A composite PET-matrix patch enhances tendon regeneration and tendon-to-bone integration for bridging repair of the chronic massive rotator cuff tears in a rabbit model.

In recent years, bridging repair has emerged as an effective approach for the treatment of massive rotator cuff tears (MRCTs). The objective of this study was to develop a composite patch that combines superior mechanical strength and biocompatibility and evaluate its potential for enhancing the outcomes of bridging repair for MRCTs. The composite patch, referred to as the PET-matrix patch (PM), was fabricated by immersing a plain-woven PET patch in decellularized matrix gel and utilizing the freeze-drying technique. The results demonstrated that the PM has reliable mechanical properties, with a maximum failure load of up to 480 N. The decellularized matrix sponge (DMS), present on the surface of the PM, displayed a loose and porous structure, with an average pore size of 62.51 µm and a porosity of 95.43%. In vitro experiments showed significant elongation of tenocytes on the DMS, with cells spanning across multiple pores and extending multiple protrusions as observed on SEM images. In contrast, tenocytes on the PET patch appeared smaller in size and lacked significant elongation. Additionally, the DMS facilitated the proliferation, migration and differentiation of tenocytes. In a rabbit model of chronic MRCTs, the PM group showed superior outcomes compared to the PET group at 4, 8 and 12 weeks after bridging repair. The PM group displayed significantly higher tendon maturing score, larger collagen diameter in the regenerated tendon and improved tendon-to-bone healing scores compared to the PET group (P < 0.05). Moreover, the maximum failure load of the tendon-bone complex in the PM group was significantly higher than that in the PET group (P < 0.05). In summary, the PM possesses reliable mechanical properties and excellent cytocompatibility, which can significantly improve the outcomes of bridging repair for chronic MRCTs in rabbits. Therefore, it holds great potential for clinical applications.

Home-Based or Supervised Physical Therapy Show Similar Functional Outcomes and Healing After Massive Rotator Cuff Repair.

PURPOSE: This study aimed to compare postoperative clinical outcomes at the 3-month, 6-month, 12-month, and latest follow-up in patients undergoing supervised physical therapy (PT) or a home-based exercise program after arthroscopic repair (ARCR) of massive rotator cuff tears (MRCTs). METHODS: A retrospective review was conducted on a prospectively maintained database of patients who underwent either supervised PT or home-based therapy after ARCR of MRCTs between January 2015 and December 2018 at a single center with a minimum 24-month follow-up. At their 2-week postoperative routine follow-up, patients are allowed to choose between home-based and supervised PT. Patient-reported outcomes (PROs) and range of motion (ROM) were collected and compared between cohorts preoperatively and at the 3-month, 6-month, 12-month, and latest follow-up. The percentage of patients reaching or exceeding the minimal clinically important difference (MCID) and patient accepted symptomatic state (PASS) for visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeon score (ASES), and Subjective Shoulder Value (SSV) were recorded for both cohorts at each time point. Complications, healing, satisfaction, and return to work were reported. Healing was evaluated via ultrasound at the latest follow-up. RESULTS: Ninety-nine patients met the study criteria: 61 in the supervised PT cohort, and 38 in the home-based cohort. The supervised PT and home-based cohorts returned to clinic for their most recent follow-up at 53±20 and 55±16 months (p=0.496) after surgery, respectively. There was no difference when comparing tendon involvement (SS, p=0.574; IS, p=0.288; SSc p=0.592), tear retraction (p=0.603), or high-grade fatty infiltration (SS, p=0.684; IS, p-0.397; SSc p=0.473) based on preoperative MRI assessment and surgery-related factors, including anterior (p=0.473) or posterior (p=0.386) slides, fixation constructs (p=0.829), or complete repair (p=0.912). Both cohorts showed similar PROs and ROM at baseline. Postoperative PROs and ROM were similar among groups at the 3-month, 6-month, 12-month, and latest follow-up. However, ASES (71.4 vs 61.2; p = 0.013) and FF (135° vs 118°; p = 0.023) were significantly higher at 3-month follow-up in the home-based cohort. Both groups comparably achieved MCID and PASS for PROs at the 3-month, 6-month, and12-month follow-up. At the latest follow-up, the supervised PT and home-based cohort achieved MCID and PASS for VAS (75% vs 81%, p=0.573; 70% vs 72%, p=0.911), ASES (76% vs 74%, p=0.777; 72% vs 72%, p=0.873), and SSV (82% vs 84%, p=0.734; 72% vs 66%, p=0.489), respectively. Satisfaction, healing, complication, and return to work rates were similar. CONCLUSION: Patients undergoing rehabilitation using a home-based protocol showed largely similar functional scores and healing to those with supervised PT after ARCR of MRCTs at the latest follow-up. Although patients with home-based therapy achieved higher FF and ASES at the 3-month follow-up, these became comparable starting at the 6-month postoperative mark. MCID and PASS were achieved similarly for PROs at each time point.

