WEBVTT 00:00:00.000 --> 00:00:03.020 Welcome back to The Deep Dive. Today we're plunging 00:00:03.020 --> 00:00:06.080 into, well, one of orthopedic surgery's really 00:00:06.080 --> 00:00:08.859 quite formidable challenges, the irreparable 00:00:08.859 --> 00:00:11.779 rotator cuff tear. This isn't your average tear, 00:00:11.919 --> 00:00:15.480 is it? It's a complex problem that really pushes 00:00:15.480 --> 00:00:17.940 the boundaries of surgical ingenuity and, of 00:00:17.940 --> 00:00:20.039 course, patient care. That's absolutely right, 00:00:20.100 --> 00:00:22.120 yes. When we talk about an irreparable tear, 00:00:22.199 --> 00:00:25.000 we're using a, well, a specific clinical definition. 00:00:25.359 --> 00:00:27.679 It's based on factors that go beyond just the 00:00:27.679 --> 00:00:29.679 size of the tear itself, although... you know, 00:00:29.780 --> 00:00:31.980 size is often part of it. Right. The literature 00:00:31.980 --> 00:00:34.240 really points to some key characteristics that 00:00:34.240 --> 00:00:37.479 make a torn rotator cuff truly irreparable. OK, 00:00:37.500 --> 00:00:40.259 let's unpack that then. What exactly distinguishes 00:00:40.259 --> 00:00:43.240 an irreparable tear from, say, just a massive 00:00:43.240 --> 00:00:45.240 tear that, you know, might still be potentially 00:00:45.240 --> 00:00:48.520 repairable? That's a very good question. Whilst 00:00:48.520 --> 00:00:51.140 many irreparable tears are massive, involving 00:00:51.140 --> 00:00:53.679 more than one or two tendons, the term irreparable 00:00:53.679 --> 00:00:55.939 specifically refers to factors that make a successful, 00:00:56.240 --> 00:00:58.859 durable surgical repair. Right. Oh, unlikely. 00:00:58.979 --> 00:01:02.179 Or even impossible. The main culprits here are, 00:01:02.399 --> 00:01:05.299 firstly, the degree of retraction. That's how 00:01:05.299 --> 00:01:07.260 far the torn tendon has pulled back from its 00:01:07.260 --> 00:01:09.879 attachment point. Often it's so severe you simply 00:01:09.879 --> 00:01:12.120 cannot physically mobilize the tissue back to 00:01:12.120 --> 00:01:15.640 the bone without putting it under excessive tension. 00:01:15.879 --> 00:01:18.879 Too tight? Exactly. And perhaps even more critically, 00:01:19.219 --> 00:01:21.620 it's about the quality of the muscle tissue itself. 00:01:22.040 --> 00:01:24.599 Muscle quality? How does that play a role? We're 00:01:24.599 --> 00:01:27.370 talking about muscle impairment. Specifically, 00:01:27.810 --> 00:01:29.769 muscle atrophy, where the muscle bulk actually 00:01:29.769 --> 00:01:33.870 shrinks, and fatty infiltration. That's where 00:01:33.870 --> 00:01:36.390 fat cells start replacing healthy muscle fibers. 00:01:37.269 --> 00:01:39.469 This change in the tissue composition means the 00:01:39.469 --> 00:01:42.359 muscle is just less functional. And even if you 00:01:42.359 --> 00:01:44.780 could somehow reattach the tendon, the muscle 00:01:44.780 --> 00:01:47.680 unit itself wouldn't generate enough force. Plus, 00:01:47.859 --> 00:01:49.739 that compromised tissue is much less likely to 00:01:49.739 --> 00:01:52.099 heal properly to the bone. So it's not just the 00:01:52.099 --> 00:01:54.500 size of the hole or how far it's pulled back, 00:01:54.519 --> 00:01:57.400 but what's actually happened to the muscle that's 00:01:57.400 --> 00:02:00.120 connected to that tendon? Precisely, yes. Think 00:02:00.120 --> 00:02:01.959 of it like trying to sew, I don't know, frayed, 00:02:01.980 --> 00:02:04.019 brittle fabric back together. It's just not going 00:02:04.019 --> 00:02:05.879 to hold the tension well, is it? The sources 00:02:05.879 --> 00:02:08.439 you've gathered really highlight this. For poster 00:02:08.439 --> 00:02:12.650 superior tears, Those involving the supraspinatus 00:02:12.650 --> 00:02:15.650 and maybe the infraspinatus tendons, the Gerber 00:02:15.650 --> 00:02:18.689 criteria are often mentioned. They describe a 00:02:18.689 --> 00:02:21.849 scenario where even if you tried to mobilize 00:02:21.849 --> 00:02:25.050 the torn tendon, you physically cannot get it 00:02:25.050 --> 00:02:27.229 close enough to the bone insertion site to fix 00:02:27.229 --> 00:02:30.430 it without undue tension when the arm is brought 00:02:30.430 --> 00:02:33.310 down to, say, 60 degrees of abduction or less. 00:02:33.610 --> 00:02:36.310 That tells you straight away the tendon is severely 00:02:36.310 --> 00:02:38.949 retracted and probably quite fibrotic, quite 00:02:38.949 --> 00:02:41.569 stiff. That paints a really vivid picture actually 00:02:41.569 --> 00:02:45.310 of how contracted and, well, immobile the tissue 00:02:45.310 --> 00:02:48.550 can become. And are there specific clinical signs 00:02:48.550 --> 00:02:50.810 then, things you look for that... point towards 00:02:50.810 --> 00:02:53.909 this rather grim prognosis. Yes, absolutely. 00:02:54.530 --> 00:02:56.629 There are several sort of red flags that surgeons 00:02:56.629 --> 00:02:58.509 look for, both from the clinical examination 00:02:58.509 --> 00:03:01.110 and from imaging, like x -rays and MRI scans. 00:03:01.449 --> 00:03:02.949 The long duration of symptoms is quite common, 00:03:03.090 --> 00:03:05.189 often six months or even longer. Significant 00:03:05.189 --> 00:03:07.009 weakness is another key sign, particularly weakness 00:03:07.009 --> 00:03:09.509 in external rotation, that's the ability to rotate 00:03:09.509 --> 00:03:11.169 your arm away from your body. Right, turning 00:03:11.169 --> 00:03:14.210 outwards. Yes, because that function is heavily 00:03:14.210 --> 00:03:17.509 reliant on those specific muscles. the supraspinatus 00:03:17.509 --> 00:03:19.810 and infraspinatus, which are often the ones torn. 00:03:20.270 --> 00:03:22.689 And what about on the scans? What shows up there? 00:03:22.990 --> 00:03:26.210 Well, on standard x -rays, a really key sign 00:03:26.210 --> 00:03:29.900 is a reduced acromiohumeral distance. That's 00:03:29.900 --> 00:03:32.099 the space between the top of the humerus, the 00:03:32.099 --> 00:03:34.300 ball part of the joint, and the underside of 00:03:34.300 --> 00:03:37.099 the acromion bone above it. Okay. If that space 00:03:37.099 --> 00:03:40.219 is less than about six millimeters, it's a strong 00:03:40.219 --> 00:03:42.319 indicator that the humeral head has started to 00:03:42.319 --> 00:03:45.080 migrate upwards because the torn cuff is no longer 00:03:45.080 --> 00:03:47.500 doing its job of holding it centered in the joint 00:03:47.500 --> 00:03:50.000 socket. So the ball is riding high. Exactly. 00:03:50.639 --> 00:03:53.560 Then MRI is crucial. It helps assess the tear 00:03:53.560 --> 00:03:55.919 itself, the size and retraction, but also the 00:03:55.919 --> 00:03:57.800 muscle quality we talked about. The PAT staging 00:03:57.800 --> 00:04:00.120 system describes the degree of tendon retraction. 00:04:00.639 --> 00:04:02.680 Stage three, for instance, means the tendon is 00:04:02.680 --> 00:04:04.560 pulled all the way back to the rim of the socket, 00:04:04.719 --> 00:04:07.139 the glenoid rim. It's essentially... completely 00:04:07.139 --> 00:04:09.240 off the humeral head. Wow, stage 3 is totally 00:04:09.240 --> 00:04:11.800 disconnected then. Pretty much, yes. And then 00:04:11.800 --> 00:04:15.419 the MRI also clearly shows the fatty infiltration 00:04:15.419 --> 00:04:17.899 within the muscle. We use the Guttalli classification 00:04:17.899 --> 00:04:20.839 to grade that, and studies consistently show 00:04:20.839 --> 00:04:23.639 that fatty infiltration exceeding 50 % of the 00:04:23.639 --> 00:04:27.000 Guttalli grade 3 or 4 is a very strong predictor 00:04:27.000 --> 00:04:30.220 that any attempt at a direct repair is, well, 00:04:30.579 --> 00:04:33.139 likely doomed to fail. The healing potential 00:04:33.139 --> 00:04:35.500 and muscle function are just too poor. Okay, 00:04:35.699 --> 00:04:38.019 that gives us a really clear definition of what 00:04:38.019 --> 00:04:40.019 we're up against here. It's not just a big hole, 00:04:40.180 --> 00:04:44.220 is it? It's retracted, poor quality tissue, and 00:04:44.220 --> 00:04:46.199 often a shoulder joint that's already started 00:04:46.199 --> 00:04:49.209 to shift upward structurally. Precisely. So our 00:04:49.209 --> 00:04:51.230 mission for this deep dive then is to take the 00:04:51.230 --> 00:04:53.209 material you've provided and really explore the 00:04:53.209 --> 00:04:56.610 whole landscape of solutions for these very challenging 00:04:56.610 --> 00:04:59.610 cases. Exactly. And the literature offers a surprisingly 00:04:59.610 --> 00:05:02.209 wide spectrum of treatment strategies. It ranges 00:05:02.209 --> 00:05:04.910 from non -surgical approaches right through to 00:05:04.910 --> 00:05:07.389 highly complex surgical reconstructions and even 00:05:07.389 --> 00:05:09.509 joint replacement surgery. So we'll delve into 00:05:09.509 --> 00:05:11.610 each one, try to understand the rationale behind 00:05:11.610 --> 00:05:15.149 it, look at the evidence supporting it, and crucially 00:05:15.149 --> 00:05:18.029 figure out who might be the right candidate for 00:05:18.029 --> 00:05:21.480 which particular procedure. Fantastic. Let's 00:05:21.480 --> 00:05:23.980 really dive into understanding why these are 00:05:23.980 --> 00:05:26.800 so difficult to treat surgically first. You mentioned 00:05:26.800 --> 00:05:29.819 direct repair isn't usually an option. Why is 00:05:29.819 --> 00:05:32.620 that, beyond the factors we've just covered? 