Aims. This study compared patients who underwent arthroscopic repair of large to massive rotator cuff tears (LMRCTs) with isolated incomplete repair of the tear and patients with incomplete repair with biceps tendon augmentation. We aimed to evaluate the additional benefit on clinical outcomes and the capacity to lower the re-tear rate. Methods. We retrospectively reviewed 1,115 patients who underwent arthroscopic rotator cuff repair for full-thickness tears between October 2011 and May 2019. From this series, we identified 77 patients (28 male, 49 female) with a mean age of 64.1 years (50 to 80). Patients were classified into groups A (n = 47 incomplete) and B (n = 30 with biceps augmentation) according to the nature of their reconstruction. Clinical scores were checked preoperatively and at six months, one year, and two years postoperatively. In preoperative MRI, we measured the tear size, the degree of fatty infiltration, and muscle volume ratio of the supraspinatus. In postoperative MRI, the integrity of the repaired rotator cuff tendon was assessed using the Sugaya classification. Tendon thickness at the footprint was evaluated on T2-weighted oblique coronal view. Results. There were no significant differences in the initial preoperative demographic characteristics. In both groups, there were significant improvements in postoperative clinical scores (p < 0.001). However, most clinical outcomes, including range of motion measurements (forward elevation, external rotation, internal rotation, and abduction), showed no differences between the pre- and postoperative values. Comparing the postoperative outcomes of both groups, no further improvement from biceps augmentation was found. Group B, although not reaching statistical significance, had more re-tears than group A (30% vs 15%; p = 0.117). Conclusion. In LMRCTs, biceps augmentation provided no significant improvement of an incomplete repair. Therefore, biceps augmentation is not recommended in the treatment of LMRCTs. Cite this article: Bone Joint J 2022;104-B(11):1234–1241

Aims. The aim of this study is to provide a detailed description of cases combining bridging patch repair with artificial ligament “internal brace” reinforcement to treat irreparable massive rotator cuff tears, and report the preliminary results. Methods. This is a retrospective review of patients with irreparable massive rotator cuff tears undergoing fascia lata autograft bridging repair with artificial ligament “internal brace” reinforcement technique between January 2017 and May 2018. Inclusion criteria were: patients treated arthroscopically for an incompletely reparable massive rotator cuff tear (dimension > 5 cm or two tendons fully torn), stage 0 to 4 supraspinatus fatty degeneration on MRI according to the Goutallier grading system, and an intact or reparable infraspinatus and/or subscapularis tendon of radiological classification Hamada 0 to 4. The surgical technique comprised two components: first, superior capsular reconstruction using an artificial ligament as an “internal brace” protective device for a fascia lata patch. The second was fascia lata autograft bridging repair for the torn supraspinatus. In all, 26 patients with a mean age 63.4 years (SD 6.2) were included. Results. All patients underwent more than two years of follow-up (mean 33.5 months (24 to 45)). All clinical scores were also improved at two-year follow-up (mean visual analogue scale 0.7 (SD 0.5) vs 6.1 (SD 1.2); p < 0.001; mean American Shoulder and Elbow Surgeons score 93.5 (SD 5.3) vs 42.5 (SD 10.8); p < 0.001; mean University of California, Los Angeles score, 31.7 (SD 3.7) vs 12.0 (SD 3.1); p < 0.001; and mean Constant-Murley score 88.7 (SD 3.5) vs 43.3 (SD 10.9); p < 0.001), and 24 of 26 fascia lata grafts were fully healed on MRI (92%). One patient had haematoma formation at the harvesting side of the fascia lata at two days postoperatively. Conclusion. The fascia lata autograft bridging repair combined with artificial ligament internal brace reinforcement technique achieved good functional outcomes, with a high rate of graft healing at two-year follow-up. Although the short-term results are promising, further studies with a greater number of patients would provide clearer results. Cite this article: Bone Joint J 2021;103-B(10):1619–1626

The February 2023 Shoulder & Elbow Roundup. 360. 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