Arthroscopic Subacromial Balloon Spacer for Massive Rotator Cuff Tears Demonstrates Improved Shoulder Functionality and High Revision-Free Survival Rates at Minimum 5-Year Follow-up.

PURPOSE: This study aimed to investigate the efficacy of arthroscopic subacromial balloon placement for massive rotator cuff tear (MRCT), assessing patient satisfaction, outcomes, shoulder functionality, pain scores, and revision-free survivorship up to eight years post the initial surgery. METHODS: In this retrospective study with prospective data collection, patients with MRCTs undergoing balloon placement from 2014 to 2017 were prospectively enrolled. Their outcomes were analyzed retrospectively over a minimum 5-year follow-up. Demographics, patient satisfaction, reoperations, and complications were documented. Minimal clinically important differences (MCIDs) were calculated for SF-12 scores and Constant-Murley score (CMS) sub-scores. Pre- and post-surgery measures statistically compared for anatomical and functional evaluations. RESULTS: In a study with 61 participants initially, 10 were lost to follow-up over 3 years. Of the remaining 51, 9 were lost at the latest follow-up. The cohort (42 participants, mean age 63.17 ± 7.66 years) was monitored for 83.98 ± 9.50 months. Seven participants required revisions within two years, resulting in an 83.33% revision-free survival rate. Significant improvements were observed from preoperative to latest follow-up: acromiohumeral interval decreased (7.83 to 6.56, p = 0.004), critical shoulder angle increased (36.10 to 38.24, p = 0.001), osteoarthritis grade increased (1.45 to 2.81, p = 0.001), SF-12 physical score improved (27.40 to 37.69, p = 0.001), and Constant-Murley total scores increased (26.50 to 68.69, p = 0.001). MCID for total Constant-Murley scores was 11.78 points. Among those without revisions, satisfaction rates were 11.43% excellent, 57.14% satisfied, and 31.43% dissatisfied. CONCLUSIONS: Employing a balloon spacer for MRCTs yielded moderate satisfaction at the 5-year follow-up, with stable revision rates within the first 2 years. Notably, low revision surgery rates, high revision-free survival, and significant shoulder functionality improvements were observed at a minimum 5-year follow-up with arthroscopic subacromial balloon placement in conjunction with biceps tenotomy and subacromial bursectomy for MRCT.

Balloon Spacer Implant is an "Intermediate Value" Innovation Relative to Partial Repair for Full-Thickness Massive Rotator Cuff Repairs: A Cost-Utility Analysis.

PURPOSE: The purpose of this study was to evaluate the cost-utility of a Balloon Spacer implant relative to partial repair (PR) for the surgical treatment of full-thickness massive rotator cuff tears (MRCT). METHODS: A decision-analytic model comparing Balloon Spacer versus PR was developed using data from a prospective, randomized, single-blinded, multi-center controlled trial of 184 randomized patients. Our model was constructed based on the various event pathways a patient could have after the procedure. The probability that each patient progressed to a given outcome and the quality-adjusted life years (QALY) associated with each outcome were derived from the clinical trial data. Incremental cost utility ratio (ICUR) and incremental net monetary benefit (INMB) were calculated based on a probabilistic sensitivity analysis using Monte Carlo simulations of 1,000 hypothetical patients progressing through the decision-analytic model. One-way sensitivity and threshold analyses were performed by varying cost, event probability, and QALY estimates. RESULTS: Balloon Spacer had an ICUR of $106,851 (95% CI, $96,317 to $119,143) relative to PR for surgical treatment of MRCT. Across all patients, Balloon Spacer was associated with greater 2-year QALY gain compared to PR (0.20 ± 0.02 for Balloon Spacer versus 0.18 ± 0.02 for PR), but with substantially higher total 2-year cost ($9,701 ± $939 for Balloon Spacer versus $6,315 ± $627 for PR). PR was associated with a positive INMB of $1,802 (95% CI, $1,653 to $1,951) over Balloon Spacer at the $50,000/QALY willingness-to-pay (WTP) threshold. CONCLUSIONS: Compared to PR, Balloon Spacer is an "intermediate value" innovation for treatment of MRCT over a 2-year postoperative period with an ICUR value that falls within the $50,000 to $150,000 WTP threshold.

3-Dimensional Bioprinting of a Tendon Stem Cell-Derived Exosomes Loaded Scaffold to Bridge the Unrepairable Massive Rotator Cuff Tear.

