We present a retrospective analysis of 50 cases of cuff tear arthropathy, treated over a seven year period by use of reverse geometry shoulder prosthesis. 98% follow-up was achieved with average follow up of 3 years. Mean (SD) age was 81.3 (9.2) years and female to male ratio was 5:1. Six patients had bilateral reverse geometry shoulder replacements. Patients were assessed with pre-operative American Shoulder and Elbow Score (pre-op ASES) and post-operative American Shoulder and Elbow Scores (post-op ASES), Oxford, Constant and SF36 scores. Mean pre-op ASES was 22.29 (95%CI: 9.1 – 37.9) and post-op ASES score was 65.2 (95%CI: 48.5 – 81.9), (P< 0.001, Paired t-test). Mean post operative Oxford score was 27.25 (95% CI: 18.4 – 27.6). Mean post operative Constant score was 63.2 (95% CI: 52.6 – 79.6). X-ray review was performed to assess scapular notching and Sirveaux score was used to grade extent of notching. 11 patients had Sirveaux grade 0, 5 had grade 1, 6 had grade 2, 12 had grade 3 and 8 had grade 4 notching. Intra-operative complications included 2 glenoid fractures. Post-operative complications included 2 acromion fractures and 2 episodes of subsidence with dislocation. None of the patients developed post operative haematoma. There was one episode of infection in one patient that required further surgery. Iteration of approach with increasing experience over the years will be discussed. Ours is the biggest series of reverse geometry prosthesis used for irreparable rotator cuff tear arthropathy published so far in the literature and our results have shown superior results in terms of improvement in function and complications. We recommend reverse geometry shoulder replacement is the way forward to treat irreparable cuff tear arthropathy of shoulder

Aims. Long-term outcomes following the use of human dermal allografts in the treatment of symptomatic irreparable rotator cuff tears are not known. The aim of this study was to evaluate these outcomes, and to investigate whether this would be a good form of treatment in young patients in whom a reverse shoulder arthroplasty should ideally be avoided. Methods. This prospective study included 47 shoulders in 45 patients who underwent an open reconstruction of the rotator cuff using an interposition GraftJacket allograft to bridge irreparable cuff tears, between January 2007 and November 2011. The Oxford Shoulder Score (OSS), pain score, and range of motion (ROM) were recorded preoperatively and at one year and a mean of 9.1 years (7.0 to 12.5) postoperatively. Results. There was significant improvement in the mean OSS from 24.7 (SD 5.4) preoperatively to 42.0 (SD 6.3) at one year, and this improvement was maintained at 9.1 years (p < 0.001), with a score of 42.8 (SD 6.8). Similar significant improvements in the pain score were seen and maintained at the final follow-up from 6.1 (SD 1.6) to 2.1 (SD 2.3) (p < 0.001). There were also significant improvements in the ROM of the shoulder, and patient satisfaction was high. Conclusion. The use of an interposition human dermal allograft in patients with an irreparable rotator cuff tear leads to good outcomes that are maintained at a mean of nine years postoperatively. Cite this article: Bone Joint J 2022;104-B(1):91–96

The surgical technique for treatment of massive rotator cuff tears, more than 5 cm, with loss of substance and tendon retraction, is still not well defined by the international orthopaedic community. A specific rehabilitation regimen or arthroscopic débridement may be insufficient in active patients who continue to suffer from pain and muscular fatigue in active forward elevation. We treated 20 patients, 14 men and 6 women, with an average age of 52 years (range 40–69) with the surgical technique consisting in acromion decompression, stabilisation of the cuff lesion with anchors, application of a prolene membrane and using a deltoid muscular flap as reinforcement. Deltoid flap is created by splitting the deltoid muscular fibres in front of the anterior border of the acromion. The inferior part of deltoid is sutured to the tendon above the synthetic membrane.

The mean patient follow-up was 24 months. The pain was completely relieved in 85% of subjects, The joint mobility increased significantly in flexion, abduction and external rotation; however, the internal rotation did not improve.

We propose this surgical technique as the procedure of choice for treating retracted ruptures of the supraspinatus associated with lesions of the supra- and the infra-spinatus.

We wished to assess the usefulness of Inspace balloon arthroplasty (IBA), in our Upper limb unit by regular patient reviews prospectively. This prospective study was started adhering to local approval process. Patients were identified in routine clinical practice by three upper limb consultants presenting with pain and disability and diagnosis of cuff tear was established clinically and on MRI. The patients were explained of ‘available’ treatment options and an information leaflet about balloon arthroplasty provided. Patients were seen in 4 weeks, in a dedicated clinic to find out their willingness to participate. Consultant shoulder surgeons carried out all Balloon arthroplasties and where the cuff was reparable or contraindications identified were excluded from study.

All the patients were reviewed by an independent clinician pre-operatively and post operatively using the assessment tools of Oxford Shoulder Scores (OSS), SF12 and VAS at 6 weeks, followed by 3, 6, 12 months and annually after.

We performed a total of 32 IBA procedures. At the latest follow-up we identified that 24 patients have completed 2 years post procedure. Of these patients 1 deceased after 6 months, 3 were lost to follow up one each at 6, 12 and 24 months. Three were revised to reverse TSA. The OSS reflects that the positive difference of 10 in the average scores (24 pre-operative versus 34 at 2 years) noted at one year follow up were maintained at 2 years. Similar observations made analysing at 12 months and 2 years scores for the VAS pain scores of 3 at 2 years compared to pre-operative score of 6 and so were improvements in both physical & mental components of SF12.

Our study observes that the IBA provides a sustainable pain relief and functional improvements over 2 years and may be a suitable alternative in physiologically compromised patients with irreparable RCT.

Aims

Favourable short-term outcomes have been reported following latissimus dorsi tendon transfer for patients with an irreparable subscapularis (SSC) tendon tear. The aim of this study was to investigate the long-term outcomes of this transfer in these patients.

Background:. Massive rotator cuff tear can cause functional disability due to instability and degenerative changes of the shoulder joint. In patients with massive irreparable rotator cuff tear, tendon transfer is often used as the salvage procedure. Latissimus dorsi and pectoris major transfer are technically demanding procedures and may incur complications. The biceps tendon transfer may provide a biologically superior tissue patch that improves the biomechanics of the shoulder joint in patients with irreparable rotator cuff tear. This study evaluated the functional outcomes of biceps tendon transfer for irreparable rotator cuff tear in 6 patients with two years and longer follow-up. Methods:. Between September 2006 and October 2011, 50 patients with 50 shoulders underwent surgical repair for MRI confirmed rotator cuff tear. Among them, six patients with massive irreparable rotator cuff tear were identified intraoperatively, and underwent proximal biceps tendon transfer to reconstruct the rotator cuff tear. The biceps tendon was tenodesed at the bicipital groove, and the proximal intra-articular portion of the biceps tendon was transected. The biceps graft was fanned out and the distal end fixed to the cancellous trough around the greater tuberosity with suture anchor. The anterior edge was sutured to the subscapularis and the posterior edge to the infraspinatus tendon or supraspinatus if present. Postoperative managements included sling protection and avoidance of strenuous exercises for 6 weeks, and then progressive rehabilitation until recovery. Results:. The evaluation parameters included VAS pain score, UCLA score, Constant score and AHES score, and X-rays of the shoulder. At follow-up of 25.3 ± 25.0 (range 22 to 63) months, the mean VAS pain score decreased from 9.3 ± 0.8 preoperatively to 1.7 ± 1.4 postoperatively (p < 0.001). All patients presented with significant improvements in pain and function of the shoulder for daily activities after surgery, however, only one patient achieved excellent results. There is no correlation of functional outcome with age, gender and body mass index. There was no infection or neurovascular complication. Discussion:. The biceps transfer provides soft tissue coverage of the humeral head, and restores the superior stability of the shoulder joint. The transferred biceps tendon also improves the mechanics and increases the compression force of the humeral head to the glenoid fossa. The results of the current study showed significant pain relief and improvement of shoulder function after biceps tendon transfer for irreparable rotator cuff tear. Conclusion:. Biceps tendon transfer is effective in the management of massive irreparable rotator cuff tear. The procedure is technically accessible with minimal surgical risks

The December 2012 Shoulder & Elbow Roundup. 360. looks at: whether allograft is biomechanically superior in large Hill-Sachs defects; glenoid bone loss in shoulder dislocators; repairing irreparable cuff tears; acromioclavicular joint injuries; whether more radiographs equals more surgery; whether reverse TSR is cheaper than hemiarthroplasty; autologous chondrocyte implantation in the shoulder; and fracture of the clavicle

Introduction. In recently, Reverse shoulder arthroplasty (RSA) in patients with irreparable rotator cuff tear has been worldwidely performed. Many studies on RSA reported a good improvement in flexion of the sholulder, however, no improvement in external rotation (ER)and internal rotation motion (IR). Additionally, RSA has some risks to perform especially in younger patients, because high rates of complications such as deltoid stretching and loosening, infection, neurologic injury, dislocation, acromial fracture, and breakage of the prosthesis after long-term use were reported. Favard et al noted a 72% survival with a Constant-Murley score of <30 at 10 years with a marked break occurring at 8 years. Boileau et al noted caution is required, as such patients are often younger, and informed consent must obviously cover the high complication rate in this group, as well as the unknown longer-term outcome. Its use should be limited to elderly patients, arguably those aged over 70 years, with poor function and severe pain related to cuff deficiency. We developed a novel strategy in 2001, in which we used the humeral head to close the cuff defect and move the center of rotation medially and distally to increase the lever arm of the deltoid muscle. Aim. The aim of this study was to investigate clinical outcome of our strategy for younger patients with an irreparable rotator cuff tear. Materials and Methods. Eighteen shoulders (9 of male patients, 9 of female patients) of patients under 70 years old with an irreparable cuff tears and who were treated with Humeral Head Replacement (HHR) and cuff reconstruction were followed up for more than 12 months. The average age was 63.9 years (range, 58–69 years). The average follow-up period was 27.3 months (range, 12–76 months). The cuff defect was successfully closed in 8 shoulders, whereas 8 shoulders required a Latissimus Dorsi transfer; one other shoulder required a Pectralis Major transfer, and one required both Latissimus dorsi and pectoralis major transfers. Range of motion (flexion, ER), the shoulder score of Japanese Orthopaedic Association (JOA score), and complications were evaluated. Results. Shoulder pain decreased in all patients after surgery. JOA score was improved from 41.1 to 82.6 points after surgery, Flexion motion improved from 72.5 to 145.6 degrees postoperatively and ER increased from 17.5 to 37.8 degrees postoperatively. There were no complications. Conclusion. In our study, HHR using the small head of the humerus and cuff reconstruction for patients under 70 years old with an irreparable rotator cuff tear yielded favorable results as compared to RSA, especially in terms of the ER Furthermore, the advantages of our strategy is able to keep bone stock of the glenoid after surgery. If revision surgery is required, RSA can be performed. Since the patients included in our study were relatively active, long-term follow-up will be required to assess their progress