00:05:32.839 --> 00:05:36.199 Well, even for massive tears that maybe don't 00:05:36.199 --> 00:05:38.540 quite meet the strict definition of irreparable 00:05:38.540 --> 00:05:41.819 but are still very large, the mechanical environment 00:05:41.819 --> 00:05:44.620 and the biological healing potential are already 00:05:44.620 --> 00:05:48.759 quite compromised. The retire rates after surgery 00:05:48.759 --> 00:05:51.740 for these massive repairs are are frankly notoriously 00:05:51.740 --> 00:05:54.139 high in the literature. They're often cited somewhere 00:05:54.139 --> 00:05:58.160 between 40 % and in some studies up to 91%. 91%, 00:05:58.160 --> 00:06:00.759 wow. Yes, sobering figure. It means that even 00:06:00.759 --> 00:06:02.740 if a surgeon can technically manage to pull the 00:06:02.740 --> 00:06:05.160 tissues together and stitch them down, the chances 00:06:05.160 --> 00:06:07.740 of that repair breaking down again over time 00:06:07.740 --> 00:06:11.000 are really quite significant. Now, for truly 00:06:11.000 --> 00:06:13.720 irreparable tears with that severe retraction 00:06:13.720 --> 00:06:16.139 and poor muscle quality we talked about, the 00:06:16.139 --> 00:06:19.360 chance of a successful functional repair drops 00:06:19.360 --> 00:06:22.110 even lower. potentially right up towards that 00:06:22.110 --> 00:06:25.509 higher end of the range. Attempting a direct 00:06:25.509 --> 00:06:27.750 repair in that scenario can sometimes even make 00:06:27.750 --> 00:06:30.509 things worse, more pain, limited motion, or it 00:06:30.509 --> 00:06:33.670 just fails very quickly. That 91 % figure is 00:06:33.670 --> 00:06:36.269 really stark, isn't it? It certainly underscores 00:06:36.269 --> 00:06:39.370 the need for alternative approaches. And it also 00:06:39.370 --> 00:06:40.910 highlights something the sources point out, that 00:06:40.910 --> 00:06:43.829 the goal isn't always achieving anatomical perfection. 00:06:44.110 --> 00:06:46.899 Absolutely not. For many patients with irreparable 00:06:46.899 --> 00:06:49.259 tears, particularly perhaps older individuals 00:06:49.259 --> 00:06:51.279 or those who don't need to perform strenuous 00:06:51.279 --> 00:06:53.740 overhead activities, the primary goals of treatment 00:06:53.740 --> 00:06:56.079 tend to shift. We're often focused much more 00:06:56.079 --> 00:06:58.420 on improving pain, restoring enough function 00:06:58.420 --> 00:07:00.899 for everyday activities, activities of daily 00:07:00.899 --> 00:07:03.079 living, and just generally enhancing their overall 00:07:03.079 --> 00:07:05.500 quality of life. It becomes less about restoring 00:07:05.500 --> 00:07:07.379 the shoulder to how it was before the injury 00:07:07.379 --> 00:07:10.600 or achieving some anatomical ideal and more about 00:07:10.600 --> 00:07:12.720 making it a comfortable and usable limb again. 00:07:12.810 --> 00:07:15.750 So managing expectations is absolutely key here. 00:07:16.029 --> 00:07:19.009 Given those challenges with direct repair, what's 00:07:19.009 --> 00:07:22.110 typically the first avenue that's explored? Well, 00:07:22.550 --> 00:07:25.189 as with many orthopedic conditions, really, the 00:07:25.189 --> 00:07:27.649 initial management is often conservative, non 00:07:27.649 --> 00:07:29.810 -operative, particularly for patients who aren't 00:07:29.810 --> 00:07:32.730 aiming for high level athletic performance or 00:07:32.730 --> 00:07:35.250 perhaps those who have significant other health 00:07:35.250 --> 00:07:37.829 issues, comorbidities. Right. The literature 00:07:37.829 --> 00:07:40.290 actually shows that even quite substantial tiers, 00:07:40.810 --> 00:07:43.670 including some classified as massive, can sometimes 00:07:43.670 --> 00:07:46.389 be managed non -operatively with quite satisfactory 00:07:46.389 --> 00:07:48.730 results, at least for a significant period. And 00:07:48.730 --> 00:07:50.889 what does that non -operative approach look like 00:07:50.889 --> 00:07:53.370 in practice? It's usually a multi -pronged strategy. 00:07:53.810 --> 00:07:56.050 Physiotherapy is absolutely the cornerstone, 00:07:56.550 --> 00:07:58.649 a structured rehabilitation program tailored 00:07:58.649 --> 00:08:01.240 specifically to the patient's needs. Okay. This 00:08:01.240 --> 00:08:03.540 focuses on strengthening the remaining intact 00:08:03.540 --> 00:08:06.220 rotator cuff muscles, improving the function 00:08:06.220 --> 00:08:08.639 of compensatory muscles like the deltoid and 00:08:08.639 --> 00:08:10.459 the scapular stabilizers around the shoulder 00:08:10.459 --> 00:08:13.060 blade, trying to regain range of motion, and 00:08:13.060 --> 00:08:15.220 also correcting posture that might be contributing 00:08:15.220 --> 00:08:17.660 to impingement problems. So essentially training 00:08:17.660 --> 00:08:19.600 the body to work around the problem. Exactly 00:08:19.600 --> 00:08:22.939 that, yes. Alongside the therapy, medical management 00:08:22.939 --> 00:08:25.819 is important too. This includes things like oral 00:08:25.819 --> 00:08:28.339 pain relief and anti -inflammatory medications 00:08:28.339 --> 00:08:31.860 just to manage the symptoms day -to -day. Injections 00:08:31.860 --> 00:08:34.299 into the subacromial space are also frequently 00:08:34.299 --> 00:08:37.620 used. Most commonly, that's corticosteroids to 00:08:37.620 --> 00:08:40.940 reduce inflammation and hopefully pain. Some 00:08:40.940 --> 00:08:43.860 sources also mention using hyaluronic acid or 00:08:43.860 --> 00:08:46.740 perhaps platelet -rich plasma, PRP, although 00:08:46.740 --> 00:08:48.940 I'd say the evidence for their long -term benefit, 00:08:48.940 --> 00:08:53.600 specifically in irreparable tears, is still evolving. 00:08:53.789 --> 00:08:56.929 Right. And does this conservative approach, does 00:08:56.929 --> 00:08:58.909 it genuinely make a difference? You mentioned 00:08:58.909 --> 00:09:00.870 satisfactory results earlier. Oh, absolutely 00:09:00.870 --> 00:09:03.570 can, yes. There are studies providing good evidence 00:09:03.570 --> 00:09:05.710 for this. For instance, Ainsworth and colleagues 00:09:05.710 --> 00:09:07.629 reported significant improvements in patient 00:09:07.629 --> 00:09:09.990 -reported outcome scores. Things like the Oxford 00:09:09.990 --> 00:09:13.049 Shoulder score and the SF -36 Quality of Life 00:09:13.049 --> 00:09:16.210 score after just a 12 -week multimodal physiotherapy 00:09:16.210 --> 00:09:18.669 program in patients who had massive tears. That's 00:09:18.669 --> 00:09:21.250 quite notable progress just from dedicated physio, 00:09:21.269 --> 00:09:23.990 isn't it? It is, yes. And then there's the really 00:09:23.990 --> 00:09:26.450 striking Levy study. They looked specifically 00:09:26.450 --> 00:09:29.330 at patients with irreparable rotator cuff tears, 00:09:29.809 --> 00:09:32.649 who also had pseudo paralysis. That's the inability 00:09:32.649 --> 00:09:36.029 to actively lift the arm above about 90 degrees. 