (15%) of unsatisfactory results, two cases of fair and two cases of poor results. Mean value of the ASES score increased from 41 (14-60) points to 83 (46-98) points. Mean value of the increased score was 42 (20-76) points. There were no cases of functional deterioration or revision surgery. CONCLUSION: Anatomical repair was considered to be practically possible in the majority of cases of massive rotator cuff tear as an initial treatment.