BACKGROUND: Unrepairable massive rotator cuff tears (UMRCTs) are challenging to surgeons owing to the severely retracted rotator cuff musculotendinous tissues and extreme defects in the rotator cuff tendinous tissues. PURPOSE: To fabricate a tendon stem cell-derived exosomes loaded scaffold (TSC-Exos-S) and investigate its effects on cellular bioactivity in vitro and repair in a rabbit UMRCT model in vivo. STUDY DESIGN: Controlled laboratory study. METHODS: TSC-Exos-S was fabricated by loading TSC-Exos and type 1 collagen (COL-I) into a 3-dimensional bioprinted and polycaprolactone (PCL)-based scaffold. The proliferation, migration, and tenogenic differentiation activities of rabbit bone marrow stem cells (BMSCs) were evaluated in vitro by culturing them in saline, PCL-based scaffold (S), COL-I loaded scaffold (COL-I-S), and TSC-Exos-S. In vivo studies were conducted on a rabbit UMRCT model, where bridging was repaired with S, COL-I-S, TSC-Exos-S, and autologous fascia lata (FL). Histological and biomechanical analyses were performed at 8 and 16 weeks postoperatively. RESULTS: TSC-Exos-S exhibited reliable mechanical strength and subcutaneous degradation, which did not occur before tissue regeneration. TSC-Exos-S significantly promoted the proliferation, migration, and tenogenic differentiation of rabbit BMSCs in vitro. In vivo studies showed that UMRCT repaired with TSC-Exos-S exhibited significant signs of tendinous tissue regeneration at the bridging site with regard to specific collagen staining. Moreover, no significant differences were observed in the histological and biomechanical properties compared with those repaired with autologous FL. CONCLUSION: TSC-Exos-S achieved tendinous tissue regeneration in UMRCT by providing mechanical support and promoting the trend toward tenogenic differentiation. CLINICAL RELEVANCE: The present study proposes a potential strategy for repairing UMRCT with severely retracted musculotendinous tissues and large tendinous tissue defects.

Defining patient satisfaction after reverse total shoulder arthroplasty: a systematic review.

BACKGROUND: The prevalence of reverse total shoulder arthroplasty (rTSA) has grown rapidly. As indications for the procedure expand, the proportion of patients who have satisfactory outcomes after rTSA has not been well defined. This systematic literature review explores overall patient satisfaction after rTSA and defines patient satisfaction based on indication for surgery. METHODS: A literature search was performed for studies describing patient satisfaction after rTSA in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Papers were included if they investigated patient satisfaction after rTSA at a minimum of 2-year follow-up. Data were collected on patient demographics, including age, gender, and body mass index. Follow-up duration, indication for surgery, and patient reported outcome measures relating to patient satisfaction were also recorded. RESULTS: There were a total of 5234 patients and 5288 shoulders from the 45 included studies. The overall study population was 61.2% female and the average age was 71.1 years (range 23-99). Satisfaction results were recorded at final follow-up, with average follow-up of 49.1 months (range 24-228). Overall patient satisfaction ranged from 77.7% to 87.8%, depending on patient satisfaction patient reported outcome measures. When stratified by diagnosis, patients with a diagnosis of glenohumeral osteoarthritis (GHOA) rated better satisfaction on all metrics when compared to patients with a diagnosis of cuff tear arthropathy or massive rotator cuff tear. CONCLUSION: This systematic review demonstrated that patients who undergo rTSA for either GHOA, cuff tear arthropathy, or massive rotator cuff tear are generally satisfied with their procedure, with the rate of satisfaction highest in GHOA. Focusing on patient satisfaction may provide the best overall assessment of health care quality in a very understandable and tangible form. Overall satisfaction rate is valuable information for patient education and can be utilized as part of effective surgical counseling.

Surgical Management of Massive Irreparable Cuff Tears/Management of Rotator Cuff Disease: Interpositional Graft for Irreparable Posterosuperior Rotator Cuff Tears.