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

Aims. Our aim was to describe the atypical pattern of increased fatty degeneration in the infraspinatus muscle compared with the supraspinatus in patients with a massive rotator cuff tear. We also wished to describe the nerve conduction and electromyography findings in these patients. Patients and Methods. A cohort of patients undergoing surgery for a massive rotator cuff tear was identified and their clinical records obtained. Their MRI images were reviewed to ascertain the degree of retraction of the torn infraspinatus and supraspinatus muscles, and the degree of fatty degeneration in both muscles was recorded. Nerve conduction studies were also performed in those patients who showed more degeneration in the infraspinatus than in the supraspinatus. Results. Out of a total of 396 patients who underwent surgery for a massive rotator cuff tear between 2006 and 2015, 35 who had more severe fatty degeneration in the infraspinatus than in the supraspinatus were identified. There were 13 men and 22 women. Their mean age was 67.2 years (56 to 81). A total of 20 (57%) had grade 4 fatty degeneration as classified by Fuchs et al, in the infraspinatus. Patte grade 3 muscle retraction was seen in 25 patients (71%). In all, eight patients (23%) had abnormal nerve conduction studies. The mean retraction of the infraspinatus was 3.6 cm (2.1 to 4.8) in patients with more severe fatty degeneration in the infraspinatus, versus 3.0 cm (1.7 to 5.5) in those with more severe degeneration in the supraspinatus (p = 0.003). The retraction ratios were 0.98 (0.61 to 1.57) and 0.77 (0.38 to 1.92), respectively (p < 0.001). Conclusion. Fatty degeneration affecting the infraspinatus more than the supraspinatus may be, in the context of a massive rotator cuff tear, due to entrapment of the suprascapular nerve at the spinoglenoid notch. Cite this article: Bone Joint J 2016;98-B:1505–9

Large and massive rotator cuff tears can cause persistent pain and significant disability. These tears are often chronic with substantial degeneration of the involved tendons. Surgical treatment is challenging and the functional outcome after repair less predictable then for smaller tears. The aim of this study was to determine the functional outcome and rate of re-rupture after mini-open repair of symptomatic large and massive rotator cuff tears using a modified two-row technique. Twenty-four patients, who were operated on under the care of a single surgeon between 2003 and 2006, were included in this study. Patients were assessed prospectively before and at a mean of 27 months after surgery using Constant Score and Oxford Shoulder Score. This assessment was carried out by an independent physiotherapist specialising in shoulder rehabilitation. At follow-up an ultrasound was carried out by a musculoskeletal radiographer to determine the integrity of the rotator cuff repair. Patient satisfaction was assessed using a simple questionnaire. The mean Constant Score improved significantly from 36 preoperatively to 68 postoperatively (p< 0.0001), the mean Oxford Shoulder Score from 39 to 20 (p< 0.0001). Four patients (16.7%) had a re-rupture diagnosed by ultrasound. 87.5% of patients were satisfied with the outcome of their surgery. Tear size and repair integrity did not significantly influence functional outcome. 87.5% of patients were satisfied or very satisfied with the outcome of their surgery. This study shows that the two-row repair of large and massive rotator cuff tears using a mini-open approach is an effective method of repair with a comparatively low re-rupture rate. It significantly improves the functional outcome and leads to a very high patient satisfaction. We conclude that these results justify repair of large to massive rotator cuff tears when possible, irrespective of chronicity of symptoms

