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Muscle advancement in massive rotator cuff repair

Current Research
Muscle advancement in massive rotator cuff repair

Background

Need exists for an improved massive RCT repair technique to maximise both repair success and patient outcomes

Good to excellent clinical outcomes and high healing rates have long been achieved in arthroscopic and mini open rotator cuff repair for small- to medium-sized rotator cuff tears (RCTs)2, 31, 34, 39. However, high failure rates persist for large to massive RCTs 12, 19, 37. Whether we should aim for complete or partial repair for massive RCTs is controversial and while some surgeons have designed ingenious procedures to improve healing after massive RCT repair, the question remains whether their excellent results depend on their skill more than technique27, 38.

Associated with poorer outcomes and increased failure following rotator cuff repair is the presence of high muscle tension at the repair site9. In addressing this, some surgeons e.g. Debeyre et al10 have reported using a technique in which the supraspinatus (SSP) muscle is elevated from the supraspinatus fossa and advanced laterally. While this decreases the tension of the distal SSP tendon with acromial osteotomy, the technique involves very invasive surgery and runs the risk of complications including nonunion at the osteotomy site41. In addition, only SSP muscles are advanced, not infraspinatus (ISP) muscles which is problematic given massive tears usually involve both. Further to this, Warner et al40 point out that suprascapular nerve (SSN) palsy may occur with excessive advancement of SSP muscles.

There appears to be a clear need for an improved massive RCT repair technique which takes into account both SSP and ISP muscles and is minimally invasive. Such a technique which is also simple and efficient would increase the probability of repair success and help maximize surgical outcomes for these patients.

Objectives

  • To determine how adding muscle advancement affects the healing rate and functional outcomes of massive rotator cuff tear repair.

Design

Prospective case series compared to age-matched historical cases.

Study Procedure

All consecutive patients indicated for elective rotator cuff repair will be considered eligible. After reading the information sheet and signing the consent form, they will be enrolled. Baseline characteristics of age, sex, hand dominance and relevant comorbidities will be recorded in a deidentified Patient Data Form (PDF) along with cuff tear size and type, associated pathology (from pre-operative imaging), pre-operative range of motion from the Constant Score and scores from 2 x Patient Reported Outcome Measures (PROMs): the American Shoulder and Elbow Society (ASES) and Western Ontario Rotator Cuff Index (WORC).

The surgery will proceed as follows:

(1) the surgeon will evaluate the rotator cuff tear via shoulder arthroscopy (as usual) and release the suprascapular nerve (if warranted);

(2) muscle advancement (the new technique) will be performed;

(3) the cuff will be repaired (as usual).

Depending on presentation, the repair will include biceps tenodesis or tenotomy. If tenodesis is performed, the type (i.e. groove or subpec) will be recorded on the PDF. Should subacromial decompression or AC Joint excision be performed (again, due to presentation) these too will be recorded along with presence (or absence) of glenohumeral arthritis (which may not have been previously diagnosed radiologically or clinically).

After the surgery, pain at 2 weeks, PROMs and range of motion at 8, 24 and 52 weeks will be recorded on the PDF and all data will then be collated and analysed.

Inclusion Criteria

  • Patients diagnosed with a massive rotator cuff tear (defined as involving at least 2 tendons) and more than 2 cm tendon retraction
  • Patients consented for shoulder arthroscopy and rotator cuff repair
  • Patients capable of giving informed consent to participate in the study

Exclusion Criteria

  • Patients with incomplete rotator cuff tears
  • Patients with isolated subscapularis or supraspinatus tendon tears
  • Patients with a failed rotator cuff repair requiring revision
  • Patients with irreparable rotator cuff tears
  • Patients with acute post trauma rotator cuff tears
  • Patients whose rotator cuff tears have a neurologic lesion such as cervical spondylotic myelopathy
  • Patients with glenohumeral osteoarthritis or rheumatoid arthritis
  • Patients with history of infection in the affected shoulder
  • Patients who are unable to have an MRI

Ethics and Governance

Approved by St Vincent’s Hospital Human Research Ethics Committee. HREC reference 2020/ETH01267.

Status

Recruiting.