00:09:36.210 --> 00:09:38.950 OK. They implemented a very targeted training 00:09:38.950 --> 00:09:41.669 program focusing on the anterior deltoid muscle, 00:09:42.190 --> 00:09:44.169 the muscle at the front of the shoulder. And 00:09:44.169 --> 00:09:48.330 the results were quite dramatic. Their mean constant 00:09:48.330 --> 00:09:51.620 scores. which measure function, went from a severely 00:09:51.620 --> 00:09:55.399 disabled level of about 26 up to 63, which represents 00:09:55.399 --> 00:09:58.480 a much more functional level. And perhaps even 00:09:58.480 --> 00:10:00.539 more impressively, their average active forward 00:10:00.539 --> 00:10:03.759 flexion lifting the arm forwards, improved from 00:10:03.759 --> 00:10:06.720 a mere 40 degrees to an average of 160 degrees. 00:10:07.080 --> 00:10:09.179 So going from barely being able to lift your 00:10:09.179 --> 00:10:11.340 arm to nearly full elevation just by training 00:10:11.340 --> 00:10:13.379 the deltoid muscle, that's a really powerful 00:10:13.379 --> 00:10:15.600 demonstration of compensation, isn't it? It truly 00:10:15.600 --> 00:10:17.639 is. It really highlights the importance of assessing 00:10:17.639 --> 00:10:19.940 and then optimizing the function of the deltoid 00:10:19.940 --> 00:10:21.460 and the other muscles surrounding the shoulder 00:10:21.460 --> 00:10:23.320 joint when the rotator cuff itself is deficient. 00:10:23.419 --> 00:10:25.879 It shows that even if the underlying structural 00:10:25.879 --> 00:10:28.559 tear doesn't actually change, the functional 00:10:28.559 --> 00:10:31.519 capacity can be significantly improved through 00:10:31.519 --> 00:10:35.080 dedicated rehabilitation. As some studies, like 00:10:35.080 --> 00:10:37.679 one by Zheng et al, observed, some patients can 00:10:37.679 --> 00:10:40.340 maintain pretty satisfactory function non -operatively 00:10:40.340 --> 00:10:43.759 for years, even whilst the pathology, the tear 00:10:43.759 --> 00:10:46.139 itself, might be progressing structurally on 00:10:46.139 --> 00:10:48.919 scans. Okay, so conservative management, especially 00:10:48.919 --> 00:10:51.840 that focused rehab, is a really critical first 00:10:51.840 --> 00:10:53.820 step and can yield some impressive functional 00:10:53.820 --> 00:10:56.960 gains. But what happens if conservative treatment 00:10:56.960 --> 00:10:59.120 just isn't sufficient, particularly for persistent 00:10:59.120 --> 00:11:02.519 pain? Yes, when pain remains a significant issue 00:11:02.519 --> 00:11:04.840 despite those conservative efforts, the next 00:11:04.840 --> 00:11:07.120 step often involves arthroscopic procedures. 00:11:07.500 --> 00:11:10.059 keyhole surgery. Right. These are typically less 00:11:10.059 --> 00:11:12.399 extensive than open surgery and importantly, 00:11:12.659 --> 00:11:14.700 they're primarily aimed at providing pain relief 00:11:14.700 --> 00:11:17.200 rather than restoring the anatomical integrity 00:11:17.200 --> 00:11:19.639 of the torn cuff. So treating the symptoms more 00:11:19.639 --> 00:11:22.879 directly then? Precisely. The pain in many of 00:11:22.879 --> 00:11:25.659 these massive and irreparable tears is significantly 00:11:25.659 --> 00:11:28.500 driven by inflammation within the subacromial 00:11:28.500 --> 00:11:31.629 bursa. That's the fluid -filled sac that normally 00:11:31.629 --> 00:11:33.750 cushions the rotator cuff tendons underneath 00:11:33.750 --> 00:11:36.590 the acromion bone. This bursa can become really 00:11:36.590 --> 00:11:39.610 thickened and inflamed, and it contains pro -inflammatory 00:11:39.610 --> 00:11:42.850 cytokines, chemicals that cause pain. Also, the 00:11:42.850 --> 00:11:45.570 ragged edges of the torn tendons themselves can 00:11:45.570 --> 00:11:48.129 be a source of pain and mechanical irritation 00:11:48.129 --> 00:11:51.429 as the shoulder moves. So what does the arthroscopic 00:11:51.429 --> 00:11:54.350 procedure actually involve doing? Well, the core 00:11:54.350 --> 00:11:56.809 procedure is usually a thorough brosectomy. That 00:11:56.809 --> 00:12:00.429 means removing the inflamed chromial buria arthroscopically. 00:12:00.870 --> 00:12:03.129 This is often combined with debridement, which 00:12:03.129 --> 00:12:05.370 essentially means trimming or smoothing out the 00:12:05.370 --> 00:12:08.149 ragged edges of the torn tendon ends. This can 00:12:08.149 --> 00:12:10.730 help alleviate that mechanical irritation and 00:12:10.730 --> 00:12:12.850 remove the inflamed tissue, thereby reducing 00:12:12.850 --> 00:12:14.889 pain. And does this approach have good evidence 00:12:14.889 --> 00:12:18.210 behind it for pain relief? Yes. Studies do support 00:12:18.210 --> 00:12:20.769 its effectiveness, particularly in, say, older 00:12:20.769 --> 00:12:23.580 or less active patients. The Liam study, for 00:12:23.580 --> 00:12:26.259 example, showed significant improvements in AC 00:12:26.259 --> 00:12:28.700 scores, that's the American shoulder and elbow 00:12:28.700 --> 00:12:31.159 surgeon score, and also a substantial reduction 00:12:31.159 --> 00:12:34.019 in pain scores following arthroscopic debridement 00:12:34.019 --> 00:12:36.820 and persectomy. So patients felt better. Yes, 00:12:36.820 --> 00:12:39.419 they reported much less pain, often dropping 00:12:39.419 --> 00:12:42.240 several points on a standard visual analog scale 00:12:42.240 --> 00:12:45.639 for pain. The goal here really is to provide 00:12:45.639 --> 00:12:48.399 that pain relief whilst preserving any remaining 00:12:48.399 --> 00:12:50.690 functional muscle tissue. like perhaps parts 00:12:50.690 --> 00:12:53.690 of the posterior cuff or, crucially, the deltoid 00:12:53.690 --> 00:12:55.870 muscle, which is so important for overall shoulder 00:12:55.870 --> 00:12:58.230 function when the cuff is deficient. That makes 00:12:58.230 --> 00:13:00.190 a lot of sense, a less invasive way to directly 00:13:00.190 --> 00:13:03.070 address a major source of the pain. But you mentioned 00:13:03.070 --> 00:13:05.029 earlier that this alone doesn't slow down the 00:13:05.029 --> 00:13:07.389 progression of osteoarthritis. That's a really 00:13:07.389 --> 00:13:09.750 key limitation, yes, and something the sources 00:13:09.750 --> 00:13:13.019 are quite clear about. Whilst debridement definitely 00:13:13.019 --> 00:13:15.399 helps with pain by managing the inflamed bursa 00:13:15.399 --> 00:13:18.700 and the torn edges, it doesn't alter the fundamental 00:13:18.700 --> 00:13:21.659 biomechanics of the shoulder joint. It doesn't 00:13:21.659 --> 00:13:24.840 stop that potential superior humeral head migration 00:13:24.840 --> 00:13:26.940 and the increased joint wear that can happen 00:13:26.940 --> 00:13:30.159 over time. So it treats a symptom. Exactly. It 00:13:30.159 --> 00:13:32.299 addresses a symptom, but not necessarily the 00:13:32.299 --> 00:13:34.720 underlying mechanical issue that might be driving 00:13:34.720 --> 00:13:37.990 future arthritis development. Now, alongside 00:13:37.990 --> 00:13:40.429 debridement, other procedures are often performed 00:13:40.429 --> 00:13:43.250 arthroscopically at the same time as adjuncts. 00:13:43.509 --> 00:13:45.590 What kind of adjuncts are we talking about? A 00:13:45.590 --> 00:13:47.690 very common one is addressing the long head of 00:13:47.690 --> 00:13:50.610 the biceps tendon. This might involve a tenotomy, 00:13:50.730 --> 00:13:52.809 which is cutting the tendon, or a tenodesis, 00:13:53.029 --> 00:13:54.870 which is cutting and then reattaching it elsewhere. 00:13:55.470 --> 00:13:57.029 Okay. The long head of the biceps tendon runs 00:13:57.029 --> 00:13:58.929 right through the shoulder joint, and it often 00:13:58.929 --> 00:14:01.769 becomes degenerative, frayed, or even partially 00:14:01.769 --> 00:14:04.129 torn in the setting of massive rotator cuff tears. 