scholarly journals The Evolution and Role of the Bursal Acromial Reconstruction

2021 ◽  
Vol 1 (2) ◽  
pp. 263502542110013
Author(s):  
Daniel M. Curtis ◽  
W. Michael Pullen ◽  
Kevin Helenius ◽  
Michael T. Freehill
Keyword(s):  
Glenohumeral Joint ◽  
Total Shoulder Arthroplasty ◽  
Treatment Options ◽  
Clinical Problem ◽  
Clinical Results ◽  
Rotator Cuff Tears ◽  
Subacromial Space ◽  
Promising Alternative ◽  
Diagnostic Arthroscopy ◽  
Superior Capsular Reconstruction

Background: Massive, irreparable rotator cuff tears (RCTs) remain a challenging clinical problem with numerous described treatment options. Bursal acromial reconstruction (BAR) represents a promising and evolving technique for a subset of patients with irreparable RCTs. Indications: BAR is indicated for patients with massive, irreparable RCTs with a primary complaint of pain, well-compensated shoulder function, and minimal radiographic degenerative changes of the glenohumeral joint as an alternative to reverse total shoulder arthroplasty or superior capsular reconstruction. Technique Description: Positioning per surgeon preference and diagnostic arthroscopy is performed. Subacromial decompression with a minimal and gentle acromioplasty is performed, followed by assessment of RCT repairability. If the tear is deemed irreparable, acromial measurements in the medial-lateral and anterior-posterior dimensions are obtained. Two pieces of acellular dermal allograft are cut to the acromial dimensions and affixed together using fibrin glue. The reactive side (facing the acromion), medial, and anterior sides of the graft are labeled. Two suture tapes are passed through the corners of the graft and self-locked and run diagonally in a cruciate configuration using an antegrade suture passer. Medial and lateral #2 fiberwire sutures are placed in a luggage-tag configuration. Neviaser (posterior), middle, and anterior acromioclavicular joint portals are created for medial sided suture passage. Medial graft sutures are shuttled through the respective medial portals and the graft is pulled into the subacromial space. The lateral sutures are then removed from percutaneous posterolateral, middle lateral, and anterolateral portals along the acromial edge. Medial sutures are retrieved using a suture grasper subcutaneously on top of the acromion through the percutaneous lateral portals. The sutures are tied through the lateral portals, starting with the medial-lateral sutures, and the knots are buried. Postoperatively, patients are progressed through passive, active-assisted, and active range of motion between weeks 2 and 6 and strengthening is progressed at 6 weeks. Results: Clinical results are lacking in the literature, but anecdotal results in our institution have demonstrated promising early outcomes. Discussion/Conclusion: BAR represents a promising alternative in the array of surgical options for treatment of irreparable RCTs.

scholarly journals Use of Gracile and semi-tendinosus tendons (GRAST) for the reconstruction of irreparable rotator cuff tears

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Marie Protais ◽  
Maxime Laurent-Perrot ◽  
Mickaël Artuso ◽  
M. Christian Moody ◽  
Alain Sautet ◽  
...  
Keyword(s):  
Rotator Cuff ◽  
Donor Site ◽  
Anatomical Study ◽  
Donor Site Morbidity ◽  
Rotator Cuff Tears ◽  
Subacromial Space ◽  
Greater Tuberosity ◽  
Working Zone ◽  
Superior Capsular Reconstruction

