Surgical management of complex irreparable rotator cuff deficiency.

The authors surgically treated 23 shoulders in 23 patients with disabling pain associated with irreparable tears of the musculotendinous cuff. In a total of 12 shoulders with preserved passive motion, normal deltoid function, loss of glenohumeral joint surfaces, and sculpturing of the coracoacromial arch, a standard or oversized Neer II humeral prosthesis without glenoid replacement was selected. A total of 11 shoulders that failed to meet these prerequisites or demanded heavy use after operation underwent arthrodesis. Twenty-two patients (12 from the hemiarthroplasty group and 10 from the arthrodesis group) were available for evaluation at an average follow-up period of 37.5 months. Comfort level and overall function were improved in both groups. Active forward elevation improved an average of 44 degrees in the hemiarthroplasty group and an average of 15 degrees in the arthrodesis group. The success of hemiarthroplasty and the problems of glenoid loosening in the presence of cuff deficiency with upward head displacement have led to the conclusion that humeral hemiarthroplasty is the preferred method for managing complex irreparable tears of the rotator cuff in which the articular surface is destroyed, yet the deltoid muscle is functional. Shoulder arthrodesis is reserved for those patients who have both irreparable tears of the rotator cuff and irreparable deficiencies of the deltoid muscle, or the younger patient with demands for substantial strength at low angles of flexion.     

Contact pressure and glenohumeral translation following subacromial decompression: how much is enough?

Subacromial decompression is a common surgical procedure that has historically included coracoacromial ligament resection. However, recent reports have advocated preserving the coracoacromial ligament to avoid the potential complication of anterosuperior escape. The optimal subacromial decompression would achieve a smooth coracoacromial arch and decreased rotator cuff contact pressures while preserving the function of the arch in glenohumeral stability. We hypothesized that a subacromial decompression with a limited acromioplasty with preservation of the coracoacromial ligament can decrease extrinsic pressure on the rotator cuff similar to a coracoacromial ligament resection, without altering glenohumeral translation. Three different subacromial decompressions, including a "smooth and move," a limited acromioplasty with coracoacromial ligament preservation, and a coracoacromial ligament resection, were performed on 6 cadaveric specimens with intact rotator cuffs. Glenohumeral translation and peak rotator cuff pressure during abduction were recorded. No change in translation was observed after a smooth and move or a limited acromioplasty. Compared to baseline specimens, anterosuperior translation was increased at 30° of abduction following coracoacromial ligament resection (P<.05). Baseline rotator cuff pressure was greatest during abduction with the arm in 30° of internal rotation. Peak rotator cuff pressure decreased up to 32% following a smooth and move, up to 64% following a limited acromioplasty, and up to 72% following a coracoacromial ligament resection. Based on the present study, a limited acromioplasty with coracoacromial ligament preservation may best provide decompression of the rotator cuff while avoiding potential anterosuperior glenohumeral translation.     

Shoulder hemiarthroplasty for glenohumeral arthritis associated with severe rotator cuff deficiency.

BACKGROUND: Hemiarthroplasty for the treatment of shoulders with glenohumeral arthritis and severe rotator cuff deficiency has been reported to provide reasonable clinical results. The purposes of this study were to determine the clinical and radiographic results of hemiarthroplasty for this condition and to identify pathological and technical factors that may influence its outcome. METHODS: Thirty patients (thirty-three shoulders) managed with hemiarthroplasty because of glenohumeral arthritis and a massive, irreparable tear of the rotator cuff were followed for an average of five years (range, two to eleven years). Eight shoulders had undergone a prior acromioplasty and resection of the coracoacromial ligament. A small prosthetic head was used in three shoulders; a medium head, in twenty-six; and a large head, in four. Clinical results were graded according to the limited-goals criteria of Neer et al. RESULTS: The mean pain score decreased from 4.2 points preoperatively to 2.2 points at the time of the most recent follow-up (p = 0.0001). However, at the time of the most recent follow-up, nine shoulders (27%) had moderate pain at rest (four shoulders) or pain with activity (five shoulders). Mean active elevation improved from 72 degrees (range, 30 degrees to 150 degrees) to 91 degrees (range, 40 degrees to 165 degrees) (p = 0.008). Anterosuperior instability occurred in seven shoulders and was associated with a history of subacromial decompression (p = 0.04). The result was graded as successful for twenty-two shoulders (67%). CONCLUSIONS: Shoulder hemiarthroplasty provides marked pain relief in three-quarters of patients with glenohumeral arthritis and severe rotator cuff deficiency. It is a reconstructive option that provides durable results, but it may be complicated by instability and progressive bone loss.     

