Chronic Pseudoparalysis Needs to Be Distinguished From Pseudoparesis: A Structural and Biomechanical Analysis

2020 ◽  
pp. 036354652096985
Author(s):  
Lukas Ernstbrunner ◽  
Rany El Nashar ◽  
Philippe Favre ◽  
Samy Bouaicha ◽  
Karl Wieser ◽  
...  
Keyword(s):  
Rotator Cuff ◽  
Fatty Infiltration ◽  
Biomechanical Model ◽  
Biomechanical Analysis ◽  
Neurological Deficits ◽  
Rotator Cuff Tears ◽  
Subscapularis Tendon ◽  
Level Of Evidence ◽  
Radiographic Measurements ◽  
Scapular Plane

Background: Chronic pseudoparalysis is generally defined as the inability to actively elevate the arm above 90° with free passive range of motion and no neurological deficits. It has been suggested that this arbitrary cutoff needs to be refined. Purpose: To analyze whether there are structural and biomechanical differences in patients with chronic pseudoparalysis and those with chronic pseudoparesis. Study Design: Case-control study; Level of evidence, 3. Methods: In this retrospective study, 50 patients with chronic massive rotator cuff tears (mRCTs; ≥2 tendons) and free passive and active scapular plane abduction <90° were divided into 2 groups: pseudoparalysis group (n = 24; active scapular plane abduction, <45°) and pseudoparesis group (n = 26; active scapular plane abduction, >45° and <90°). Radiographic measurements included the critical shoulder angle, acromiohumeral distance, posterior acromial tilt, anterior and posterior acromial coverages, and posterior acromial height on outlet views. Measurements on magnetic resonance imaging (MRI) included fatty infiltration of the rotator cuff muscles, anterior (subscapularis) and posterior (infraspinatus/teres minor) tear extensions, and global (anterior + posterior) tear extension in the parasagittal plane. A published musculoskeletal model was used to simulate the effect of different mRCTs on the muscle force required for scapular plane abduction. Results: Plain radiographs revealed no differences between patients with chronic pseudoparalysis and those with pseudoparesis. MRI assessment showed significant differences between patients with chronic pseudoparalysis and those with pseudoparesis with respect to fatty infiltration of the subscapularis (2.9 vs 1.6; P < .001) and infraspinatus (3.6 vs 3.0; P < .001) muscles, and anterior (−23° vs 4°; P < .001), posterior (−23° vs −14°; P = .034), and global rotator cuff (225° vs 190°; P < .001) tear extensions. The anterior tear extension in patients with chronic pseudoparalysis always involved more than 50% of the subscapularis, which was associated with an odds ratio of 5 for inability to actively abduct more than 45°. The biomechanical model was unable to find a combination of muscles that could balance the arm in space when the tear extended beyond the supraspinatus and the cranial subscapularis. Conclusion: This study confirms that chronic pseudoparalysis and pseudoparesis are associated with different structural lesions. In the setting of a chronic mRCT, involvement of more than 50% of the subscapularis tendon with fatty infiltration of stage 3 is associated with pseudoparalysis of active scapular plane abduction <45°. The key function of the subscapularis was confirmed in the biomechanical model.

scholarly journals Augmented latissimus dorsi transfer: initial results in patients with massive irreparable posterosuperior rotator cuff tears

2018 ◽  
Vol 11 (1_suppl) ◽  
pp. 59-67 ◽  
Author(s):  
Claudia C. Sidler-Maier ◽  
Jennifer A. Mutch ◽  
Martin Sidler ◽  
Dimitra Leivadiotou ◽  
Jubin B. Payandeh ◽  
...  
Keyword(s):  
Rotator Cuff ◽  
Rotator Cuff Repair ◽  
Latissimus Dorsi ◽  
Negative Impact ◽  
Case Series ◽  
Rotator Cuff Tears ◽  
Subscapularis Tendon ◽  
Level Of Evidence ◽  
Latissimus Dorsi Transfer ◽  
Cuff Repair

