Joshua A. Greenspoon

Arthroscopic Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears

Massive irreparable rotator cuff tears in young patients are a particular challenge for the orthopaedic surgeon. Surgical treatment options include debridement, partial rotator cuff repair, patch-augmented rotator cuff repair, bridging rotator cuff reconstruction with graft interposition, tendon transfer, and reverse total shoulder arthroplasty. Recently, reconstruction of the superior glenohumeral capsule using a fascia lata autograft has been suggested to reduce superior glenohumeral translation and restore superior stability. Promising clinical results have been reported in 1 case series of 23 patients, indicating that superior capsular reconstruction may be a promising tool to manage massive irreparable rotator cuff tears. This article describes our preferred technique for arthroscopic superior capsule reconstruction.

Massive rotator cuff tears: pathomechanics, current treatment options, and clinical outcomes.

Rotator cuff tear size has an important effect on clinical outcomes after repair. Management options for massive rotator cuff tears are numerous, and selection of the most appropriate treatment method for individual patients can be a challenge. An understanding of the pathomechanics, treatment, and clinical outcomes in patients with massive rotator cuff tears can serve as a guide for clinical decision-making. The purpose of this article was to review treatment options and clinical outcomes for the management of massive rotator cuff tears.

Two-Year Outcomes After Arthroscopic Rotator Cuff Repair in Recreational Athletes Older Than 70 Years:

Background: Outcomes after arthroscopic rotator cuff repair in recreational athletes older than 70 years are not widely reported. Purpose: To evaluate clinical outcomes after arthroscopic repair of full-thickness rotator cuff tears in recreational athletes aged 70 years or older. Study Design: Case series; Level of evidence, 4. Methods: Institutional review board approval was obtained before initiation of this study. Data were collected prospectively and were retrospectively reviewed. From December 2005 to August 2012, patients who were at least 70 years of age, who described themselves as recreational athletes, and who underwent a primary or revision arthroscopic repair of full-thickness supraspinatus tears by a single surgeon were identified from a surgical registry. Demographic data, surgical data, and the following pre- and postoperative clinical outcomes scores were collected: American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Short Form–12 Physical Component Summary (SF-12 PCS), and Single Assessment Numeric Evaluation (SANE). Acromiohumeral distance and Goutallier classifications were recorded. Patient satisfaction (range, 1-10, 10 = best) and reasons for activity modification were collected at final follow-up. Results: Forty-nine shoulders (44 patients) were included. The mean age was 73 years (range, 70-82 years). There were 33 men and 11 women (5 bilateral). The mean preoperative acromiohumeral distance was 9.2 mm (range, 3.0-15.9 mm). All patients had Goutallier classifications of 0, 1, or 2. Mean follow-up was 3.6 years (range, 2.0-6.9 years) in 43 of 49 (88%) shoulders. No rotator cuff repairs were revised, however, 1 patient had surgical treatment for stiffness. All postoperative outcomes measures demonstrated significant improvements when compared with their preoperative baselines. The mean ASES score was 90.3 (range, 60-100), the mean SANE score was 85.1 (range, 29-100), the mean QuickDASH score was 11.3 (0-50), and the mean SF-12 PCS score was 51.6 (range, 38-58) with a median patient satisfaction of 10 (range, 1-10). Patients who modified their recreational activities due to postoperative weakness were significantly less satisfied (P = .018). In this study, 24 of 31 (77%) who responded were able to return to their sport at a similar level of intensity. Conclusion: Arthroscopic rotator cuff repair was highly effective at reducing pain, improving function, and returning patients to sport in recreational athletes 70 years of age and older.