PURPOSE OF REVIEW: Increasingly, massive irreparable rotator cuff tears present a treatment challenge due to their high re-tear rates. The reparability of such tears depends on factors like tear size, the number of involved tendons, tendon retraction extent, muscular atrophy, fatty infiltration, and the presence or absence of arthritis. There are non-surgical and several surgical treatment options described each with their specific indications, contraindications, pros, and cons. Bridging reconstruction restores the superior rotator cuff tissue and arrests humeral head superior migration. The purpose of his review is to explore the existing literature on interpositional graft mechanics, indications, surgical technique, and clinical outcomes. It aims to understand how these parameters can facilitate the incorporation of bridging reconstruction using interpositional grafts into a surgeon's practice for managing massive irreparable rotator cuff tears. RECENT FINDINGS: Interpositional grafts for irreparable massive rotator cuff tears can either be auto-, allo-, xenografts, or synthetic material and are best suited for patients who are relatively younger, no glenohumeral arthritis, and minimal to no fatty infiltration and muscle atrophy. Short to medium term outcome studies available report good functional, clinical, and radiological improvements with bridging reconstruction utilizing acellular dermal matrix allograft. Interpositional grafts for management of irreparable posterosuperior cuff tears provides improved clinical and radiological outcomes with minimal complications and thus a viable and valuable surgical technique for a shoulder surgeon's armamentarium.

Double tendon transfer for massive rotator cuff tear: A case report.

INTRODUCTION AND IMPORTANCE: 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. CASE PRESENTATION: 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. CLINICAL DISCUSSION: 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. CONCLUSION: 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.

Arthroscopic repair of large and massive rotator cuff tears-"sandwich augmentation" with the long head of the biceps tendon: a technical note.

For most shoulder surgeons, addressing massive rotator cuff tears that have retracted ends poses a significant challenge. This study introduces a technique, termed the "sandwich augmentation technique," which incorporates the long head of the biceps tendon (LHBT) into a single-row rotator cuff repair. The procedure, performed arthroscopically with the patient in the lateral decubitus position, involves attaching the LHBT and rotator cuff tissues together to the greater tuberosity. This effectively sandwiches them within the rotator cuff footprint. The goal of this technique is to enhance the thickness of the fully interposed cuff margin, thereby providing better support for the repair. The sandwich augmentation technique, which integrates the biceps into the rotator cuff repair, has demonstrated positive clinical outcomes and moderate anatomical results. It also prevents superior migration of the humeral head in cases of large or massive rotator cuff tears. Further research is required to assess the long-term effectiveness of this procedure.

Histologic and biomechanical comparison of fascia lata autograft, acellular dermal xenograft, and synthetic patch for bridging massive rotator cuff tear in a rabbit model.

Background: Bridging repair has emerged as a promising and reliable treatment strategy for the massive rotator cuff tears (MRCTs). However, there remains a lack of evidence on which bridging graft provides the better repair results, and a dearth of animal studies comparing bridging repairs with different grafts. The purpose of this study was to evaluate the histological and biomechanical outcomes of commonly used grafts (autologous fascia lata (FL), acellular dermal matrix graft (ADM), and polyethylene terephthalate (PET) patch). Methods: A total of 66 male New Zealand White Rabbits were used to mimic a model of unilateral chronic MRCTs. The rabbits were randomly divided into three groups: (1) FL group, which underwent bridging repair with autologous FL; (2) ADM group, which underwent bridging with ADM; and (3) PET group, which underwent bridging with PET patch. Tissue samples were collected and subjected to histological analysis using Hematoxylin and eosin, Picrosirius red, Safranin O/Fast green staining, and Immunostaining. Collagen diameter and fibril density in the regenerated tendon was analyzed with transmission electron microscopy (TEM). Additionally, biomechanical tests were performed at 6 and 12 weeks after repair. Results: The regenerated tendon successfully reattached to the footprint in all experimental groups. At 6 weeks after repair, the FL group had a significantly higher Modified Tendon Histological Evaluation (MTHE) score at the regenerated tendon than the PET group (13.2 ± 1.64 vs 9.6 ± 1.95, respectively; P = 0.038). The picrosirius red staining results showed that the FL group had a significantly higher type I collagen content than the ADM and PET groups at 6 weeks, and this difference was sustained with the PET group at 12 weeks (P < 0.05). Immunofluorescence analysis against CD68 indicated that the number of macrophage infiltrates was significantly lower in the FL group than in the ADM and PET groups (P < 0.05). At 12 weeks after repair, the area of Safranin O metachromasia was significant greater in ADM group than that in the PET group (P = 0.01). The FL group showed a significantly larger collagen diameter in the regenerated tendon than the PET group (P < 0.05), as indicated by TEM results. Furthermore, the FL group resulted in a greater failure load (at 6 weeks; 118.40 ± 16.70 N vs 93.75 ± 9.06 N, respectively; P = 0.019) and elastic modulus (at 6 weeks; 12.28 ± 1.94 MPa vs 9.58 ± 0.79 MPa, respectively; P = 0.024; at 12 weeks; 15.02 ± 2.36 MPa vs 11.63 ± 1.20 MPa, respectively; P = 0.032) than the ADM group. Conclusions: This study demonstrated that all three grafts could successfully bridging chronic MRCTs in a rabbit model. However, autologous FL promoted tendon regeneration and maturation, and enhanced the tensile properties of the tendon-to-bone complex when compared with ADM and PET grafts.

