Humeral head fracture and cuff

During the past decade the evaluation of the rotator cuff in the management of proximal humeral fractures has received increasing attention. Different studies have investigated the pathomorphology, prevalence and impact of rotator cuff lesions on the outcome of non-operative or surgical treatment of proximal humeral fractures. Tendon defects, either chronic or trauma related, are observed mainly in the anterosuperior or posterosuperior aspect of the rotator cuff and present as partial- or full-thickness tears. Structural changes of the rotator cuff muscles including atrophy and fatty infiltration in the context of proximal humeral fractures have been inadequately investigated. The prevalence of coexisting rotator cuff pathology varies between 5 and greater than 50% depending on the method of evaluation, the fracture morphology and the age of the patient. The influence of a concomitant rotator cuff tear on the clinical outcome has not been conclusively investigated. However, different studies indicate that some lesions can be a source of persistent pain and functional deficit after conservative or surgical management of proximal humeral fractures. Therefore, a simultaneous repair of the rotator cuff defect during surgical reconstruction of the proximal humerus is indicated.     

Humeruskopffraktur und Manschette

During the past decade the evaluation of the rotator cuff in the management of proximal humeral fractures has received increasing attention. Different studies have investigated the pathomorphology, prevalence and impact of rotator cuff lesions on the outcome of non-operative or surgical treatment of proximal humeral fractures. Tendon defects, either chronic or trauma related, are observed mainly in the anterosuperior or posterosuperior aspect of the rotator cuff and present as partial- or full-thickness tears. Structural changes of the rotator cuff muscles including atrophy and fatty infiltration in the context of proximal humeral fractures have been inadequately investigated. The prevalence of coexisting rotator cuff pathology varies between 5 and greater than 50% depending on the method of evaluation, the fracture morphology and the age of the patient. The influence of a concomitant rotator cuff tear on the clinical outcome has not been conclusively investigated. However, different studies indicate that some lesions can be a source of persistent pain and functional deficit after conservative or surgical management of proximal humeral fractures. Therefore, a simultaneous repair of the rotator cuff defect during surgical reconstruction of the proximal humerus is indicated.     

Treatment options for irreparable postero-superior cuff tears in young patients

Rotator cuff tears (RCTs) occur more commonly with advanced age, with most rotator cuff abnormalities in patients less than 30 years old being painful tendinoses or partial-thickness RCTs. Irreparable postero-superior cuff tears has been reported as frequent as 7% to 10% in the general population, and the incidence of irreparable RCTs in young patients is still unknown. Several surgical procedures have been proposed for young patients with irreparable postero-superior RCTs, such as rotator cuff debridement, partial rotator cuff repair, biceps tenotomy/tenodesis, rotator cuff grafting, latissimus dorsi tendon transfer, and reverse shoulder arthroplasty. After being thoroughly investigated in open surgery, arthroscopic techniques for latissimus dorsi tendon transfer have been recently described. They have been shown to be an adequate option to open surgery for managing irreparable postero-superior RCTs refractory to conservative management.     

Arthroscopic Rotator Cuff Repairs: An Anatomic and Biomechanical Rationale for Different Suture-Anchor Repair Configurations

The goal of rotator cuff repairs is to achieve high initial fixation strength, minimize gap formation, maintain mechanical stability under cyclic loading, and optimize the biology of the tendon-bone interface until the cuff heals biologically to the bone. We have seen an evolution in our approaches to fixing rotator cuff tears from open to mini-open to all arthroscopic. In our arthroscopic techniques, we have also seen a change in the types of anchors and sutures we use and our repair techniques including an evolution in techniques that include single row, double row, and, most recently, transosseous equivalent fixation. Single-row repairs are least successful in restoring the footprint of the rotator cuff and are most susceptible to gap formation. Double-row repairs have an improved load to failure and minimal gap formation. Transosseous equivalent repairs have the highest ultimate load and resistance to shear and rotational forces and the lowest gap formation. This review will discuss the anatomy and biomechanics of a normal rotator cuff, the biomechanical factors that play a role in rotator cuff repairs, the initial fixation repair mechanics, and finally propose an algorithm for rotator cuff fixation based on tissue quality and tear configuration.     

