Margin convergence vs. superior capsular reconstruction for massive irreparable rotator cuff tears: outcomes are equivalent unless there is preoperative pseudoparesis.

BACKGROUND: 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. METHODS: 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). RESULTS: 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). CONCLUSION: 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.

Humeral head coverage in arthroscopic partial repair of massive rotator cuff tears improves functional outcomes: an analysis of influential factors.

BACKGROUND: Although partial rotator cuff repair has shown good outcomes, differences in clinical outcomes remain concerns. This study was performed to determine whether patients with humeral head coverage would show better functional outcomes than patients without humeral head coverage and to identify the factors for humeral head coverage after arthroscopic partial repair of massive tears. METHODS: We performed a retrospective study of 63 patients with massive rotator cuff tears who underwent arthroscopic partial repair between 2012 and 2018. Two to four margin convergences were first performed; then, the Mason-Allen technique was performed. The patients were divided into 2 groups: those with humeral head coverage (38 cases) and those without humeral head coverage (25 cases). The following factors were evaluated: age; sex; hypertension; diabetes; osteoporosis; preoperative and postoperative pseudoparalysis, visual analog scale (VAS) pain score, Constant score, acromiohumeral distance, and subacromial bony spur; and subscapularis tear and repair. Muscle atrophy and fatty degeneration were evaluated by magnetic resonance imaging preoperatively, and the integrity of the repaired cuff was evaluated by ultrasonography at a minimum of 2 years after surgery. RESULTS: Compared with preoperative values, significant improvements in VAS pain scores (from 6.27 to 2.32 in patients with humeral head coverage and from 7.00 to 2.81 in those without humeral head coverage) and Constant scores (from 51.35 to 75.95 and from 44.62 to 69.81, respectively) were observed in both groups (P < .001). Statistical analysis revealed that postoperative VAS pain scores (2.32 vs. 2.81) and Constant scores (75.95 vs. 69.81) in patients with humeral head coverage were superior to those in patients without humeral head coverage (P = .044 and P = .003, respectively). The integrity of the repaired cuff was evaluated by ultrasonography, and partial tears were found in 4 of 37 patients with humeral head coverage and 2 of 26 patients without humeral head coverage (P = .816). Univariable logistic regression analysis revealed that age (P < .001), comorbidity (P = .005), symptom duration (P = .023), preoperative shoulder mobility (P < .001), maintained acromiohumeral distance (P = .006), subscapularis tear (P = .026), and less preoperative supraspinatus and infraspinatus muscle atrophy (P = .001 and P = .010, respectively) had significant correlations with humeral head coverage. CONCLUSIONS: Overall satisfactory results were achieved in most patients regardless of high retear rates, but patients with partial repair covering the humeral head were associated with better outcomes than patients without humeral head coverage. Multivariable regression analysis revealed that age (<70 years, P = .003), capability of shoulder mobility (P = .005), maintenance of the acromiohumeral space (>7 mm, P = .016), and less atrophy of the rotator cuff muscles (P = .021) were favorable factors to achieve humeral head coverage during surgical partial repair of massive rotator cuff tears.

Arthroscopic modified Mason-Allen technique for large U- or L-shaped rotator cuff tears.

PURPOSE: While a conventional single- or double-row repair technique could be applied for repair of C-shaped tears, a different surgical strategy should be considered for repair of U- or L-shaped tears because they typically have complex patterns with anterior, posterior, or both mobile leaves. This study was performed to examine the outcomes of the modified Mason-Allen technique for footprint restoration in the treatment of large U- or L-shaped rotator cuff tears. METHODS: Thirty-two patients who underwent an arthroscopic modified Mason-Allen technique for large U- or L-shaped rotator cuff tears between January 2012 and December 2013 were included in this study. Margin convergence was first performed to reduce the tear gap and tension, and then, an arthroscopic Mason-Allen technique was performed to restore the rotator cuff footprint in a side-to-end repair fashion. All patients were evaluated preoperatively and for a minimum of 2 years of follow-up with a visual analog scale (VAS) for pain, Constant score, and ultrasonography. RESULTS: There was significant improvement in all VAS and Constant scores compared with the preoperative values (P < 0.001). Functional results by Constant scores included 9 cases that were classified as excellent, 11 cases as good, 8 cases as fair, and 2 cases as poor. Binary logistic regression analysis revealed that heavy work, pseudoparalysis, joint space narrowing, fatty degeneration of the SST and IST, and a positive tangent sign were found to significantly correlate with functional outcomes. Multivariable logistic regression analysis revealed that only fatty degeneration of the SST was a risk factor for fair/poor clinical outcomes. Complications occurred in 5 of the 32 patients (15.6 %), and the reoperation rate due to complications was 6.3 % (2 of 32 patients). CONCLUSIONS: An arthroscopic modified Mason-Allen technique was sufficient to restore the footprint of the rotator cuff in our data. Overall satisfactory results were achieved in most patients, with the exception of those with severe fatty degeneration. An arthroscopic modified Mason-Allen technique could be an effective and reliable alternative for patients with large U- or L-shaped rotator cuff tears. LEVEL OF EVIDENCE: Case Series, Therapeutic Level IV.