00:14:04.409 --> 00:14:06.929 And this itself can be a significant source of 00:14:06.929 --> 00:14:09.149 anterior shoulder pain, pain at the front. So 00:14:09.149 --> 00:14:11.350 it's another source of damaged tissue causing 00:14:11.350 --> 00:14:14.549 pain within the joint. Exactly. Surgeons notice 00:14:14.549 --> 00:14:16.529 clinically that some patients who experienced 00:14:16.529 --> 00:14:19.049 a spontaneous rupture of their biceps tendon 00:14:19.049 --> 00:14:21.789 actually reported a paradoxical improvement in 00:14:21.789 --> 00:14:24.110 their overall shoulder pain. Interesting. Which 00:14:24.110 --> 00:14:26.649 led to the idea of intentionally performing a 00:14:26.649 --> 00:14:29.389 surgical tonotomy, cutting the biceps tendon 00:14:29.389 --> 00:14:32.509 arthroscopically. The usual technique is to cut 00:14:32.509 --> 00:14:35.070 the tendon near its origin on the glenoid, the 00:14:35.070 --> 00:14:37.950 socket, allowing it to retract down the arm out 00:14:37.950 --> 00:14:39.750 of the joint. And the idea is just to remove 00:14:39.750 --> 00:14:42.590 that painful degenerated bit of tissue from within 00:14:42.590 --> 00:14:45.429 the joint space. Precisely. Cutting it near the 00:14:45.429 --> 00:14:47.690 origin is allowed to reduce the risk of the remaining 00:14:47.690 --> 00:14:50.950 stump causing irritation later on. However, it 00:14:50.950 --> 00:14:52.970 is important to note that whilst tonotomy can 00:14:52.970 --> 00:14:55.090 provide good pain relief for specific biceps 00:14:55.090 --> 00:14:57.809 pathology, the literature actually presents somewhat 00:14:57.809 --> 00:14:59.950 conflicting long -term results when you compare 00:14:59.950 --> 00:15:02.850 it to debridement alone, specifically for the 00:15:02.850 --> 00:15:06.350 irreparable rotator cuff tear itself. Some studies 00:15:06.350 --> 00:15:08.690 show no significant additional long -term functional 00:15:08.690 --> 00:15:11.409 benefit from just adding a tonotomy if the primary 00:15:11.409 --> 00:15:13.889 pathology isn't actually biceps -driven pain. 00:15:14.009 --> 00:15:16.129 Interesting. So it's really an adjunct for a 00:15:16.129 --> 00:15:19.330 specific identifiable problem, not necessarily 00:15:19.330 --> 00:15:22.389 a universal benefit for all irreparable tears. 00:15:23.110 --> 00:15:25.350 What else might be done? Suprascapular nerve 00:15:25.350 --> 00:15:28.049 release is another consideration sometimes. The 00:15:28.049 --> 00:15:31.169 SSN, the suprascapular nerve, innervates both 00:15:31.169 --> 00:15:33.529 the supraspinatus and infraspinatus muscles, 00:15:33.649 --> 00:15:35.789 the ones commonly affected in these postural 00:15:35.789 --> 00:15:38.269 superior irreparable tears. Okay. And the nerve 00:15:38.269 --> 00:15:40.049 itself can sometimes be a source of pain and 00:15:40.049 --> 00:15:42.299 weakness in these patients. Why would the nerve 00:15:42.299 --> 00:15:45.019 get involved in a rotator cuff tear? That seems 00:15:45.019 --> 00:15:47.659 indirect. Well, the exact mechanisms are still 00:15:47.659 --> 00:15:50.799 debated, actually. But the proposed ideas, the 00:15:50.799 --> 00:15:53.240 pathogenesis include things like traction injury 00:15:53.240 --> 00:15:56.299 on the nerve as the torn muscles retract and 00:15:56.299 --> 00:15:59.259 pull on the nerve branches or potentially entrapment 00:15:59.259 --> 00:16:01.679 of the nerve as it passes through specific anatomical 00:16:01.679 --> 00:16:03.940 notches near the shoulder blade, perhaps due 00:16:03.940 --> 00:16:06.659 to scar tissue formation or even the fatty infiltration 00:16:06.659 --> 00:16:08.320 that develops around the damaged muscle. And 00:16:08.320 --> 00:16:10.299 how would that be diagnosed? Clinical suspicion 00:16:10.299 --> 00:16:13.320 might arise from specific pain patterns or perhaps 00:16:13.320 --> 00:16:16.299 isolated muscle weakness that seems out of proportion. 00:16:16.889 --> 00:16:20.750 MRI can sometimes show severe atrophy of the 00:16:20.750 --> 00:16:23.610 supraspinatus and infraspinatus muscles or sometimes 00:16:23.610 --> 00:16:26.149 suggest areas of potential compression along 00:16:26.149 --> 00:16:28.750 the nerve's path. However, the gold standard 00:16:28.750 --> 00:16:31.870 really for confirming nerve involvement is electromyography, 00:16:32.149 --> 00:16:35.590 EMG, and nerve conduction studies. These directly 00:16:35.590 --> 00:16:37.830 assess the electrical activity and function of 00:16:37.830 --> 00:16:40.090 the nerve and the muscles it supplies. And the 00:16:40.090 --> 00:16:42.129 treatment for that. Conservative management is 00:16:42.129 --> 00:16:45.370 always the first line, things like rest, physiotherapy, 00:16:45.970 --> 00:16:48.429 anti -inflammatory medications. If there's clear 00:16:48.429 --> 00:16:50.429 evidence of nerve compression from the imaging 00:16:50.429 --> 00:16:53.049 or the EMG studies, or if the pain and weakness 00:16:53.049 --> 00:16:55.730 are really refractory to conservative care, then 00:16:55.730 --> 00:16:57.649 surgical decompression or release of the nerve 00:16:57.649 --> 00:17:00.230 can be performed. And that's often done arthroscopically 00:17:00.230 --> 00:17:03.039 nowadays as well. We also touched briefly on 00:17:03.039 --> 00:17:05.740 tuberoplasty earlier, sometimes called reversed 00:17:05.740 --> 00:17:08.460 subacromial decompression. That sounds like it 00:17:08.460 --> 00:17:10.259 addresses the bone changes, the high -riding 00:17:10.259 --> 00:17:13.380 head you mentioned. It does, yes. As the humeral 00:17:13.380 --> 00:17:15.980 head migrates superiorly, because there's no 00:17:15.980 --> 00:17:18.579 functioning rotator cuff holding it down, the 00:17:18.579 --> 00:17:21.099 greater tuberosity, that's the bony bump at the 00:17:21.099 --> 00:17:23.339 top of the humerus where the cuff normally attaches, 00:17:24.000 --> 00:17:26.160 can start to rub directly against the underside 00:17:26.160 --> 00:17:29.500 of the acromion bone. Ouch. Yes. And this can 00:17:29.500 --> 00:17:31.839 be a significant source of pain and impingement, 00:17:32.039 --> 00:17:34.759 particularly during movement. Tuberoplasty, whether 00:17:34.759 --> 00:17:36.900 it's performed open as described originally by 00:17:36.900 --> 00:17:39.859 Fenlin or arthroscopically as described by Scheibel, 00:17:40.519 --> 00:17:43.220 involves surgically removing that prominent impinging 00:17:43.220 --> 00:17:45.299 portion of the greater tuberosity. So you're 00:17:45.299 --> 00:17:47.279 essentially smoothing out the bones that are 00:17:47.279 --> 00:17:50.180 clashing together. Exactly that. The goal isn't 00:17:50.180 --> 00:17:52.380 necessarily to create more space in the traditional 00:17:52.380 --> 00:17:55.180 subacromial decompression sense, but rather to 00:17:55.180 --> 00:17:57.619 create a smoother, less painful articulation 00:17:57.619 --> 00:18:00.220 between the humeral head and the acromeon as 00:18:00.220 --> 00:18:02.819 the arm moves through its range. It's important 00:18:02.819 --> 00:18:05.519 though to preserve the coracoacromial arch during 00:18:05.519 --> 00:18:08.319 this procedure, as that structure provides important 00:18:08.319 --> 00:18:10.200 stability to the shoulder. And does this help 00:18:10.200 --> 00:18:13.000 patients? What are the outcomes? Studies specifically 00:18:13.000 --> 00:18:15.740 on tuberoplasty have reported improvements in 00:18:15.740 --> 00:18:18.660 pain levels, activities of daily living, range 00:18:18.660 --> 00:18:22.279 of motion, and also constant scores. What's particularly 00:18:22.279 --> 00:18:24.319 interesting, as noted by authors like Sendlin 00:18:24.319 --> 00:18:27.579 and Scheibel, is that despite the fact that underlying 00:18:27.579 --> 00:18:30.519 osteoarthritis might continue to progress radiographically 00:18:30.519 --> 00:18:33.559 over time, The clinical benefits derive from 00:18:33.559 --> 00:18:35.960 the tuberoplasty itself, so the pain reduction 00:18:35.960 --> 00:18:38.500 and the improved function that comes from alleviating 00:18:38.500 --> 00:18:41.420 that specific bony impingement can often still 00:18:41.420 --> 00:18:43.680 be maintained long term. Okay, that covers quite 00:18:43.680 --> 00:18:45.819 a range of arthroscopic interventions, mostly 00:18:45.819 --> 00:18:48.000 focused on pain and smoothing out the mechanics, 00:18:48.000 --> 00:18:51.000 it seems. Let's move on to something quite different 00:18:51.000 --> 00:18:53.500 now, a relatively newer concept that's mentioned 00:18:53.500 --> 00:18:57.079 in the sources, the subacromial biodegradable 00:18:57.079 --> 00:19:00.160 spacer. This device has certainly generated a 00:19:00.160 --> 00:19:01.859 lot of discussion, hasn't it? It has indeed, 00:19:02.039 --> 00:19:04.420 yes. It's a fascinating area where the evidence 00:19:04.420 --> 00:19:07.720 is still actively evolving. The device, often 00:19:07.720 --> 00:19:09.519 known commercially as the in -space balloon, 00:19:10.019 --> 00:19:12.400 is typically made of polyolactide, which is a 00:19:12.400 --> 00:19:15.220 material that biodegrades slowly over time. It's 00:19:15.220 --> 00:19:18.059 inserted arthroscopically into that subacromial 00:19:18.059 --> 00:19:20.700 space, positioned above any remaining rotator 00:19:20.700 --> 00:19:23.900 cuff tissue and below the acromion bone, and 00:19:23.900 --> 00:19:26.079 then it's inflated, usually with saline solution. 