The relative importance of acromial morphology and age with respect to rotator cuff pathology

The purpose of this study was to examine the relationship between patient age, acromial morphology, and rotator cuff pathology. Data on 523 patients who had arthroscopic and/or open shoulder surgery were reviewed. Acromial morphology was classified by the system of Bigliani. All patients were categorized by postoperative diagnosis as having tendinitis of the rotator cuff, partial rotator cuff tear, complete rotator cuff tear, and non-rotator cuff-related pathology. Univariate analysis results for acromial morphology (P <.001), age (P <.001), and gender (P =.019) showed a significant association with rotator cuff pathology. Fifty percent of patients with rotator cuff tendinitis had type I acromions, and 58% of patients with full-thickness rotator cuff tears had type III acromions. Stratified univariate analysis revealed no significant association between acromial morphology and rotator cuff pathology in patients who were over 50 years old. Patients with full-thickness rotator cuff tears were significantly older than those with partial-thickness tears or tendinitis. A larger proportion of male patients than female patients had full-thickness rotator cuff tears. Multivariable logistic regression analysis identified acromial morphology, age, and gender as independent multivariate predictors of rotator cuff pathology. Age, acromial morphology, and gender all have an independent association with rotator cuff pathology.     

Arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair is being performed by an increasing number of orthopaedic surgeons. The principles, techniques, and instrumentation have evolved to the extent that all patterns and sizes of rotator cuff tear, including massive tears, can now be repaired arthroscopically. Achieving a biomechanically stable construct is critical to biologic healing. The ideal repair construct must optimize suture-to-bone fixation, suture-to-tendon fixation, abrasion resistance of suture, suture strength, knot security, loop security, and restoration of the anatomic rotator cuff footprint (the surface area of bone to which the cuff tendons attach). By achieving optimized repair constructs, experienced arthroscopic surgeons are reporting results equal to those of open rotator cuff repair. As surgeons' arthroscopic skill levels increase through attendance at surgical skills courses and greater experience gained in the operating room, there will be an increasing trend toward arthroscopic repair of most rotator cuff pathology.     

Current Perspectives on Rotator Cuff Anatomy

Understanding the anatomy of the rotator cuff and the surrounding structures that influence its function is essential to treating rotator cuff disease. During the past decade, advances in basic science and surgical technology have improved our knowledge of this anatomy. This review article presents the current concepts on rotator cuff anatomy and how they should be used in the surgical management of rotator cuff tears.     

Rotator cuff tears: diagnosis and therapy

Since the life span of our society is increasing and the expectation of high functional demands is growing more and more older people take part in sports activities emphasises the necessity of early diagnosis of rotator cuff lesions and their correct treatment. The goal of any diagnostic means should be a proper treatment of rotator cuff lesions according to the detected pathology. New arthroscopic techniques to surgically reconstruct rotator cuff tears have brought the operative repair techniques another step further. In cases of large and complex cuff tears the surgeon can individually select an adequate reconstruction procedure which includes anatomical-, partial-, tendon-transfer and muscle-transfer repairs. In cases of irreparable tears with cuff-tear arthropathy and consecutive superior migration of the humeral head hemiarthroplasty or the inverse deltoid prosthesis have to be considered. Based on clinical, radiological and arthroscopic findings we developed algorithms that will lead to the best suited procedure for a given lesion.     

Massive irreparable rotator cuff tears

Management of massive irreparable posterosuperior rotator cuff tears is a surgical challenge, particularly in young active patients without any signs of osteoarthritis. Different surgical techniques have been described. To the three main deficits of active range of motion previously reported for a massive irreparable cuff tear, i.e., isolated loss of active elevation (ILEA), isolated loss of active external rotation (ILER), and combined loss of elevation and external rotation (CLEER), we add two new entities: isolated loss of active internal rotation (ILIR) and combined loss of active elevation and active internal rotation (CLEIR). We suggest that a combined deficit (CLEER or CLEIR) could lead to a new definition of a pseudoparalytic shoulder and propose a novel algorithm to redefine the role of latissimus dorsi transfer in each of these situations. We also describe a fully arthroscopic latissimus dorsi transfer technique that prevents any deltoid muscle insult, offers better visualization of the neighboring neurovascular structures at risk, and allows simultaneous management of biceps pathology and partial rotator cuff repair.     

Rotator cuff tear arthropathy

Rotator cuff tear arthropathy represents a spectrum of shoulder pathology characterized by rotator cuff insufficiency, diminished acromiohumeral distance with impingement syndromes, and arthritic changes of the glenohumeral joint. Additional features may include subdeltoid effusion, humeral head erosion, and acetabularization of the acromion. Although the progression of rotator cuff tears seems to play a role in the development of cuff tear arthropathy, information is lacking regarding the natural progression of rotator cuff tears to cuff tear arthropathy. Controversy remains about the role of basic calcium phosphate crystals in the development of cuff tear arthropathy. Nonsurgical management is the first line of treatment in most patients. Traditionally, surgical management of rotator cuff tear arthropathy has been disappointing because of the development of complications long-term and poor patient satisfaction with functional outcomes. Recent studies, however, report promising experience with reverse ball-and-socket arthroplasty.     