Background The surgical treatment of irreparable massive rotator cuff tears is challenging. The purpose of the present study was to report the initial outcomes after a modified latissimus dorsi transfer (LDT) augmented by acellular dermal allograft (ADA). Methods This retrospective study includes 24 patients managed with LDT using ADA augmentation as a bursal-sided onlay between March 2009 and December 2015. Results All patients were men with a mean age of 57 years (range 48 years to 70 years). Seven patients had a previously failed rotator cuff repair and ten patients presented with a deficient subscapularis tendon. At last follow-up (mean 27 months), there was a significant improvement in active forward flexion (mean increase 31°; p = 0.016), and abduction by 25° ( p = 0.059). The acromiohumeral distance remained stable and the failure rate was low (4%). Neither a history of previous rotator cuff surgery, nor the presence of a subscapularis tear had a negative impact on functional outcome. Conclusions In our cohort of patients, LDT augmented with ADA was a reasonable option for patients with previously failed rotator cuff repair, as well as in the subgroup of patients with a deficient subscapularis tendon. Level of evidence Level IV: Therapeutic study (case series)

scholarly journals Pseudoparalysis and pseudoparesis of the shoulder

2021 ◽  
Author(s):  
Roland Stefan Camenzind ◽  
Laurent Lafosse ◽  
Thibault Lafosse
Keyword(s):  
Rotator Cuff ◽  
Range Of Motion ◽  
Rotator Cuff Tear ◽  
Rotator Cuff Tears ◽  
Subscapularis Tendon ◽  
Cuff Tear ◽  
Active Range Of Motion ◽  
Definition Of ◽  
Shoulder Elevation ◽  
Scapular Plane

Abstract Background Clinical presentation of massive rotator cuff tears range from pain to loss of active range of motion. Pseudoparalysis and pseudoparesis are defined inconsistently in the literature, but both include limited active with maintained passive range of motion. Objective This article aims to provide a consistent definition of pseudoparalysis and pseudoparesis of the shoulder and show structural and biomechanical differences between these two types of rotator cuff tear with their implications for treatment. Methods A literature review including key and basic papers discussing clinical symptoms, biomechanical differences, and their impact on therapeutic options for pseudoparalysis and pseudoparesis was performed. Results Biomechanically, structural differences between pseudoparalysis (active scapular plane abduction <45°) and pseudoparesis (active scapular plane abduction 45–90°) exist. For massive posterosuperior rotator cuff tears, the integrity of the inferior subscapularis tendon is the most predictive factor for active humeral elevation. Patients with pseudoparalysis have a higher grade of subscapularis tendon involvement (>50%) and fatty infiltration of the subscapularis muscle. Treatment options depend on the acuteness and repairability of the tear. Rotator cuff repair can reliably reverse the active loss of active range of motion in acute and reparable rotator cuff tears. In chronic and irreparable cases reverse total shoulder arthroplasty is the most reliable treatment option in elderly patients. Conclusion The most concise definition of pseudoparalysis is a massive rotator cuff tear that leads to limited active (<45° shoulder elevation) with free passive range of motion in the absence of neurologic deficits as the reason for loss of active elevation. The integrity of the subscapularis tendon is the most important difference between a pseudoparalytic and pseudoparetic (active shoulder elevation 45–90°) shoulder. Decision-making for surgical options depends more on reparability of the tendon tear and patient age than on differentiation between pseudoparalysis and pseudoparesis.

scholarly journals Association Between Rotator Cuff Tears and Superior Migration of the Humeral Head: An MRI-Based Anatomic Study

2021 ◽  
Vol 9 (6) ◽  
pp. 232596712110098
Author(s):  
Matthew Y. Siow ◽  
Brendon C. Mitchell ◽  
Michael Hachadorian ◽  
Wilbur Wang ◽  
Tracey Bastrom ◽  
...  
Keyword(s):  
Rotator Cuff ◽  
Humeral Head ◽  
Rotator Cuff Tears ◽  
Subscapularis Tendon ◽  
Inclusion Criteria ◽  
Rotator Cuff Disease ◽  
Level Of Evidence ◽  
Shoulder Mri ◽  
Magnetic Resonance Imaging Mri ◽  
The Relationship