Aims. The aim of this study was to describe a quantitative 3D CT method to measure rotator cuff muscle volume, atrophy, and balance in healthy controls and in three pathological shoulder cohorts. Methods. In all, 102 CT scans were included in the analysis: 46 healthy, 21 cuff tear arthropathy (CTA), 18 irreparable rotator cuff tear (IRCT), and 17 primary osteoarthritis (OA). The four rotator cuff muscles were manually segmented and their volume, including intramuscular fat, was calculated. The normalized volume (NV) of each muscle was calculated by dividing muscle volume to the patient’s scapular bone volume. Muscle volume and percentage of muscle atrophy were compared between muscles and between cohorts. Results. Rotator cuff muscle volume was significantly decreased in patients with OA, CTA, and IRCT compared to healthy patients (p < 0.0001). Atrophy was comparable for all muscles between CTA, IRCT, and OA patients, except for the supraspinatus, which was significantly more atrophied in CTA and IRCT (p = 0.002). In healthy shoulders, the anterior cuff represented 45% of the entire cuff, while the posterior cuff represented 40%. A similar partition between anterior and posterior cuff was also found in both CTA and IRCT patients. However, in OA patients, the relative volume of the anterior (42%) and posterior cuff (45%) were similar. Conclusion. This study shows that rotator cuff muscle volume is significantly decreased in patients with OA, CTA, or IRCT compared to healthy patients, but that only minimal differences can be observed between the different pathological groups. This suggests that the influence of rotator cuff muscle volume and atrophy (including intramuscular fat) as an independent factor of outcome may be overestimated. Cite this article: Bone Jt Open 2021;2(7):552–561

Massive irreparable rotator cuff tears often lead to superior migration of the humeral head, which can markedly impair glenohumeral kinematics and function. Although treatments currently exist for treating such pathology, no clear choice exists for the middle-aged patient demographic. Therefore, a metallic subacromial implant was developed for the purpose of restoring normal glenohumeral kinematics and function. The objective of this study was to determine this implant's ability in restoring normal humeral head position. It was hypothesized that (1) the implant would restore near normal humeral head position and (2) the implant shape could be optimized to improve restoration of the normal humeral head position. A titanium implant was designed and 3D printed. It consisted of four design variables that varied in both implant thickness (5mm and 8mm) and curvature of the humeral articulating surface (high constraint and low constraint. To assess these different designs, these implants were sequentially assessed in a cadaver-based biomechanical testing protocol. Eight cadaver specimens (64 ± 13 years old) were loaded at 0, 30, and 60 degrees of glenohumeral abduction using a previously developed shoulder simulator. An 80N load was equally distributed across all three deltoid heads while a 10N load was applied to each rotator cuff muscle. Testing states included a fully intact rotator cuff state, a posterosuperior massive rotator cuff tear state (cuff deficient state), and the four implant designs. An optical tracking system (Northern Digital, Ontario, Canada) was used to record the translation of the humeral head relative to the glenoid in both superior-inferior and anterior-posterior directions. Superior-Inferior Translation. The creation of a posterosuperior massive rotator cuff tear resulted in significant superior translation of the humeral head relative to the intact cuff state (P=0.016). No significant differences were observed between each implant design and the intact cuff state as all implants decreased the superior migration of the humeral head that was observed in the cuff deficient state. On average, the 5mm low and high constraint implant models were most effective at restoring normal humeral head position to that of the intact cuff state (-1.3 ± 2.0mm, P=0.223; and −1.5 ± 2.3mm, P=0.928 respectively). Anterior-Posterior Translation. No significant differences were observed across all test states for anterior-posterior translation of the humeral head. The cuff deficient on average resulted in posterior translation of the humeral head, however, this was not statistically significant (P=0.128). Both low and high constraint implant designs were found to be most effective at restoring humeral head position to that of the intact cuff state, on average resulting in a small anterior offset (5mm high constraint: 2.0 ± 4.7mm, P=1.000; 8mm high constraint: 1.6 ± 4.9mm, P=1.000). The 5mm high constraint implant was most effective in restoring normal humeral head position in both the superior-inferior and anterior-posterior directions. The results from this study suggest the implant may be an effective treatment for restoring normal glenohumeral kinematics and function in patients with massive irreparable rotator cuff tears. Future studies are needed to address the mechanical efficiency related to arm abduction which is a significant issue related to patient outcomes

Purpose of the study: Fragile bone and weak soft tissues can create a serious challenge for arthroplasty of the rheumatoid arthritis shoulder. Patients seen late after rotator cuff tears become irreparable may also present a stiff shoulder, further complicating the procedure. Material and methods: The purpose of this study was to assess outcome at more than five years in a prospective series of 12 patients with rheumatoid arthritis of the shoulder with an irreparable rotator cuff tear treated with a hemiarthroplasty with a mobile cup. The radiological and clinical results were compared with those obtained in a control series of ten bipolar humeral prostheses implanted for centered or excentered degenerative disease with irreparable cuff tears. Results: The mean preoperative Constant score was 16.9 points: pain 2.5, activity 4.2, active mobility 9.5, strength 0.7. Active ROM was 63.8° for anterior elevation, 45° for abduction, and 12° for external rotation. At last follow-up, the mean postoperative Constant score was 39.4 points: pain 10.7, activity 10.8, active mobility 13.8, strength 4.1. Mean active anterior elevation was 83.7°, abduction 70.4°, and external rotation 29.1°. Outcome was not significantly different from the control group with degenerative joint disease (p< 0.05). Discussion: The overall Constant score, especially the pain score, was significantly improved (p< 0.05). Improvement in joint motion was modest but comparable with other series in the literature and even better than with conventional hemiarthroplasty for the same indication. There were few complications, mainly superior subluxation favored by the preoperative infra-scapularis or infraspinatus tears. Glenoid wear was significant despite the dual mobility concept. There were no cases of loosening. Conclusion: These results show that hemiarthroplasty with a mobile cut provides acceptable mid-term results for the advanced-stage rheumatoid shoulder with an irreparable rotator cuff tear. Results in this series were comparable with that in the control group of patients with degenerative joint disease. Consequently, the status of the rotator cuff appears to be more important that the inflammatory or degenerative etiology. Certain cuff tears involving the infrascapularis raise the risk of superoanterior instability and could be a limitation for this method. A more constrained prosthesis might be advisable

Massive, irreparable rotator cuff tears occur in about 15% of patients with ruptures of the rotator cuff tendons. There is no consistently agreed management for irreparable rotator cuff tears, however, latissimus dorsi tendon transfer is a recognised technique. We aimed to review the functional outcome of patients undergoing this operation at a single tertiary referral centre. Fourteen latissimus dorsi transfer procedures in thirteen patients from May 2007 to May 2008 were retrospectively reviewed. The mean age of patients undergoing the procedure was fifty nine years. All patients were confirmed to have massive, irreparable (>5cm) rotator cuff tears as determined by MRI or ultrasound. Modified Constant scores (assessing shoulder pain, functional activity and movement) determined pre-operatively and post latissmus dorsi transfer were compared. The mean duration of follow up was 12 months. The mean Modified Constant Score (maximum = 75) improved from 23 points pre-operaively to 52 points post latissimus dorsi transfer (p < 0.05). All patients had improvement in shoulder pain following the operation. There was a trend for younger patients to have greater improvement in functional activity and shoulder movement. From our series, latissimus dorsi transfer is effective at improving functional outcomes in patients with massive, irreparable rotator cuff tears, especially in younger age groups

Introduction:. Reverse shoulder arthroplasty (RSA) is a reasonable treatment modality in patients with Cuff Tear Arthropaty and massive irreparable cuff tears. RSA has been shown to increase patient function and decrease pain. The aim of this study is to evaluate the clinical and radiographic results of a 44 polyethylene glenosphere. Methods:. Since 2008 we treated 88 patients with cuff tear arthropaty and irreparable massive cuff tear, using an RSA. We selected 80 patients with minimum FU of 24 months in which we used an implant with polyethylene glenosphere and metal humeral insert. Size of the glenosphere used was 44. All patients were assessed with the Constant score and with VAS. The shoulder ROM was measured preoperatively and postoperatively. Results:. Average age of the patients was 71 years old. Average duration of FU was 34 months. All measures improved significantly (p < 0.0001). The mean Constant improved from 15.6 to 60.2. VAS improved from 6 to 2,5. Forward flexion increased from 40 ° to 126,4 °, abduction from 41 ° to 103 °, external rotation from 15.1 to 17.3 and internal rotation increased by two level. We report 22 cases of scapular notching without clinical influence and without implant mobilization. Conclusion:. This is the first report of the use of a polyethylene glenosphere. Data from this study suggest that RSA with a polyethylene glenosphere may be a viable treatment for patients with glenohumeral arthritis and a massive rotator cuff tear. Future studies will be necessary to determine the longevity of the implant and whether it will provide continued improvement in function

Introduction. Reverse total shoulder replacement is performed for the treatment of rotator cuff arthropathy, massive irreparable cuff tears and failed shoulder hemiarthroplasty with irreparable rotator cuff tears. The aim of this study was to assess the clinical and radiological outcome of single surgeon series of Equinoxe® reverse total shoulder replacement at a district general hospital. Materials/Methods. Consecutive patients who underwent Equinoxe® reverse total shoulder replacement at our unit from Jun 2008 to Dec 2010 were retrospectively reviewed. Indications for surgery, complications and radiological outcomes were assessed. Oxford shoulder score was used to assess the functional outcome. Results. Between Jun 2008 and Dec 2012, forty-one reverse total shoulder replacements were performed by the senior author in 37 patients. Of these, Equinoxe® prostheses were used in 27 operations (26 patients). These included 22 female and 4 male patients. Cuff arthropathy was the commonest preoperative diagnosis (23 patients), followed by proximal humeral fracture non-union (2 patients), failed hemiarthroplasty (one patient) and failed resurfacing (one patient). The mean follow up was 10 months (3 to 17 months). At the time of the study, three patients had died due to unrelated causes, two were not contactable and the remaining 21 patients were analysed. The mean oxford shoulder score was 35.8 (21–48). Nineteen patients (90.5%) graded their outcome a good to excellent while 2 patients (9.5%) graded as poor. Seventeen patients (81%) expressed that they would recommend this operation. One patient (4.7%) had infection and another had dislocation. Overall, there were 3 reoperations (14.3%); first washout, second change of humeral tray and third excision of lateral end of clavicle and reattachment of deltoid. Two patients (9.5%) had small glenoid notching. There was no loosening, neurovascular injury or postoperative haematoma. Conclusion. Early outcome of Equinoxe reverse shoulder replacement is promising. Longer follow-up is required to further assess the outcome

