Management of irreparable massive rotator cuff tears: a systematic review and meta-analysis of patient-reported outcomes, reoperation rates, and treatment response.

BACKGROUND: There is no consensus on the treatment of irreparable massive rotator cuff tears. The goal of this systematic review and meta-analysis was to (1) compare patient-reported outcome scores, (2) define failure and reoperation rates, and (3) quantify the magnitude of patient response across treatment strategies. METHODS: The MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and Scopus databases were searched for studies including physical therapy and operative treatment of massive rotator cuff tears. The criteria of the Methodological Index for Non-randomized Studies were used to assess study quality. Primary outcome measures were patient-reported outcome scores as well as failure, complication, and reoperation rates. To quantify patient response to treatment, we compared changes in the Constant-Murley score and American Shoulder and Elbow Surgeons (ASES) score with previously reported minimal clinically important difference (MCID) thresholds. RESULTS: No level I or II studies that met the inclusion and exclusion criteria were found. Physical therapy was associated with a 30% failure rate among the included patients, and another 30% went on to undergo surgery. Partial repair was associated with a 45% retear rate and 10% reoperation rate. Only graft interposition was associated with a weighted average change that exceeded the MCID for both the Constant-Murley score and ASES score. Latissimus tendon transfer techniques using humeral bone tunnel fixation were associated with a 77% failure rate. Superior capsular reconstruction with fascia lata autograft was associated with a weighted average change that exceeded the MCID for the ASES score. Reverse arthroplasty was associated with a 10% prosthesis failure rate and 8% reoperation rate. CONCLUSION: There is a lack of high-quality comparative studies to guide treatment recommendations. Compared with surgery, physical therapy is associated with less improvement in perceived functional outcomes and a higher clinical failure rate.

Objective evaluation of lengthening in reverse shoulder arthroplasty.

BACKGROUND: Reverse shoulder arthroplasty requires a re-tensioning of the deltoid to obtain active elevation and implant stability. Currently, there is no objective and reliable technique described for the preoperative planning of reverse shoulder prosthesis or the postoperative evaluation of deltoid tension and arm lengthening. The purpose of this investigation was to outline a standardized technique for measuring deltoid length and to preoperatively plan a reverse shoulder arthroplasty, and to determine whether complications are related to inadequate deltoid lengthening. METHODS: Fifty-eight patients were included in this radiographic review. Variations in humeral length, overall arm length, and the height of the subacromial space were evaluated before and after reverse shoulder arthroplasty. RESULTS: The average postoperative lengthening of the humerus was 2 +/- 7 mm (range, -9-16, P = .243) and the arm was lengthened 23 +/- 12 mm (range, 1-47, P <.001). Measured preoperative and postoperative differences of the subacromial space were statistically significant when comparing the operated and contralateral arm (P < .0001). Lengthening was not correlated to sex (P = .242), acromial fractures, or neurological complications (P = .83). However, in cases of postoperative instability, both humeral and overall arm lengthening were statistically lower (P < .0001). CONCLUSION: A technique to preoperatively plan adequate deltoid tensioning using radiographs of the contralateral arm is described. This technique is critical in challenging cases and postoperatively in cases of complication to assess the deltoid length. Subjective intraoperative criteria to evaluate deltoid tension should be replaced by objective measures to prevent insufficient or excessive deltoid tension. LEVEL OF EVIDENCE: Level 3.

Fatty infiltration of the supraspinatus: a reliability study.

BACKGROUND: The Goutallier classification of rotator cuff fatty infiltration is an accepted standard, yet no recommendations exist for which computed tomography plane is best to identify fatty infiltration of the supraspinatus. Our purpose was to determine the most reliable plane to evaluate supraspinatus fatty infiltration, assess reliability of the tangent sign, and to correlate fatty infiltration and muscle atrophy. METHODS: Fatty infiltration in 87 computed tomography scans was reviewed by 3 shoulder surgeons using the 5-tiered Goutallier classification and a separate 3-grade scale. The supraspinatus muscle was evaluated in the axial, coronal, and sagittal plane. The tangent sign was used to assess muscle atrophy. RESULTS: The axial plane produced the highest agreement for both the 5-tiered and 3-tiered systems. An objective radiographic marker was described to reliably determine grade 3 fatty infiltration. The tangent sign produced excellent agreement for the presence of muscle atrophy. A significant relationship between the tangent sign and fatty infiltration was discovered (P < .0001); grades 3 and 4 fatty infiltration correlated statistically with supraspinatus atrophy. CONCLUSION: The tangent sign is acceptable for determining the presence of muscle atrophy and clinical decision making. A positive tangent sign is an indicator of advanced fatty infiltration. The axial computed tomography plane should be used when evaluating fatty infiltration. LEVEL OF EVIDENCE: Level 3; Diagnostic study.

Subscapularis insufficiency and the risk of shoulder dislocation after reverse shoulder arthroplasty.