Rotator cuff interval reconstruction

Five pairs of cadaveric shoulders underwent posterior and anterior drawer and inferior sulcus tests in five progressive conditions: intact, vented, following opening of the rotator cuff interval, reconstruction of the interval, and transfer of the coracoacromial ligament. The surgical treatments--vented, open rotator cuff interval, reconstruction, and coracoacromial ligament transfer--had an effect compared to the intact shoulders on the inferior stiffness (P = .00002) and on the anteroposterior stiffness (P = .00031). The difference between the stiffness of the reconstructed rotator cuff interval compared to the coracoacromial ligament transfer was significant for loading in the AP direction (P = .006) and for loading in the inferior direction (P = .005).     

Management of irreparable rotator cuff tears and glenohumeral arthritis

Glenohumeral arthritis with irreparable rotator cuff tears remain a difficult entity to treat. Varied causes include rotator cuff tear arthropathy, osteoarthritis, or rheumatoid arthritis with irreparable cuff tear. Common symptoms are progressive pain and dysfunction. Physical examination may reveal pain, crepitance, rotator cuff weakness, and loss of motion and function. Radiographs may reveal varying degrees of osteophyte formation, sclerotic bone, superior humeral head migration, and bony erosion. Additional imaging modalities may reveal cuff tear size, retraction, atrophy, and fatty infiltration. Failure of nonoperative management may lead to operative intervention. Rotator cuff repair or reconstruction may help prevent progression of tears and future arthritic changes. In patients with moderate to severe glenohumeral arthritis and irreparable rotator cuff tears, hemiarthroplasty is currently the procedure of choice. For patients with severe cuff dysfunction or loss of coracoacromial arch, or for patients who require revision, the reverse shoulder prosthesis may offer a treatment option. Future management continues to be defined with additional study.     

Stress distribution patterns at the coracoacromial arch in rotator cuff tear measured by computed tomography osteoabsorptiometry.

When a rotator cuff tear occurs, forces compressing the humeral head toward the glenoid are disturbed, and the kinematics of the glenohumeral joint change. Therefore, stress distributions at the coracoacromial arch in cuff tear shoulders should differ from those in normal shoulders. To investigate this hypothesis, we studied stress distribution patterns at the coracoacromial arch in normal and cuff tear shoulders using a computed tomography (CT) osteoabsorptiometry method, in which bone density correlates directly with long-term physiologic loading. Eight normal subjects and 11 patients with cuff tear were examined. The stress distributions at the undersurface of the acromion and the posterolateral surface of the coracoid process differed markedly between normal and cuff tear shoulders. In cuff tear shoulders, a high-density area was located at the anterior or the anterolateral part of the undersurface of the acromion, while it was located at the posterior part in all but one normal shoulder. Additionally, a high-density area was located at the superior or the lateral part of the coracoid process in most of the cuff tear shoulders; on the other hand, it was located at the base in all but one normal shoulder. We believe that the differences in stress distribution patterns are due to impingement at the coracoacromial arch in cuff tear shoulders. CT osteoabsorptiometry can provide useful information in performing coracoacromial arch decompression for cuff tear shoulders.     

Histological analysis of the coracoacromial arch: Correlation between age-related changes and rotator cuff tears

The purpose of this study was to analyze age-related changes in the coracoacromial arch and correlate these degenerative changes with rotator cuff tears. We obtained 80 shouldes from 40 cadavers. The mean age at death was 58.4 years. We performed a gross examination of the rotator cuff and the acromion and histological examination of the coracoacromial ligament. The statistical significance of any difference for each group considered was determined by Student's t-test. The rotator cuff was normal in 66 specimens; there was an articular-side partial tear in 4 cases, a bursal-side partial tear in 6 cases, and a full-thickness tear in 4 cases. Age was correlated with increasing incidence and severity of cuff tears. We noted age-related degenerative changes in the coracoacromial ligament, degeneration of the acromial bone-ligament junction, and acromial spur formation. Anterior acromial spur was not related to the morphology of the acromion. We observed an increased incidence of bursal-side and complete cuff tears when the acromion was curved or beaked. Degenerative changes in the undersurface of the acromion were also present when the rotator cuff was normal. Bursal-side and complete cuff tears were associated with severe degenerative changes in the acromion in 100% of cases. Articular-side cuff tears were not related either to acromial morphology or degenerative changes in the coracoacromial arch. The association between cuff tears and acromial spur was more evident in the presence of a type III acromion. Our results would suggest that the incidence and severity of rotator cuff tears are correlated with aging and with the morphology of the acromion. Rotator cuff tears that involve the bursal side are often associated with changes in the coracoacromial ligament and the undersurface of the acromion. However, degenerative changes in the coracoacromial arch are always related to aging, also in the presence of a normal rotator cuff. Articular-side partial tears do not cause damage to the undersurface of the acromion.     