The purpose of this study was to evaluate outcome following arthroscopic biceps tenotomy or tenodesis for massive irreparable rotator cuff tears associated with biceps lesions. This is a retrospective study of sixty-eight consecutive patients (mean age 68 ± 6 years) with seventy-two irreparable rotator cuff tears treated with arthroscopic biceps tenotomy (thirty-nine cases) or tenodesis (thirty-three cases). All patients were evaluated clinically and radiographically at a mean follow-up of thirty-five months (range, 24–52). Fifty-three patients (78%) were satisfied. Constant score improved from forty-six to sixty-seven points (p< 0.001). Presence of a healthy, intact teres minor on preoperative imaging correlated with increased postoperative external rotation (40 vs. 18°, p< 0.05) and higher Constant score (p< 0.05). Three patients with a pseudoparalyzed shoulder did not benefit from the procedure and did not regain active elevation above the horizontal level. By contrast, fifteen patients with painful loss of active elevation recovered active elevation. The acromiohumeral distance decreased 1 mm on average, and only one patient developed glenohumeral osteoarthritis. There was no difference between tenotomy and tenodesis (Constant Score sixty-one vs. seventy-three). A “Popeye” sign was clinically apparent in twenty-four tenotomy patients (61%), but none were bothered by it. Two patients required reoperation with a reverse prosthesis. Arthroscopic biceps tenotomy and tenodesis effectively treats severe pain or dysfunction caused by an irreparable rotator cuff tear associated with biceps pathology. Shoulder function is significantly lower if the teres minor is atrophic or fatty infiltrated. Pseudoparalysis or severe cuff arthropathy are contraindications

Chronic massive irreparable rotator cuff tears represent a treatment challenge and the optimal surgical technique remains controversial. Superior capsular reconstruction (SCR) has been proposed as a means to provide superior stability to the glenohumeral joint, thus facilitating restoration of shoulder function. However, despite the growing use of SCR there is a paucity of data evaluating the outcomes when performed using a dermal allograft. The purpose of this study was to (1) report the overall survival rate (reoperation and clinical failure) of SCR (2) evaluate for pre-operative factors predicting reoperation and clinical failure. From January 1, 2015 to November 31, 2017, 65 patients were diagnosed with irreparable rotator cuff tears and consented for a superior capsular reconstruction. These surgeries were performed by 6 surgeons, all fellowship trained in either sports or shoulder and elbow fellowships. Outcomes were graded as excellent, satisfactory, or unsatisfactory using the modified Neer scale. An unsatisfactory result was defined as a clinical “failure”. The Kaplan-Meier survival models were created to analyze reoperation-free and failure-free survival for the entire group. The reconstruction was performed using a dermal allograft. There were 31 patients excluded due to insufficient follow-up (< 6 months), leaving 34 included in this study. The mean follow-up was 12 months (range, 6–23). The average number of prior surgeries was 0.91 (range, 0–5), with 52.9% of patients receiving a prior rotator cuff repair and 38.2% of patients with a prior non-rotator cuff arthroscopy procedure. The one and two-year survival-free of surgery was 64% and 44% and the one and two-year survival free of failure was 34% and 16% following SCR, respectively. For the patients that underwent a reoperation, 62.5% (n= 5/8) underwent reverse shoulder replacements, 25% (n= 2/8) latissimus dorsi tendon transfers, and 12.5% (n= 1/8) a diagnostic arthroscopy. The average period between the primary and revision surgery was 10.2 months (range, 2.1–18.5). All but two patients (75%, n= 6/8) had at least one surgery prior to the SCR. There were 14/34 (41.2%) patients who experienced pain, weakness, and restricted range of motion. These patients were defined as clinical failures with an unsatisfactory grading on Neer's criteria. Previous surgery predicted reoperation (80% vs 43%, p = 0.03). Female gender predicted clinical failure (100% vs 43%, p < 0 .01). Superior Capsule Reconstruction performed for large to massive rotator cuff tears has a high rate of persistent pain and limited function leading to clinical failure in 65% (n= 22/34) of patients. The rate of failure is increased in revision cases, female gender and increased Goutallier fatty infiltration of the infraspinatus. Narrowed indications are recommended given the surgical complexity and high rate of early failure

Does the pre-operative range of active anterior elevation alter the outcome of reverse shoulder prosthesis? A review of 96 cases. Aims: The aim of this retrospective study was to analyse the results of reverse shoulder prosthesis in massive, irreparable rotator cuff tears in terms of the preoperative active anterior elevation (AAE). Materials and Methods: This was a retrospective study of 96 reverse shoulder prostheses in patients with a mean age of 74 years, and with an average follow-up of 30 months. We divided the patients into three groups for the purposes of the study. Group 1 had an AAE less than 60° (n=51); group 2 had an AAE between 60 and 120° (n=39); group 3 had an AAE above 120° (n=6). The majority had off-centre arthritis with a Fukuda Hamada classification of IV or V (n=77); only 19 fell within classes I, II or III. We excluded patients who had previously had a failed anterior cuff repair or arthroplasty and those with a diagnosis of rheumatoid arthritis. Results: There was no significant difference in constant score between the three groups based on preoperative AAE: group 1: 63.50; group 2: 65.05; group 3: 65.16. Analysis of the 96 reverse prostheses in relation to the Fukuda Hamada classification also showed no difference: types I, II and III had a constant score of 64.37; types IV and V a score of 63.68. However, the improvement in AAE (I), rotation (RE1 and RI) and in power was significantly greater in shoulders with pseudoparalysis (p< 0.001): group 1: I = 71.43%; group 2: I = 33.48%; group 3: I = 3.03%. The degree of improvement of the pseudoparalytic shoulders (group 1) was influenced by the Fukuda Hamada classification (p< 0.01): 77.78% for stages I, II and III compared with 69% for stages IV and V. Discusssion and conclusion: This retrospective study confirms that the reverse shoulder prosthesis is a beneficial treatment for massive, irreparable cuff tears in older patients with shoulder psuedoparalysis. Its use is debatable if the preoperative AAE is over 120°, in which case hemiarthroplasty may be a better option. The benefit of the reverse prosthesis is greatest in the shoulder with pseudoparalysis, no glenohumeral arthritis (Fukuda I, II or III), and no previous surgical intervention

Purpose of the study: This retrospective analysis was conducted to study the gain provided by a latissimus dorsi flap used as first-intention treatment (group 1) or secondary treatment after prior failure (group 2) for irreparable rotator cuff tears. Material and methods: This series included ten women and nine men, mean age 58 years (range 42-64). The initial tear was a massive (> 5 cm) posterosuperior tear in 16 patients and extended to the upper third of the infra-scapularis in three. Surgery was undertaken because of persistent pain and limited joint motion despite rehabilitation. A subacromial impingement was noted in 15/20 shoulders on the arthroscan and fatty degeneration was noted as grade 3.31 on average for the supraspinatus and 3.1 for the infraspinatus (Goutallier and Bernageau classification). The latissimus dorsi flap was harvested via the superolateral approach and fixed with anchors in the superior border of the infrascapularis and on the trochiter after avivement. Tendon stumps were sutured to the medial part of the aproneurotic sheath of the latissimus dorsi. Results: Overall outcome and outcome in group 1 patients (14 shoulders) and group 2 patients (five shoulders) were noted. Mean follow-up was 19.72 months (range 12–48). The overall Constant score progressed from 33.10 to 54.9 with a mean gain of 53° for elevation (98–151°) and 11° for external rotation (21.5–32.1°). For group 1, the Constant score progressed from 31 (15/51) to 58 (40/75) with a mean gain of 37° elevation (121–155°) and 13° external rotation (22.8–35°). For group 2, the Constant score progressed from 33 to 52 (40/75) with a mean gain of 32° elevation (88–120°) and 6° external rotation (18–24°). Pain improved from 6.3 to 11.8 on the Constant score. Discussion and conclusion: Used as a first intention treatment for massive irreparable cuff tears with fatty degeneration scored greater than grade 3, the latissimus dorsi flap provides better results than when it is used after failure of a prior procedure. Results are good for pain relief and active elevation (45°) but modest for external rotation (6–13°) and zero for force. The two failures and the two cases of only fair subjective outcome were in group 2. We reserve the procedure for painful pseudo-paralytic shoulders in subjects aimed less than 60 years who do not respond to prolonged rehabilitation