Arthroscopic margin convergence of large-sized rotator cuff tears does not lead to better clinical outcome compared with conventional repair.

Background: The margin convergence (MC) technique is used to repair longitudinal-type tears as direct repair of the apex of the longitudinal-type tear from medial to lateral is challenging. Few studies have compared the postoperative clinical outcomes and retear rates of arthroscopic rotator cuff repair (ARCR) using the MC technique with those of conventional ARCR without using the MC technique. Therefore, this study aimed to investigate the efficacy of MC on the clinical outcome and retear rates of patients with large-sized rotator cuff tears. It was hypothesized that ARCR using the MC technique would yield clinical outcome and retear rates similar to those of ARCR without using the MC technique. Methods: The medical records of consecutive patients who underwent ARCR for large-sized rotator cuff tears were retrospectively evaluated. Forty-four and 35 shoulders were repaired using MC (MC group) and not using MC (non-MC group), respectively. The range of motion (ROM) and the Japanese Orthopaedic Association (JOA) score were assessed preoperatively and after a minimum follow-up period of 12 months postoperatively. Magnetic resonance imaging was performed at least 3 months postoperatively to determine whether the tendons had healed. Results: The average postoperative follow-up duration was 26.6 months and 24.3 months in the MC and non-MC groups, respectively. The mean ROM and JOA score improved significantly in both groups postoperatively; however, the postoperative range of external rotation and the total JOA score was significantly lower in the MC group. The overall retear rate did not differ significantly between the MC (13/44, 29.5%) and non-MC (7/35, 20.0%) groups, respectively (P = .332). No significant differences were observed between the cases with retears in the 2 groups in terms of the postoperative ROM and the total JOA score. In contrast, the postoperative range of external rotation and the total JOA score of the patients with healed tendons in the MC group were significantly poorer than those of the patients with healed tendons in the non-MC group. Conclusion: ARCR using MC of large-sized longitudinal-type tears does not lead to better postoperative range of external rotation and clinical outcome compared with those of conventional repair.

Treatment options for massive irreparable rotator cuff tears: a review of arthroscopic surgical options.

While functional reconstruction of massive irreparable rotator cuff tears remains a challenge, current techniques aimed at recentering and preventing superior migration of the humeral head allow for clinical and biomechanical improvements in shoulder pain and function. Recentering of the glenohumeral joint reduces the moment arm and helps the deltoid to recruit more fibers, which compensates for insufficient rotator cuff function and reduces joint pressure. In the past, the concept of a superior capsular reconstruction with a patch secured by suture anchors has been used. However, several innovative arthroscopic treatment options have also been developed. The purpose of this article is to present an overview of new strategies and surgical techniques and if existing present initial clinical results. Techniques that will be covered include rerouting the long head of the biceps tendon, utilization of the biceps tendon as an autograft to reconstruct the superior capsule, utilization of a semitendinosus tendon allograft to reconstruct the superior capsule, superior capsular reconstruction with dermal allografts, and subacromial spacers.

Outcomes After Arthroscopic Rotator Cuff Repair Using Margin Convergence Versus Superior Capsular Reconstruction: Should Candidates for Margin Convergence Be Treated With Superior Capsular Reconstruction?