Summary Statement. In this study, massive rotator cuff tears were treated using an absorbable collagen-based patch or a non-absorbable synthetic patch. Results demonstrated the efficacy of the use of the synthetic prolene patch especially for elderly patients. Introduction. The treatment of massive rotator cuff tears presents a challenging problem in shoulder surgery. Traditional repair techniques are associated with high rupture rates due to excessive tension on the repair and the presence of degenerated tendon tissue. These factors have led to attempts to reconstruct the rotator cuff with grafts, using synthetic materials or biologic tissues. The purpose of this study was to compare the efficacy of the use of pericardium patch with the use of prolene patch in the repair of extensive rotator cuff tears. Materials & Methods. A retrospective series of 180 patients, 115 men and 65 women with a mean age of 66.8 years treated for a massive rotator cuff tear from 1997 to 2008 is reported. The inclusion criteria were: patients symptomatic with pain, deficit of elevation, not responsive to the physiotherapy, tear size (massive: 2 or more tendons), minimum follow-up of 2 years since surgery, active and motivated patients. Patients were divided into three groups according to the type of treatment received: group 1 was treated with Pericardium patch, group 2 with Prolene patch, group 3 with simple suture. All groups were homogeneous. Plain radiographs, ultrasound and MRI were performed preoperatively and at 3 years. Patients were clinically evaluated using the UCLA score before surgery and at 2 months and 3 years after surgery (mean follow-up 2, 6 years). Pain was assessed by use of VAS scale, strength by the use of dynamometer. The surgical procedure (mini-open technique) was similar in all groups. Statistical analysis was conducted by one-way ANOVA between groups of treatment with Dunnett's C post-hoc correction for multiple comparisons. P-values of 0.05 or less were considered as statistically significant. Results. After 2 months the mean VAS was 6.85±1.11, 6.45±1.01, 4.9±0.9 while the mean UCLA was 11.28±1.43, 13.35±14.21, 20.85±12.77, respectively for Control, Collagen and Prolene group. After 36 months the mean VAS was 3.7±1.01, 4.05±0.98, 3.23±1.07, while the mean UCLA was 14.73±1.96, 14.86±2.08, 24.6±3.3 respectively for Control, Collagen and Prolene group. In addition, after 36 months elevation on the scapular plane was 140.75°±10.48, 141.58°±11.87, 174.75°±8.1 and abduction strength was 8.57kg±0.63, 8.82kg±0.7, 13.61kg±0.84, respectively for Control, Collagen and Prolene group. Retear rate after 12 months was 40% (24/60) for Control group, 48.33% (29/60) for Collagen group, 15% (9/60) for Prolene group. Conclusion. The use of Prolene patch as an augmentation graft in the treatment of massive rotator cuff tears is safe and, in most patients, can give a significant pain relief and improvement of range of motion and strength with few complications

Introduction: In many cases of massive rotator cuff tears, especially in cases of revision repairs the shoulder surgeon is facing a technical and biological challenge. The loss of collagenous material in the tendon, coupled with poor quality of the remaining rotator cuff, makes obtaining a mechanically strong repair difficult. Primary closure of such defects may result in excessive tissue tension, which may further increase the chance of failure. Purpose: The objective of this study is to determine the feasibility of using xenogeneic small intestine submucosa (SIS) as a biomaterial to reinforce repair of massive rotator cuff tears. Clinical Material and Methods: Nine patients ranging in age from 52 to 74 with massive rotator cuff tears were selected for the study. Selection of these patients was based upon the quality of remaining rotator cuff tendon tissue at the time of the repair. Seven cases after failed repair of massive rotator cuff tear and two cases of long standing neglected rotator cuff tears in patients with weight bearing shoulders (bilateral below the knees amputation and incomplete paraplegia after anterior poliomyelitis) were selected for this study. In all patients first the tear was repaired by well-known techniques: tendon to tendon, tendon to bone through bone tunnels or using suture anchors. After the repair was accomplished, the poor quality tissue obtained was reinforced by a patch of Restore Orthobiologic Soft Tissue Implant (DePuy, Johnson & Johnson). The Restore Implant is a xenograft obtained of ten layers of porcine small intestine submucosa, it is biocompatible, infection resistant, possess predictable mechanical properties, and, perhaps most significantly, induce a host connective and epithelial tissue response that results in regeneration of specialized connective tissues. Results: Follow-up ranging between 6 to 22 month excellent and good results were observed in eight cases (88%), whereas in the patient aged 74, the cuff repair failed again (after two previous failures). In the eight successful cases an almost normal painfree active range of movements was observed three month after surgery. Conclusions: The results confirm the usefulness of the SIS graft material in the patients having questionable quality cuff tissue remaining after repair. Use of the Restore soft tissue implant could possibly be utilized to strengthen the repair, as well as the inside ingrowth of the tendon, leading to a successful repair of the rotator cuff

Aim: The aim of our study was to review the massive rotator cuff tears that were repaired arthroscopically and evaluate the clinical results in respect to repair integrity as well as the effect on the progression of osteoarthritis. Materials and Methods: We reviewed 56 (39 male,17 female) consecutive patients who underwent arthroscopic repair of their massive rotator cuff tears using biodegradable anchors by the senior author. The technique relies on the suspension bridge principal as described by S.Burkhart (1997). The mean age was 68.2 years (30–86) with most patients between 75 and 85 years. The mean follow up was 31months (24–41). Objective evaluation was done using the Constant score and subjective with the Oxford score. Osteoarthritis was investigated with radiographs and repair integrity with ultrasound. SPSS 16 for Windows was used for the statistical analysis of out results. Results: 93% of the patients had good (11%) or excellent results according to the Oxford score and 91% had Constant score over 75. The improvement in the scores was significant statistically in all parameters (p=0.000, p for strength=0.001). Thirteen patients had postoperative OA, but this was not correlated with the results or the improvement and 11/13 had excellent Oxford scores and Constant scores over75. Seventeen patients had a re-tear which was not correlated with the results or the improvement and 15/17 had excellent Oxford scores and Constant scores over 75. Seven patients had both osteoarthritis and retear but again improvement and results were not affected. Conclusion: Arthroscopic repair of massive rotator cuff tears has excellent clinical results regardless of the development of osteoarthritis or the repair integrity and should be the first line of treatment