Abstract Background Irreparable rotator cuff tears are common and difficult to treat. Techniques for “filling the loss of substance” require fixation to the rotator cuff stump (tendon augmentation) or to the glenoid (superior capsular reconstruction), which are complicated by the narrow working zone of the subacromial space. The main objective of this study was to determine whether a braided graft of gracilis (GR) and semitendinosus (ST) could fill a loss of tendon substance from an irreparable rupture of the supra- and infraspinatus, by fixing the graft to the greater tuberosity and the spine of the scapula. Methods This was a cadaveric study with the use of ten specimens. The GRA and ST tendons were harvested, braided and reinforced with suture. An experimental tear of the supraspinatus (SS) and upper infraspinatus (IS) retracted at the glenoid was made. The GRAST transplant was positioned over the tear. The transplant was attached to the greater tuberosity by two anchors and then attached to the medial third of the scapular spine by trans-osseous stitching. The percentage of filling obtained was then measured and passive mobility of the shoulder was assessed. We proceeded to the same technique under arthroscopy for a 73 years old patient whom we treated for a painful shoulder with irreparable cuff tear. We inserted a GRAST graft using arthroscopy. Results The Braided-GRAST allowed a 100% filling of the loss of tendon substance. Mobility was complete in all cases. Conclusion This technique simplifies the medial fixation and restores the musculo-tendinous chain where current grafting techniques only fill a tendinous defect. The transplant could have a subacromial “spacer” effect and lower the humeral head. The donor site morbidity and the fate of the transplant in-vivo are two limits to be discussed. This anatomical study paves the way for clinical experimentation.

scholarly journals Shoulder Positioning during Superior Capsular Reconstruction: Computational Analysis of Graft Integrity and Shoulder Stability

Biology ◽  
2021 ◽  
Vol 10 (12) ◽  
pp. 1263
Author(s):  
Madalena Antunes ◽  
Carlos Quental ◽  
João Folgado ◽  
Clara de Campos Azevedo ◽  
Ana Catarina Ângelo
Keyword(s):  
Glenohumeral Joint ◽  
Reaction Force ◽  
Supraspinatus Tendon ◽  
Rotator Cuff Tears ◽  
Joint Reaction Force ◽  
Superior Capsular Reconstruction ◽  
Key Factor ◽  
Long Head ◽  
Shoulder Position ◽  
Shoulder Stability

The shoulder position during fixation of the graft may be a key factor impacting the outcome of arthroscopic superior capsular reconstruction (ASCR) in irreparable rotator cuff tears (IRCTs). However, biomechanical evidence regarding this effect is lacking. The aim of this study was to evaluate the influence of the shoulder position during fixation of the graft on shoulder stability and graft tear risk in ASCR. A 3-D musculoskeletal model of the upper limb was modified to account for the fixation of the graft in ASCR, assuming a full-thickness tear of the supraspinatus tendon. The concomitant tenotomy of the long head of the biceps (LHB) tendon was also studied. The biomechanical parameters evaluated included the strain of the graft and the glenohumeral joint reaction force (GH JRF), which were used to evaluate graft integrity and shoulder stability, respectively. Fixation of the graft considering abduction angles greater than 15° resulted in a high risk for graft tearing when the arm was adducted to the side of the trunk. For abduction angles below 15°, the mean shoulder stability improved significantly, ranging between 6% and 20% (p < 0.001), compared with that in the preoperative condition. The concomitant tenotomy of the LHB tendon resulted in loss of stability when compared to ASCR with an intact LHB tendon. The position of the shoulder during fixation of the graft has a significant effect on shoulder stability and graft tear risk after ASCR in IRCTs. This study provides new and important information regarding the role of shoulder positioning during fixation of the graft.

scholarly journals Irreparable Rotator Cuff Tears Without Arthritis Treated With Reverse Total Shoulder Arthroplasty

2016 ◽  
Vol 10 (1) ◽  
pp. 296-308 ◽  
Author(s):  
Mandeep S. Virk ◽  
Gregory P. Nicholson ◽  
Anthony A. Romeo
Keyword(s):  
Rotator Cuff ◽  
Shoulder Arthroplasty ◽  
Total Shoulder Arthroplasty ◽  
Treatment Options ◽  
Young Patients ◽  
Reverse Total Shoulder Arthroplasty ◽  
Rotator Cuff Tears ◽  
Patient Comfort ◽  
Dramatic Improvement ◽  
Reverse Total Shoulder

