Posterosuperior Rotator Cuff Tears and Associated Pathologies - Revision history

Alexandre.laedermann: /* What would Codman have thought about this? */

2020-01-27T21:45:29Z

What would Codman have thought about this?

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Alexandre.laedermann: /* What would Codman have thought about this? */

2020-01-27T21:44:35Z

What would Codman have thought about this?

Alexandre.laedermann: /* What would Codman have thought about this? */

2020-01-27T21:43:19Z

What would Codman have thought about this?

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Alexandre.laedermann at 21:34, 27 January 2020

2020-01-27T21:34:35Z

Alexandre.laedermann: /* Prevalence */

2020-01-03T14:46:17Z

Prevalence

Alexandre.laedermann: /* Conclusion */

2020-01-03T14:43:44Z

Conclusion

Alexandre.laedermann: /* Conclusion */

2020-01-03T14:41:49Z

Conclusion

Alexandre.laedermann: /* Reverse Shoulder Arthroplasty */

2020-01-03T14:37:14Z

Reverse Shoulder Arthroplasty

Alexandre.laedermann: /* Biological Augmentation */

2020-01-03T14:35:23Z

Biological Augmentation

Alexandre.laedermann: /* Subacromial Balloon Interposition */

2020-01-03T14:34:52Z

Subacromial Balloon Interposition

← Older revision		Revision as of 21:44, 27 January 2020
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	==What would Codman have thought about this?==		==What would Codman have thought about this?==
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		+	NON-OPERATIVE TREATMENT OF RUPTURE OF THE SUPRASPINATUS
		+	TENDON
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		+	I think every general surgeon who could see one of the complete cases at operation would agree that no form of physiotherapy could influence beneficially one of these lesions, except in a subjective way. The subjective symptoms might possibly be alleviated to a certain degree by massage or by diathermy, but as a matter of fact, nearly all patients say that these agents are of little help. From the very nature of the lesion, manipulations and forced exercises can do no good and might do some harm. If it is determined that a patient is not to have an operation, there are two rational plans of treatment: (1) Fixation in elevation to relax the tendon, improve the blood supply and approximate the torn ends; (2) Gentle "stooping exercises" to help nature smooth off the irregular surface of the lesion. This is merely an aid to nature's own partially successful method.
		+	Fixation in elevation, to be effective, would necessarily have to be instituted soon after the injury, and would require at least three weeks. It would be useless in old cases, yet even in the old cases one can see, when the bursa is open on the operating table, that there is a tendency toward approximation of the torn ends of the tendon as the arm is abducted. Of course, in these old cases the proximal end is retracted and cicatrized in its retracted position. Even prolonged fixation in such cases could accomplish little except in possibly diminishing the size of the defect. This tendency to approximation observed at operation in old cases, when the arm is abducted, shows that it is probable that if the rupture were small, this treatment, if immediately instituted, would be worth while. If I were the patient, I would prefer incision and suture to this problematical and uncomfortable, even if reasonable, plan.
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		+	The "stooping exercise" method is founded on the pathologic findings described in Chapter III. Clearly nature has developed this method of absorption of the tuberosity to restore function after this accident, for as these patients, after a year or two of misery, improve somewhat, it is fairly clear that this method of smoothing off the eminence and sulcus which caused the jog is the best she can do. Nature's plan is the combination of this slow smoothing-off of the tuberosity and meanwhile increasing the supply of fluid, which, as the lower portion of the capsule becomes tense in any action, is forced up to the site of friction.
		+	The idea of the stooping exercises is to begin this process with the weight taken off the arm so that the irregular surface is not forced up under the acromion by muscular tension. If the patient stands and elevates the arm, the very point which is sore becomes the fulcrum on the acromion for the deltoid to exert its power. When the patient stoops with the arm relaxed, the scapula can be abducted on the humerus without the need of the fulcrum either on the glenoid or acromion. Gravity takes the place of the power of the deltoid.
		+	It is clear that until a patient can swing his arms freely in the stooping position without pain, he is not ready to use the arm when standing.
		+	To patients who refuse operation I explain these mechanics and impress on them what I have said in the last paragraph. I also try to teach them to sleep with the arm abducted, with the hand behind the head. Palliatives in the form of drugs or physiotherapy are not often required in these cases. The pain is always bearable, if they do not increase it with work or exercise which make a fulcrum of the sore point. I think I can accomplish more with these patients by explanation of the mechanics of their trouble than I can with any palliative measures. Show a workman the normal function of the joint, the necessity of the supraspinatus to maintain the fulcrum on the glenoid, the tendency, without it, for the fulcrum to ride on the sore spot where it touches the acromion, the changed action of the weight of the arm when stooping or lying with the hand behind the head, and, as a rule, he will get your drift. He knows about levers and weights. When he understands his condition, he will get rid of the fear element and realize that though his arm is impaired, he has not really lost the use of it. He has learned that he has lost the use of certain motions unless he is willing to stand the pain. This education has more therapeutic value than drugs or electrical treatment. Massage, of course, may do good in stimulating the nutrition of the tissues, but it cannot unite the tendon.
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		+	It has seemed to me best to present my operations on the shoulder tabulated in this way, rather than to give complete case histories of each patient. Many of the cases have been used in the text to illustrate different points, sometimes only the occupation being used and perhaps in another place the preoperative diagnosis given to compare with the operative findings, etc. Under the comments at the right of this table the page numbers are given when the individual cases are referred to in the text. Should any one desire to do so, he could, by referring to these pages, make up brief individual case histories. As a rule, the cases which have been spoken of in the text are those in which the result was poor or fair. Those which I have considered good, lack detail. On the whole, compared with the results of the cases in the rest of the table, the outcome in the cases of complete rupture has been relatively poor. The reader is urged to bear in mind that in all the cases on which I have operated my attempts were more or less delayed, for only cases 18, 27, 42, 49,106,115,127, 128, 129 and 135 were done within two months of the accident. In cases 49 and 115 suture was impossible, and cases 27 and 42 could not be traced over a period of years, although the immediate results were good. I probably should not have written this book at all had the results all been good, for one of my chief objects is to urge prompt diagnosis and immediate operation.
		+	Some of the cases marked "poor" actually did obtain some improvement. For instance, Case 88 worked over a year after the operation and then had another accident, so that his total compensation was the maximum allowed by law. Case 89 has worked steadily as a watchman after he had made a settlement with the insurer. I feel that I have certainly not exaggerated the benefits of surgery in these delayed cases, for I am sure something was accomplished in all of them, even in cases such as number 115 where no suture was attempted, for at least a definite diagnosis was made, as a basis for a settlement. If, as I hope, eventually the profession comes to realize the importance and frequency of this lesion, and the laboring class becomes educated to take it seriously, exploration through a small incision will be the rule in doubtful cases. When the insurance companies become interested in the problem, I shall be glad to cooperate in making a more extensive survey of the economic side than that which is presented on page 176.
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		+	REFERENCE
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		+	Wilson and Fowler have modified my operative methods. References to their articles will be found at the end of Chapter V.