Clinical and Anatomic Predictors of Outcomes After the Latarjet Procedure for the Treatment of Anterior Glenohumeral Instability With Combined Glenoid and Humeral Bone Defects

Background: The Latarjet procedure for the treatment of recurrent anterior shoulder instability is highly successful, but reasons for failure are often unclear. Measurements of the “glenoid track” have not previously been evaluated as potential predictors of postoperative stability. Hypothesis: There are clinical and anatomic characteristics, including the glenoid track, that are predictive of outcomes after the Latarjet procedure. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent the Latarjet procedure for anterior shoulder instability with glenoid bone loss before October 2012 were assessed for eligibility. Patient-reported subjective data that were prospectively collected and retrospectively reviewed included demographic information, patient satisfaction, pain measured on a visual analog scale (VAS), questions regarding instability, Single Assessment Numeric Evaluation (SANE) scores, American Shoulder and Elbow Surgeons (ASES) scores, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores, and Short Form–12 Physical Component Summary (SF-12 PCS) scores. Anatomic measurements were performed of the coracoid size (surface area and width), width of the conjoined tendon and subscapularis tendon, estimated glenoid defect surface area, Hill-Sachs interval (HSI), and projected postoperative glenoid track engagement. Failure was defined as the necessity for revision stabilization or continued instability (dislocation or subjective subluxation) at a minimum of 2 years postoperatively. Results: A total of 38 shoulders in 38 patients (33 men, 5 women) with a mean age of 26 years (range, 16-43 years) were included. The mean follow-up for 35 of 38 patients (92%) was 3.2 years (range, 2.0-7.9 years); 25 of 38 had undergone prior stabilization surgery, and 6 had workers’ compensation claims. All mean subjective outcome scores significantly improved (P < .05), with a high median satisfaction score of 9 of 10. Eight patients had failures because of continued instability. Patients with moderate or higher preoperative pain scores (VAS ≥3) had a negative correlation with postoperative SF-12 PCS scores (ρ = 0.474, P = .022). Patients with outside-and-engaged (Out-E) or “off-track” lesions were 4.0 times more likely to experience postoperative instability (relative risk, 4.0; 95% CI, 1.32-12.2; P = .33). The width of patients’ coracoid processes was also directly associated with postoperative stability (P = .014). Moreover, 50% (4/8) of failures demonstrated Out-E glenoid tracks (off-track lesions) versus 16% (4/25) of those without recurrent instability (P = .033). Five of 8 failures were considered as such because of subjective subluxation events, not frank dislocations. Four of the 6 patients with workers’ compensation claims had failed results (P = .016). Conclusion: Workers’ compensation claims were associated with continued instability, and patients with higher preoperative pain levels demonstrated lower SF-12 PCS scores postoperatively. The concept of the glenoid track may be predictive of stability after the Latarjet procedure and may be helpful in surgical decision making regarding the treatment of Hill-Sachs lesions at risk for persistent engagement. Although stability and patient satisfaction are high after the Latarjet procedure, subjective complaints of subluxation may be more common than previously estimated.

Patch-Augmented Rotator Cuff Repair and Superior Capsule Reconstruction

Background: Massive rotator cuff tears in active patients with minimal glenohumeral arthritis remain a particular challenge for the treating surgeon. Methods: A selective literature search was performed and personal surgical experiences are reported. Results: For patients with irreparable rotator cuff tears, a reverse shoulder arthroplasty or a tendon transfer are often performed. However, both procedures have rather high complication rates and debatable long-term results, particularly in younger patients. Therefore, patch-augmented rotator cuff repair or superior capsule reconstruction (SCR) have been recently developed as arthroscopically applicable treatment options, with promising biomechanical and early clinical results. Conclusion: For younger patients with irreparable rotator cuff tears wishing to avoid tendon transfers or reverse total shoulder arthroplasty, both patch-augmentation and SCR represent treatment options that may delay the need for more invasive surgery.