Background: Superior humeral migration has been established as a component of rotator cuff disease, as it disrupts normal glenohumeral kinematics. Decreased acromiohumeral interval (AHI) as measured on radiographs has been used to indicate rotator cuff tendinopathy. Currently, the data are mixed regarding the specific rotator cuff pathology that contributes the most to humeral head migration. Purpose: To determine the relationship between severity of rotator cuff tears (RCTs) and AHI via a large sample of magnetic resonance imaging (MRI) shoulder examinations. Study Design: Cohort study; Level of evidence, 3. Methods: A search was performed for 3-T shoulder MRI performed in adults for any indication between January 2010 and June 2019 at a single institution. Three orthopaedic surgeons and 1 musculoskeletal radiologist measured AHI on 2 separate occasions for patients who met the inclusion criteria. Rotator cuff pathologies were recorded from imaging reports made by fellowship-trained musculoskeletal radiologists. Results: A total of 257 patients (mean age, 52 years) met the inclusion criteria. Of these, 199 (77%) had at least 1 RCT, involving the supraspinatus in 174 (67.7%), infraspinatus in 119 (46.3%), subscapularis in 80 (31.1%), and teres minor in 3 (0.1%). Full-thickness tears of the supraspinatus, infraspinatus, or subscapularis tendon were associated with significantly decreased AHI (7.1, 5.3, and 6.8 mm, respectively) compared with other tear severities ( P < .001). Having a larger number of RCTs was also associated with decreased AHI (ρ = –0.157; P = .012). Isolated infraspinatus tears had the lowest AHI (7.7 mm), which was significantly lower than isolated supraspinatus tears (8.9 mm; P = .047). Conclusion: Although various types of RCTs have been associated with superior humeral head migration, this study demonstrated a significant correlation between a complete RCT and superior humeral migration. Tears of the infraspinatus tendon seemed to have the greatest effect on maintaining the native position of the humeral head. Further studies are needed to determine whether early repair of these tears can slow the progression of rotator cuff disease.

Postoperative New-Onset Pseudoparalysis: A Retrospective Analysis of 430 Consecutive Arthroscopic Repairs for Large to Massive Rotator Cuff Tears

2018 ◽  
Vol 46 (7) ◽  
pp. 1701-1710 ◽  
Author(s):  
Hyeon Jang Jeong ◽  
Sung Min Rhee ◽  
Joo Han Oh
Keyword(s):  
Risk Factors ◽  
Rotator Cuff ◽  
Fatty Infiltration ◽  
Rotator Cuff Tears ◽  
Level Of Evidence ◽  
Massive Rotator Cuff Tear ◽  
Supraspinatus Tear ◽  
The Mean ◽  
Mean Time ◽  
New Onset

Background: The authors have sometimes encountered postoperative new-onset pseudoparalysis (PONP) after arthroscopic repair for large to massive rotator cuff tear (ARCR). As there are insufficient data regarding PONP, the authors aimed to determine whether such a condition is characterized by obvious risk factors, as well as to assess the conditions under which it can be reversed. Purpose: To evaluate the predictors of PONP development after ARCR and its reversal and to integrate these predictors into a scoring system that can be applied in clinical practice. Study Design: Case-control study; Level of evidence, 3. Methods: The authors retrospectively analyzed 430 consecutive ARCRs performed between March 2010 and May 2016. Patients were stratified according to the occurrence of PONP. To determine the risk factors of PONP, the authors compared the PONP and control groups (patients who did not experience PONP) in terms of demographic, clinical, and operative characteristics. Results were expressed in terms of odds ratios (ORs). Results: The incidence of PONP was 6.0% (26 of 430). Predictors of PONP included torn subscapularis (OR, 7.875; 95% CI, 1.780-34.956; P = .007), ≥30-mm retraction of the torn supraspinatus (OR, 4.657; 95% CI, 1.537-14.203; P = .007), age ≥65 years (OR, 3.865; 95% CI, 1.465-10.040; P = .006), and preoperative stiffness (OR, 2.954; 95% CI, 1.212-7.159; P = .017). The reversal rate of PONP was 65.4% (17 of 26), and the mean time to PONP reversal was 10 months. The occurrence and reversal of PONP were not related to retear. Fatty infiltration of the supraspinatus lower than Goutallier grade 3 was the sole predictor of reversal (OR, 22.000; 95% CI, 1.857-260.648; P = .014). Conclusion: Although the incidence of PONP after ARCR was low (6.0%), the risk of PONP was higher in patients with a torn subscapularis, larger supraspinatus tear size, older age, and preoperative stiffness. The mean time from PONP onset to reversal was 10 months, and PONP reversal was affected solely by fatty infiltration of the supraspinatus. Therefore, surgeons should consider the risk for PONP and attempt to identify high-risk patients before rotator cuff repair.

scholarly journals Preoperative Fatty Infiltration of the Teres Minor Negatively Affects Postoperative Outcomes in Patients With Rotator Cuff Pathology

2020 ◽  
Vol 8 (10) ◽  
pp. 232596712096010
Author(s):  
Erik J. Sarkissian ◽  
Michelle Xiao ◽  
Geoffrey D. Abrams
Keyword(s):  
Rotator Cuff ◽  
Clinical Outcomes ◽  
Fatty Infiltration ◽  
Rotator Cuff Tears ◽  
Full Thickness ◽  
Level Of Evidence ◽  
Partial Thickness ◽  
Goutallier Classification ◽  
Teres Minor