	OPERATIVE TREATMENT OF RUPTURE OF THE SUPRASPINATUS		OPERATIVE TREATMENT OF RUPTURE OF THE SUPRASPINATUS

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 ==Key Words==
 Shoulder arthroscopy; Rotator cuff lesion; Partial repair; Tear pattern; Classification; Massive; Reparable and non-repairable; Irreparable; Imaging; Recurrent; Failed; Revision surgery; Open and arthroscopic approach; Conservative or non-operative treatment; Physiotherapy; Functional outcomes; Prognostic factors; Latissimus dorsi transfer; Subacromial spacer interposition; Balloon; Biceps tenotomy; Superior capsular reconstruction; Reverse arthroplasty; Magnetic resonance imaging (MRI) arthrography (MRA); Fosbury flop tear; New tear pattern; FUSSI; SAM.
 ==Biomechanics of the Posterosuperior Rotator Cuff==

@@ Line 442: / Line 442: @@
 [[File:1562482680697-lg.jpg|center|thumb|600x600px|Figure. 26 Coronal T1 weighted image of a right shoulder that demonstrates (black arrow) an abnormally thickened supraspinatus (9.5 mm). Reproduced from Lädermann et al., with permission.]]
 [[File:1562483248519-lg.jpg|center|thumb|600x600px|Figure. 27 Coronal T1 weighted MRA image with fat saturation of a right shoulder demonstrates adhesions between the bursal side of the tendon and the wall of the subacromial bursa (red arrow), and abnormal orientation of the fibers stump (yellow arrow). Reproduced from Lädermann et al., with permission.]]
-Additionally, patients with this lesion were also found to have an accumulation of fluid in the superomedial part of the subacromial bursa as well as adhesions between the wall of the subacromial bursa and the tendon of the supraspinatus. Since the original description, another group verified the same entity.
+Additionally, patients with this lesion were also found to have an accumulation of fluid in the superomedial part of the subacromial bursa as well as adhesions between the wall of the subacromial bursa and the tendon of the supraspinatus. Since the original description, another group verified the same entity.<ref>Nakamizo H. Arthroscopic repair for subacromial incarceration of a torn rotator cuff. AP-SMART 2015;2:90-4.</ref>
 =====Surgical Technique=====