Rotator cuff tears are the most common cause of shoulder disability, affecting 10% of the population under 60 and 40% of those aged 70 and above. Massive irreparable rotator cuff tears account for 30% of all tears and their management continues to be an orthopaedic challenge. Traditional surgical techniques, that is, tendon transfers are performed to restore shoulder motion, however, they result in varying outcomes of stability and complications. Superior capsular reconstruction (SCR) is a novel technique that has shown promise in restoring shoulder function, albeit in limited studies. To date, there has been no biomechanical comparison between these techniques. This study aims to compare three surgical techniques (SCR, latissimus dorsi tendon transfer and lower trapezius tendon transfer) for irreparable rotator cuff tears with respect to intact cuff control using a clinically relevant biomechanical outcome of rotational motion. Eight fresh-frozen shoulder specimens with intact rotator cuffs were tested. After dissection of subcutaneous tissue and muscles, each specimen was mounted on a custom shoulder testing apparatus and physiologic loads were applied using a pulley setup. Under 2.2 Nm torque loading maximum internal and external rotation was measured at 0 and 60 degrees of glenohumeral abduction. Repeat testing was conducted after the creation of the cuff tear and subsequent to the three repair techniques. Repeated measures analysis with paired t-test comparisons using Sidak correction was performed to compare the rotational range of motion following each repair technique with respect to each specimen's intact control. P-values of 0.05 were considered significant. At 0° abduction, internal rotation increased after the tear (intact: 39.6 ± 13.6° vs. tear: 80.5 ± 47.7°, p=0.019). Internal rotation was higher following SCR (52.7 ± 12.9°, intact - SCR 95% CI: −25.28°,-0.95°, p=0.034), trapezius transfer (74.2 ± 25.3°, intact – trapezius transfer: 95% CI: −71.1°, 1.81°, p=0.064), and latissimus transfer (83.5 ± 52.1°, intact – latissimus transfer: 95% CI: −118.3°, 30.5°, p=0.400) than in intact controls. However, internal rotation post SCR yielded the narrowest estimate range close to intact controls. At 60° abduction, internal rotation increased after the tear (intact: 38.7 ± 14.4° vs. tear: 49.5 ± 13°, p=0.005). Internal rotation post SCR did not differ significantly from intact controls (SCR: 49.3 ± 10.1°, intact – SCR: 95% CI: −28°, 6.91°, p=0.38). Trapezius transfer showed a trend toward significantly higher internal rotation (65.7 ± 21.1°, intact – trapezius transfer: 95% CI: −55.7°, 1.7°, p=0.067), while latissimus transfer yielded widely variable rotation angle (65.7 ± 38°, intact – latissimus transfer: 95% CI: −85.9°, 31.9°, p=0.68). There were no significant differences in external rotation for any technique at 0° or 60° abduction. Preliminary evaluation in this cadaveric biomechanical study provides positive evidence in support of use of SCR as a less morbid surgical option than tendon transfers. The cadaveric nature of this study limits the understanding of the motion to post-operative timepoint and the results herein are relevant for otherwise normal shoulders only. Further clinical evaluation is warranted to understand the long-term outcomes related to shoulder function and stability post SCR

This study aims to investigate the mechanical properties of a rotator cuff tear repaired with a polypropylene interposition graft in an ovine infraspinatus ex-vivo model. Twenty fresh shoulders from skeletally mature sheep were used in this study. A tear size of 20 mm from the tendon joint was created in the infraspinatus tendon to simulate a large tear in fifteen specimens. This was repaired with a polypropylene mesh used as an interposition graft between the ends of the tendon. Eight specimens were secured with mattress stitches while seven were secured to the remnant tendon on the greater tuberosity side by continuous stitching. Remaining five specimens with an intact tendon served as a control group. All specimens underwent cyclic loading with a universal testing machine to determine the ultimate failure load and gap distance. Gap distance increased with progressive cyclic loading through 3000 cycles for all repaired specimens. Mean gap distance after 3000 cycles for both continuous and mattress groups are 1.7 mm and 4.2 mm respectively (P = .001). Significantly higher mean ultimate failure load was also observed with 549.2 N in the continuous group, 426.6 N in the mattress group and 370 N in the intact group. The use of a polypropylene mesh as an interposition graft for large irreparable rotator cuff tears is biomechanically suitable and results in a robust repair that is comparable to an intact rotator cuff tendon. When paired with a continuous suturing technique, it demonstrates significantly resultant superior biomechanical properties that may potentially reduce re-tear rates after repairing large or massive rotator cuff tears

Rotator cuff tears are common, with failure rates of up to 94% for large and massive tears. 1. For such tears, reattachment of the musculotendinous unit back to bone is problematic, and any possible tendon-bone repair heals through scar tissue rather than the specially adapted native enthesis. We aim to develop and characterise a novel soft-hard tissue connector device, specific to repairing/bridging the tendon-bone injury in significant rotator cuff tears, employing decellularised animal bone partially demineralised at one end for soft tissue continuation. Optimisation samples of 15×10×5mm. 3. , trialled as separate cancellous and cortical bone samples, were cut from porcine femoral condyles and shafts, respectively. Samples underwent 1-week progressive stepwise decellularisation and a partial demineralisation process of half wax embedding and acid bathing. Characterisations were performed histologically for the presence/absence of cellular staining in both peripheral and central tissue areas (n=3 for each cortical/cancellous, test/PBS control and peripheral/central group), and with BioDent reference point indentation (RPI) for pre- and post-processing mechanical properties. Histology revealed absent cellular staining in peripheral and central cancellous samples, whilst reduced in cortical samples compared to controls. Cancellous samples decreased in wet mass after decellularisation by 45.3% (p<0.001). RPI measurements associated with toughness (total indentation depth, indentation depth increase) and elasticity (1st cycle unloading slope) showed no consistent changes after decellularisation. X-rays confirmed half wax embedding provided predictable control of the mineralised-demineralised interface position. Initial optimisation trials show proof-of-concept of a soft-hard hybrid scaffold as an immune compatible xenograft for irreparable rotator cuff tears. Decellularisation did not appreciably affect mechanical properties, and further biological, structural and chemical characterisations are underway to assess validity before in vivo animal trials and potential clinical translation

Purpose. Chronic massive rotator cuff tears are challenging to repair completely because of the development of tendon retraction with inelasticity, muscle atrophy and fatty infiltration. The objective of this study was to investigate the clinical outcome and MRI findings after arthroscopic superior capsule reconstruction (ASCR) for symptomatic irreparable rotator cuff tears. Methods. From 2011 to 2013, 12 shoulders in 12 consecutive patients (mean, 70.8 years) with irreparable massive rotator cuff tears underwent ASCR using fascia lata. We used suture anchors to attach the graft medially to the glenoid superior tubercle and laterally to the greater tuberosity as same technique by Mihata et al. We added side-to-side sutures between the graft and infraspinatus tendon and between the graft and residual anterior supraspinatus/subscapularis tendon to improve force coupling. Physical examination, clinical rating system, and magnetic resonance imaging (MRI) were performed before surgery; at 6 and 12 months after surgery; and 6 months thereafter. Average follow-up was 19.1 months (12 to 28 months) after surgery. We assessed patients preoperatively by using the scoring systems of the shoulder index of the American Shoulder and Elbow Surgeons (ASES), the Japanese Orthopaedic Association, and the University of California, Los Angeles. Results. Mean active elevation increased from 59° to 111° significantly and external rotation increased from 28 to 33. The average preoperative scores were 16.0 points by ASES, 48.0 points by JOA, and 10.8 points by UCLA. Average clinical outcome scores all improved significantly after ASCR at the final follow-up (ASES, 73.3 points; JOA, 73.7 points; UCLA, 22.7 points). There was surgical complication as infection. Although infection was controlled by arthroscopic irrigation, the transplanted tendon was absorbed, and preoperative conditions did not functionally improve. Five patients had graft tear during follow-up. Postoperative active range of motion in the healed patients was significantly greater than in the unhealed patients who had graft tears. Conclusions. ASCR restored superior glenohumeral stability and function of the shoulder joint with irreparable rotator cuff tears compared to preoperative function in the cases without postoperative complications. However ratio of graft tears were 50% and clinical results of these cases were not improved sufficiently

Purpose of the study: The appropriate treatment for massive irreparable rotator cuff tears is a subject of debate. The purpose of this work was to analyze at mean five years follow-up a series of 16 shoulders treated with a latissimus dorsi flap. Material and methods: These 16 patients (seven women) were aged 56 years on average. The procedure was a revision for four shoulders. The tears were all posterosuperior tears and caused invalidating pain in all patients. Mean anterior elevation was 93°. External rotation was 12°. The Constant score, assessed in eleven patients, was 27 points on average. The subacromial space measured 8 mm on average. Supraspinatus fatty degeneration was grade 2 in 45% and grade 3 in 55%. Infraspinatus degeneration was grade 3 in 80% and grade 4 in 20%. The latissimus dorsi flap was associated with a teres major flap in four shoulders and with a deltoid flap in seven. The semi-sitting position was used for 15 of the 16 patients. Discussion: Treatment of massive irreparable rotator cuff tears is a controversial issue. When the subacromial space is preserved, the presence of muscle atrophy and tendon retraction despite forced mobilization it is logical to use several muscle transfers. This small series demonstrated that a significant improvement can be obtained. Nevertheless the postoperative period is long and indications must remain limited. We discuss our results in comparison with other reported series

The treatment of patients with arthritis of the glenohumeral joint with an associated massive irreparable cuff tear is challenging. Since these patients usually have proximal migration of the humerus, the CTA extended head allows a surface with a low coefficient of friction to articulate with the acromion. Between 2001 and 2006 a total of 48 patients with arthritis of the shoulder joint associated with a massive cuff tear, were treated with a CTA head. The indications for use being Seebauer Type 1a and 1b appearances on x-ray and active abduction of the arm to more than 60° with appropriate analgesia. Preoperatively, a Constant score and an ASES pain and function score were completed as well as standard radiological assessment. These were repeated at follow up. Paired t tests were carried out for all the variables. A Kaplan-Meier survival analysis was performed. Follow up varied between 2 and 8 years. Improvements in pain, function and all movement parameters were significant at p< 0.001. There was no change in the strength component. Survival analysis showed 94% survival at 8 years (95% CL 8%) there were 2 revisions and 5 deaths. Radiological assessment at follow up revealed no evidence of humeral stem loosening. In 5 (17%) cases however there was evidence of erosion in the surface of the acromion and in 13 (45%) erosion of the glenoid. Finally one component was also seen to have subluxed anteriorly. This head design has been in use for a number of years. To date there appears to be no reported outcome of their use. This series shows that in an appropriately selected patient a satisfactory clinical outcome can be maintained in the short to medium term. The presence of erosion of the glenoid but also the under surface of the acromion does require continuing monitoring

Purpose. Management of massive, degenerative, and irreparable rotator cuff tears is challenging. Excessive re-tear rates and poor clinical outcome after standard repair have led to alternative methods of treatment. Tendon transfers and shoulder arthroplasty have had mixed results; both are invasive procedures with high potential morbidity. We began performing rotator cuff augmentation and replacement using GraftJacket allograft acellular human dermal matrix as a biologic minimally invasive alternative in this difficult population almost 6 years ago. This article highlights our preferred arthroscopic technique and early results. Method. From January 2004 to June 2007, 45 patients (36 men, 9 women) with massive rotator cuff tears were treated arthroscopically with the GraftJacket allograft. All patients completed a preoperative University of California, Los Angeles (UCLA) score. Follow-up was a minimum of 2 years (range, 24–68 months) and patients completed UCLA, Western Ontario Rotator Cuff (WORC), and American Shoulder and Elbow Surgeons (ASES) scores. Results. Analysis was performed using the 3 validated outcomes measurement scores. The mean UCLA score increased from 18.4 preoperatively to 27.5 postoperatively (P < .000). The average WORC score was 75.2, and the ASES score was 84.1 at the final follow-up. Conclusion. Evidence-based data to outline an algorithm for management of irreparable rotator cuff tears is being developed. We documented significant clinical improvement with arthroscopic rotator cuff reconstruction using the GraftJacket allograft acellular human dermal matrix. The procedure is safe and associated with high patient satisfaction, without the morbidity of tendon transfer or arthroplasty. For those few cases where further surgery is required, no bridges are burned. The early success of this procedure warrants further study with more patients, longer follow-up, and higher levels of evidence-based investigation