Clinical Outcomes of Arthroscopic Superior Capsular Reconstruction Using Fascia Lata Autograft Versus Reverse Shoulder Arthroplasty in Patients 65 Years and Older With Irreparable Rotator Cuff Tears: A Retrospective Cohort Study.

Background: Arthroscopic superior capsular reconstruction (ASCR) and reverse shoulder arthroplasty (RSA) have both shown favorable outcomes in patients with irreparable rotator cuff tears (IRCTs). Purpose: To (1) compare the clinical outcomes of ASCR versus RSA in patients aged ≥65 years with IRCTs and (2) compare serial changes in clinical outcomes between treatment groups. Study Design: Cohort study; Level of evidence, 3. Methods: This study included patients with IRCTs without glenohumeral osteoarthritis who underwent either ASCR or RSA between March 2013 and December 2020 and had at least 2 years of follow-up data. We assessed active range of motion, a visual analog scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, and the Single Assessment Numeric Evaluation (SANE) score at the preoperative, short-term (postoperative 6-12 months), and final follow-up times. Results: In total, 64 patients (ASCR, 31 patients; RSA, 33 patients) were included. The mean age of patients was 71.3 ± 4.4 and 72.9 ± 4.1 years, and the mean final follow-up duration was 42 ± 21.8 and 37.7 ± 21.7 months in the ASCR and RSA groups, respectively. At the short-term follow-up, RSA achieved significant improvements in all clinical outcomes, except for internal rotation (IR), while ASCR only showed significant improvements in VAS pain, ASES, and SANE scores. Compared with the preoperative period, both ASCR and RSA achieved significant improvements in all clinical outcomes, except for IR in the RSA group at the final follow-up. The ASCR group achieved better IR and ASES scores at the final follow-up, while the time taken to recover from pseudoparalysis was shorter after RSA. The ASCR group showed a 67.8% graft healing rate at the 1-year follow-up, while the RSA group showed 12.1% of scapular notching at the final follow-up. No other postoperative complications were observed in either group. Conclusion: ASCR and RSA achieved favorable clinical outcomes in the study cohort. At the short-term follow-up, RSA showed significant improvements in all clinical outcomes, except for IR, while ASCR only showed significant improvements in VAS pain, ASES, and SANE scores. At the final follow-up, however, ASCR had better IR and ASES scores compared with RSA.

Combination of Superior and Posterior Capsular Release Versus Superior Capsular Release Alone in Arthroscopic Repair of Large-to-Massive Rotator Cuff Tears.

Background: Superior capsular release has been used to reduce tendon tension, especially in arthroscopic repair of large-to-massive rotator cuff tears. Some clinicians have used a more extensive release of capsules in arthroscopic cuff repair for adequate reduction of torn tendons to footprints. Purpose: To explore the effects of additional posterior capsular release for superior capsular release in arthroscopic repair of large-to-massive rotator cuff tears. Study Design: Cohort study; Level of evidence, 3. Methods: We compared 26 shoulders that underwent superior and posterior capsular release (group S&P) with 26 shoulders that underwent superior capsular release alone (group S) in arthroscopic repair of large-to-massive rotator cuff tears between January 23, 2013 and December 2, 2015. The visual analog scale for pain, American Shoulder and Elbow Surgeons score, Constant score, and range of motion (ROM) and muscle power were checked preoperatively and at 2 years postoperatively. Follow-up ultrasound was checked at 2 years postoperatively. Results: In both groups, the overall mean functional outcomes improved from preoperatively to postoperatively. Patients in group S&P showed more pre- to postoperative improvement than patients in group S with regard to internal rotation ROM (mean difference, 30.0° vs 20.6°; P < .001) and internal rotation power (3.4 vs 1.8 kgf; P = .001). Patients in group S had a higher retear rate on the follow-up ultrasound than patients in group S&P, but this difference did not reach statistical significance (23.1% vs 11.5%, respectively; P = .465). Conclusion: In the current study, patients who underwent superior and posterior capsular release in arthroscopic repair of large-to-massive rotator cuff tears had greater postoperative improvement in internal rotation ROM and power compared with patients who underwent superior capsular release alone.

Top 50 most impactful publications on massive rotator cuff tears.