Editorial Commentary: Rotator Cuff Repair: Graft Augmentation Provides Promising Clinical Outcomes

Rotator cuff repair has benefitted from many technologic advances including the advent of arthroscopy, improved implant materials, and refined repair techniques. Despite our efforts to improve the science of rotator cuff repair, clinical advances have lagged far behind. Graft augmentation of rotator cuff repairs is an emerging and heterogeneous field that has significantly improved both healing rates and patient-reported metrics in initial data reporting. Treatment algorithms that guide the use of this novel surgical modality are of benefit to practicing orthopaedic surgeons.     

Surgical treatment of os acromiale with and without associated rotator cuff tears

Nineteen consecutive patients treated surgically for meso-os acromiale and subacromial pathology were reviewed retrospectively, with a mean length of follow-up of 40 months (range, 24-94 months). Of the patients, 11 (58%) were treated with acromioplasty in the presence of a stable os acromiale; 8 patients (42%) underwent open reduction-internal fixation for an unstable and painful os fragment. Of the 19 patients, 8 (42%) with an os acromiale had an associated full-thickness rotator cuff tear. Overall, only 10 of 19 patients (53%) achieved a satisfactory result. All 8 patients (100%) treated with open reduction-internal fixation achieved union of the os fragment, although only 3 (37.5%) achieved a satisfactory result. Of the 11 patients who underwent acromioplasty, only 7 (64%) achieved a satisfactory result. The outcome of surgical management of symptomatic meso-os acromiale with concomitant rotator cuff pathology was satisfactory in 4 of 8 patients in our study group. The rate of satisfactory results was similar in patients with (50%) and without (55%) associated rotator cuff tears. When we analyzed our results to exclude workers' compensation patients, 80% achieved satisfactory results (compared with only 22% in our workers' compensation group).     

Editorial Commentary: Steroid Injections Prior to Arthroscopic Rotator Cuff Repair—Is It Time to Rethink a Conservative Treatment Paradigm?

The standard of care for most rotator cuff conditions over the past half century or longer has been a trial of nonoperative treatment including nonsteroidal anti-inflammatory agents, physiotherapy, and steroid injections prior to surgery. There is compelling basic science data to suggest a negative effect of corticosteroids on tissue quality. Chronicity of the tear is a risk factor for unsuccessful repair, but other factors including use of tobacco products, repair technique, and postoperative management all have an impact. Evidence either in favor of or against use of steroid injections as a treatment option is limited or weak at best. Given advances in rotator cuff repair techniques and successful long-term outcomes, treating surgeons should be mindful of how injections might affect surgical outcomes owing to either delayed surgical intervention or a direct effect on tissue quality.     

Chronic massive rotator cuff tears: evaluation and management

Most studies of rotator cuff repairs report high success rates. However, the majority of these studies combine the results of surgical management of rotator cuff tears of various sizes; few published reports specifically evaluate the management of chronic massive tears. Chronic massive rotator cuff tears may be acute traumatic, chronic atraumatic, or acute-on-chronic. A detailed history and thorough physical examination often are sufficient to establish the diagnosis. Radiographic evaluation can reveal osseous changes suggestive of pathology. Magnetic resonance imaging can determine the size of rotator cuff tears and status of the muscles but generally is not necessary for patients who are not candidates for surgery. Chronic massive rotator cuff tears without glenohumeral arthritis can be managed nonsurgically or with sub-acromial debridement, rotator cuff repair, or rotator cuff reconstruction. However, treatment of these patients is challenging, and results are comparatively inferior to those of treating patients with smaller rotator cuff tears.     

Editorial Commentary: Is Magnetic Resonance Imaging of the Shoulder Ever Appropriate in Evaluating Patients With Calcific Tendinopathy of the Rotator Cuff?

Calcific tendinopathy of the rotator cuff is a common pathology that often presents with clinical symptoms simulating a rotator cuff tear. The reported incidence of rotator cuff tear in the setting of calcific tendinopathy varies widely; however, the reported incidence of full-thickness rotator cuff tear on imaging in calcific tendinopathy is consistently low (<5%). In patients with symptomatic calcific tendinopathy, initial conservative management followed by minimally invasive treatments should be employed prior to performing shoulder magnetic resonance imaging to assess for a rotator cuff tear. A shoulder magnetic resonance imaging may be performed for preoperative planning prior to surgical removal of calcium deposits, but even in this patient population, the incidence of full-thickness rotator cuff tear is low.     