Patch-Augmented Latissimus Dorsi Transfer and Open Reduction–Internal Fixation of Unstable Os Acromiale for Irreparable Massive Posterosuperior Rotator Cuff Tear

Latissimus dorsi transfer is a reasonable treatment option for massive posterosuperior rotator cuff tears that can substantially improve chronically painful and dysfunctional shoulders. This report and accompanying video describe the treatment of an active 43-year-old man with severe pain and weakness in the right shoulder after 3 failed rotator cuff repairs. Preoperative imaging showed a massive posterosuperior rotator cuff tear retracted to the glenoid as well as a hypermobile os acromiale likely causing dynamic impingement and recurrent rotator cuff tears. After diagnostic arthroscopy, the latissimus tendon is harvested and augmented with a 3-mm human acellular dermal patch (ArthroFlex; Arthrex, Naples, FL). The native rotator cuff tissue is repaired as much as possible, and the latissimus tendon is passed underneath the deltoid and posterior to the teres minor. The patch-augmented tendon is then integrated into a double-row SpeedBridge repair of eight 4.75-mm BioComposite SwiveLock anchors (Arthrex). The bony surface of the os acromiale is prepared and then fixed to the acromion with 2 cannulated partially threaded screws and additional tension-band wiring. Postoperative rehabilitation initially focuses on early passive range of motion, followed by active and active-assisted motion and a biofeedback program starting at 6 weeks postoperatively.

Cost-Effectiveness of Arthroscopic Rotator Cuff Repair Versus Reverse Total Shoulder Arthroplasty for the Treatment of Massive Rotator Cuff Tears in Patients With Pseudoparalysis and Nonarthritic Shoulders

PURPOSE To determine the most cost-effective treatment strategy for patients with massive rotator cuff tears and pseudoparalysis of the shoulder without osteoarthritis of the glenohumeral joint (PP without OA). Specifically, we aimed to compare arthroscopic rotator cuff repair (ARCR) versus reverse total shoulder arthroplasty (RTSA) and investigate the effect of patient age on this decision. METHODS A Markov decision model was used to compare 3 treatment strategies for addressing PP without OA: (1) ARCR with option to arthroscopically revise once, (2) ARCR with immediate conversion to RTSA on potential failure, and (3) primary RTSA. Hypothetical patients were cycled through the model according to transition probabilities, meanwhile accruing financial costs, utility for time in health states, and disutilities for surgical procedures. Utilities were derived from the Short Form-6D scale and expressed as quality-adjusted life-years. Model parameters were derived from the literature and from expert opinion, and thorough sensitivity analyses were conducted. TreeAge Pro 2015 software was used to construct and assess the Markov model. RESULTS For the base-case scenario (60-year-old patient), ARCR with conversion to RTSA on potential failure was the most cost-effective strategy when we assumed equal utility for the ARCR and RTSA health states. Primary RTSA became cost-effective when the utility of RTSA exceeded that of ARCR by 0.04 quality-adjusted life-years per year. Age at decision did not substantially change this result. CONCLUSIONS Primary ARCR with conversion to RTSA on potential failure was found to be the most cost-effective strategy for PP without OA. This result was independent of age. Primary ARCR with revision ARCR on potential failure was a less cost-effective strategy. LEVEL OF EVIDENCE Level IV, economic and decision analysis.

Irreparable Rotator Cuff Tears: Restoring Joint Kinematics by Tendon Transfers

Background: Tendon transfers can be a surgical treatment option in managing younger, active patients with massive irreparable rotator cuff tears. The purpose of this article is to provide an overview of the use of tendon transfers to treat massive irreparable rotator cuff tears and to summarize clinical outcomes. Methods: A selective literature search was performed and personal surgical experiences are reported. Results: Latissimus dorsi transfers have been used for many years in the management of posterosuperior rotator cuff tears with good reported clinical outcomes. It can be transferred without or with the teres major (L’Episcopo technique). Many surgical techniques have been described for latissimus dorsi transfer including single incision, double incision, and arthroscopically assisted transfer. Transfer of the pectoralis major tendon is the most common tendon transfer procedure performed for anterosuperior rotator cuff deficiencies. Several surgical techniques have been described, however transfer of the pectoralis major beneath the coracoid process has been found to most closely replicate the force vector that is normally provided by the intact subscapularis. Conclusion: Tendon transfers can be used successfully in the management of younger patients with massive irreparable rotator cuff tears and minimal glenohumeral arthritis. Improvements in clinical outcomes scores and range of motion have been demonstrated. This can delay arthroplasty, which is of particular importance for younger patients with high functional demands.