Background: Bibliometric analysis is a useful tool for measuring the scholarly impact of a topic and its more and less heavily studied aspects. The purpose of this study is to use bibliometric analysis to comprehensively analyze the 50 articles with the highest citation indices in studies evaluating the treatment and outcomes of massive rotator cuff tears (mRCTs). Methods: This cross-sectional study identified articles within the Scopus database published through December 2022. Keywords used were "massive rotator cuff tear." Articles were sorted in chronological order. The year published and number of citations were recorded. A citation index (CI) was calculated for each article by dividing the number of citations by number of years published [1 citation/1 year published (2021) = CI of 1]. Of these, the 50 articles with the highest CIs were carried forward for evaluation. Frequencies and distributions were assessed for data of each variable collected. Results: These search methods produced 625 articles regarding mRCT research (ranging from January 1986 to December 2022). Four of the top 10 most impactful articles were published in the 2010s. The level of evidence (LOE) published with the greatest frequency was level of evidence 4 (41%). The journal Arthroscopy published the highest number within the top 50 (26%) followed by the Journal of Bone and Joint Surgery and the American Journal of Sports Medicine (20% each). Clinical studies composed 88% of the top 50. Case series (38%) predominated, while systematic reviews (20%) and randomized control trials (8%) were less prevalent. The majority of studies concentrated on the clinical outcomes of certain interventions (62%), mainly comparing multiple interventions. Conclusion: Despite the relatively high prevalence of mRCTs (40% of all tears), this topic comprises only a small proportion of all rotator cuff research. This analysis has identified gaps within and limitations of the findings concerning mRCTs for researchers to propose research questions targeting understudied topics and influence the future treatment and outcomes of this clinically difficult diagnosis.

Surgical management for massive rotator cuff tears: a network meta-analysis of randomized controlled trials.

Background: Multiple surgical strategies have been developed for treating massive rotator cuff tears (mRCTs). However, there is still no consensus on the best surgical option for mRCTs. Through a network meta-analysis, we aimed to comprehensively and systematically analyse the evidence in randomized controlled trials to help clinicians make evidence-based clinical decisions for patients with mRCTs. Methods: Our study was a network meta-analysis of the surgical management of mRCTs (PROSPERO Registration ID: CRD42023397971). We searched PubMed, EMBASE, Cochrane and Web of Science for randomized controlled trials that examined the efficacy of surgical management for mRCTs up to 3 November 2022. A three-step method was employed for the study process. Study selection, data extraction and risk of bias evaluation were conducted by two independent reviewers. R software (version 4.2.1) and Stata (version 15.1) were used for the data analysis. Results: From 10,633 publications, we included 15 randomized controlled trials (996 participants) for the quantitative analysis. In terms of both long-term and short-term surgical effects, there were no statistically significant differences among surgical interventions such as patch-augmented rotator cuff repair (RCR), RCR with platelet-rich plasma, arthroscopic decompression, bridging reconstruction, arthroscopic RCR with platelet-leukocyte membrane, open RCR, mini-open RCR, arthroscopic debridement, superior capsular reconstruction, arthroscopic suture-spanning augmented repair, subacromial balloon spacer and latissimus dorsi tendon transfer. Based on algorithms, the probability ranking suggests that patch augmentation is the most highly ranked surgical intervention for achieving better short-term surgical outcomes. Furthermore, arthroscopic-associated mini-open RCR was ranked as the highest surgical intervention for achieving better long-term surgical effects. Conclusions: Based on the available data from the included studies, similar surgical efficacies were observed among the reported intervention measures for mRCTs. The patch augmentation technique was found to potentially achieve better short-term surgical outcomes, which is consistent with previous reports. However, the best surgical interventions for achieving long-term surgical effects remain unknown. More high-quality research is needed to evaluate the efficacy and safety of these interventions and to guide clinical practice.

Clinical outcomes are unchanged after a mean of 12 years after reverse shoulder arthroplasty: a long-term re-evaluation.

Background: The medium-term results of reverse shoulder arthroplasty (RSA) that has been performed by a single surgeon have been previously reported. The purpose of this study was to investigate the minimum 10-year clinical and radiographic outcomes of these patients. Methods: In this prospective cohort study, 27 patients were evaluated after RSA for massive rotator cuff tear with or without eccentric osteoarthritis (OA) or concentric OA with the Constant-Murley Score (CMS), range of motion (ROM), and a radiologic assessment. Results: At a mean 12-year follow-up, the CMS and ROM were significantly improved when compared with the baseline values (all P < .001). Once stratified by diagnosis, no difference in the ROM or total CMS was found between patients with massive rotator cuff tear with/without eccentric OA and those with concentric OA. Neither ROM nor CMS decreased when compared to the mid-term values of the previous study, for both the overall population and the diagnosis-stratified groups. Scapular notching was reported in 66.7% of cases that was similar to the data reported at mid-term follow-up. The calcification rate was 59.3% at the long-term evaluation, and there were no differences between the same case-series population (51.9%; P = .785) and the whole population at mid-term follow-up (47%; P = .358). Conclusion: RSA led to excellent clinical and functional outcomes for patients up to 17 years postoperatively, and there was no decrease in the CMS over time. No loosening of implants was noted, and the rate of scapular notching was 66%, mostly grade 1 or 2.