Anatomy of provocative tests for impingement syndrome of the shoulder

The purpose of this study was to describe the extra- and intra-articular anatomic relationships present during the Neer and Hawkins tests. Nine fresh-frozen cadaveric shoulders were positioned in the impingement position described by Neer (n = 5) or that described by Hawkins (n = 4), embedded in polyurethane, and studied with the use of a cross-sectional technique. All shoulders placed in the Neer position demonstrated soft tissue contact with the medial acromion and contact between the articular surface of the rotator cuff tendons and the anterosuperior glenoid rim. Shoulders placed in the Hawkins position demonstrated consistent contact between soft tissues and the coracoacromial ligament. In all Hawkins positioned shoulders, contact between the articular surface of the rotator cuff tendons and the anterosuperior glenoid was observed. The subscapularis tendon was deformed by the coracoid in 1 of the Hawkins positioned specimens. Although factors inherent to human subjects such as edema and muscle tone may influence the anatomy, these provocative tests for subacromial impingement appear to elicit contact consistent with impingement.     

Improvement in comfort and function after cuff repair without acromioplasty

The repair of full thickness rotator cuff tears traditionally has included acromioplasty and coracoacromial ligament section. Acromioplasty can be complicated by deltoid detachment, compromise of the deltoid lever arm, anterosuperior instability, and adhesions of the rotator cuff tendons under the bleeding cancellous bone of the osteotomized acromion. This report concerns the improvement in shoulder function at a minimum of 2 years after 27 full thickness rotator cuff repairs were done without deltoid detachment, acromioplasty, or section of the coracoacromial ligament. The mean number of Simple Shoulder Test functions that the patients could do increased from six of 12 before surgery to 10 of 12 at an average followup of 4 years after surgery. Eight of 12 individual Simple Shoulder Test functions were significantly improved after the procedure. There also was a significant improvement in the Short Form-36 comfort, physical role function, and mental health scores. When done without acromioplasty, cuff repair avoids the possibility of deltoid detachment, altered deltoid mechanics, anterosuperior instability, and tendon scarring to the cancellous undersurface of the acromion.     

Histological and ultrastructural changes in the undersurface of the acromion with subacromial impingement

Background We examined histological changes in the undersurface of the acromion in patients with symptoms of subacromial impingement, in order to clarify whether or not these changes are the main cause of rotator cuff tear.

Methods We studied 39 shoulders. The undersurface of the acromion and the coracoacromial ligament were examined by light microscopy and transmission electron microscopy.

Results The distinct four-layer structure seen in the undersurface of the acromion of normal subjects was not found in any of our patients. In patients with full-thickness cuff tear, the extent of the tear had a greater association with the degree of degeneration in the undersurface of the acromion than age or the duration of illness. There was little association between structural changes in the coracoacromial ligament and the extent of or the presence of full-thickness cuff tear, or the duration of illness, but there was a strong association with patient age.

Interpretation The histological changes in the undersurface of the acromion in patients without cuff tear were merely minute changes compared to those in patients with full-thickness cuff tear. We conclude that the advanced degenerative changes in the undersurface of the acromion result from full-thickness cuff tear.     

Histological and ultrastructural changes in the undersurface of the acromion with subacromial impingement

Background We examined histological changes in the undersurface of the acromion in patients with symptoms of subacromial impingement, in order to clarify whether or not these changes are the main cause of rotator cuff tear.

Methods We studied 39 shoulders. The undersurface of the acromion and the coracoacromial ligament were examined by light microscopy and transmission electron microscopy.

Results The distinct four-layer structure seen in the undersurface of the acromion of normal subjects was not found in any of our patients. In patients with full-thickness cuff tear, the extent of the tear had a greater association with the degree of degeneration in the undersurface of the acromion than age or the duration of illness. There was little association between structural changes in the coracoacromial ligament and the extent of or the presence of full-thickness cuff tear, or the duration of illness, but there was a strong association with patient age.

Interpretation The histological changes in the undersurface of the acromion in patients without cuff tear were merely minute changes compared to those in patients with full-thickness cuff tear. We conclude that the advanced degenerative changes in the undersurface of the acromion result from full-thickness cuff tear.     