00:19:26.400 --> 00:19:28.599 So you're literally placing a balloon in the 00:19:28.599 --> 00:19:30.960 shoulder. What's the thinking behind doing that? 00:19:31.299 --> 00:19:34.160 Well, the proposed mechanism is primarily biomechanical. 00:19:35.039 --> 00:19:38.519 The idea is that by occupying space in that subacromial 00:19:38.519 --> 00:19:42.259 area, it's hypothesized to firstly reduce friction 00:19:42.259 --> 00:19:45.160 between the humeral head and the acromion. Secondly, 00:19:45.319 --> 00:19:47.779 to help lower the humeral head slightly, pushing 00:19:47.779 --> 00:19:50.019 it back down towards a more centered position 00:19:50.019 --> 00:19:53.259 in the joint. And thirdly, to facilitate smoother 00:19:53.259 --> 00:19:55.920 gliding during arm movement. And how is it actually 00:19:55.920 --> 00:19:58.700 used in practice? Typically it's implanted after 00:19:58.700 --> 00:20:00.740 the initial arthroscopic steps we've discussed, 00:20:00.960 --> 00:20:03.259 like a brisectomy and maybe some debridement. 00:20:03.700 --> 00:20:05.900 The surgeon selects the appropriate size of the 00:20:05.900 --> 00:20:08.140 spacer based on the size of the irreparable tear. 00:20:08.299 --> 00:20:10.599 And how long does this balloon actually stay 00:20:10.599 --> 00:20:13.000 there? Well, the material is designed to gradually 00:20:13.000 --> 00:20:16.200 deflate over about 10 weeks or so and then fully 00:20:16.200 --> 00:20:19.099 degrade and be absorbed by the body over approximately 00:20:19.099 --> 00:20:22.259 15 months. What was initially quite curious in 00:20:22.259 --> 00:20:24.440 the early literature was that clinical improvements 00:20:24.440 --> 00:20:27.799 reported by patients seemed to persist well beyond 00:20:27.799 --> 00:20:30.079 the point where the spacer had physically disintegrated. 00:20:30.380 --> 00:20:33.099 That sounds quite promising, doesn't it? A temporary 00:20:33.099 --> 00:20:35.599 intervention with potentially lasting benefits. 00:20:36.279 --> 00:20:38.900 The initial theoretical benefits certainly sounded 00:20:38.900 --> 00:20:41.700 compelling things like preserving the acromio 00:20:41.700 --> 00:20:44.099 -humeral distance, optimizing force balance. 00:20:44.359 --> 00:20:47.019 That was certainly the initial hope, yes, and 00:20:47.019 --> 00:20:49.700 the theoretical basis for its use. The idea was 00:20:49.700 --> 00:20:52.339 that by temporarily lowering the humeral head 00:20:52.339 --> 00:20:54.819 and reducing that friction, it would improve 00:20:54.819 --> 00:20:57.450 pain. and potentially even slow down the progression 00:20:57.450 --> 00:20:59.769 of degenerative changes in the joint. But your 00:20:59.769 --> 00:21:02.450 source material includes some significant contrasting 00:21:02.450 --> 00:21:04.650 evidence about those theoretical benefits. This 00:21:04.650 --> 00:21:06.869 is where the deep dive really gets into the nuances 00:21:06.869 --> 00:21:09.210 of the research, I suppose. Absolutely. And this 00:21:09.210 --> 00:21:12.029 is a really critical point for understanding 00:21:12.029 --> 00:21:14.190 the current landscape regarding these spacers. 00:21:14.650 --> 00:21:17.730 The Garrigas -Perez et al study, which was published 00:21:17.730 --> 00:21:20.130 in the Journal of the American Academy of Orthopedic 00:21:20.130 --> 00:21:23.299 Surgeons back in 2022. Right. presented findings 00:21:23.299 --> 00:21:26.079 that directly challenged some of those initial 00:21:26.079 --> 00:21:30.299 theoretical benefits. Their results quite significantly, 00:21:30.700 --> 00:21:32.980 did not demonstrate that the spacer prevented 00:21:32.980 --> 00:21:36.339 superior humeral head migration, or indeed arthropathic 00:21:36.339 --> 00:21:39.059 changes, the development of arthritis. So not 00:21:39.059 --> 00:21:41.420 only did it not prevent them, but the study actually 00:21:41.420 --> 00:21:43.759 found that the acromio -humeral distance, that 00:21:43.759 --> 00:21:45.539 space we talked about, actually worsened over 00:21:45.539 --> 00:21:47.819 time. And the hamada stage, which is the x -ray 00:21:47.819 --> 00:21:50.200 grading of the arthritis, also worsened during 00:21:50.200 --> 00:21:52.000 their follow -up period. That is correct. That 00:21:52.000 --> 00:21:54.380 was a key and somewhat surprising finding because 00:21:54.380 --> 00:21:57.500 it directly contradicted that core biomechanical 00:21:57.500 --> 00:22:00.000 goal of the device. which was to maintain or 00:22:00.000 --> 00:22:02.579 improve the subacromial space and prevent that 00:22:02.579 --> 00:22:05.400 upward migration. Furthermore, their study reported 00:22:05.400 --> 00:22:08.019 relatively low functional outcomes. When they 00:22:08.019 --> 00:22:09.900 looked at various standard orthopedic scores 00:22:09.900 --> 00:22:12.339 like the constant score, the ACs, the simple 00:22:12.339 --> 00:22:15.920 shoulder test, SST, and the DHH score, the results 00:22:15.920 --> 00:22:18.420 were generally not as robust as perhaps seen 00:22:18.420 --> 00:22:21.180 with other procedures or maybe in some of the 00:22:21.180 --> 00:22:23.240 initial early reports on the spacer. Patient 00:22:23.240 --> 00:22:25.539 satisfaction in their series was also only around 00:22:25.539 --> 00:22:29.019 62 .5%. So objectively, the joint seemed to be 00:22:29.019 --> 00:22:30.859 getting worse on x -rays, and the functional 00:22:30.859 --> 00:22:33.640 benefits and patient happiness weren't overwhelmingly 00:22:33.640 --> 00:22:36.299 positive in that study. That's a fair summary 00:22:36.299 --> 00:22:38.940 of their specific findings, yes. Whilst perceived 00:22:38.940 --> 00:22:41.039 quality of life measured by something like the 00:22:41.039 --> 00:22:42.960 UroCohl score might have seemed less impaired, 00:22:43.480 --> 00:22:45.200 the objective measures of the joint structure 00:22:45.200 --> 00:22:47.619 itself and the specific shoulder function scores 00:22:47.619 --> 00:22:50.740 were, well, concerningly low, or even worsening 00:22:50.740 --> 00:22:53.339 over time in their cohort. And what about complications? 00:22:53.720 --> 00:22:56.099 Did that study shed any light on the risks involved? 00:22:56.380 --> 00:22:59.259 Yes, it did. Garrigas -Perez and colleagues reported 00:22:59.259 --> 00:23:02.619 a 13 % complication rate in their series. This 00:23:02.619 --> 00:23:05.279 included instances of deep infection and also 00:23:05.279 --> 00:23:07.680 balloon migration where the spacer moves from 00:23:07.680 --> 00:23:11.440 its intended position. Okay. Now, whilst these 00:23:11.440 --> 00:23:14.339 aren't necessarily exceedingly high rates compared 00:23:14.339 --> 00:23:17.420 to some very complex joint procedures, they are 00:23:17.420 --> 00:23:19.799 nevertheless serious complications that can require 00:23:19.799 --> 00:23:22.319 further surgery and potentially jeopardize the 00:23:22.319 --> 00:23:24.880 overall viability of the shoulder joint, perhaps 00:23:24.880 --> 00:23:27.460 in a situation where a less complex intervention 00:23:27.460 --> 00:23:30.140 pathway might otherwise have been chosen. Okay, 00:23:30.180 --> 00:23:33.599 so the subacronial spacer. It's clearly an innovative 00:23:33.599 --> 00:23:35.980 concept, but the evidence, certainly based on 00:23:35.980 --> 00:23:38.690 this more recent study, appears quite mixed. 00:23:39.470 --> 00:23:41.390 While it might offer some temporary pain relief 00:23:41.390 --> 00:23:43.269 or functional improvement for certain patients, 00:23:44.029 --> 00:23:45.970 this higher level evidence raises significant 00:23:45.970 --> 00:23:48.230 questions about its ability to durably prevent 00:23:48.230 --> 00:23:50.269 that superior migration or the progression of 00:23:50.269 --> 00:23:53.069 arthritis. And it highlights potentially lower 00:23:53.069 --> 00:23:55.769 functional outcomes and a non -trivial risk of 00:23:55.769 --> 00:23:57.730 complications compared to what might have been 00:23:57.730 --> 00:24:00.809 initially hoped or reported. That's a really 00:24:00.809 --> 00:24:03.289 critical piece of evolving understanding based 00:24:03.289 --> 00:24:05.400 on the literature, isn't it? It certainly is, 00:24:05.539 --> 00:24:07.339 and it makes the decision of whether or not to 00:24:07.339 --> 00:24:10.380 use a spacer much more complex now. It requires 00:24:10.380 --> 00:24:12.880 really careful consideration of this conflicting 00:24:12.880 --> 00:24:15.539 data alongside all the other treatment options 00:24:15.539 --> 00:24:18.599 that are available. Absolutely. Moving on from 00:24:18.599 --> 00:24:20.700 temporary implants then, let's look at attempts 00:24:20.700 --> 00:24:23.799 to actually modify the torn tissue itself. The 00:24:23.799 --> 00:24:27.099 sources discuss the possibility of doing a partial 00:24:27.099 --> 00:24:30.440 rotator cuff repair. How is that different from 00:24:30.440 --> 00:24:33.099 attempting a full repair, which we know is often 00:24:33.099 --> 00:24:36.140 not possible? Right. So in an irreparable tear, 00:24:36.299 --> 00:24:39.019 by definition, you cannot pull all the torn tendon 00:24:39.019 --> 00:24:41.319 back to its original anacomical footprint on 00:24:41.319 --> 00:24:43.740 the bone without creating excessive tension. 