BACKGROUND: Both margin convergence rotator cuff repair (MC-RCR) and superior capsular reconstruction (SCR) result in improved clinical outcomes in the treatment of massive rotator cuff tears (RCTs). The question remains whether it is better to perform MC-RCR using native, albeit occasionally deficient, tissues or to perform primary SCR. PURPOSE/HYPOTHESIS: To compare the clinical results of MC-RCR versus SCR for the treatment of massive RCTs. It was hypothesized that SCR would yield better outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Included were patients who underwent arthroscopic MC-RCR or SCR for massive RCTs performed by a single surgeon between 2014 and 2019. MC-RCR was performed if it was technically possible to close the defect; otherwise, SCR was performed. Outcomes were assessed at 6 months and then annually using American Shoulder and Elbow Surgeons; Single Assessment Numerical Evaluation; shortened version of Disabilities of the Arm, Shoulder and Hand; 12-Item Short Form Health Survey Physical Component Summary; and patient satisfaction scores. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) were compared between groups. Revision surgeries and complications were reported. RESULTS: Included were 46 patients in the MC-RCR group (mean age, 59 ± 8 years) and 46 patients in the SCR group (mean age, 57 ± 7 years); 29 patients in each group were available at 2-year follow-up. Preoperative outcome scores were not significantly different between groups. Within groups, all outcome scores improved from pre- to postoperatively (P < .05), with no significant differences in postoperative scores or patient satisfaction between groups. No significant between-group differences were noted in the percentage of patients who reached the MCID, SCB, and PASS (MCID, 92.3% vs 84.6%; SCB, 80.8% vs 80.8%; and PASS, 66.7% vs 66.7%). SCR had a significantly lower survivorship rate compared with MC-RCR (84.7% vs 100%) (P = .026). CONCLUSION: Both MC-RCR and SCR provided similar improvement in outcomes; however, SCR resulted in a significantly lower survivorship rate at 2 years postoperatively. If an RCT is technically repairable, we recommend that it be repaired primarily, even if MC techniques are needed to close the defect. SCR remains a good option for massive RCTs that are not technically repairable.

Open side-to-side repair for non-repairable tendon-to-bone rotator cuff tear. Clinical and anatomic outcome at a mean 5 years' follow-up.

INTRODUCTION: Anatomical tendon-to-bone repair of retracted rotator cuff tear is a difficult challenge given the high rate of recurrence. HYPOTHESIS: The study hypothesis was that side-to-side repair of U-shaped retracted tear allows tendon healing with satisfactory medium-term clinical results. MATERIALS AND METHODS: Between 1999 and 2007, 35 patients (mean age 53.5 years) were operated on with this open technique. On the De Orio and Cofield classification, tendon lesions were medium in 5 cases, large in 25 and massive in 5. Subacromial space was in all cases greater than 7 mm. Fatty infiltration grade was less than or equal to 2 on Goutallier's classification in all cases except for 1 grade3 (supraspinatus only). At last follow-up, patients were assessed clinically (Constant score) and radiographically. Tendon healing was assessed by ultrasound (31 cases) or CT-arthrography (4 cases). RESULTS: Mean follow-up was 60 months. Constant score improved significantly, from 64.7 ± 10 preoperatively to 77.1 ± 14 postoperatively (P < 0.05). Recurrence rate was 17.1%. Subacromial space was < 6 mm postoperatively in 2 cases. DISCUSSION: Side-to-side repair, bringing the posterior cuff onto the anterior edge of the tear, allowed tension-free repair of retracted tear if the preoperative reparability criteria are met: subacromial space equal to or greater than 7 mm, and absence of fatty infiltration significantly greater than grade 2 on the Goutallier classification. Under these conditions, clinical and anatomical results were satisfactory at a mean 5 years' follow-up. LEVEL OF EVIDENCE: IV, retrospective.

Technique for margin convergence in rotator cuff repair.

The purpose of the present study is to describe the technique of margin convergence for U-shaped rotator cuff tears and report the clinical outcomes and ultrasonography with a minimum of 2 years follow-up. Three hundred eleven patients with a rotator cuff tear were prospectively enrolled in a registry at one institution. Inclusion criteria included any patient undergoing arthroscopic margin convergence for a rotator cuff tear. Exclusion criteria included open or mini-open rotator cuff repairs or suture anchor fixation to the cuff insertion without margin convergence. The outcome measurements included physical examination, manual muscle testing, the American Shoulder and Elbow Surgeons (ASES) score, and ultrasonography. Nineteen patients met the study criteria and 13 were available for 2-year follow-up (68.4%). The mean age of this cohort was 62.2 ± 7.5 years with a mean pre-operative rotator cuff tear size of 4.0 ± 1.6 cm. The ASES score increased significantly from 50.0 ± 17.7 before surgery to 83.3 ± 19.5 at 2 years (P = 0.01). The active forward elevation also improved from 156.2 ± 11.9° before surgery to 168.0 ± 12.1 at 2 years (P = 0.03). The active external rotation 54.4 ± 14.5 at baseline and improved to 57.1 ± 19.1 at 2 years (P = 0.04). The strength also increased significantly from 6.7 ± 6.4 to 10.6 ± 4.9 lb at 1 year (P = 0.048). The post-operative ultrasound demonstrated that 46.2% of rotator cuff tears were healed at 2 years. In conclusion, margin convergence is a useful technique for U-shaped tears that are difficult to mobilize.