'If he thought that I was going to go and hurt myself, he had another thing coming': Treatment experiences of those with large to massive rotator cuff tears and the perspectives of healthcare practitioners.

OBJECTIVE: To explore the treatment experiences of those diagnosed with large to massive rotator cuff tears and the perspectives of healthcare practitioners providing their care. DESIGN: A qualitative descriptive study using reflexive thematic analysis. SETTING: In-person focus groups were undertaken in a clinical setting (private practice [n = 1]; public outpatient [n = 2]). Semi-structured interviews were conducted online via Microsoft Teams. PARTICIPANTS: Patients diagnosed with these tears (n = 12) and healthcare practitioners (n = 11). RESULTS: Two interlinking themes were identified based on the care received and provided for patients with symptomatic large to massive rotator cuff tears:1) Positive treatment experiences and management: Education, clear communication and reassurance around prognosis were the foundation of positive patient-clinician care. Sub-themes of pain relief, exercise prescription and confidence in their pathway underpinned this experience. This proficiency in care was affirmed by some healthcare practitioners who spoke about the importance of confidence and experience in their management plan even in times of poor progress.2) Negative treatment experiences and management: Uncertainty, delays and exacerbation of pain flawed the patient-clinician care. Sub-themes of inappropriate pain relief, inappropriate exercise prescription and uncertainty impacted their care. Some healthcare practitioners acknowledged knowledge gaps led to uncertainty especially when choosing the next step of care and were quick to escalate care to deflect this uncertainty. CONCLUSIONS: The findings suggest discordance exists between the patient's experiences and expectations when the delivery of care was by less experienced and confident healthcare practitioners in the management of this condition. This highlights the need for improved education and support for healthcare practitioners.

Preoperative magnetic resonance imaging rotator cuff tendon stump classification correlates with the surgical outcomes following superior capsular reconstruction.

HYPOTHESIS: This study aimed to investigate the correlation between rotator cuff stump classification and postoperative outcomes after superior capsular reconstruction (SCR). METHODS: A total of 75 patients who underwent SCR between June 2013 and May 2021 were included in this study. Based on stump classification using the signal intensity ratio of the tendon rupture site to the deltoid muscle in the coronal view of preoperative T2-weighted, fat-suppressed magnetic resonance imaging scans, the patients were classified into types 1, 2, and 3 with ratios of <0.8, 0.8-1.3, and >1.3 (44, 17, and 14 patients, respectively). The American Shoulder and Elbow Surgeons (ASES), Constant, and visual analog scale (VAS) scores for pain and range of motion were evaluated at a minimum of 1 year of follow-up postoperatively. The acromiohumeral distance and rotator cuff arthropathy according to the Hamada classification were assessed on plain radiography. The graft integrity was evaluated by magnetic resonance imaging at 3 and 12 months postoperatively and annually thereafter. RESULTS: Clinical and radiological outcomes were significantly improved after SCR. In comparison with type 2 and 3 patients, type 1 patients had significantly higher ASES scores (type 1, 2, and 3 = 84 ± 10, 75 ± 15, and 76 ± 14; all P = .014), Constant scores (type 1, 2, and 3 = 65 ± 5, 61 ± 9, and 56 ± 13; all P = .005), and forward flexion (type 1, 2, and 3 = 155 ± 10, 154 ± 15, and 145 ± 13; all P = .013). However, these statistical differences between groups were below the established minimum clinically important difference values for the ASES and Constant scores after rotator cuff repair. The graft failure rate after surgery was lower in the type 1 group than that in the other 2 groups; however, the difference was not statistically significant (P = .749). CONCLUSION: Patients with stump classification type 1 showed significantly better functional scores (ASES and VAS scores) and forward flexion; however, the clinical importance of these differences may be limited. Stump classification may be useful for predicting postoperative clinical outcomes.

Subacromial Balloon Spacer for the Massive Irreparable Cuff Tear.

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. 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.

Clinical outcomes of medialized single-row repair with fascia lata graft augmentation for large and massive rotator cuff tears.