00:24:44.539 --> 00:24:46.779 A partial repair is based on a biomechanical 00:24:46.779 --> 00:24:49.099 concept often called the suspension bridge analogy, 00:24:49.480 --> 00:24:51.420 which was popularized by Dr. Steven Burkhart. 00:24:51.599 --> 00:24:54.420 OK. The idea is that certain key components of 00:24:54.420 --> 00:24:56.609 the rotator cuff particularly a thickened band 00:24:56.609 --> 00:24:58.910 within it called the rotator cable, act a bit 00:24:58.910 --> 00:25:01.109 like the main cables of a suspension bridge. 00:25:01.569 --> 00:25:04.170 They transmit forces across the joint, even if 00:25:04.170 --> 00:25:06.009 parts of the deck, the rest of the tendon are 00:25:06.009 --> 00:25:09.029 missing. So if you can't fix everything, the 00:25:09.029 --> 00:25:11.190 idea is to fix the most structurally important 00:25:11.190 --> 00:25:14.109 parts to restore at least some function. Precisely. 00:25:14.250 --> 00:25:17.150 The goal isn't full anacomical coverage of the 00:25:17.150 --> 00:25:20.109 bone, but rather to repair enough tissue to restore 00:25:20.109 --> 00:25:22.450 a stable fulcrum for the humeral head to rotate 00:25:22.450 --> 00:25:25.789 against, and crucially, to reestablish some of 00:25:25.789 --> 00:25:28.410 the important transverse force couples that help 00:25:28.410 --> 00:25:30.230 keep the humeral head centered in the glenoid 00:25:30.230 --> 00:25:33.230 socket during movement. The literature suggests 00:25:33.230 --> 00:25:36.970 that for poster superior tears, repairing at 00:25:36.970 --> 00:25:39.390 least the whole subscapularis tendon at the front, 00:25:39.579 --> 00:25:42.200 if that's involved, and at least the inferior 00:25:42.200 --> 00:25:44.279 half of the infospinatus tendon at the back, 00:25:44.539 --> 00:25:45.980 particularly where it connects to that rotator 00:25:45.980 --> 00:25:48.500 cable structure, seems to be critical for achieving 00:25:48.500 --> 00:25:51.349 a functionally successful partial repair. And 00:25:51.349 --> 00:25:54.150 does this approach, this functional partial repair, 00:25:54.329 --> 00:25:56.990 actually work in practice? Well, studies have 00:25:56.990 --> 00:25:59.569 shown some promising results. For example, Porcellini 00:25:59.569 --> 00:26:01.890 and colleagues published on the outcomes of doing 00:26:01.890 --> 00:26:04.589 a functional partial repair of just the infraspinatus 00:26:04.589 --> 00:26:07.069 in massive tears, even leaving parts of the greater 00:26:07.069 --> 00:26:09.430 tuberosity footprint uncovered. They reported 00:26:09.430 --> 00:26:12.490 significant improvements in constant scores and 00:26:12.490 --> 00:26:14.990 simple shoulder test scores, indicating better 00:26:14.990 --> 00:26:17.880 function and reduced pain. And crucially, they 00:26:17.880 --> 00:26:20.160 also observed an increase in the acromiohumeral 00:26:20.160 --> 00:26:22.759 distance after the surgery, suggesting that the 00:26:22.759 --> 00:26:24.819 partial repair actually helped to re -center 00:26:24.819 --> 00:26:27.140 the humeral head, even though they didn't achieve 00:26:27.140 --> 00:26:30.099 full anatomical coverage. That's really encouraging, 00:26:30.220 --> 00:26:33.640 isn't it? That focusing on restoring those key 00:26:33.640 --> 00:26:36.500 biomechanical elements, even with what looks 00:26:36.500 --> 00:26:39.619 like an incomplete anatomical repair, can still 00:26:39.619 --> 00:26:42.119 lead to good functional outcomes and potentially 00:26:42.119 --> 00:26:45.240 even improve the joint mechanics. Yes, it suggests 00:26:45.240 --> 00:26:48.369 that sometimes Less is more if you target the 00:26:48.369 --> 00:26:50.890 right structures. Now, let's move into what are 00:26:50.890 --> 00:26:53.390 often considered the more involved surgical options, 00:26:53.950 --> 00:26:56.529 tendon transfer procedures. When do these typically 00:26:56.529 --> 00:26:58.910 come into play? Tendon transfers are generally 00:26:58.910 --> 00:27:01.650 reserved for a quite specific subset of patients. 00:27:02.390 --> 00:27:04.329 Typically, we're thinking about younger, more 00:27:04.329 --> 00:27:06.930 active individuals who have a really significant 00:27:06.930 --> 00:27:09.369 functional deficit, things like severe weakness 00:27:09.369 --> 00:27:12.470 or a major loss of rotation, specifically because 00:27:12.470 --> 00:27:14.980 of any irreparable tear. They're usually considered 00:27:14.980 --> 00:27:17.740 when simpler procedures like the debridement 00:27:17.740 --> 00:27:20.759 or even a partial repair aren't really expected 00:27:20.759 --> 00:27:23.819 to address the primary problem, which is often 00:27:23.819 --> 00:27:27.299 that profound muscle weakness. The sources often 00:27:27.299 --> 00:27:30.019 refer to them as salvage procedures. Salvage. 00:27:30.460 --> 00:27:33.319 Yes, because they are complex undertakings used 00:27:33.319 --> 00:27:35.799 when the less invasive options are deemed insufficient 00:27:35.799 --> 00:27:38.539 and perhaps joint replacement isn't yet indicated, 00:27:39.019 --> 00:27:40.720 often because the patient is younger or they 00:27:40.720 --> 00:27:42.299 don't have significant arthritis in the joint 00:27:42.299 --> 00:27:45.329 yet. So definitely not for everyone, but perhaps 00:27:45.329 --> 00:27:47.630 for those with severe disability who really want 00:27:47.630 --> 00:27:50.289 to regain significant function. Exactly that. 00:27:50.430 --> 00:27:53.190 Careful patient selection is absolutely paramount 00:27:53.190 --> 00:27:55.950 here. The factors influencing the decision include 00:27:55.950 --> 00:27:58.150 the patient's age and their activity level, their 00:27:58.150 --> 00:28:00.730 overall health, and any other medical conditions, 00:28:01.269 --> 00:28:03.349 the specific pattern of weakness and functional 00:28:03.349 --> 00:28:05.950 loss they're experiencing, the stability of the 00:28:05.950 --> 00:28:08.269 joint itself, and critically, as I mentioned, 00:28:08.690 --> 00:28:11.730 the absence of significant glenohumeral osteoarthritis. 00:28:12.000 --> 00:28:14.640 If there's already advanced arthritis present, 00:28:15.259 --> 00:28:17.339 a tendon transfer is usually not a suitable option. 00:28:18.160 --> 00:28:20.460 And the biomechanical idea here is essentially 00:28:20.460 --> 00:28:23.259 to use a different healthy muscle to do the job 00:28:23.259 --> 00:28:25.880 that the damaged rotator cuff muscle used to 00:28:25.880 --> 00:28:28.900 do. That's the core principle, yes. You're essentially 00:28:28.900 --> 00:28:32.019 rerouting a working muscle and its tendon from 00:28:32.019 --> 00:28:33.960 somewhere else around the shoulder or even the 00:28:33.960 --> 00:28:37.200 trunk and attaching it to the bone. near where 00:28:37.200 --> 00:28:39.599 the torn rotator cuff tendon used to insert. 