HYPOTHESIS: Dislocation is the most common serious complication after reverse shoulder arthroplasty. One theorized cause is subscapularis insufficiency because the tendon cannot be repaired at the time of surgery. There are no documented risk assessments of reverse total shoulder arthroplasty dislocation related to this cause. The study objective was to quantify the risk of postoperative dislocation after reverse total shoulder arthroplasty in patients with a subscapularis tendon that was irreparable at the time of surgery. METHOD: A prospective evaluation was done of 138 consecutive reverse arthroplasties performed through a deltopectoral approach by a single surgeon (average follow-up, 36 months). RESULTS: The subscapularis was reparable in 62 patients and irreparable in 76 at the conclusion of the procedure. Seven postoperative dislocations occurred; all dislocations were in patients whose subscapularis was irreparable (P = .012). Dislocations were more likely in patients with complex diagnoses, including proximal humeral nonunion, fixed glenohumeral dislocation, and failed prior arthroplasty. CONCLUSIONS: This report documents that an irreparable subscapularis tendon at the time of reverse total shoulder arthroplasty using a deltopectoral approach results in a statistically significant risk for postoperative dislocation. LEVEL OF EVIDENCE: Level IV, Case Series, Treatment Study.

Understanding the Importance of the Teres Minor for Shoulder Function: Functional Anatomy and Pathology.

Although the teres minor is often overlooked in a normal shoulder, it becomes a key component in maintaining shoulder function when other rotator cuff tendons fail. The teres minor maintains a balanced glenohumeral joint and changes from an insignificant to the most significant external rotator in the presence of major rotator cuff pathology. The presence or absence of the teres minor provides prognostic information on the outcomes of reverse total shoulder arthroplasty and tendon transfers. Clinical tests include the Patte test, the Neer dropping sign, the external rotation lag sign, and the Hertel drop sign. Advanced imaging of the teres minor can be used for classification using the Walch system. Understanding the function and pathology surrounding the teres minor is paramount in comprehensive management of the patient with shoulder pathology. Appropriate clinical examination and imaging of the teres minor are important for preoperative stratification and postoperative expectations.

Arthroscopic debridement in the treatment of patients with isolated tears of the subscapularis.

PURPOSE: To evaluate the treatment of properly selected patients with isolated subscapularis tears by arthroscopic debridement and release of the long head of the biceps. METHODS: Eleven shoulders that had undergone arthroscopic debridement in the treatment of subscapularis tears were reviewed. In all patients, 3 months of appropriate nonoperative management had been unsuccessful. Patients were selected for arthroscopic debridement if the tear was thought to be irreparable, or if the patient was older and unwilling to participate in the rehabilitation required after repair had been completed. Mean age at surgery was 64 years. The mean time interval from onset of symptoms to surgery was 11 months. Seven tears were traumatic, and 4 were degenerative. Four tears involved the superior third of the subscapularis tendon, 2 involved the superior two thirds of the subscapularis tendon, and 5 were complete tears. Nine shoulders also had dislocation or subluxation of the long head of the biceps tendon; these patients underwent concomitant biceps tenotomy. Patients were evaluated clinically and radiographically at a mean 34-month follow-up (range, 24 to 48 months). RESULTS: The mean Constant score increased from 49 points preoperatively to 80 points postoperatively (P < .0001). Nine patients were satisfied or very satisfied with the results. Preoperatively, 2 patients had mild glenohumeral arthritis. Postoperatively, radiographs demonstrated no progression of arthritis and no new-onset arthritis in these 2 patients. CONCLUSIONS: The combination of arthroscopic debridement and biceps tenotomy in the treatment of subscapularis tears with biceps disease in selected patients yields good objective improvement and a high degree of patient satisfaction. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

A new combinatorial method for synthesizing, screening, and discovering antifouling surface chemistries.

A set of diverse monomers were synthesized using combinatorial chemistry and tested using our unique high-throughput screening platform. The versatility of our platform is exemplified by possible applications in reducing biological fouling on ship hulls, filtration membranes, and surgical instruments, to name a few. To demonstrate its efficacy, the novel monomers were graft-polymerized onto light sensitive poly(ether sulfone) (PES) membranes via atmospheric-pressure plasma polymerization. A diverse library was synthesized by reacting a common vinyl ester linker with a library of maleimides containing various different functional groups. This allowed us to produce a library of many different surfaces and graft them all using the same linker chemistry. The modified surfaces were then tested and screened for the best antiprotein adsorption (nonfouling) properties. Membranes, functionalized with carboxylic acid, zwitterionic, and ester groups, had the lowest protein adhesion compared with that of an unmodified control PES membrane after a static fouling test. After dynamic fouling, these same functionalities as well as a hydroxyl group exhibited the highest permeability. These monomers performed better than our best previously synthesized amide monomers as well as our best poly(ethylene glycol) monomers, which are known to have very high protein resistance. Hansen solubility parameters qualitatively predicted which monomers performed best, indicating favorable interactions with water molecules.