Background: The teres minor is a critical component of the rotator cuff and serves as one of the few external rotators of the humerus. Information is lacking regarding the effect of teres minor atrophy in isolation and in the setting of concomitant full-thickness rotator cuff tears on outcomes in patients undergoing rotator cuff surgery. Purpose: To investigate the effect of preoperative teres minor fatty infiltration on postoperative clinical outcomes in patients with and without full-thickness rotator cuff pathology. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of patients undergoing primary arthroscopic shoulder surgery between 2014 and 2016 was performed. Preoperative magnetic resonance imaging was used to determine fatty infiltration for each rotator cuff muscle using the modified Goutallier classification. American Shoulder and Elbow Surgeons (ASES) as well as the shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores were obtained preoperatively and during follow-up. Exclusion criteria included prior surgery on the ipsilateral shoulder or a diagnosis of inflammatory arthropathy. For analysis, patients were dichotomized to grade 0 or grade 1-4 atrophy of the teres minor as well as to full-thickness or partial-thickness rotator cuff pathology. Results: A total of 36 of 47 (76.6%) patients (mean age, 63 years; range, 45-76 years) were available for postoperative follow-up at a mean of 40 months (range, 30-48 months). Postoperative ASES score was significantly higher and QuickDASH score was significantly lower among all patients in the grade 0 group compared with the grade 1-4 group. Postoperative ASES and QuickDASH scores were not significantly different in patients with partial-thickness rotator cuff tears at any time point. However, the postoperative ASES score was significantly higher and QuickDASH score was significantly lower in the grade 0 versus grade 1-4 group for patients with full-thickness rotator cuff pathology. Conclusion: Preoperative teres minor atrophy in patients undergoing surgery for rotator cuff pathology may impair postoperative clinical outcomes, especially in patients with full-thickness tears.

scholarly journals Treatment of irreparable rotator cuff tears with superior capsular reconstruction

2021 ◽  
Vol 8 (1) ◽  
Author(s):  
Nobuyuki Yamamoto ◽  
Eiji Itoi
Keyword(s):  
Rotator Cuff ◽  
Fatty Infiltration ◽  
Young Patients ◽  
Surgical Techniques ◽  
Optimal Solution ◽  
Clinical Results ◽  
Rotator Cuff Tears ◽  
Level Of Evidence ◽  
Early Results ◽  
Superior Capsular Reconstruction

Abstract The treatment of irreparable rotator cuff tears with severe muscle atrophy and fatty infiltration remains a challenge, especially in young patients. Many surgical procedures for these tears have been reported. No one surgical treatment has proven to be an optimal solution. Recently, reconstruction of the superior capsule with an allograft or autograft has gained popularity. In this manuscript, we reviewed the biomechanical and clinical reports that have assessed superior capsular reconstruction and clarified the issues about the surgical techniques and indication which have been discussed recently. Reconstruction of the superior capsule has shown promising early results with good clinical outcomes. Biomechanical studies have suggested various mechanisms of this procedure. Although good clinical results and biomechanical data are available, more research is necessary to further define the surgical indications and improve the surgical outcomes of this procedure. Level of evidence Level V.

scholarly journals Biceps Detachment Preserves Joint Function in a Chronic Massive Rotator Cuff Tear Rat Model

2018 ◽  
Vol 46 (14) ◽  
pp. 3486-3494 ◽  
Author(s):  
Mengcun Chen ◽  
Snehal S. Shetye ◽  
Julianne Huegel ◽  
Corinne N. Riggin ◽  
Daniel J. Gittings ◽  
...  
Keyword(s):  
Rotator Cuff ◽  
Shoulder Joint ◽  
Shoulder Function ◽  
Rotator Cuff Tears ◽  
Subscapularis Tendon ◽  
Joint Function ◽  
Massive Rotator Cuff Tears ◽  
Sham Surgery ◽  
Biceps Tenotomy