Decompressive surgery in the tendinitis and tear stages of rotator cuff disease

Eighty-six shoulders with rotator cuff disease (54 with tendinitis and 32 with rotator cuff tear stage) operated on to relieve the impingement exerted by the coracoacromioclavicular arch on the rotator cuff were analyzed. The median follow-up time was 5.0 years. Partial resection of the anterior undersurface of the acromion, excision of the coracoacromial ligament or of the lateral end of the clavicle (and most commonly a combination of all three measures), were the methods used to achieve decompression. The final results show a substantial improvement in 83% of the cases. The results were related to the extent of acromial resection, preoperative range of the painful arc, and age ; but no statistically significant prognostic signs could be determined. There was some evidence, however, that a wide painful arc and extensive resection of the acromion were associated with a poor outcome. The indications for clavicular resection remain somewhat uncertain. Clavicular resection combined with acromioplasty seemed to give somewhat fewer good results, but the procedure is nevertheless indicated in cases with subacromial impingement associated with acromioclavicular osteoarthrithis. Decompressive surgery proved to be as effective in the tendinitis stage of the disease as in the case of rotator cuff tear. Conclusive operative release of shoulder impingement in rotator cuff disease is a useful procedure in patients with painful arc symptoms resistant to conservative treatment. The result can be improved by refinement of both indications and techniques.     

The coracoacromial ligament: the morphology and relation to rotator cuff pathology

We dissected 80 shoulders from 44 fresh cadavers to define variants of the coracoacromial ligament and their relationship to rotator cuff degeneration. The shapes and the geometric data of the ligaments were investigated, and the rotator cuffs of the cadavers were evaluated macroscopically. Five main types of coracoacromial ligaments were found: Y-shaped, broad band, quadrangular, V-shaped, and multiple-banded. The Y-shaped ligament was the most frequent type, with a frequency of 41.3%, and the V-shaped ligament (11.2%) has not been previously reported. Of the cadavers that were dissected bilaterally, 64% showed the same type of ligament. There was no statistical significance between rotator cuff degeneration and the type or geometric measurement of the ligament. However, the coracoacromial ligaments with more than 1 bundle showed significant association with rotator cuff degeneration with a longer lateral border and larger coracoid insertion.     

Coracoacromial ligament release for shoulder impingement syndrome using the Universal Subcutaneous Endoscope system.

We developed a new operative procedure of coracoacromial ligament release for shoulder impingement syndrome. The operative procedure was confirmed by cadaveric studies and applied to clinical cases in 40 shoulders of 37 patients who suffered from shoulder impingement without bony abnormalities. The subacromial space was observed under local anesthesia using the Universal Subcutaneous Endoscope (USE) system on an outpatient basis. A popping phenomenon was observed between the coracoacromial ligament and the greater tuberosity of the humerus, which was covered by the rotator cuff, and the coracoacromial ligament was resected with a rongeur under endoscopic visualization in all shoulders. Resection of the coracoacromial ligament relieved the impingement and clinical signs, as in open or arthroscopic resection of the coracoacromial ligament. Resection of the coracoacromial ligament using the USE system is a safe and less-stressful surgical invasion than open or standard arthroscopic resection of the coracoacromial ligament.     

Calcifying tendinitis of the rotator cuff: functional outcome after arthroscopic treatment

In this study, we assessed the functional results after arthroscopic excision of rotator cuff calcifications. Sixty-one shoulders in 57 patients with chronic calcifying tendinitis of the rotator cuff were treated with arthroscopic excision, subacromial bursa debridement and shaving. In patients with fraying or roughness of the coracoacromial ligament, an acromioplasty was also performed. Patients were evaluated after a mean follow-up of 15 months. The modified Constant score and DASH score significantly improved from 33.4 to 66.8 and from 49.7 to 17.3 respectively. Performing an acromioplasty did not influence the final outcome. Frozen shoulder was a frequent complication (18%) without significant effect on the final DASH or Constant score. The presence of residual calcifications after arthroscopic needling did not influence the final outcome. We therefore believe that the presence of residual calcifications can be accepted if this is deemed necessary to preserve the integrity of the tendon.     