Introduction:. Lateralization of reversed shoulder arthroplasty provides improvement in range of motion and decreases inferior scapular notching. The purpose of this study was to verify if the autologous cancelous bone graft harvested from the humeral head does heal constantly in a large cohort of patients followed for a long time. Methods:. Cohort of 92 consecutive patients operated between 2006 and 2010 with a BIORSA for definitive shoulder pseudoparalysis, secondary to cuff tear arthropathy (CTA) or massive, irreparable cuff tear (MCT). The autogenous cancelous graft was harvested from humeral head in all cases. Eight patients were lost for follow up, and four died before 2 years. The remaining 80 patients underwent clinical, radiographic and CT assessment at a minimum FU of 24 months. Mean age was 73 years. Three independent observers evaluated notching, partial or total glenoid or humeral loosening and viability of the graft. Constant-Murley score, range of motion and subjective shoulder value (SSV) were recorded. The mean follow up was 39 months (range 24–74 months). Results:. The bone graft did healed completely in 96% of the cases (77/80); the thickness of the graft remained stable through the years. There were two cases of glenoid loosening: one nonunion of the graft at the scapular side was due to an important superior tilt of the glenosphere; one failure of fixation at the baseplate side was related to a low-grade infection. Another patient had a partial radiolucent line between graft and native glenoid located only above the central peg. No other radiolucent line around peg, screws or baseplate was found. Inferior scapula notching was observed in 19% of the cases (mainly grade 1 and 2). Each parameters of Constant score improved, and the mean SSV increased from 27% to 78%. Conclusion:. This study shows that: (1) autologous cancellous bone graft, harvested from the humeral head, does heal to the native glenoid despite the advanced age of the patients; and (2) BIO-RSA allows improvement of shoulder function (mobility, pain, strength, subjective value) with a low rate of scapular notching

The combination of an irreparable tear of the rotator cuff and destructive arthritis of the shoulder joint may cause severe pain, disability and loss of independence in the aged. Standard anatomical shoulder replacements depend on a functioning rotator cuff, and hence may fail in the presence of tears in the cuff. Many designs of non-anatomical constrained or semi-constrained prostheses have been developed for cuff tear arthropathy, but have proved unsatisfactory and were abandoned. The DePuy Delta III reverse prosthesis, designed by Grammont, medialises and stabilises the centre of rotation of the shoulder joint and has shown early promise. This study evaluated the mid-term clinical and radiological results of this arthroplasty in a consecutive series of 50 shoulders in 43 patients with a painful pseudoparalysis due to an irreparable cuff tear and destructive arthritis, performed over a period of seven years by a single surgeon. A follow-up of 98% was achieved, with a mean duration of 39 months (8 to 81). The mean age of the patients at the time of surgery was 81 years (59 to 95). The female to male ratio was 5:1. During the seven years, six patients died of natural causes. The clinical outcome was assessed using the American Shoulder and Elbow score, the Oxford Shoulder Score and the Short-form 36 score. A radiological review was performed using the Sirveaux score for scapular notching. The mean American Shoulder and Elbow score was 19 (95% confidence interval (CI) 14 to 23) pre-operatively, and 65 (95% CI 48 to 82) (paired t-test, p < 0.001) at final follow-up. The mean Oxford score was 44 (95% CI 40 to 51) pre-operatively and 23 (95% CI 18 to 28) (paired t-test, p < 0.001) at final follow-up. The mean maximum elevation improved from 55° pre-operatively to 105° at final follow-up. There were seven complications during the whole series, although only four patients required further surgery

Objective: This study evaluates the preoperative conventional anteroposterior radiography in non-operated patients with cuff tear arthropathy. It analyses the radiological findings in relation to the status of the rotator cuff and clinical outcome. The aim of the study is to define the usefulness of this radiographical examination in cuff tear arthropathy. Methodology: This study analyses the preoperative radiological (AP-view, (Artro-)CT-scan or MRI-scan) and clinical characteristics (Constant-Murley-score plus active and passive mobility testing) and the peroperative findings in a cohort of 315 patients of which 282 had eccentric omarthrosis according to the classification of Hamada and 33 patients with centered omarthrosis who have at least two irreparable tendon tears. Those patients were part of a multicenter, retrospective, consecutive study of the French Orthopaedic Society (SOFCOT-2006). All patients had no surgical antecedents and were all treated with prosthetic shoulder surgery for a painful irreparable cuff tear arthropathy (reverse -(84%) or hemi-(8%) or double cup prosthesis (8%)). Results: Fatty degeneration of a rotator cuff muscle decreases its strength (p < 0.0001). In the presence of tendons lesser bony wear is seen at the acromion (acetabularisation, (p< 0.005), the glenoid (superomedial wear p=0.005) as well as the humeral head (femoralization, p=0.002). The radiological classifications according to Hamada and Favard seem not to be as appropriate to reflect accurately the location and extent of the tendino-muscular degeneration as the acromial acetabularization and humeral sphericity. The acromio-humeral distance is a good indicator for the location and the extend of the cuff tear arthropathy. A smaller acromio-humeral distance (95% CI: 4mm + 1) is only present if the postero-superior muscles are fatty degenerated (Goutallier stade III & IV) and a larger distance is calculated (95% CI: 7mm + 3) when only the antero-superior muscles are diseased. The coracoid tip in cuff tear arthropathy-patients is almost always positioned in the inferior half of the glenoid (84%). A bigger supero-inferior distance of the glenoid in relation to the radius of the humeral head indicates more structural destruction of rotator cuff status (tendinous and muscular) and a worse clinical outcome. Conclusion: This study defines the use of a conventional radiological antero-posterior view to evaluate eccentric omarthrosis as very useful. The direction of eccentricity in the scapular plane of the body and type of wear, situated either at the glenoïd, acromion or humeral head are determined by the location and extent of the tendinous lesion and the degree of fatty degeneration of the rotator cuff muscle

Surgical repair of posterosuperior rotator cuff tears has a poorer outcome and a higher rate of failure compared with repairs of supraspinatus tears. In this prospective cohort study 28 consecutive patients with an irreparable posterosuperior rotator cuff tear after failed conservative or surgical treatment underwent teres major tendon transfer. Their mean age was 60 years (48 to 71) and the mean follow-up was 25 months (12 to 80). The mean active abduction improved from 79° (0° to 150°) pre-operatively to 105° (20° to 180°) post-operatively (p = 0.011). The mean active external rotation in 90° abduction improved from 25° (0° to 70°) pre-operatively to 55° (0° to 90°) post-operatively (p < 0.001). The mean Constant score improved from 43 (18 to 78) pre-operatively to 65 (30 to 86) post-operatively (p < 0.001). The median post-operative VAS (0 to 100) for pain decreased from 63 (0 to 96) pre-operatively to 5 (0 to 56) post-operatively (p < 0.001). In conclusion, teres major transfer effectively restores function and relieves pain in patients with irreparable posterosuperior rotator cuff tears and leads to an overall clinical improvement in a relatively young and active patient group with limited treatment options. Cite this article: Bone Joint J 2013;95-B:523–9

Introduction: Massive irreparable degenerative rotator cuff tears are amongst the most difficult conditions for treatment in shoulder surgery. These involve usually elderly patients, which present with severely painful and restricted active shoulder movement. These patients have low demand from their shoulders, mainly for pain relief and performing their simple activities of daily living. Major surgery for major tendon transfer will not be advisable in these cases in view of the morbidity involved and the questionable outcome. We suggest a simple non-surgical rehabilitation treatment consisting on anterior deltoid strengthening exercises in the supine position for re-education of the anterior deltoid to compensate for the absent rotator cuff. Methods: 17 patients with degenerative (non traumatic) Massive irreparable rotator cuff tears were recruited. They were all greater than 70 years of age and of mixed gender. Patients were English speaking, had full mental faculties and gave informed consent. They suffered no other shoulder pathology and were not participants in any other upper limb rehabilitation. All patients complained on severe shoulder pain and severely limited active range of motion with inability to actively elevate the arm to the horizontal. They all had full passive range of motion. The diagnosis of a Massive irreparable rotator cuff tear was confirmed by diagnostic ultrasound scan. The shoulder function was evaluated using the Constant Score. Patients’ active shoulder ranges of motion were recorded and video-recorded as well. Each participant was taught the initial 6-week of self Deltoid muscle exercise, executed in supine, at least three times a day. They were instructed that when they felt better control on their active shoulder movements to gradually recline up the head of the bed and continue with the same simple exercise. They were reviewed at 6 weeks re-assessed and re-taught the same exercise, with a 2kg weight in their hand. At the 12th week they were reassessed using the constant score, and their active range of motion was video recorded again. Results: 90% of the participants expressed a significant improvement in their upper limb function already after 6 weeks of treatment. All components of the Constant score (beside the strength) have improved. 90% reported less pain and found general activities of daily living easier to execute and a diminished level of muscle fatigue. 10% of the patients were able to establish a recording of > 1.26kg on the myometer in 90 degrees of abduction. 10% failed to report any benefit. Discussion and Conclusion: Anterior deltoid strengthening exercises in the supine position for re-education of the anterior deltoid seem to have a significant beneficial effect for restoration of shoulder function and pain relief in the majority of patients with Massive irreparable degenerative rotator cuff tears. Using this simple non-invasive rehabilitation technique helps to re-educate the anterior deltoid to compensate for the absent rotator cuff and restore shoulder function