Background: Irreparable rotator cuff (RC) tears without arthritis is a challenging clinical problem in young adults. Reverse total shoulder arthroplasty (RTSA) has been proposed as one of the surgical treatment options for this condition. Methods: In this review, we discuss the current understanding of the role of RTSA for the management of irreparable RC tears without arthritis based on authors personal experience and available scientific literature. Results: Reverse total shoulder arthroplasty (RTSA) is a constrained arthroplasty system that can allow the deltoid and remaining rotator cuff to substitute for the lost function of irreparable RC. Furthermore, the pain relief is consistent with often a dramatic improvement in patient comfort, shoulder function and stability. In patients with pseudoparalysis of the shoulder without advanced arthritis, RTSA effectively restores forward elevation above the shoulder but may not dramatically improve external (ER) or internal rotation (IR). However, due to concerns over implant longevity, caution has to be exercised when using RTSA for symptomatic irreparable RC tears with preserved active forward elevation (AFE) and in patients less than 65 years of age. Conclusion: RTSA is a reasonable surgical option for irreparable rotator cuff repair without arthritis. However, caution should be exercised when offering RTSA to young patients and patient without pseudoparalysis because they can have a higher complication and dissatisfaction rate. In addition, longevity of RTSA and subsequent need for revision surgery remains a significant concern in this population.

scholarly journals Massive Rotator Cuff Tear Bridging Reconstruction Using Acellular Dermal Matrix: Mid-term Results (219)

2021 ◽  
Vol 9 (10_suppl5) ◽  
pp. 2325967121S0032
Author(s):  
Moayd Awad ◽  
Sara Sparavalo ◽  
Jie Ma ◽  
Ivan Wong
Keyword(s):  
Rotator Cuff ◽  
Total Shoulder Arthroplasty ◽  
Acellular Dermal Matrix ◽  
Rotator Cuff Tears ◽  
Dermal Matrix ◽  
Massive Rotator Cuff Tears ◽  
Superior Capsular Reconstruction ◽  
Patient Reported ◽  
Reverse Total Shoulder

Objectives: Management of massive rotator cuff tears remains a challenge despite development of different surgical techniques. Bridging reconstruction was developed to improve clinical outcomes and to avoid the morbidity associated with tendon transfers and arthroplasty. To date, there have been no studies assessing the mid-term clinical outcome for patients undergoing this procedure. The objective of this study was to evaluate the mid-term clinical outcomes of patients who underwent bridging reconstruction using acellular dermal matrix for large/massive rotator cuff tears (> 3 cm). Methods: A retrospective chart review was conducted for patients who underwent bridging reconstruction between 2010 and 2018 by one surgeon (IW). Patients with a minimum follow-up of two years were included. All patients completed self-reported questionnaires (Western Ontario Rotator Cuff (WORC) Index and the Disabilities of the Shoulder, Arm and Hand (DASH) score) pre-operatively and post-operatively at six months, one year and annually thereafter. Results: One hundred charts were reviewed, and 20 patients were excluded due to lack of pre- or post-operative outcome scores. This cohort of patients consisted of 80 patients mean age of 58.6 ± 9.1 years and an average follow-up of 5.1 ± 1.6 years. The mean pre- and post-operative WORC scores (± SD) were 61.4 ± 20.6 and 28.1 ± 25.5 (p < 0.001), respectively. The mean pre- and post-operative DASH scores were 52.2 ± 19.7 and 23.1 ± 22.4 (p < 0.001), respectively. There was an improvement in WORC and DASH over time with the most significant improvement during the first year post-operatively (Figure 1). Seventy-eight percent of patients met the minimal clinically important difference (MCID) for WORC while 77% of patients met the MCID for DASH. Our results show significant mid-term clinical improvement in WORC and DASH scores that is similar to previously published data that showed significant improvements in other patient-reported outcome scores. We believe these positive outcomes to be a result of better force coupling within the shoulder as compared to other surgical treatments such as maximal repair, superior capsular reconstruction, and reverse total shoulder arthroplasty. Conclusions: Arthroscopic bridging reconstruction for the treatment of massive rotator cuff tears results in significant improvement of patient reported outcomes (as measured using the WORC and DASH scores) at a mean follow up of five years. This may suggest that bridging reconstruction is a good treatment alternative as compared to superior capsular reconstruction or reverse total shoulder arthroplasty. Longer follow-up with a prospective study design is necessary to determine the longevity of these outcomes.