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 '''''<small>Table: Results of the different techniques of irreparable rotator cuff tear treatment from representative series</small>'''''
-[[File:1562520882562-lg.jpg|center|thumb|600x600px|Figure. 38 †: Constant score, ‡: American Shoulder and Elbow Surgeons (ASES) score, NA: non available.]]
+[[File:1562520882562-lg.jpg|center|thumb|720x720px|Figure. 38 †: Constant score, ‡: American Shoulder and Elbow Surgeons (ASES) score, NA: non available.|alt=]]
-<br />
+The initial use of complex and expensive techniques in management of posterosuperior irreparable rotator cuff tears is actually not supported. Further prospective and comparative studies with large cohort populations and long-term follow-up are necessary to establish effectiveness of expensive or complicated procedures such as SCR, biological augmentation or subacromial spacer as reliable and useful alternative treatment for irreparable rotator cuff tears.<br />
 ==References==
 <references />

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 Various surgeries are proposed for similar posterosuperior irreparable rotator cuff tears and preoperative patient' clinical evaluation. There is no panacea for primary treatment and patients must be aware, in case of palliative or non-prosthetic option, of an alarming rate of structural failure (around 50%) in the short term (Table).
-Table: Results of the different techniques of irreparable rotator cuff tear treatment from representative series
+'''''<small>Table: Results of the different techniques of irreparable rotator cuff tear treatment from representative series</small>'''''
 ==References==
 <references />

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 =====Reverse Shoulder Arthroplasty=====
-Reverse shoulder arthroplasty has emerged as a treatment for irreparable rotator cuff tears. Two recent systematic reviews confirmed that this is a reliable procedure to improve mobility and strength, producing an improvement in pain and postoperative outcome scores.
+Reverse shoulder arthroplasty has emerged as a treatment for irreparable rotator cuff tears. Two recent systematic reviews confirmed that this is a reliable procedure to improve mobility and strength, producing an improvement in pain and postoperative outcome scores.<ref>Petrillo S, Longo UG, Papalia R, Denaro V. Reverse shoulder arthroplasty for massive irreparable rotator cuff tears and cuff tear arthropathy: a systematic review. Musculoskelet Surg 2017;101:105-12.</ref><ref>Sevivas N, Ferreira N, Andrade R, et al. Reverse shoulder arthroplasty for irreparable massive rotator cuff tears: a systematic review with meta-analysis and meta-regression. J Shoulder Elbow Surg 2017;26:e265-e77.</ref>
-. Petrillo S, Longo UG, Papalia R, Denaro V. Reverse shoulder arthroplasty for massive irreparable rotator cuff tears and cuff tear arthropathy: a systematic review. Musculoskelet Surg 2017;101:105-12.
+Moreover, reverse shoulder arthroplasty yielded benefits considered cost-effective when compared with other treatments, especially in elderly patients with irreparable rotator cuff tears.<ref>Kang JR, Sin AT, Cheung EV. Treatment of Massive Irreparable Rotator Cuff Tears: A Cost-effectiveness Analysis. Orthopedics 2017;40:e65-e76.</ref>
-. Sevivas N, Ferreira N, Andrade R, et al. Reverse shoulder arthroplasty for irreparable massive rotator cuff tears: a systematic review with meta-analysis and meta-regression. J Shoulder Elbow Surg 2017;26:e265-e77.
+Reverse shoulder arthroplasty should be considered in older patients for whom long period of immobilization and rehabilitation is undesirable.<ref>Lädermann A, Denard PJ, Tirefort J, Collin P, Nowak A, Schwitzguebel AJ. Subscapularis- and deltoid-sparing vs traditional deltopectoral approach in reverse shoulder arthroplasty: a prospective case-control study. Journal of orthopaedic surgery and research 2017;12:112.</ref>
-Moreover, reverse shoulder arthroplasty yielded benefits considered cost-effective when compared with other treatments, especially in elderly patients with irreparable rotator cuff tears.
+Even if the rate of complications was high in the two above mentioned systematic reviews, a dramatic decrease has been observed with new designs and better techniques.<ref>Lädermann A, Lo EY, Schwitzguebel AJ, Yates E. Subscapularis and deltoid preserving anterior approach for reverse shoulder arthroplasty. Orthopaedics & traumatology, surgery & research : OTSR 2016;102:905-8.</ref>
-. Kang JR, Sin AT, Cheung EV. Treatment of Massive Irreparable Rotator Cuff Tears: A Cost-effectiveness Analysis. Orthopedics 2017;40:e65-e76.
+Recently, the complication rate has been reported to be lower. However, caution should still be exercised when offering reverse shoulder arthroplasty to young patient that are often disappointed by the results.<ref>Ernstbrunner L, Suter A, Catanzaro S, Rahm S, Gerber C. Reverse Total Shoulder Arthroplasty for Massive, Irreparable Rotator Cuff Tears Before the Age of 60 Years: Long-Term Results. J Bone Joint Surg Am 2017;99:1721-9.</ref><ref>Virk MS, Nicholson GP, Romeo AA. Irreparable Rotator Cuff Tears Without Arthritis Treated With Reverse Total Shoulder Arthroplasty. Open Orthop J 2016;10:296-308.</ref>
 ====Conclusion====