References

  • Affonso J, Nicholson GP, Frankle MA, Walch G, Gerber C, Garzon-Muvdi J, et al. Complications of the reverse prosthesis: prevention and treatment. Instr Course Lect 2012;61:157-68
  • Bell S, Lim YJ, Coghlan J. Long-term longitudinal follow-up of mini-open rotator cuff repair. J Bone Joint Surg Am 2013;95:151-7.
  • Bigliani LU, Dalsey RM, McCann PD, April EW. An anatomical study of the suprascapular nerve. Arthroscopy 1990;6:301-5.
  • Boulahia A, Edwards TB, Walch G, Baratta RV. Early results of a reverse design prosthesis in the treatment of arthritis of the shoulder in elderly patients with a large rotator cuff tear. Orthopedics 2002;25:129-33.
  • Burkhart SS, Athanasiou KA, Wirth MA. Margin convergence: a method of reducing strain in massive rotator cuff tears. Arthroscopy 1996;12:335-8.
  • Charousset C, Zaoui A, Bellaïche L, Piterman M. Does autologous leukocyte-platelet-rich plasma improve tendon healing in arthroscopic repair of large or massive rotator cuff tears? Arthroscopy 2014;30:428-35.
  • Codsi MJ, Hennigan S, Herzog R, Kella S, Kelley M, Leggin B, et al. Latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears. Surgical technique. J Bone Joint Surg Am 2007;89:1-9.
  • Costouros JG, Porramatikul M, Lie DT, Warner JJ. Reversal of suprascapular neuropathy following arthroscopic repair of massive supraspinatus and infraspinatus rotator cuff tears. Arthroscopy 2007;23:1152-61.
  • Davidson PA, Rivenburgh DW. Rotator cuff repair tension as a determinant of functional outcome. J Shoulder Elbow Surg 2000;9:502-6.
  • Debeyre J, Patie D, Elmelik E. Repair of ruptures of the rotator cuff of the shoulder. J Bone Joint Surg Br 1965;47:36-42.
  • Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff; assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg 1999;8:599- 605.
  • Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am 2004;86:219- 24.
  • Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am 2000;82:505-15.
  • Gerber C, Vinh TS, Herter R, Hess CW. Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report. Clin Orthop Relat Res 1988;(232):51-61.
  • Goutallier D, Postel JM, Van Driessche S, Godefroy D, Radier C. Tension-free cuff repairs with excision of macroscopic tendon lesions and muscular advancement: results in a prospective series with limited fatty muscular degeneration. J Shoulder Elbow Surg 2006;15:164-72.
  • Grimberg J, Kany J. Latissimus dorsi tendon transfer for irreparable postero-superior cuff tears: current concepts, indications, and recent advances. Curr Rev Musculoskelet Med 2014;7:22-32.
  • Guery J, Favard L, Sirveaux F, Oudet D, Mole D, Walch G. Reverse total shoulder arthroplasty. Survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am 2006;88:1742-7.
  • Hakimi O, Mouthuy PA, Carr A. Synthetic and degradable patches: an emerging solution for rotator cuff repair. Int J Exp Pathol 2013;94:287- 92.
  • Henry P, Wasserstein D, Park S, Dwyer T, Chahal J, Slobogean G, et al. Arthroscopic repair for chronic massive rotator cuff tears: a systematic review. Arthroscopy 2015;31:2472-80.
  • Heuberer PR, Kölblinger R, Buchleitner S, Pauzenberger L, Laky B, Auffarth A, et al. Arthroscopic management of massive rotator cuff tears: an evaluation of débridement, complete, and partial repair with and without force couple restoration. Knee Surg Sports Traumatol Arthrosc 2016;24:3828-37.
  • Iannotti JP, McCarron J, Raymond CJ, Ricchetti ET, Abboud JA, Brems JJ, et al. Agreement study of radiographic classification of rotator cuff tear arthropathy. J Shoulder Elbow Surg 2010;19:1243-9.
  • Kim KC, Shin HD, Cha SM, Kim JH. Repair integrity and functional outcomes for arthroscopic margin convergence of rotator cuff tears. J Bone Joint Surg Am 2013;95:536-41.
  • Kim SJ, Lee IS, Kim SH, Lee WY, Chun YM. Arthroscopic partial repair of irreparable large to massive rotator cuff tears. Arthroscopy 2012;28:761-8.
  • Lafosse L, Lanz U, Saintmard B, Campens C. Arthroscopic repair of subscapularis tear: surgical technique and results. Orthop Traumatol Surg Res 2010;96:S99-108.
  • Lafosse L, Reiland Y, Baier GP, Toussaint B, Jost B. Anterior and posterior instability of the long head of the biceps tendon in rotator cuff tears: a new classification based on arthroscopic observations. Arthroscopy 2007;23:73-80.