scholarly journals Use of Gracile and Semi-tendinosus tendons (GRAST) for the reconstruction of irreparable rotator cuff tears

2020 ◽  
Author(s):  
Marie Protais ◽  
Maxime Laurent-Perrot ◽  
Mickaël Artuso ◽  
M. Christian Moody ◽  
Alain Sautet ◽  
...  
Keyword(s):  
Rotator Cuff ◽  
Donor Site ◽  
Anatomical Study ◽  
Donor Site Morbidity ◽  
Rotator Cuff Tears ◽  
Subacromial Space ◽  
Greater Tuberosity ◽  
Working Zone ◽  
Superior Capsular Reconstruction

Abstract Purpose Irreparable rotator cuff tears are common and difficult to treat. Techniques for "filling the loss of substance" require fixation to the rotator cuff stump (tendon augmentation) or to the glenoid (superior capsular reconstruction), which are complicated by the narrow working zone of the subacromial space. The main objective of this study was to determine whether a braided graft of gracilis (GR) and semitendinosus (ST) could fill a loss of tendon substance from an irreparable rupture of the supra- and infraspinatus, by fixing the graft to the greater tuberosity and the spine of the scapula. Methods This was a cadaveric study with the use of ten specimens. The GRA and ST tendons were harvested, braided and reinforced with suture. An experimental tear of the supraspinatus (SE) and upper infraspinatus (IE) retracted at the glenoid was made. The GRAST transplant was positioned over the tear. The transplant was attached to the greater tuberosity by two anchors and then attached to the medial third of the scapular spine by trans-osseous stitching. The percentage of filling obtained was then measured and passive mobility of the shoulder was assessed. Results The Braided-GRAST allowed a 100% filling of the loss of tendon substance. Mobility was complete in all cases. Conclusion This technique simplifies the medial fixation and restores the musculo-tendinous chain where current grafting techniques only fill a tendinous defect. The transplant could have a subacromial "spacer" effect and lower the humeral head. The donor site morbidity and the fate of the transplant in-vivo are two limits to be discussed. This anatomical study paves the way for clinical experimentation.

scholarly journals Clinical Outcome after Arthroscopic Capsular Release for Adhesive Capsulitis of the Shoulder

2018 ◽  
Vol 21 (3) ◽  
pp. 127-133 ◽  
Author(s):  
Jae Chul Yoo ◽  
Kyoung Hwan Koh ◽  
Min Soo Shon ◽  
Kyu Hwan Bae ◽  
Tae Kang Lim
Keyword(s):  
Glenohumeral Joint ◽  
Constant Score ◽  
Adhesive Capsulitis ◽  
Clinical Results ◽  
Subacromial Space ◽  
Capsular Release ◽  
Clinical Evaluations ◽  
Arthroscopic Capsular Release ◽  
Partial Rotator Cuff Tear

BACKGROUND: This study was undertaken to evaluate the outcome of the arthroscopic capsular release for adhesive capsulitis of the shoulder.METHODS: This study retrospectively investigated thirty shoulders in 29 patients who presented with recalcitrant adhesive capsulitis and underwent arthroscopic treatments. Other than typical findings of adhesive capsulitis, combined pathologies in the glenohumeral joint and subacromial space were evaluated by arthroscopy. Clinical evaluations were performed using the Constant's score and ranges of motion (ROM) at preoperative, 6 months postoperatively and at the final follow-up.RESULTS: Our study included 17 women and 12 men with a mean age of 53.8 years (range, 34?74). Mean follow-up duration was 24 months (range, 12?40 months). Assessment of combined pathologies revealed that partial rotator cuff tear of less than 25% thickness, was most common (overall 83.3%; with bursal 57% and articular 23%). Subacromial synovitis and adhesion were also frequent (53.3%). The Constant score and ranges of motion significantly improved at the final follow-up, compared with preoperative levels. However, clinical results at 6 months postoperatively were found to be significantly inferior to those observed at the final follow-up (p≤0.001 for all factors). Functional impairment was the major complaint in 59.3% patients at the 6 months follow-up.CONCLUSIONS: Although arthroscopic capsular release yielded favorable outcome at the mean 24 months follow-up, pain and motion limitations at 6-month postoperatively persisted in more than 50% of our patients. While combined pathologies were commonly encountered during arthroscopy, although their effects on surgical outcome in adhesive capsulitis remains unclear in this study.