Background: Lesions of the long head of the biceps tendon are often associated with massive rotator cuff tears (MRCTs), and biceps tenotomy is frequently performed for pain relief and functional reservation. However, the efficacy and safety of biceps tenotomy regarding the effects on the surrounding tissues in chronic MRCT are unclear. Hypothesis: Biceps tenotomy would result in improved mechanical and histological properties of the intact subscapularis tendon and improved in vivo shoulder function while not compromising glenoid cartilage properties. Study Design: Controlled laboratory study. Methods: Right supraspinatus and infraspinatus tendons were detached in 25 male Sprague-Dawley rats, followed by 4 weeks of cage activity to create a chronic MRCT condition. Animals were randomly divided into 2 groups and received either biceps tenotomy (n = 11) or sham surgery (n = 14) and were sacrificed 4 weeks thereafter. Forelimb gait and ground-reaction forces were recorded 1 day before the tendon detachment (baseline), 1 day before the surgical intervention (biceps tenotomy or sham), and 3, 7, 10, 14, 21, and 28 days after the intervention to assess in vivo shoulder joint function. The subscapularis tendon and glenoid cartilage were randomly allocated for mechanical testing or histologic assessment after the sacrifice. Results: Compared with sham surgery, biceps tenotomy partially restored the in vivo shoulder joint function, with several gait and ground-reaction force parameters returning closer to preinjury baseline values at 4 weeks. With biceps tenotomy, mechanical properties of the subscapularis tendons were improved, while mechanical properties and histological Mankin scores of the glenoid cartilage were not diminished when compared with the sham group. Conclusion: Biceps tenotomy in the presence of chronic MRCT partially preserves overall shoulder function and potentially restores subscapularis tendon health without causing detrimental effects to joint cartilage. This laboratory study adds to the growing literature regarding the protective effects of biceps tenotomy on the shoulder joint in a chronic MRCT model. Clinical Relevance: This study provides important basic science evidence supporting the use of biceps tenotomy in patients with massive rotator cuff tears.

Evaluating the Outcomes of Rotator Cuff Repairs With Polytetrafluoroethylene Patches for Massive and Irreparable Rotator Cuff Tears With a Minimum 2-Year Follow-up

2018 ◽  
Vol 46 (13) ◽  
pp. 3155-3164 ◽  
Author(s):  
Vasanth Seker ◽  
Lisa Hackett ◽  
Patrick H. Lam ◽  
George A.C. Murrell
Keyword(s):  
Rotator Cuff ◽  
Range Of Motion ◽  
External Rotation ◽  
Case Series ◽  
Shoulder Function ◽  
Rotator Cuff Tears ◽  
Level Of Evidence ◽  
Irreparable Tear ◽  
Pain At Rest

Background: Massive and irreparable rotator cuff tears are difficult to manage surgically. One technique is to use a synthetic polytetrafluoroethylene (PTFE) patch to bridge the tear. However, there is little information regarding the outcomes of this procedure. Purpose: To determine the ≥2-year outcomes of patients for whom synthetic patches were used as tendon substitutes to bridge irreparable rotator cuff defects. Study Design: Case series; Level of evidence, 4. Methods: This retrospective cohort study used prospectively collected data. Patients included those with a synthetic patch inserted as an interposition graft for large and/or irreparable rotator cuff tears with a minimum 2-year follow-up. Standardized assessment of shoulder pain, function, range of motion, and strength was performed preoperatively, at 6 and 12 weeks, and at 6 months and ≥2 years. Radiograph and ultrasound were performed preoperatively, at 6 months, and ≥2 years. Results: At a mean of 36 months, 58 of 68 eligible patients were followed up, and 53 of 58 (90%) patches remained in situ. Three patches failed at the patch-tendon interface, while 1 patient (2 shoulders/patches) went on to have reverse total shoulder replacements. Patient-ranked shoulder stiffness ( P < .001), frequency of pain with activity and sleep ( P < .0001), level of pain at rest and overhead ( P < .0001), and overall shoulder function improved from bad to very good ( P < .0001) by 6 months. Supraspinatus (mean ± SEM: 29 ± 16 N to 42 ± 13 N) and external rotation (39 ± 13 N to 59 ± 15 N) strength were the most notable increases at the ≥2-year follow-up ( P < .0001). Passive range of motion also improved by 49% to 67%; forward flexion, from 131° to 171°; abduction, from 117° to 161°; external rotation, from 38° to 55°; and internal rotation, from L3 to T10 ( P < .0001) preoperatively to ≥2 years. The most improvement in passive range of motion occurred between 12 months and ≥2 years. The mean (SD) Constant-Murley score was 90 (12), while the American Shoulder and Elbow Surgeons score was 95 (8). Conclusion: At 36 months postoperatively, patients who had synthetic patches used as tendon substitutes to bridge irreparable rotator cuff defects reported less pain and greater overall shoulder function as compared with preoperative assessments. They demonstrated improved range of passive motion and improved strength. The data support the hypothesis that the technique of using a synthetic PTFE patch to bridge a large and/or irreparable tear has good construct integrity and improves patient and clinical outcomes.

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