The indications for use of a glenoid component are: 1.) sufficient degenerative changes on the glenoid to expose the subchondral bone 2.) the glenoid should have sufficient glenoid bone stock to allow for secure and longterm fixation of the component, and 3.) the rotator cuff should be intact or repairable and the humeral head should be centred within the glenoid component. Other factors that secondarily affect the decision to use a glenoid component, include the patient’s age and activity level, which should be such that they are not likely to result in multiple revisions for glenoid wear or loosening. Given these factors most patients with osteoarthritis, the leading indication for prosthetic replacement for arthritis should undergo a total shoulder replacement. Patients with acute proximal humeral fractures, the overall leading indication for prosthetic arthroplasty, should have a hemiarthroplasty. Patients with rotator cuff tear arthropathy or crystalline arthropathy are indicated for hemiarthroplasty due to the massive irreparable cuff tears present in these conditions. Patients with rheumatoid arthritis have variable diseases affecting the rotator cuff and variable degrees of bone loss resulting in the need to individualise the indications for the use of a glenoid to the patient’s pathoanatomy. The reason for use of a glenoid component, when indicated, is the fact that pain relief and function is predictably better when compared to hemiarthroplasty for the same indication and pathoanatomy. Proper insertion of a glenoid component requires wide exposure of the glenoid fossa and bone preparation, which for most general orthopaedic surgeons is difficult and not reproducible. This is, in my opinion, the primary reason that hemiarthroplasty or bipolar arthroplasty is used for treatment of many patients with primary osteoarthritis. Both of these procedures result, on average, in a less favourable outcome than non-constrained total shoulder arthroplasty. Osteoarthritis is characterised by flattening and enlargement of the humeral head and is associated with peripheral osteophyte formation. Loss of articular cartilage results in eburnated bone and on the glenoid side posterior bone loss. Capsular contracture results in loss of passive arcs of motion, particularly anteriorly with loss of external rotation. Posterior subluxation of the humeral head can occur, associated with anterior soft tissue contracture and/or posterior glenoid bone loss. The severity of this pathoanatomy is variable among patients with primary osteoarthritis and each of these factors will have a variable effect on outcome of shoulder arthroplasty as well as the indication for hemiarthroplasty versus total shoulder arthroplasty. In a 2–7 year follow-up multicentre study using the DePuy Global Shoulder in 127 patients, those cases with osteoarthritis without humeral head subluxation, severe glenoid bone loss, or rotator cuff tears had the best results, for pain relief and function, with total shoulder arthroplasty. In patients with severe glenoid bone loss total shoulder has improved function when compared to hemiarthroplasty. This finding supports the data of others that demonstrate less favourable results of hemiarthroplasty for treatment of osteoarthritis in cases with eccentric glenoid wear. Patients with humeral head subluxation have less favourable results regardless of the use of a hemiarthroplasty or total shoulder arthroplasty. The presence of a full thickness reparable rotator cuff tear limited to the supraspinatus tendon does not adversely affect outcome or the ability to use a glenoid component. Patients with less than 10° of external rotation achieve statistically less postoperative forward flexion and external rotation than those patients with greater degrees of preoperative external rotation

The management of patients with massive irreparable rotator cuff tears (RCT) has traditionally proved challenging. This prospective study was undertaken with the aim to assess the overall functional outcome following the use of human dermal allograft in the reconstruction of massive irreparable RCT. 15 patients were included in the study, having a median age of 63 years. All patients underwent open reconstruction of massive irreparable RCT. None of the selected patients had evidence of significant gleno-humeral arthritis. All patients were evaluated pre- and post- operatively by the treating surgeon, and followed up for 12 months. The same physiotherapy protocol was prescribed for all patients. Initial and follow-up assessments were done at regular intervals using the Oxford and quick-DASH scoring systems. A very high patient satisfaction rate, with substantial improvement in pain and function was noted. There was substantial improvement in Oxford shoulder score from a mean of 23.3 to 8.7 (p<0.01), and a similar improvement in mean quick-DASH score from 50.3 to 23.0 (p<0.01). Of the 15 patients, 11 had an improvement of >10 in Oxford score, with these reporting a score of <10 after 12 months. None of the patients had any significant complications because of the surgery, and none had a deterioration in Oxford score from their pre-operative status. We found that Human dermal allograft is a very effective tool in the repair of massive irreparable RCT, with excellent follow-up results after one year

Reverse total shoulder arthroplasty (RTSA) was designed to treat the cuff-deficient shoulder with arthritis and irreparable rotator cuff tears of the supraspinatus and infraspinatus tendons. The results of RTSA in this patient population have been very good and reliable in the majority of cases. However, it has also been reported that patients whose rotator cuff tear involves the supraspinatus, infraspinatus and teres minor and who demonstrate a ‘horn-blower's sign’ do very poorly if a muscle transfer is not performed to improve external rotation in these shoulders in abduction. The loss of the teres minor in these patients results in grave difficulty for the patient attempting to perform their activities of daily living even if they can obtain reasonable good forward flexion. The muscle transfer that is most commonly used for these select patients is a latissmus dorsi tendon transfer in conjunction with RTSA. The purpose of this talk is to review the pathology of this problem and review the technique for its surgical treatment

Aim. To determine the benefit of dissolvable Balloon Arthroplasy in managing patients with massive irreparable rotator cuff tears (RCT). Methods. This is prospective pilot study carried out adhering to the local approval process. Patients having massive cuff tear with pain or functional limitation were seen by consultants and MRI confirmed the diagnosis. The patients were explained of ‘all available’ treatment options and information leaflet about the new procedure balloon arthroplasty, provided. Patients were seen after 4 weeks in a dedicated clinic to find out if they were willing to participate. Patients were seen by a physiotherapist pre and post-operatively at 6 weeks then at 3, 6 and 12months in addition to medical follow-ups, using VAS, Oxford Shoulder, Constant and SF36 scores. All procedures were carried out by consultant shoulder surgeons and where the cuff was reparable or contraindications identified were excluded. Results. Of the 25 recruited 4 were lost for follow up. 17 of the remaining 21 completed 12 month follow up, and the remaining completed their 6 month follow up. Male to female ratio was 2:1 and no surgical complications were noted. Two patients required an inverse shoulder arthroplasty. Improvements were noted in the SF36, VAS and OSS. Conclusion. The balloon arthroplasty seems to offer benefit for a group of patients who are unfit or not keen on major surgery to offer pain relief possibly function. Recommendations cannot be made due to the study but suggest a multicentre study

Management of irreparable rotator cuff tears is challenging and controversial. Surgeons have been utilising biological tissue scaffolding to augment repairs, but there are concerns regarding viability and function. We wished to investigate this viability and clinical outcome in a small group of patients. All procedures were performed by a single surgeon over a three-year period. Inclusion criteria were patients with large cuff tears and failure of non-operative treatment. Exclusion criteria were patients with glenohumeral arthritis and where cuff repair could not be successfully performed. Open rotator cuff repair followed by augmentation with Graft Jacket® Regenerative Tissue Matrix (Wright Medical) was performed in all patients. A structured cuff repair physiotherapy protocol was then followed. Follow-up was at six months and at minimum twenty-four months post-operatively where Constant scores (CS) and Oxford Shoulder scores (OSS) were noted and a repeat ultrasound performed. Fourteen patients underwent the procedure. No patient was lost to follow-up. There were seven males and seven females with a mean age of 63 years (range 31–77). At minimum twenty-four month follow-up, thirteen patients had flexion and abduction above 90 degrees and symmetrical external rotation. Mean CS was 81 (range 70–91) and mean OSS was 46 (range 41–48). Shoulder ultrasound revealed an intact Graft Jacket® in all thirteen patients. The final patient had lower functional movement and lower CS (34) and OSS (25) and ultrasound identified a re-rupture. This study indicates that augmentation of large rotator cuff repairs with biological tissue scaffolding is a viable option and has good functional results

Treatment of massive rotator cuff tears can be challenging. Previous studies with irreparable rotator cuff tears showed good clinical results of tendon healing with the arthroscopic insertion of a protective biodegradable spacer balloon filled with saline solution between the repaired tendon and the acromion [1,2], but so far no scientific evidence has showed how the device alters pressures over the repaired tendon. This biomechanical study investigated the effects of a spacer inserted in the subacromial space on pressures over the repaired rotator cuff tendon in passive motion cycles typical for post-operative rehabilitation routines. Six human cadaveric shoulders were prepared with the humerus cut 15cm below the joint and embedded in a pot, while the scapula fixed at three points on a plate. A rotator cuff tear was simulated and repaired using a suture anchor and a Mason-Allen suture. The specimens were then mounted on a custom-made pneumatic testing rig to induce passive motion cycles of adduction-abduction (90–0°) and flexion-extension (0–40°) with constant glenohumeral and superior loads and tension is exerted on the supraspinatus tendon with weights. A pressure sensor was placed between the supraspinatus tendon and the acromion. After pressure measurements for 15 cycles of each motion type, the InSpace balloon (OrthoSpace, Inc, Israel) was inserted and the specimens tested and pressure measured again for 15 cycles. Statistically significant changes in peak pressures were then measured before and after balloon. Peak pressures were measured near 90 degrees abduction. No statistical differences were observed for internal-external rotation before and after balloon-shaped subacromial spacer was inserted. Mean pressures in abduction-adduction were significantly reduced from 121.7 ± 9.5 MPa to 51.5 ± 1.2 MPa. Peak pressures after repair were 1171.3 ± 99.5 MPa and 1749.6 ± 80.7 MPa in flexion-extension and abduction-adduction motion, respectively, and significantly decreased to 468.7 ± 16.0 MPa and 535.1 ± 27.6 MPa after spacer insertion (p<0.0001). The use of the spacer above the repaired tendon reduced peak pressures and distributed them more widely over the sensor during both abduction-adduction and flexion-extension motions and therefore can reduce the stress on the rotator cuff repair. The InSpace system may reduce the pressure on the repaired tendon, thus potentially protecting the repair. Further studies to investigate this phenomenon are warranted, in particular relating these changes to shoulder kinematics following tear repair and spacer insertion

The February 2023 Shoulder & Elbow Roundup³⁶⁰ looks at: Arthroscopic capsular release or manipulation under anaesthesia for frozen shoulder?; Distal biceps repair through a single incision?; Distal biceps tendon ruptures: diagnostic strategy through physical examination; Postoperative multimodal opioid-sparing protocol vs standard opioid prescribing after knee or shoulder arthroscopy: a randomized clinical trial; Graft healing is more important than graft technique in massive rotator cuff tear; Subscapularis tenotomy versus peel after anatomic shoulder arthroplasty; Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty; Conservative versus operative treatment of acromial and scapular spine fractures following reverse total shoulder arthroplasty.

