Abstract
Massive irreparable rotator cuff tears without glenohumeral arthritis are a common cause of shoulder pain and disability. Many surgical treatment options have been proposed, including debridement, partial repair, tendon transfer, superior capsule reconstruction, balloon spacer placement, bursal acromial reconstruction, and reverse shoulder arthroplasty. Interposition graft bridging reconstruction, as evidenced by the mid-term results of the current study, may also be considered, at least for now. However, let’s see if this procedure will truly stand the test of time because all orthopaedic surgeons know that the one thing that ruins good results is long-term follow-up!
Massive irreparable rotator cuff tears without glenohumeral arthritis are a common cause of shoulder pain and disability. Many surgical treatment options have been proposed, including debridement, partial repair, tendon transfer, superior capsule reconstruction, balloon spacer placement, bursal acromial reconstruction, and reverse shoulder arthroplasty.
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All seem to show varying degrees of improvement with decreased pain and improved function. We can now add to this list interposition graft bridging (also known as “bridging reconstruction”) as Awad, Sparavalo, Ma, King, and Wong,4
in the article “Interposition Graft Bridging Reconstruction of Irreparable Rotator Cuff Tears Using Acellular Dermal Matrix: Medium-Term Results,” have presented their series of patients with a mean follow-up period of 5.3 years (range, 2-9 years). The results showed that both the Western Ontario Rotator Cuff score and the Disabilities of the Arm, Shoulder and Hand score significantly improved from preoperatively to postoperatively and 92% and 74% of patients met the minimal clinically important difference for the Western Ontario Rotator Cuff score and Disabilities of the Arm, Shoulder and Hand score, respectively.With many options to offer patients with an irreparable rotator cuff tear, how does one choose? Patient factors such as age, activity level, hand dominance, job status, risk tolerance, and comorbidities clearly affect the decision process. Surgical considerations such as product availability, technical skill, and tissue quality can also play a role. However, we believe that one of the most important factors to consider is identifying the root cause of the pain and disability. Various causes have been proposed.
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Are the symptoms caused by superior migration of the humeral head affecting rotator cuff stabilization of the humerus in the glenoid? If so, then procedures that depress and center the humeral head in the glenoid should be an effective option (e.g., superior capsule reconstruction). However, if impingement of the humeral head with subsequent acetabularization on the acromion is the more likely cause, then procedures that act as interpositional spacers or grafts are more likely to succeed. Many of these procedures can do both.So, ultimately, what are the factors that make one procedure more favorable than another? They are reliability, durability, and reproducibility. In other words, procedures that are consistently easy to perform, have a low complication rate, and provide good results that do not degrade over time will endure in the long run. Interposition graft bridging reconstruction, as evidenced by the mid-term results of the current study, may be considered as one of those procedures, at least for now. However, let’s see if this procedure will truly stand the test of time because all orthopaedic surgeons know that the one thing that ruins good results is long-term follow-up!
Supplementary Data
- ICMJE author disclosure forms
References
- Management of the irreparable rotator cuff tear.J Am Acad Orthop Surg. 2019; 27: 909-917
- Irreparable rotator cuff tears: Current treatment options.Orthop Rev (Pavia). 2019; 11: 8146
- Treatment strategy for irreparable rotator cuff tears.Clin Orthop Surg. 2018; 10: 119-134
- Interposition graft bridging reconstruction of irreparable rotator cuff tears using acellular dermal matrix: Medium-term results.Arthroscopy. 2021; 38: 699-700
- Intraoperative determinants of rotator cuff repair integrity: An analysis of 500 consecutive repairs.Am J Sports Med. 2012; 40: 2771-2776
- Partial repair of irreparable rotator cuff tears.Arthroscopy. 1994; 10: 363-370
- Fluoroscopic comparison of kinematic patterns in massive rotator cuff tears. A suspension bridge model.Clin Orthop Relat Res. 1992; 284: 144-152
- Outcome comparison of graft bridging and superior capsule reconstruction for large to massive rotator cuff tears: A systematic review.Am J Sports Med. 2020; 48: 2828-2838
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Footnotes
The author reports the following potential conflicts of interest or sources of funding: M.D.F. is Associate Editor for Arthroscopy. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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© 2021 by the Arthroscopy Association of North America