The shoulder girdle is an extremely mobile joint. Rotator cuff tears alter the existing equilibrium between bony structures and muscles. The “subacromial impingement syndrome” resulting from this unbalance leads to an extension of the rotator cuff lesion. Many authors have postulated a “mechanism of compensation”, but its existence still requires evidence. According to this model, the longitudinal muscles of the shoulder and the undamaged muscles of the rotator cuff would be able to functionally compensate, supersede the function of rotator cuff, and reduce symptoms. The aim of this study was to evaluate muscular activation of the medium fibers of deltoid, the superior fibers of pectoralis major, the latissimus dorsi and the infraspinatus by a superficial electromyographic study (EMG) and the analysis of kinematics in patients with a massive rotator cuff tear. We evaluated 30 subjects: 15 had pauci-symptomatic massive rotator cuff tear (modest pain and preserved movement), and 15 were healthy controls. Paired t-test showed significant different activations (p< 0.05) of these 4 muscles between the pathological joint and the healthy one in the same patient. The unpaired t-test, after comparing the mean EMG values of the 4 muscles, produced a significant difference (p< 0.05) between the experimental group and control group. This study showed that a mechanism of muscular compensation is activated in patients suffering from rotator cuff tear, involving the deltoid and the infra-spinatus muscle, as already presented in literature, but also demonstrated the activation of 2 other muscles: the latissimus dorsi and the pectoralis major. It is, therefore, probable that, in these patients, these muscles, which would not normally pull the head of the humerus downwards, adapt in order to compensate for the pathological situation. We believe that these data are valuable in the surgical and rehabilitation planning in patients with a massive rotator cuff tear

Aim. To assess clinical outcome of massive rotator cuff tear repair using triceps myotendinous flap. Method. This is a prospective cohort of 43 patients (24 male, 19 female) with average age of 62 years. The primary indication of surgery was pain. Patients with massive rotator cuff tear involving supraspinatus and infraspinatus, showing retraction and fatty infiltration in MRI were selected. Few (8/43) were with failed surgical treatment and rest had conservative treatment failed. They underwent rotator cuff repair during Feb 1999 to Jan 2004. The long head of the triceps was detached from the olecranon, rotated 180 degrees from its pivot point with its major vascular pedicle under the deltoid and acromion through the posterior capsule and attached to the greater tuberosity and any remnant of remaining cuff. All patients were assessed pre-operatively, at 3, 6 and 12 months post-operatively clinically and also using UCLA pain and functional score for shoulder. Shoulder range of motion was assessed before and after the surgery. 24 patients had minimum of 1 year and 19 had 2 year minimum follow-up. Results. The mean total UCLA score of 9.7 pre-operatively improved to 27.8 (p<0.0001) following the operation. The mean pre-operative UCLA pain score 2.2 improved to 7.8 post-operatively (p<0.001). The UCLA functional score improved from a pre-operative average of 3.4 to 8.2 (p<0.0001) following the operation. There was significant improvement in forward elevation, external and internal rotation but not abduction. There was no weakness in elbow extension. Complications: 3 superficial infections, 1 ulnar neuritis (resolved in 6 weeks), 1 olecranon bursitis (resolved in 3 months). Conclusion. Long head triceps tendon transfer is an effective technique to alleviate pain and improve functions in patients with massive rotator cuff tear, specially in difficult group of patients with limited options

The October 2012 Shoulder & Elbow Roundup. 360. looks at: fast-absorbing suture anchors for use in shoulder labral tears; double-row rotator cuff repair; degenerate massive rotator cuff tears addressed with partial repair; open and arthroscopic stabilisation of Bankart lesions; predicting the risk of revision humeral head replacement; arthroscopic treatment for frozen shoulder; and long-term follow-up of the Bristow-Latarjet procedure