Aims

The current evidence comparing the two most common approaches for reverse total shoulder arthroplasty (rTSA), the deltopectoral and anterosuperior approach, is limited. This study aims to compare the rate of loosening, instability, and implant survival between the two approaches for rTSA using data from the Dutch National Arthroplasty Registry with a minimum follow-up of five years.

Aims

Orthopaedic surgery requires grafts with sufficient mechanical strength. For this purpose, decellularized tissue is an available option that lacks the complications of autologous tissue. However, it is not widely used in orthopaedic surgeries. This study investigated clinical trials of the use of decellularized tissue grafts in orthopaedic surgery.

Aims

Reverse total shoulder arthroplasty (RTSA) using trabecular metal (TM)-backed glenoid implants has been introduced with the aim to increase implant survival. Only short-term reports on the outcomes of TM-RTSA have been published to date. We aim to present the seven-year survival of TM-backed glenoid implants along with minimum five-year clinical and radiological outcomes.

Massive irreparable rotator cuff tears (MIRCTs) represent a difficult situation especially in painful and pseudoparalytic patients. A new technique, consisting of an arthroscopic implantation of an inflatable biodegradable “balloon”, serving as a temporary subacromial spacer, has been introduced recently for MIRCTs. The purpose of this paper is: 1) to present the efficacy and safety results of patients treated with the balloon; 2) to show that these results are maintained over time, after balloon degradation; 3) to compare these results to published results of other procedures available for MIRCTs. This paper presents the first group of 22 patients (females/males 13/8, one bilateral), treated in a single-surgeon, prospective and on-going series of 97 shoulders operated with the balloon, since September 2010. The mean age is 69.3 (52–86) and the average follow-up 52.5 months. The balloon is inserted arthroscopically and inflated with saline. The procedure is simple with a short operative time (10–20 min). It can also supplement partial repairs, especially of the subscapularis, as well as repairable massive tears with bad tissue quality. The balloon is not used in severe cuff tear arthropathy or complete insufficiency of the external rotators. Final outcome scores, Constant (CS) and UCLA scores are obtained at least three years after complete balloon degradation (which occurs within 12 months), and are also compared to those of other treatments available for MIRCTs. No device related safety issues were observed in this group. Good results, including rapid pain relief and restoration of active motion, which maintained over time, are obtained in 85% of the patients. The CS has improved significantly (average preop/postop: pain 2.9/12.7; ADL 6.8/17.4; ROM 22.8/36.6; strength 3.1/5.6; TOTAL 35.8/72.3; NORMATIVE 42.7/86.4). The UCLA score has also improved significantly (preop/postop: pain 1.9/8.6; function 3.9/8.6; active flexion 3.5/4.5; strength in flexion 2.4/3.4; satisfaction 0/4.5; TOTAL 11.2/29.8). Pseudoparalysis is reversed (average preop/postop flexion 86°/156.8°). The CS and UCLA score for the balloon are superior compared to published results of debridement, biceps tenotomy/tenodesis, partial repair, tuberoplasty and latissimus dorsi transfer. CS (86.4/63.8), CS pain (12.7/11.9) and flexion (156.8/128.0) are also better for the balloon compared to the reverse prosthesis. The balloon is indicated for MIRCTs, as well as reparable massive tears with a high risk of retear. The implantation is a straightforward and short procedure, which has excellent safety profile and positive effect on painful MIRCTs including pseudoparalysis. The balloon provides significant improvement in the CS and UCLA score that persists way beyond its degradation. The balloon patients' shoulder function is superior to the other available treatment options. Additional studies are needed to further confirm the effectiveness of the balloon as a first line treatment for MIRCTs

Reverse total shoulder arthroplasty (RTSA) is an increasingly common treatment for osteoarthritic shoulders with irreparable rotator cuff tears. Although very successful in alleviating pain and restoring some function, there is little objective information relating geometric changes imposed by the reverse shoulder and arm function, particularly the moment generating capacity of the shoulder muscles. Recent modeling studies of reverse shoulders have shown significant variation in deltoid muscle moment arms over a typical range of humeral offset locations in shoulders with RTSA. The goal of this study was to investigate the sensitivity of muscle moment arms as a function of varying the joint center and humeral offset in three representative RTSA subjects that spanned the anatomical range from our previous study cohort. We hypothesized there may exist a more beneficial joint implant placement, measured by muscle moment arms, compared to the actual surgical implant configuration. A 12 degree of freedom, subject-specific model was used to represent the shoulders of three patients with RTSA for whom fluoroscopic measurements of scapular and humeral kinematics during abduction had been obtained. The computer model used subject-specific in vivo abduction kinematics and systematically varied humeral offset locations over 1521 different perturbations from the surgical placement to determine moment arms for the anterior, lateral and posterior aspects of the deltoid muscle. The humeral offset was varied from its surgical position ±4 mm in the anterior/posterior direction, ±12mm in the medial/lateral direction, and −10 mm to 14 mm in the superior/inferior direction. The anterior deltoid moment arm varied up to 20 mm with humeral offset and center of rotation variations, primarily in the medial/lateral and superior/inferior directions. Similarly, the lateral deltoid moment arm demonstrated variations up to 20 mm, primarily with humeral offset changes in the medial/lateral and anterior/posterior directions. The posterior deltoid moment arm varied up to 15mm, primarily in early abduction, and was most sensitive to changes of the humeral offset in the superior/inferior direction. The goal of this study was to assess the sensitivity of the deltoid muscle moment arms as a function of joint configuration for existing RTSA subjects. High variations were found for all three deltoid components. Variation over the entire abduction arc was greatest in the anterior and lateral deltoid, while the posterior deltoid moment arm was mostly sensitive to humeral offset changes early in the abduction arc. Moment arm changes of 15–20 mm represent a significant amount of the total deltoid moment arm. This means there is an opportunity to dramatically change the deltoid moment arms through surgical placement of the joint center of rotation and humeral stem. Computational models of the shoulder may help surgeons optimize subject-specific placement of RTSA implants to provide the best possible muscle function, and assist implant designers to configure devices for the best overall performance

Reverse total shoulder arthroplasty (RTSA) is an increasingly common treatment for osteoarthritic shoulders with irreparable rotator cuff tears. Although very successful in alleviating pain and restoring some function there is little objective information relating geometric changes imposed by the reverse shoulder and the moment generating capacity of the shoulder muscles. Recent modeling studies of reverse shoulders have shown significant variation in deltoid muscle moment arms over varied joint centers for shoulders with RTSA. The goal of this study was to investigate the sensitivity of muscle moment arms as a function of varying the joint center in one representative RTSA subject. We hypothesized there may exist a more beneficial joint implant placement, measured by muscle moment arms, compared to the actual surgical implant placement. A 12 degree of freedom, subject-specific model was used to represent the shoulder of a patient with RTSA for whom fluoroscopic measurements of scapular and humeral kinematics during abduction had been obtained. The computer model used these abduction kinematics and systematically varied joint center locations over 1521 different perturbations from the surgical placement to determine moment arms for the anterior, lateral and posterior aspects of the deltoid muscle. The joint center was varied from its surgical position ±4 mm in the anterior/posterior direction, 0–24 mm in the medial/lateral direction, and −10 mm to 14 mm in the superior/inferior direction. The anterior deltoid moment arm varied up to 16mm with center of rotations variations, primarily in the medial/lateral and superior/inferior directions (Figure 2, Table 1(Figure 1)). Similarly, the lateral deltoid moment arm demonstrated variations up to 13 mm, primarily with joint center changes in the anterior/posterior and superior/inferior directions. The posterior deltoid moment arm varied up to 10mm, primarily in early abduction, and was most sensitive to changes of the joint center in demonstrated a sensitivity of 6 mm corresponding to variations in the superior/inferior directions (Figure 2). The goal of this study was to assess the sensitivity of the deltoid muscle moment arms as a function of joint configuration for an existing RTSA subject. High variations were found for all three deltoid components. Variation over the entire abduction arc was greatest in the anterior and lateral deltoid, while the posterior deltoid moment arm was mostly sensitive to joint center changes early in the abduction arc. Moment arm changes of 10–16mm represent a significant amount of the total deltoid moment arm. This means there is an opportunity to dramatically change the deltoid moments arms through surgical placement of the joint center of rotation. Computational models of the shoulder may help surgeons optimize subject-specific placement of RTSA implants to provide the best possible muscle function, and assist implant designers to configure devices for the best overall performance

The aim of this study is to assess the clinical outcome following latissiumus dorsi transfer for massive irreparable tears of the rotator cuff. Between 1996 and 2002 seven patients with massive irreparable rotator cuff tears were treated by transfer of the latissimus dorsi by a single surgeon. Their mean age at time of surgery was 65 years. Five patients were female, five were primary procedures and two were revisions. Patients were assessed with MRI pre-operatively; the decision to plan a transfer was made clinically. At time of operation all were found to massive irreparable tears of the cuff including Supraspinatus and Infraspinatus, Subscapularis was intact in all cases. Five of the transfers were implanted to a bone trough, one was sutured to a tendon stump, and one was augmented with a Teflon patch. Mean time to follow up was 21 months. All patients were assessed by the lead author or by his Specialist Registrar. Six patients had a good result, one had a poor result this was a revision procedure resulting in deltoid origin detachment. Functional outcome significantly improved post-transfer. Constant score 62.1% vs 36.1% (p< 0.0005, Paired t-test), Pain was also significantly reduced post-transfer, both when active 7.1 vs. 2.2 p (< 0.005) and when at rest 3.7 vs. 1.2 (p< 0.005). Conclusion: These results are compatible with those published for Latissimus Dorsi Transfer. Latissimus Dorsi Transfer can be effective in restoring shoulder function and reducing pain following massive irreparable tears of the rotator cuff

Introduction: The suspension bridge principle relies on a firm fixation of the torn rotator cuff at the anterior and posterior margins of the greater tuberosity leaving a mobile section between the two points. In massive rotator cuff tears which cannot be approximated, a partial repair can be performed using the above principle. The aim of this study is to evaluate the functional and radiological results using the above technique with bio-absorbable anchors. Materials and Methods: This is a prospective study of a consecutive series of 59 patients who were found intraoperatively to have a rotator cuff tear of greater than 5cm. There were 41 men and 18 women with an average age of 68 years (range). The average length of follow up was 16 months (12 to 26 months). Patients were assessed objectively with the Constant score, and subjectively with the Oxford questionnaire. Cuff integrity was evaluated using ultrasound. Results: Using the Constant score, the outcome was excellent in 30(51.5%), fair in 24(40.5%) and poor in 5(8.5%). 55(93%) patients had an improvement in pain whilst all had increased movement. 51(86%) had improved activities of daily living, whilst 43(72.3%) had improvement in recreational activities. Ultrasound demonstrated the repair remained firmly anchored in position in 54 patients (91.5%). Five patients showed complete disruption and represented poor functional outcome. Patient satisfaction was 94.9%. Conclusion: Our results confirm that a water tight repair is not necessary for a good functional outcome for massive irreparable tears. The biodegradable anchors have been shown to be holding the repairs well at medium term follow up. In patients with a massive irreparable rotator cuff tear, the suspension bridge principle is a valuable technique