scholarly journals Management of Irreparable Rotator Cuff Tears: Superior Capsular Reconstruction vs. Marginal Convergence (236)

2021 ◽  
Vol 9 (10_suppl5) ◽  
pp. 2325967121S0034
Author(s):  
Neel Patel ◽  
Nyaluma Wagala ◽  
Christopher Como ◽  
Bryson Lesniak ◽  
Albert Lin
Keyword(s):  
Rotator Cuff ◽  
Range Of Motion ◽  
Treatment Options ◽  
Reoperation Rate ◽  
Rotator Cuff Tears ◽  
Treatment Groups ◽  
Superior Capsular Reconstruction ◽  
The Mean ◽  
Reverse Total Shoulder

Objectives: Irreparable rotator cuff tears can be challenging to manage in younger patients who are not well indicated for reverse total shoulder replacement. Treatment options in this patient population include both marginal convergence (MC) and superior capsular reconstruction (SCR). While both treatment options have demonstrated good short term outcomes, they have vastly different associated costs and operative times. Thus, the purpose of this study was to compare range of motion (ROM), patient reported outcomes, and re-operation rates following MC and SCR. We hypothesized that SCR would outperform MC regarding functional and subjective outcomes. Methods: A retrospective review was conducted on 44 patients from two surgeons with irreparable rotator cuff tears that underwent either MC (28 patients, 28 shoulders) or SCR (16 patients, 16 shoulders) from 2014-2019 at a single academic center. Patient inclusion criteria were the following: failed conservative or prior surgical management, no or mild glenohumeral arthritis, Goutallier grade 3 or 4 fatty infiltration of the involved muscles, Hamada grade 1 or 2 rotator cuff arthropathy, intact or repairable subscapularis tear and minimum of 1 year follow-up. Visual Analogue Scale (VAS) for pain, active forward flexion (FF) and external rotation (ER) range of motion, reoperation rate, and rate of conversion to reverse total shoulder arthroplasty were evaluated. For statistical analysis, t-tests were used to determine differences in functional outcomes and VAS, while Chi-Squared tests were used to determine differences in the rate of re-operation and conversion to arthroplasty (*p < 0.05). Results: The mean age at the time of surgery for the MC and SCR groups was 64.4 and 58.5 years, respectively, with an average follow-up of 31.5 months for the MC group and 17.8 months for the SCR group. There were no significant differences in the mean age at the time of surgery, gender, body mass index, pre-operative FF and ER, and pre-operative VAS between the groups. The MC group did not have a significant improvement FF with a mean pre-operative FF of 144.4°(range: 30-170°) and post-operative FF of 150.5°(range: 90-180). The same was true for the SCR group, with a mean pre-operative FF 127.5°(range: 40-170°) and post-operative FF of 146.3°(range: 40-170). There was also no significant improvement in ER post-operatively in either group. Both the MC and SCR group had significant improvements in VAS for pain from an average of 7.3 (range: 1-10) pre-operatively to 2.5 (range: 0-10) post-operative for the MC group (p < 0.01) and from 7.3 (range: 3-10) pre-operatively to 1 (range: 0-4) post-operative for the SCR group (p < 0.01). There were no significant differences in the post-operative FF or ER, change in FF or ER, post-operative VAS, or change in VAS between the two treatment groups. The rate of conversion to arthroplasty was not significantly different between the groups at 3.6% for the MC group and 12.5% for the SCR group. Additionally, the overall reoperation rate was not significantly different between the MR and SCR groups at 10.7% and 12.5%, respectively. Conclusions: There were no significant differences between the MC and SCR treatment groups. While both MC and SCR were effective in improving VAS for pain, neither treatment consistently resulted in significant improvement in ROM. Further studies with long term outcomes are needed to determine if there are certain indications for which one treatment results in better outcomes.

Sign in / Sign up

Export Citation Format

Share Document