The aim is to evaluate the effectiveness of pericardium patch as a tendon augmentation graft in the repair of massive rotator cuff tear. This is prospective study analysis of a consecutive series of 60 patients who underwent open repair of a massive rotator cuff tear with patch between 1999 and 2007. The inclusion criteria were: symptomatic with pain, deficit of elevation, not responsive to the physiotherapy, tear size (massive: 2 or more tendons), minimum follow-up of 2 years since surgery, active and motivated patients. All were assessed preoperatively with plain radiographs (anteroposterior and axillary views), ultrasound and NMR of the shoulder. The study group consistent of 60 patients (39 men and 21 women) with the mean age of was 66 years (range, 46–81). The mean duration of symptoms before repair was 18 months (range 3–48). Patients were assessed with UCLA score, visual analog scale (Vas scale) and ultrasound preoperatively, at 1 year, and at 3 years. The change in UCLA scores, Vas scale were analyzed with the paired Student's test, assuming a normal distribution of the total score. Satisfactory results were achieved in 49 patients: mean preoperative UCLA score improved from 9.3 to 16.9 at final follow-up. For pain, the mean preoperative value of Vas scale was 9,1, postoperative mean value was 4.9. Range of motion and abduction power improved not significantly after surgery, although patients satisfaction levels were high. Imaging studies identified intact patch in 15 patients and patch detachment in 45. No adverse side effects (infection, rejection, allergy) were reported during the study period. The results of our study suggest that patients (appropriately selected) with a massive full-thickness rotator cuff tear can be expected to have a pain relief after repair, but not a significantly improved of functional outcome

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

Aims. Acromial fractures following reverse shoulder arthroplasty (RSA) have a wide range of incidences in reported case series. This study evaluates their incidence following RSA by systematically reviewing the current literature. Materials and Methods. A systematic review using the search terms “reverse shoulder”, “reverse total shoulder”, or “inverted shoulder” was performed using PubMed, Web of Science, and Cochrane databases between 1 January 2010 and 31 March 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Studies were included if they reported on RSA outcomes and the incidence rate of acromial and/or scapular spine fractures. The rate of these fractures was evaluated for primary RSA, revision RSA, RSA indications, and RSA implant design. Results. The review included 90 articles out of 686 identified after exclusions. The incidence rate of acromial and/or scapular spine fractures was 2.8% (253/9048 RSAs). The fracture rate was similar for primary and revision RSA (2.8% vs 2.1%; p = 0.4). Acromial fractures were most common after RSA for inflammatory arthritis (10.9%) and massive rotator cuff tears (3.8%). The incidence was lowest in RSA for post-traumatic arthritis (2.1%) and acute proximal humerus fractures (0%). Lateralized glenosphere design had a significantly higher rate of acromial fractures compared with medial glenosphere designs. Conclusion. Based on current English literature, acromial and/or scapular spine fractures occur at a rate of 2.8% after RSA. The incidence is slightly more common after primary compared with revision arthroplasty. Also, higher rates of acromial fractures are reported in RSA performed for inflammatory arthritis and in the lateralized glenoid design. Cite this article: Bone Joint J 2019;101-B:627–634

Reverse shoulder arthroplasty (RSA) was released into the United States market in 2004 for the indication of Rotator Cuff Tear Arthropathy. Since that time the indications have widened and now include massive rotator cuff tears that are not deemed to be surgically repairable. This diagnosis includes patients that are considered young in terms of shoulder replacement surgery. These patients do not have the radiographic changes of arthropathy, but most have undergone multiple surgical procedures in the past to attempt to repair the rotator cuff deficiency. These younger patients have a different post-op expectation than the patient with advanced arthropathy over the age of 70. The complication rate seen in this younger patient population is higher than seen in the older population undergoing RSA. The post-operative survey for satisfaction is also considerably lower in the younger population group. RSA for massive rotator cuff tears in a younger population under the age of 65 years gives a lower patient satisfaction result and a higher complication rate than age-matched patients older than 65 years. Although this is still the best procedure available for this difficult diagnosis, patients younger than 65 years should be consulted as to what their expectations are post-operatively. Pain relief is still the main reason to undergo an RSA