00:28:40.319 --> 00:28:42.740 The goal is to restore that lost force couple, 00:28:43.420 --> 00:28:45.839 improve the kinematics, the actual movement patterns 00:28:45.839 --> 00:28:48.380 of the shoulder, and thereby hopefully restore 00:28:48.380 --> 00:28:51.299 strength and function. The specific muscle chosen 00:28:51.299 --> 00:28:53.339 depends very much on which part of the rotator 00:28:53.339 --> 00:28:56.039 cuff is irreparable. Is it the post -re superior 00:28:56.039 --> 00:28:58.589 section or the antre superior section? Okay, 00:28:58.609 --> 00:29:00.609 let's break that down by the tear location then. 00:29:00.789 --> 00:29:02.670 For those irreparable post or superior tears, 00:29:03.150 --> 00:29:05.289 the ones involving the supraspinatus and infraspinatus 00:29:05.289 --> 00:29:07.589 at the top and back, what are the main transfer 00:29:07.589 --> 00:29:09.970 options? Well, the most established and perhaps 00:29:09.970 --> 00:29:12.410 best -known transfer for post or superior tears 00:29:12.410 --> 00:29:15.960 is the latissimus dorsi transfer. often abbreviated 00:29:15.960 --> 00:29:19.079 as LD transfer. The latissimus dorsi is that 00:29:19.079 --> 00:29:21.380 large muscle in the back, sometimes called the 00:29:21.380 --> 00:29:24.140 lats, that primarily functions as an internal 00:29:24.140 --> 00:29:27.019 rotator, an extensor, and an adductor of the 00:29:27.019 --> 00:29:30.180 arm. By carefully detaching its tendon from where 00:29:30.180 --> 00:29:32.740 it inserts on the humerus and rerouting it up 00:29:32.740 --> 00:29:34.880 and over to the area of the torn supraspinatus 00:29:34.880 --> 00:29:37.920 and infraspinatus, it can actually be retrained 00:29:37.920 --> 00:29:41.259 to help with external rotation. And importantly, 00:29:41.740 --> 00:29:44.000 it can also provide a downward pull on the humeral 00:29:44.000 --> 00:29:46.559 head, which helps to counteract the upward pull 00:29:46.559 --> 00:29:48.539 of the deltoid muscle that happens when the cuff 00:29:48.539 --> 00:29:50.640 is deficient. So you're effectively teaching 00:29:50.640 --> 00:29:52.740 a muscle to do pretty much the opposite of its 00:29:52.740 --> 00:29:55.160 original job. That's a simplified way to put 00:29:55.160 --> 00:29:58.500 it, yes. With dedicated post -operative rehabilitation, 00:29:59.039 --> 00:30:00.940 the patient learns to activate the transferred 00:30:00.940 --> 00:30:03.319 muscle to assist with movements like external 00:30:03.319 --> 00:30:05.960 rotation, and sometimes it can help with abduction 00:30:05.960 --> 00:30:09.420 too, lifting the arm out to the side. This procedure 00:30:09.420 --> 00:30:11.559 actually has quite a long history. It was originally 00:30:11.559 --> 00:30:13.920 used for nerve injuries like brachial plexus 00:30:13.920 --> 00:30:16.640 palsy. Suitable candidates for an LD transfer 00:30:16.640 --> 00:30:19.220 typically have an irreparable postural superior 00:30:19.220 --> 00:30:21.839 tear with significant muscle atrophy and fatty 00:30:21.839 --> 00:30:25.000 infiltration, usually atoliate grade 3 or worse. 00:30:25.740 --> 00:30:28.460 They have marked impairment of abduction, and 00:30:28.460 --> 00:30:31.160 particularly external rotation, often demonstrated 00:30:31.160 --> 00:30:33.660 by positive lag signs on clinical examination. 00:30:33.779 --> 00:30:36.420 And who would be excluded? Who isn't suitable 00:30:36.420 --> 00:30:39.059 for this? Key contraindications highlighted in 00:30:39.059 --> 00:30:41.400 the literature include significant subscapularis 00:30:41.400 --> 00:30:43.819 tendon insufficiency. That's the muscle at the 00:30:43.819 --> 00:30:46.720 front. If that muscle is also not working well, 00:30:46.960 --> 00:30:49.119 the overall stability and the ability to lift 00:30:49.119 --> 00:30:51.640 the arm forward will likely be compromised, even 00:30:51.640 --> 00:30:54.240 with the transfer. OK. Also, advanced eccentric 00:30:54.240 --> 00:30:56.839 arthritis hamata stage 4 or higher established 00:30:56.839 --> 00:30:59.299 pseudo -paralysis that isn't simply due to pain 00:30:59.299 --> 00:31:01.519 inhibiting movement, significant deltoid muscle 00:31:01.519 --> 00:31:04.299 dysfunction, and also severe fatty infiltration 00:31:04.299 --> 00:31:06.660 of the teres minor muscle, which is another important 00:31:06.660 --> 00:31:08.940 external rotator at the back. These are generally 00:31:08.940 --> 00:31:11.579 considered contraindications. The sources really 00:31:11.579 --> 00:31:13.920 stress the need for an intact and well -functioning 00:31:13.920 --> 00:31:16.420 subscapularis for the LD transfer to have the 00:31:16.420 --> 00:31:18.660 best chance of success, particularly for restoring 00:31:18.660 --> 00:31:21.200 forward elevation. How is this transfer actually 00:31:21.200 --> 00:31:24.049 performed surgically? Historically, it often 00:31:24.049 --> 00:31:26.950 involved a two -incision technique, one incision 00:31:26.950 --> 00:31:29.250 on the back to harvest the LD tendon and another 00:31:29.250 --> 00:31:31.789 on the shoulder for the insertion. More commonly 00:31:31.789 --> 00:31:34.549 now, surgeons use single -incision approaches 00:31:34.549 --> 00:31:37.630 or even arthroscopy -assisted techniques to try 00:31:37.630 --> 00:31:40.769 and minimize the surgical invasiveness. Habermeyer 00:31:40.769 --> 00:31:43.210 described a single V -shaped incision that can 00:31:43.210 --> 00:31:45.410 apparently improve visualization. And what about 00:31:45.410 --> 00:31:47.849 the outcomes for LD transfer? Is it reliable? 00:31:47.970 --> 00:31:50.200 Does it work well? It is generally considered 00:31:50.200 --> 00:31:52.319 very effective for reducing pain and improving 00:31:52.319 --> 00:31:54.900 function, although restoring full normal strength 00:31:54.900 --> 00:31:58.000 is perhaps more variable. Long -term follow -up 00:31:58.000 --> 00:31:59.819 studies, such as those published by Gerber's 00:31:59.819 --> 00:32:02.160 group, have shown significant improvements in 00:32:02.160 --> 00:32:04.910 subjective shoulder value scores. constant scores, 00:32:05.289 --> 00:32:07.589 pain levels, and also active range of motion, 00:32:07.910 --> 00:32:10.049 including gains in that crucial external rotation. 00:32:10.210 --> 00:32:12.329 But... However, they also found that factors 00:32:12.329 --> 00:32:14.910 like pre -existing subscapularis insufficiency 00:32:14.910 --> 00:32:17.990 or severe fatty infiltration of the teres minor 00:32:17.990 --> 00:32:20.670 were indeed associated with poorer outcomes, 00:32:21.089 --> 00:32:22.869 which really reinforces the importance of that 00:32:22.869 --> 00:32:24.950 careful patient selection we discussed. What 00:32:24.950 --> 00:32:26.970 about the Lepiskopo procedure? Is that something 00:32:26.970 --> 00:32:29.029 different? The Lepiskopo procedure is related, 00:32:29.210 --> 00:32:31.789 yes. It's essentially a modified technique that 00:32:31.789 --> 00:32:35.130 adds the transfer of the teres major muscle along 00:32:35.130 --> 00:32:38.569 with the latissimus dorsi. Okay. This was also 00:32:38.569 --> 00:32:40.950 initially used for brachial plexus injuries, 00:32:41.329 --> 00:32:43.750 but it's been adapted for massive rotator cuff 00:32:43.750 --> 00:32:46.730 tears, particularly for addressing really severe 00:32:46.730 --> 00:32:49.869 external rotation deficits. The idea of including 00:32:49.869 --> 00:32:51.809 the teres major is to provide some additional 00:32:51.809 --> 00:32:54.759 external rotation power. Boileau and colleagues 00:32:54.759 --> 00:32:57.240 have even described combining the Lepiskopo transfer 00:32:57.240 --> 00:33:00.019 with a reverse shoulder arthroplasty in certain 00:33:00.019 --> 00:33:03.420 very complex cases. So adding even more complexity 00:33:03.420 --> 00:33:06.200 to specifically target that external rotation 00:33:06.200 --> 00:33:08.680 deficit. Precisely. Another transfer that's been 00:33:08.680 --> 00:33:10.500 gaining quite a bit of attention more recently 00:33:10.500 --> 00:33:13.660 for posterior -superior tears is the lower trapezius 00:33:13.660 --> 00:33:16.700 transfer or LT transfer. The lower trapezius? 00:33:16.700 --> 00:33:18.259 That sounds like a completely different approach. 00:33:18.339 --> 00:33:20.579 How does that work biomechanically? Well, the 00:33:20.579 --> 00:33:22.519 lower trapezius transfer involves harvesting 00:33:22.519 --> 00:33:25.180 the distal lower portion of the LT muscle and 00:33:25.180 --> 00:33:27.849 its tendon. This is typically augmented with 00:33:27.849 --> 00:33:30.509 a graft, often an Achilles tendon allograft, 00:33:30.630 --> 00:33:32.569 sometimes with a piece of bone block attached. 00:33:33.049 --> 00:33:35.390 And this graft is then rerouted around the side 00:33:35.390 --> 00:33:37.609 of the scapula, the shoulder blade, to be attached 00:33:37.609 --> 00:33:40.349 to the footprint of the torn infraspinatus or 00:33:40.349 --> 00:33:42.890 perhaps the posterior supraspinatus on the humerus. 