Arthroscopic Double-Row Transosseous Equivalent Rotator Cuff Repair with a Knotless Self-Reinforcing Technique

Background: Rotator cuff tears are a significant cause of shoulder morbidity. Surgical techniques for repair have evolved to optimize the biologic and mechanical variables critical to tendon healing. Double-row repairs have demonstrated superior biomechanical advantages to a single-row. Methods: The preferred technique for rotator cuff repair of the senior author was reviewed and described in a step by step fashion. The final construct is a knotless double row transosseous equivalent construct. Results: The described technique includes the advantages of a double-row construct while also offering self reinforcement, decreased risk of suture cut through, decreased risk of medial row overtensioning and tissue strangulation, improved vascularity, the efficiency of a knotless system, and no increased risk for subacromial impingement from the burden of suture knots. Conclusion: Arthroscopic knotless double row rotator cuff repair is a safe and effective method to repair rotator cuff tears.

Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis Minimum 5-Year Follow-up

Background: There are little data on midterm outcomes after the arthroscopic management of glenohumeral osteoarthritis (GHOA) in young active patients. Purpose: To report outcomes and survivorship for the comprehensive arthroscopic management (CAM) procedure for the treatment of GHOA at a minimum of 5 years postoperatively. Study Design: Case series; Level of evidence, 4. Methods: The CAM procedure was performed on a consecutive series of 46 patients (49 shoulders) with advanced GHOA who met criteria for shoulder arthroplasty but instead opted for a joint-preserving, arthroscopic surgical option. The procedure included glenohumeral chondroplasty, capsular release, synovectomy, humeral osteoplasty, axillary nerve neurolysis, subacromial decompression, loose body removal, microfracture, and biceps tenodesis. Outcome measures included the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Short Form–12 (SF-12) Physical Component Summary (PCS), visual analog scale for pain, and satisfaction scores. Kaplan-Meier survivorship analysis was performed with failure defined as progression to total shoulder arthroplasty (TSA). Results: Forty-six consecutive patients (49 shoulders) who underwent a CAM procedure at a minimum of 5 years from surgery were included. Two patients were excluded for refusing to participate before study initiation. The mean age at surgery was 52 years (range, 27-68 years) in 15 women and 29 men. All patients were recreational athletes with 7 former collegiate or professional athletes. Twelve shoulders (26%) progressed to TSA at a mean of 2.6 years (range, 0.5-8.2 years). For survivorship analysis, the status of the shoulder (preservation of the native joint or progression to TSA) at a minimum of 5 years was known for 45 of 47 (96%) shoulders. Survivorship was 95.6% at 1 year, 86.7% at 3 years, and 76.9% at 5 years. For surviving shoulders, minimum 5-year subjective outcome data were available for 28 of 32 (87.5%) shoulders at a mean of 5.7 years (range, 5-8 years). The mean (±SD) ASES score was 84.5 ± 17, the mean SANE score was 82 ± 18, the mean QuickDASH score was 15 ± 13, the mean SF-12 PCS score was 51.0 ± 9.1, and median patient satisfaction was 9 of a possible 10 points. Conclusion: This study demonstrates significant improvements in midterm clinical outcomes and high patient satisfaction after the arthroscopic CAM procedure for GHOA, with a 76.9% survivorship rate at a minimum of 5 years postoperatively. For patients looking for an alternative to TSA, the CAM procedure can provide reasonable outcomes and should be considered an effective procedure in appropriately selected, young active patients. Further studies are warranted to evaluate long-term outcomes and durability after this procedure.