Graft Augmentation of Repairable Rotator Cuff Tears: An Algorithmic Approach Based on Healing Rates

We provide our algorithm for tissue augmentation of rotator cuff repairs based on the current available evidence regarding rotator cuff healing. A variety of factors are associated with healing following rotator cuff repair. Increasing tear size and retraction as well as severe fatty degeneration have been associated with worsening rates of tendon healing. Given the correlation between tendon healing and postoperative outcomes, it is important to identify patients at high risk for failure and to modify their treatment accordingly to minimize the risk of early biomechanical failure and maximize the potential for structural healing. One approach that may be used to improve healing is tissue augmentation. Tissue augmentation is the use of tissue patches and scaffolds to provide rotator cuff reinforcement. Surgical management for rotator cuff tears (RCTs) continues to be a challenging task in orthopaedic surgery today. Appropriate treatment measures require an in depth understanding and consideration of the patient’s prognostic factors such as age, fatty infiltration of the rotator cuff muscles, bone mineral density, rotator cuff retraction, anteroposterior tear size, work activity, and degenerative changes of the joint. Using these factors within the Rotator Cuff Healing Index, we can determine a patient’s surgical treatment that will yield the maximum healing rate. For nonarthritic RCTs, joint-preserving strategies should be first-line treatment options. For young, active patients with a reparable RCT and minimal fatty infiltration, a complete repair can be effective. For young patients with irreparable RCTs, superior capsular reconstructions, and tendon transfers are viable options. For elderly patients with low work activity, an irreparable RCT and significant fatty infiltration, a partial repair with or without graft augmentation can be attempted if minimal to no arthritic changes are seen.Level of EvidenceLevel V, expert opinion.     

Traumatic rotator cuff tears - Current concepts in diagnosis and management

Rotator cuff tears represent one of common shoulder pathologies presenting over a wide spectrum of age groups and varying presentation. Typically, rotator cuff tears occur more frequently in elderly than in younger patients, following a chronic or acute-on-chronic course and usually secondary to due to tendon degeneration. Though there has been a considerable debate in the literature of the terms “acute” and “traumatic” used in the classification of rotator cuff tears, there appears to be consensus about the need for early diagnosis to facilitate prompt surgical treatment and the improve patient outcome. Significant differences in rotator cuff tears between those occurring in younger and older patients could be due to mechanism of injury, presentation, severity of the tear, biological healing potential and rehabilitation. Acute traumatic rotator cuff tears especially in younger age group represent a distinct entity from other patterns of rotator cuff tears. Consequently, a high index of suspicion, focused clinical examination, complementary imaging is a pre-requisite for an early diagnosis and effective management.We analyze the biomechanical consequences of acute rotator cuff tears along with characteristic mechanism of injury and spectrum of tendon involvement. The evolving concepts in the diagnosis and management of these distinct injuries are discussed with review of current literature.     

All arthroscopic treatment of rotator cuff tears

Although shoulder arthroscopy was initially performed solely for subacromial decompression, at present it is widely used for rotator cuff repairs and reconstruction. All arthroscopic rotator cuff repairs have been performed increasingly over the past decade and favorable long-term results have been reported in the literature. All arthroscopic rotator cuff repair has advantages over mini-open, or open rotator cuff repair, because it is associated with less postoperative pain and morbidity, and a more rapid improvement in shoulder motion. However, complete arthroscopic rotator cuff repair is a technically difficult procedure, with some limitations including relative weakness of tendon sutures and the need for more experience. It is essential that the merits and demerits associated with this technique should be balanced depending on the individual condition of the patient and the degree of experience gained. This article revisits all arthroscopic rotator cuff repair with regard to advantages and disadvantages, surgical techniques, indications, postoperative rehabilitation, and the results both in the light of the literature and our experience.     

Early complications from the use of porcine dermal collagen implants (Permacol) as bridging constructs in the repair of massive rotator cuff tears. A report of 4 cases

The repair of massive rotator cuff tears can be very challenging. Different surgical techniques are described in the literature, including debridement of the cuff with subacromial decompression, attempts at direct partial repair, various tendon transfers, shoulder hemiarthroplasty, reversed shoulder arthroplasty and allograft augmentation. Following favourable published evidence of the use of porcine dermal collagen implants, Permacol (Tissue Science Laboratories, Hampshire, UK, now known as Collagen Repair Patch, Zimmer, Warsaw, Ind) as a bridging device to repair massive defects, we used it in four of our patients. However, we have seen with great concern that in all four cases, the grafts failed between 3-6 months after a promising early postoperative period. We report on these 4 cases giving clinical, radiographic and histological findings. We conclude that although Permacol has man obvious advantages, it should not be used to bridge irreparable massive rotator cuff tears.     

Editorial Commentary: Restoration of Rotator Cuff Footprint Anatomy Is All That Matters,No Matter How We Get There

Delamination of rotator cuff tears presents a challenge to shoulder arthroscopists. Tear pattern recognition and an understanding of anatomy as it relates to the superior capsule guide treatment strategies. The key to management of a delaminated rotator cuff tear is to recognize differential retraction of respective layers. Successful outcomes of surgical management require conscientious and deliberate restoration of the attachment points of the cable. The goal is to produce an anatomic repair.