BACKGROUND: A high postoperative retear rate after arthroscopic rotator cuff repair (ARCR) of large and massive tears remains a problem. This study evaluated rotator cuff integrity after ARCR with fascia lata graft augmentation for large and massive rotator cuff tears and compared clinical outcomes between patients with intact repairs and retears. METHODS: Forty-five patients with rotator cuff tears who could not undergo primary repair due to tendon retraction underwent arthroscopic medialized single-row repair with fascia lata graft augmentation. The patients' minimum follow-up was 2 (2-9) years. Supraspinatus cuff integrity was evaluated postoperatively by magnetic resonance imaging. We compared the clinical outcomes of patients with intact repairs vs. retears based on the University of California-Los Angeles (UCLA), Constant, and Japanese Orthopaedic Association (JOA) scores. We also evaluated their range of motion (ROM) and muscle strength. RESULTS: Retears were observed in 11 of 45 patients. UCLA, Constant, and JOA scores significantly improved postoperatively compared to preoperatively in the intact repair (all P < .001) and retear (all P < .036) groups. The intact repair group had significantly higher Constant (75.6 [mean] ± 9.9 [SD] vs. 69.8 ± 7.9; P = .026) and JOA (94.4 ± 6.9 vs. 89.8 ± 5.9; P = .041) scores than the retear group. Forward elevation, abduction, and the strengths of abduction and external rotation significantly improved in the intact repair group (all P < .003) but not in the retear group (all P > .05). The intact repair group had significantly higher postoperative forward flexion (165° ± 15° vs. 154° ± 23°; P = .036), abduction (164° ± 17° vs. 151° ± 26°; P = .029), and abduction strength (3.5 ± 2.2 kg vs. 2.3 ± 1.2 kg; P = .017) than the retear group. In the intact repair group (n = 34), Sugaya type I:II ratio differed significantly between postoperative 3 months (2:32) and 24 months (24:10) (P < .001). Repaired tendon thickness did not decrease significantly between 3 months (7.1 mm) and 2 years (6.9 mm) (P = .543). CONCLUSIONS: ARCR with fascia lata graft augmentation of large and massive rotator cuff tears showed a 24.4% retear rate but significantly improved the clinical scores, ROMs, and muscle strength with excellent cuff integrity in the intact repair group. However, the differences in the Constant and UCLA scores between the intact repair and retear groups were under the minimal clinically important difference, and their clinical significance is uncertain. Our results confirm that ARCR with fascia lata graft augmentation improves patients' postoperative outcomes if the repair site is maintained postoperatively.

Massive and irreparable rotator cuff tear treatment by arthroscopic partial repair with long head of the biceps tendon augmentation provides better healing and functional results than partial repair only.

BACKGROUND: The aim of this study was to compare the clinical and radiologic outcomes of 2 treatment methods for massive and irreparable rotator cuff tears (RCTs): partial repair (PR) and PR with long head of the biceps tendon (LHBT) augmentation. Biceps tendon augmentation is believed to promote better healing at the bone-tendon junction, leading to improved clinical and radiologic outcomes. METHODS: This retrospective comparative study included patients with chronic, massive and irreparable RCTs involving both the supraspinatus (SSP) and infraspinatus muscles. Only patients with failure of nonoperative treatment and at least 1 year of follow-up between 2013 and 2018 were analyzed. The patients were divided into 2 groups based on the chosen treatment method. Irreparability was defined intraoperatively as the inability to achieve sustainable repair of the SSP after complete release, typically corresponding to a Goutallier classification of stage ≥ 3 and Patte classification of stage 3. The clinical assessment protocol involved measurements of range of motion and shoulder strength, as well as the Constant-Murley score (CMS) and Simple Shoulder Test score. Radiologic assessment comprised measurements of the acromiohumeral distance, Hamada classification, Sugaya classification, and Goutallier classification of both the SSP and infraspinatus. RESULTS: The study included data from 60 patients (30 in each group) with a mean age of 62.5 years and a mean follow-up period of 34.5 months. The retear rate was 43.3% for PR with LHBT augmentation and 73.3% for PR alone (P = .036). During the final examination, statistically significant differences in favor of PR with LHBT augmentation were observed for the CMS (76.2 ± 10.9 vs. 70.9 ± 11.5, P = .034), Sugaya classification (3.5 ± 1.1 vs. 4.1 ± 0.9, P = .035), and acromiohumeral distance (5.8 ± 2 mm vs. 4.7 ± 1.3 mm, P = .021). There were no significant differences between the groups in range of motion, shoulder strength, Hamada classification, Simple Shoulder Test score, and postoperative Goutallier stage. CONCLUSION: PR with LHBT augmentation for patients with irreparable, massive RCTs provides a lower retear rate and better humeral head centralization, as well as improved results measured by the CMS, compared with PR alone.