The goal of this retrospective study was to evaluate the result of this technique proposed as initial treatment (group 1: 17 cases) or after a failure of repairing cuff (group 2: 7 cases). Materials and Methods: Eleven females and thirteen males with an average age of fifty six years were available for this study. Initial rupture was always massive (2 tendons, retracted to the glenoid level), superior and posterior(20 cases) with superior lesion of the subscapularis in 4 cases. An ascension of the humeral head was found in 18 cases. Degree of fatty degeneration evaluated with CT arthrogram was 3.45 for the supra spinatus and 3.25 for the infra spinatus. The latissimus dorsi was harvested with axillary approach and released from the angle of the scapula to be able to cover the humeral head. Coraco acromial arch was preserved. Abduction splint was maintained 6 weeks. Results: The average follow up was 21 months(12/48). For the 24 patients Constant score was improved from 34,6 to 55,6(+21): a significant improvement of forward active elevation from 98° to 153 (+55°) but a little improvement of external rotation from 23 to 33 (+10°). The best results were obtained in group 1: constant score progressed from 34 to 58 (+24) with an increasing of 66° (98 to 164°) of forward active elevation and 13°(22 to 35°) of external rotation. Results of group 2 are less: Constant score progressed from 36 to 51(+15), forward elvevation 33°(96 to 129°) and 3° (27 to 30°) of active external rotation. 2 failures caused by a rupture of the transfer. Painrelief was obtained in 90% but any improvement of strength. Discussion and Conclusion: Ours results indicate that latissimus dorsi transfer improves range of motion, pain, function and patient satisfaction with irreparable rotator cuff tear. We recommend to use it for pseudoparalytic and painfull shoulder, with a persistent acriomo humeral space, after failure of rehabilatation, for young patient. A stable humeral head with a good subscapularis without previous operation are good pronostic factors

Outcomes for a RSP to treat either a previous operated shoulder (revision procedure) was compared to a primary RSP. Twenty primary RSP (6M, 14F) for an irreparable rotator cuff tear (IRCT) with glenohumeral arthritis /anterior superior arch deficiency and 31 revision RSP (10M, 21F) (previous rotator or cuff surgery, hemi or total shoulder arthroplasty) were evaluated at an average of 24 months postoperatively. Mean age at the time of RSP was 72.3 for primaries 67.2 for revisions. Assessment with pre- and postoperatively SF-36, SST, ASES scores, physical exam, satisfaction surveys, and radiographs was performed. Primary RSP improvements /Revision RSP improvements were: 9.4 sf-36 PCS/ 6.3 sf-36 PCS, 1.8 SST/ 1.6 SST,31.8ASES / 17.5ASES (p< 0.05),49.2 elevation/ 14.2 elevation (p< 0.05) and 57.8 external rotation/ 30 external rotation. 71.3% Excellent/good/. 56% Excellent/ good (p< 0.05), 21.4% satisfactory/ 33.3% satisfactory, 7.1% unsatisfactory outcome/ 9.5% unsatisfactory outcome. Complications only occurred in the revisions including component disassociation, glenoid loosening, recurrent instability, and infection. Primary RSP provides predictable improvements in pain and function with minimal complications. Revision RSP has a higher complication rate and improvements in pain and function are less reliable. Conventional shoulder arthroplasty for patients with IRCT with gle-nohumeral arthritis/anterior superior arch deficiency has resulted in adequate pain relief but functional improvement has not been predictable. Thus, the initial operative selection for these patients must consider the effect of a failed reconstructive attempt on patient outcomes

Introduction. Insufficient arthroscopic cuff tear reconstruction leading to massive osteoarthritis and irreparable rotator cuff tears might be salvaged by implantation of an inverted total shoulder prosthesis Delta in the elderly. However, despite the generally high success rate and satisfying clinical results of inverted total shoulder arthroplasty, this treatment option has potential complications. Therefore, the objective of this study was a prospective evaluation of the clinical and radiological outcome after a minimum of 2 years follow-up of patients undergoing inverted shoulder replacement with or without prior rotator cuff repair. Patients and Methods. Sixty-eight shoulders in 66 patients (36 women and 30 men) operated between February 2002 and June 2007 with a mean age of 66 years (ranging from 53 to 84 years) were first assessed preoperatively and then at minimum 2 years follow-up, using the Constant score for pain, Constant Shoulder Score, Oxford Shoulder Score, UCLA Shoulder rating scale, DASH Score, Rowe Score for Instability and Oxford Instability Score. 29 patients (Group A) had undergone previous shoulder arthroscopy for cuff tear reconstruction at a mean of 29 months (range 12 to 48 months) before surgery and 39 patients (Group B) underwent primary implantation of an inverted total shoulder prosthesis Delta. Any complications in both groups were assessed according to Goslings and Gouma. Results. We report statistically significant improvements of all obtained scores at a mean follow-up of 42 months (ranging from 24 to 96 months) in both groups. Significant outcome differences between 29 patients with previous shoulder arthroscopy for cuff tear reconstruction and 39 without previous shoulder arthroscopy were not observed. Eight complications occurred altogether, in terms of a nerve lesion once, loosening of the humeral stem three times, and loosening or fracture of the glenoid component four times. Conclusion. We did not detect any statistically significant impact of previous insufficient shoulder arthroscopy for cuff tear reconstruction on the outcome and survival rate after the implantation of the inverted total shoulder prosthesis Delta. We conclude that reverse total shoulder arthroplasty with the Delta prosthesis is significantly beneficial in terms of less shoulder pain, higher stability and gain of range of motion without this beneficial effect being significantly weakened by previous insufficient shoulder arthroscopy for cuff tear reconstruction. We believe that previous arthroscopic cuff tear reconstruction should therefore be included in the treatment algorithm

INTRODUCTION: In irreparable rotator cuff tear associated with pseudoparalysis, inverse prostheses have shown to be able to restore overhead elevation and strength. If the rotator cuff disease involves the teres minor muscle, pseudoparalysis in external rotation can adversely affect function and functional outcome of inverse arthroplasty. The goal of our study was to evaluate the outcome of inverse total shoulder arthroplasty combined with latissimus dorsi transfer for combined pseudoparalysis in elevation and external rotation. MATERIAL AND METHODS: From 1998 till 2005, we retrospectively analyzed 11 shoulders in 10 patients with at a mean follow up of 20 months. All 11 shoulders had a massive rotator cuff tear with fatty degeneration of the posterosuperior cuff including teres minor exceeding stage 2 according to Goutallier and an average osteoarthritis grade 2 according to Samilson and Prieto Data assessment included pre- and postoperative clinical examination and Constant Score as well as standard radiographs. RESULTS At follow up, subjective shoulder value increased from 27% to 68%, Constant Score improved significantly from 48% to 94%, flexion from 106° to 141°, abduction from 95° to 150° and strength from 0.2 to 4.9 (p< 0.05). Although no gain was seen in active external rotation in adduction, a significant loss of external lag was noted from 47° to 9° (p< 0.05). All patients were able to perform overhead activities with increase in functional use of the arm (p< 0.05). Complication requiring revision included postoperative infection in one and hematoma in another case. CONCLUSION: Irreparable rupture of the posterosuperior rotator cuff involving with pseudoparalysis of elevation and external rotation,, the implantation of an inverse prosthesis combined with latissimus dorsi transfer can increase active range of motion and substantially improve functional external rotation, as opposed to the published results of the inverse prosthesis alone, which do not improve active external rotation

BACKGROUND. Reverse total shoulder arthroplasty (RTSA) provides an alternative to standard total shoulder arthroplasty in the treatment of selected complex shoulder problems including failed shoulder replacements. The purpose of this report is to present outcome of RTSA using Comprehensive Reverse System (CRS) as either primary or revision treatment choice. PATIENTS AND MATERIALS. Between September 2010 and April 2012, 54 patients (36 females, 18 males) with the mean age of 68.4 (±10) underwent RTSA-CRS. In 27 patients RTSA-CRS was performed as a revision due to failed previous arthroplasty. Primary underlying conditions included AVN (2), massive irreparable rotator cuff tear (2), primary osteoarthritis (7), post-traumatic osteoarthritis (2), rheumatoid arthritis (6), and rotator cuff arthropathy (8). It was not possible to complete the operation in 6 patients (4 revisions group 2 AVN cases) due to substantial glenoid erosion. Preoperative CT scan was performed in 50% of patients to assess the bony stock of the glenoid. In some patients ultrasound and MRI were performed to acquire additional information. A total of 46 patients were followed-up by means of antroposterior and axial plain X-rays, pain and satisfaction level (VAS/0–10), stiffness, Constant Score, Oxford Shoulder Score, SF-12 (Physical and mental Subscales), and range of movement for a mean duration of 6.5 months (±4.2). RESULTS. The table presents the pre- and postoperative outcome variables for both primary and revision RTSA-CRS groups. The majority of outcome measures indicated a considerable improvement in both groups during the short term follow-up. Significant correlations were noted in-between some key outcome variables. However; due to the short period of follow-up and continuity of collecting data, we intend to produce a more realistic picture of the results s and outcome of the RTSA-CRS in coming years. COMPLICATIONS. There was no vascular complication. Disassociation of glenosphere from the base-plate happened in one patient 8 weeks post-op due to technical mistake, this was repaired later with a satisfactory outcome. One case had enormous hematoma formation 72 hours post-op due to anticoagulants administration leading to second stage evacuation and increased stiffness of shoulder. One patient sustained deltoid partial rupture due to recurrent falls and managed by conservatively. Another patient sustained a type C periprosthetic fracture and was later revised to custom-made stem prosthesis. CONCLUSION. The results of this short-term report indicate a satisfactory and acceptable outcome for RTSA-CRS as reflected in the assessment tools in both primary and revision cases, however with superior results in the primary group. Long-term follow-up is essential to have a more rational assessment of the clinical outcome as well as associated complications