  • Lafosse L, Tomasi A, Corbett S, Baier G, Willems K, Gobezie R. Arthroscopic release of suprascapular nerve entrapment at the suprascapular notch: technique and preliminary results. Arthroscopy 2007;23:34-42.
  • Lo IK, Burkhart SS. Arthroscopic repair of massive, contracted, immobile rotator cuff tears using single and double interval slides: technique and preliminary results. Arthroscopy 2004;20:22-33.
  • Lo IK, Burkhart SS. Double-row arthroscopic rotator cuff repair: re-establishing the footprint of the rotator cuff. Arthroscopy 2003;19:1035-42.
  • Mihata T, Lee TQ, Watanabe C, Fukunishi K, Ohue M, Tsujimura T, et al. Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy 2013;29:459-70.
  • Mori D, Funakoshi N, Yamashita F. Arthroscopic surgery of irreparable large or massive rotator cuff tears with low-grade fatty degeneration of the infraspinatus: patch autograft procedure versus partial repair procedure. Arthroscopy 2013;29:1911-21.
  • Neyton L, Godenèche A, Nové-Josserand L, Carrillon Y, Cléchet J, Hardy MB. Arthroscopic suture-bridge repair for small to medium size supraspinatus tear: healing rate and retear pattern. Arthroscopy 2013;29:10-7.
  • Park MC, Elattrache NS, Ahmad CS, Tibone JE. “Transosseousequivalent” rotator cuff repair technique. Arthroscopy 2006;22:1360.e1-5.
  • Paxton ES, Teefey SA, Dahiya N, Keener JD, Yamaguchi K, Galatz LM. Clinical and radiographic outcomes of failed repairs of large or massive rotator cuff tears: minimum ten-year follow-up. J Bone Joint Surg Am 2013;95:627-32.
  • Peters KS, McCallum S, Briggs L, Murrell GA. A comparison of outcomes after arthroscopic repair of partial versus small or medium-sized full-thickness rotator cuff tears. J Bone Joint Surg Am 2012;94:1078-85. h
  • Reilly P, Bull AM, Amis AA, Wallace AL, Richards A, Hill AM, et al. Passive tension and gap formation of rotator cuff repairs. J Shoulder Elbow Surg 2004;13:664-7.
  • Resch H, Povacz P, Ritter E, Matschi W. Transfer of the pectoralis major muscle for the treatment of irreparable rupture of the subscapularis tendon. J Bone Joint Surg Am 2000;82:372-82.
  • Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair. A prospective outcome study. J Bone Joint Surg Am 2007;89:953-60.
  • Van der Zwaal P, Pool LD, Hacquebord ST, van Arkel ER, van der List MP. Arthroscopic side-to-side repair of massive and contracted rotator cuff tears using a single uninterrupted suture: the shoestring bridge technique. Arthroscopy 2012;28:754-60.
  • Van der Zwaal P, Thomassen BJ, Nieuwenhuijse MJ, Lindenburg R, Swen JW, van Arkel ER. Clinical outcome in all-arthroscopic versus mini-open rotator cuff repair in small to medium-sized tears: a randomized controlled trial in 100 patients with 1-year follow-up. Arthroscopy 2013;29:266-73.
  • Warner JP, Krushell RJ, Masquelet A, Gerber C. Anatomy and relationships of the suprascapular nerve: anatomical constraints to mobilization of the supraspinatus and infraspinatus muscles in the management of massive rotator-cuff tears. J Bone Joint Surg Am 1992;74:36-45.
  • Yamanaka Y, Matsumoto T, Iijima K. The osteotomy of the acromion with an operation of a massive cuff tear]. Shoulder Joint 1994;18:273-8 [in Japanese].
  • Yokoya S, Nakamura Y, Harada Y, Ochi M, Adachi N, Outcomes of arthroscopic rotator cuff repair with muscle advancement for massive rotator cuff tears. J Shoulder Elbow Surg (2019) 28, 445–452
  • Yoo JC, Ahn JH, Koh KH, Lim KS. Rotator cuff integrity after arthroscopic repair for large tears with less-than-optimal footprint coverage. Arthroscopy 2009;25:1093-100.
  • Yoon JP, Chung SW, Kim JY, Lee BJ, Kim HS, Kim JE, et al. Outcomes of combined bone marrow stimulation and patch augmentation for massive rotator cuff tears. Am J Sports Med 2016;44:963-71.
  • National Statement on Ethical Conduct in Human Research (2007) – Updated December 2013 (The National Statement), Commonwealth of Australia, Canberra.

sydney-shoulder-research-institute-projects

Lead Investigator:

Dr Ben Cass

Commenced:

2020

Category:

Current Projects

In Research - Current

Reverse Total Shoulder Arthroplasty: Comparative Study of New Technologies

In Research - Current

Muscle advancement in massive rotator cuff repair