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 =====Biological Augmentation=====
-These techniques involve using a graft (allo, auto, or xeno) or synthetic patch to bridge the defect in the rotator cuff and improve connection of the tendon remnant at least at the border of the original footprint. During this procedure, the torn rotator cuff tendons are released, mobilized, and undergo a partial repair. The graft is then sutured on top of the residual defect between the lateral margin of the medial fixed rotator cuff tendon and its native insertion site on the lateral footprint and humerus. A systematic review confirm that this approach improved function with a high rate of structural integrity rates on MRI at 12-month minimum follow-up.
+These techniques involve using a graft (allo, auto, or xeno) or synthetic patch to bridge the defect in the rotator cuff and improve connection of the tendon remnant at least at the border of the original footprint. During this procedure, the torn rotator cuff tendons are released, mobilized, and undergo a partial repair. The graft is then sutured on top of the residual defect between the lateral margin of the medial fixed rotator cuff tendon and its native insertion site on the lateral footprint and humerus. A systematic review confirm that this approach improved function with a high rate of structural integrity rates on MRI at 12-month minimum follow-up.<ref>Lewington MR, Ferguson DP, Smith TD, Burks R, Coady C, Wong IH. Graft Utilization in the Bridging Reconstruction of Irreparable Rotator Cuff Tears: A Systematic Review. Am J Sports Med 2017;45:3149-57.</ref>
 =====Reverse Shoulder Arthroplasty=====

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 The biodegradable spacer (balloon shape) is arthroscopically implanted between the acromion and the humeral head. The subacromial spacer has been designed to create a physical barrier between tissues in the subacromial space and keep the humeral head depressed when the rotator cuff is not efficient to facilitate deltoid action, thus permitting improvement in glenohumeral joint motion with significant pain reduction. At 5 years follow-up, a recent study on the subacromial spacer with an associated biceps tenotomy reported that 85% of the patients showed a clinically significant improvement of at least 15 points in Constant score, while 62% showed at least 25 points of improvement.<ref>Senekovic V, Poberaj B, Kovacic L, et al. The biodegradable spacer as a novel treatment modality for massive rotator cuff tears: a prospective study with 5-year follow-up. Arch Orthop Trauma Surg 2017;137:95-103.</ref>
-Deranlot et al. described in a series of 37 patients (39 shoulders) a significant improvement of the Constant score from 45 preoperatively to 76 at a mean of 33 months follow-up. In their study, 92% of the shoulders also underwent a long head of biceps tenotomy.Deranlot J, Herisson O, Nourissat G, et al. Arthroscopic Subacromial Spacer Implantation in Patients With Massive Irreparable Rotator Cuff Tears: Clinical and Radiographic Results of 39 Retrospectives Cases. Arthroscopy 2017;33:1639-44.
+Deranlot et al. described in a series of 37 patients (39 shoulders) a significant improvement of the Constant score from 45 preoperatively to 76 at a mean of 33 months follow-up. In their study, 92% of the shoulders also underwent a long head of biceps tenotomy.<ref>Deranlot J, Herisson O, Nourissat G, et al. Arthroscopic Subacromial Spacer Implantation in Patients With Massive Irreparable Rotator Cuff Tears: Clinical and Radiographic Results of 39 Retrospectives Cases. Arthroscopy 2017;33:1639-44.</ref>
 =====Biological Augmentation=====