反式全肩关节假体置换治疗巨大不可修复肩袖撕裂

目的探讨反式全肩关节置换术（reverse total shoulder arthroplasty,RTSA）治疗巨大不可修复肩袖撕裂的临床治疗效果。 方法对南京中医药大学附属医院2018年5月至2020年1月收治的采取RTSA治疗的13例巨大不可修复肩袖撕裂患者的临床资料进行回顾性分析。记录术前及最后一次随访时患者的肩关节前屈、外展、外旋活动,美国肩肘外科协会评分（American shoulder and elbow surgeons score,ASES）及美国加州大学洛杉矶分校（University of California at Los Angeles,UCLA）评分评估患者肩关节功能。并记录患者发生并发症的情况及影像学检查结果。术前行MR确定肩袖脂肪浸润程度,CT评价肩胛盂骨质情况及有无缺损,术后使用X线评估假体情况。 结果13例患者均随访至少12个月以上。统计术前与术后12个月数据之间的关系,术后12个月肩关节前屈、外展、外旋活动,ASES评分和UCLA评分较术前明显提高,差异具有统计学意义（P<0.01）。随访期内13例患者中有1例患者因局部血肿在术后1周行切开血肿清除引流术,所有患者功能恢复良好。 结论RTSA治疗巨大不可修复肩袖撕裂临床效果良好。     

Biomechanics of coracoacromial arch modification

Although the biomechanics of the coracoacromial arch and coracoacromial ligament (CAL) morphology are well studied, to our knowledge, the biomechanics of the coracoacromial arch after CAL resection and medial reattachment have not yet been studied. The purpose of this report is to examine the biomechanical consequences of coracoacromial arch alteration and subsequent reconstruction in cadaveric specimens. Anterosuperior humeral head translation was measured after the application of an anterosuperior 150-N load under 5 sequential scenarios: (1) intact CAL, (2) subperiosteal CAL release, (3) standard acromioplasty, (4) CAL reconstruction, and (5) modified Neer acromioplasty. A significant decrease in anterosuperior migration was found after CAL reconstruction compared with both anterior acromioplasty (P = .038) and modified Neer acromioplasty (P = .01). Thus, in patients with massive rotator cuff tears, reconstruction of the CAL may provide the necessary stabilizing force to prevent excessive anterosuperior translation and possible humeral head escape from the coracoacromial arch.     

Anatomy of the coracoacromial veil

The coracoacromial (CA) ligament plays an important role in the stability of the shoulder joint by limiting superior translation of the glenohumeral joint. This ligament is further divided into anterolateral and posteromedial bands. Attached to the CA ligament, a supportive structure was noted in some previous studies. The purpose of this study was to learn more about the anatomy of this structure. Twenty-eight shoulders were obtained. Deltoid and trapezius muscles were removed without damaging the rotator cuff and coracoacromial arch. The CA ligament was dissected further to reveal two constituent bands, an anterolateral and a posteromedial band. A connective tissue structure was noted between the posteromedial band, CA ligament, and rotator interval capsule. This structure was oriented as an L-shaped curtain, which the authors termed the "coracoacromial veil." Anatomical position of this veil provides a stabilizing link between the CA ligament and the rotator interval capsule. This structure potentially limits inferior translation of the glenohumeral joint.     

Endoscopic management of shoulder pain in long-term haemodialysis patients

In 48 shoulders of 29 patients receiving long-term haemodialysis and complaining of intolerable shoulder pain, endoscopic resection of the coracoacromial ligament was performed under local anaesthesia on an outpatient basis, using the Universal Subcutaneous Endoscope system. Predominant endoscopic findings were proliferation of the subacromial bursae and popping between the coracoacromial ligament and the rotator cuff. Amyloid originating from beta 2 microglobulin (beta 2-M) was demonstrated in 87% of the resected coracoacromial ligaments and 86% of the subacromial bursae. Resection of the coracoacromial ligament relieved the shoulder pain in all patients.     

Editorial Commentary: Yet Another Arrow in the Quiver for Surgical Treatment of the Rotator Cuff–Deficient Shoulder: Will It Fly Fast and Far or Fall Short Like Other Options Have?

Rotator cuff tears are common. When indicated, surgical repair is a highly successful procedure. There are circumstances when there is not enough tendon to perform an anatomic repair because of tear size, retraction, and/or atrophy. This clinical scenario, massive irreparable rotator cuff tear, has no perfect solution. Many options exist in treating massive irreparable rotator cuff tears: partial tendon repairs, debridement, tuberoplasty, intercalary allograft repairs, tendon transfers, superior capsular reconstruction, hemiarthroplasty, arthrodesis, and reverse total shoulder arthroplasty. No superior technique has been described. Another treatment has been added to this list: inserting a biodegradable balloon within the subacromial space to reduce the articulation of the humeral head on the acromion and aid in recentering the humeral head to restore balance to the remaining rotator cuff and improve deltoid function.