Introduction. The pathophysiology of high failure rates following rotator cuff tendon repairs, particularly massive tears, is not fully understood. Collagen structural changes have been shown to alter tendon thermal and mechanical properties. Thermal changes in small biopsies, detected by differential scanning calorimetry (DSC) can help to quantify collagen structural differences in torn rotator cuff tendons. This study aimed to form a quantitative rather than qualitative assessment, of whether differences in collagen structure and integrity existed between small biopsies of normal, small and massive rotator cuff tears using DSC. Methods. Thermal properties were measured for 27 human biopsies taken intra-operatively from normal, small, and massive rotator cuff tendon tears. 3 samples were taken from each patient and subjected to a modulated temperature ramp between 20–80°C at a rate of 2°C per minute with 0.318°C amplitude. The melting temperature (TM) is proposed to represent amide-amide hydrogen bond breakage and resulting protein backbone mobility. Denaturing temperature (TD) reportedly corresponds to the temperature at which the proteins fall out of solution. Denaturation enthalpy (H) should correlate with the amount of triple helical structure. Based upon a pre-study power calculation, this study had 90% power to detect a 10% difference in melting and denaturation temperature between groups with alpha=0.05. 1 specimen per patients was also frozen and cryosectioned and polarised light microscopy was used for quantitative validation. The effect of tear size on heat related parameters were performed using a one-way ANOVA test. A student's unpaired t-test was used to search for differences between individual groups (small tears, massive tears and normal tendons). Results. Small and massive rotator cuff tears had significantly higher melting temperature (TM), and denaturation enthalpy (H) compared to controls. The denaturing temperature (TD) was higher in the massive tears only compared to normal tears. No difference was detected between small and massive tears. Histology of massive tendon tears confirmed greater collagen structural disruption compared to small tears and controls. Conclusion. These novel findings suggest greater quantifiable collagen structural disruption in rotator cuff tears, compared to controls. A decrease in important thermal properties of torn tendons suggests that the material is intrinsically less stable. It is likely that torn tendons cannot withstand changes in temperature or stress as well as a perfect material could, particularly for massive tears which are more amenable to denaturation. This study offers insight into possible mechanisms for, or adaptation to, failure in tears and reduced strength

After establishing anatomical feasibility, functional reconstruction to replace the anterolateral part of the deltoid was performed in 20 consecutive patients with irreversible deltoid paralysis using the sternoclavicular portion of the pectoralis major muscle. The indication for reconstruction was deltoid deficiency combined with massive rotator cuff tear in 11 patients, brachial plexus palsy in seven, and an isolated axillary nerve lesion in two. All patients were followed clinically and radiologically for a mean of 70 months (24 to 125). The mean gender-adjusted Constant score increased from 28% (15% to 54%) to 51% (19% to 83%). Forward elevation improved by a mean of 37°, abduction by 30° and external rotation by 9°. The pectoralis inverse plasty may be used as a salvage procedure in irreversible deltoid deficiency, providing subjectively satisfying results. Active forward elevation and abduction can be significantly improved

BACKGROUND:. Few studies have evaluated at a medium-term follow-up the use of semiconstrained reverse shoulder arthroplasty (RSA) for primary glenohumeral osteoarthritis, massive rotator cuff tear, or cuff tear arthropathy excluding any other shoulder disease. Moreover, data on patients' quality of life after this surgery are lacking. METHODS:. In this prospective cohort study, 80 patients were evaluated after an RSA for either primary osteoarthritis, massive rotator cuff tear, or cuff tear arthropathy with the Constant-Murley score (CMS), ROM, and Short Form Health Survey (SF-36). A radiologic assessment was performed pre- and postoperatively. RESULTS:. At a mean 5-year follow-up, the cumulative survival rate was 97.3% and significant improvements in the CMS and ROM were observed when compared with the baseline values. The CMS was 93.2% of the sex- and age-matched normal values. The postoperative SF-36 scores showed no significant differences compared with normative data. Younger patients and subjects with worse preoperative conditions achieved the greatest benefit after RSA. A 70% scapular notching rate was noted and the length of follow-up was found to be associated with the severity of scapular notching. CONCLUSIONS:. This study introduces new predictors for surgical outcomes, and it shows that patients who had undergone RSA a mean of 5 years earlier exhibit similar functionality and health-related quality of life with respect to healthy controls

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