00:33:43.309 --> 00:33:45.750 Does taking part of the trapezius muscle affect 00:33:45.750 --> 00:33:48.390 scapular movement or stability? That sounds like 00:33:48.390 --> 00:33:50.849 it could be a concern. That's a very valid concern, 00:33:50.849 --> 00:33:53.710 yes, and the sources do discuss it. However, 00:33:54.210 --> 00:33:56.079 the general consensus seems to be that if the 00:33:56.079 --> 00:33:57.940 serratus anterior muscle, which is another key 00:33:57.940 --> 00:34:00.279 scapular stabilizer, is functioning normally, 00:34:00.759 --> 00:34:03.119 the risk of developing significant scapular winging 00:34:03.119 --> 00:34:06.099 or instability from harvesting, just the lower 00:34:06.099 --> 00:34:08.179 portion of the trapezius, is considered relatively 00:34:08.179 --> 00:34:10.699 low. What kind of results are reported for the 00:34:10.699 --> 00:34:13.639 LT transfer, then? Studies, like one by Elhassan 00:34:13.639 --> 00:34:16.559 and colleagues, have reported really quite significant 00:34:16.559 --> 00:34:18.980 improvements in active range of motion after 00:34:18.980 --> 00:34:21.679 lower trapezius transfer for these irreparable 00:34:21.679 --> 00:34:25.219 postural superior tears. Specifically, they noted 00:34:25.219 --> 00:34:28.079 gains in abduction, forward flexion, and external 00:34:28.079 --> 00:34:30.739 rotation, as well as substantial reductions in 00:34:30.739 --> 00:34:34.059 pain levels. And how does it stack up biomechanically 00:34:34.059 --> 00:34:37.159 against the more traditional LD transfer? Is 00:34:37.159 --> 00:34:39.500 one better? This is where the comparison gets 00:34:39.500 --> 00:34:42.139 really interesting actually. Biomechanical studies, 00:34:42.320 --> 00:34:44.420 including work by people like Hartzler and Omid, 00:34:44.820 --> 00:34:46.639 have compared the moment arms of these different 00:34:46.639 --> 00:34:49.239 transfers. The moment arm essentially tells you 00:34:49.239 --> 00:34:51.699 how effectively the muscle's force can generate 00:34:51.699 --> 00:34:53.980 rotational movement at the shoulder joint. Right. 00:34:54.320 --> 00:34:56.239 Their findings suggest that the lower trapezius 00:34:56.239 --> 00:34:58.559 transfer might actually have a larger external 00:34:58.559 --> 00:35:00.980 rotation moment arm, particularly when the arm 00:35:00.980 --> 00:35:03.179 is in an adducted position close to the body. 00:35:04.090 --> 00:35:06.349 OMID studies specifically propose that the LT 00:35:06.349 --> 00:35:08.730 transfer might be biomechanically superior to 00:35:08.730 --> 00:35:11.329 the LD transfer in terms of restoring the native 00:35:11.329 --> 00:35:14.070 glenohumor mechanics and the joint forces required 00:35:14.070 --> 00:35:16.570 for both elevation and rotation. So potentially 00:35:16.570 --> 00:35:19.469 a more powerful or perhaps more efficient muscle 00:35:19.469 --> 00:35:22.030 substitute for restoring those lost movements 00:35:22.030 --> 00:35:25.010 depending on the arm position. That's certainly 00:35:25.010 --> 00:35:27.349 the implication from the biomechanical analysis 00:35:27.349 --> 00:35:31.559 that it could provide a more, shall we say, natural 00:35:31.559 --> 00:35:34.119 force vector for shoulder function compared to 00:35:34.119 --> 00:35:36.739 the LD. That covers the postero superior side 00:35:36.739 --> 00:35:38.880 pretty thoroughly. What about irreparable tears 00:35:38.880 --> 00:35:41.260 on the other side, the antero superior side, 00:35:41.639 --> 00:35:43.960 primarily involving the subscapularis end in 00:35:43.960 --> 00:35:47.159 the SSC? Yes, antero superior tears, particularly 00:35:47.159 --> 00:35:50.460 isolated irreparable subscapularis tears, are 00:35:50.460 --> 00:35:52.460 generally less frequent than postero superior 00:35:52.460 --> 00:35:55.239 ones, but they cause quite different functional 00:35:55.239 --> 00:35:57.980 deficits. Patients typically present with pain 00:35:57.980 --> 00:36:00.269 at the front of the shoulder, anterior shoulder 00:36:00.269 --> 00:36:03.090 pain, and significant weakness in internal rotation. 00:36:03.469 --> 00:36:05.789 This makes tasks like tucking in a shirt or reaching 00:36:05.789 --> 00:36:09.130 behind the back very difficult. Clinically, tests 00:36:09.130 --> 00:36:11.429 like the belly press test, the bear hug test, 00:36:11.469 --> 00:36:13.429 and the lift -off test are usually positive, 00:36:13.670 --> 00:36:16.010 indicating that internal rotation weakness. And 00:36:16.010 --> 00:36:18.329 similar to the posterior tiers, I assume direct 00:36:18.329 --> 00:36:20.949 repair is often unsuccessful if the tissue quality 00:36:20.949 --> 00:36:23.289 is poor. Exactly the same principle applies, 00:36:23.530 --> 00:36:27.039 yes. For chronic SSE tiers, especially those 00:36:27.039 --> 00:36:30.480 with significant fatty infiltration again, Goutalier 00:36:30.480 --> 00:36:33.940 grade 3 or higher direct repair has generally 00:36:33.940 --> 00:36:36.880 poor outcomes due to high rates of retire. So 00:36:36.880 --> 00:36:39.400 in these specific cases, tendon transfers are 00:36:39.400 --> 00:36:41.340 again considered as potential salvage options, 00:36:41.659 --> 00:36:43.980 and the primary transfer used for irreparable 00:36:43.980 --> 00:36:47.110 SSE cares is the pectoralis major transfer. or 00:36:47.110 --> 00:36:49.510 PMA transfer. Transferring the pectoralis muscle 00:36:49.510 --> 00:36:52.489 from the chest, how does that help restore internal 00:36:52.489 --> 00:36:55.389 rotation? Well the pectoralis major is that large 00:36:55.389 --> 00:36:58.070 chest muscle that assists with flexion, adduction, 00:36:58.289 --> 00:37:01.250 and crucially internal rotation of the arm. The 00:37:01.250 --> 00:37:03.269 procedure involves detaching its tendon from 00:37:03.269 --> 00:37:05.730 its insertion on the humerus and then transferring 00:37:05.730 --> 00:37:08.570 it more posteriorly and superiorly onto the lesser 00:37:08.570 --> 00:37:10.829 tuberosity, which is where the torn subscapularis 00:37:10.829 --> 00:37:13.130 footprint is located. This allows it to be used 00:37:13.130 --> 00:37:15.510 to provide active internal rotation power. Who 00:37:15.510 --> 00:37:17.929 is the ideal candidate for a PMA transfer then? 00:37:18.369 --> 00:37:20.650 Candidates typically have an irreparable antra 00:37:20.650 --> 00:37:23.909 -superior tear involving the subscapularis. They 00:37:23.909 --> 00:37:26.769 should have minimal to no significant glenohumeral 00:37:26.769 --> 00:37:29.369 arthritis. They need a well -functioning deltoid 00:37:29.369 --> 00:37:31.730 muscle. Generally, they're younger than about 00:37:31.730 --> 00:37:35.110 65. And importantly, they need to have an intact 00:37:35.110 --> 00:37:38.130 or at least repairable post -tra -superior rotator 00:37:38.130 --> 00:37:41.579 cuff. the supraspinatus and infraspinatus. Why 00:37:41.579 --> 00:37:44.079 is the posterior cuff being intact so important 00:37:44.079 --> 00:37:46.940 for this anterior transfer? Well, just as the 00:37:46.940 --> 00:37:49.820 subscapularis is crucial for the success of posterior 00:37:49.820 --> 00:37:52.780 superior transfers like the LD, having a functioning 00:37:52.780 --> 00:37:55.659 posterior superior cuff is absolutely vital for 00:37:55.659 --> 00:37:57.659 the overall balance and stability of the shoulder 00:37:57.659 --> 00:37:59.980 when the subscapularis at the front is deficient 00:37:59.980 --> 00:38:02.119 and being replaced by the pectoralis major transfer. 00:38:02.679 --> 00:38:04.460 The force couples around the joint need to be 00:38:04.460 --> 00:38:06.880 balanced for effective movement and also to prevent 00:38:06.880 --> 00:38:08.599 that superior migration. of the humeral head. 00:38:08.659 --> 00:38:11.059 Right, makes sense. In terms of surgical technique, 00:38:11.719 --> 00:38:13.280 there are different approaches described for 00:38:13.280 --> 00:38:16.840 the PMA transfer. Some transfer the tendon anterior 00:38:16.840 --> 00:38:19.260 to the conjoined tendon that's formed by the 00:38:19.260 --> 00:38:21.800 short head of the biceps and the corcobrachialis, 00:38:21.860 --> 00:38:23.659 while others prefer to pass it underneath the 00:38:23.659 --> 00:38:26.940 conjoined tendon. Dr. Warner described an approach 00:38:26.940 --> 00:38:29.739 specifically underneath the clavicular head of 00:38:29.739 --> 00:38:32.460 the pectoralis major, which aims to avoid potential 00:38:32.460 --> 00:38:34.780 injury to the musculocutaneous nerve, which can 00:38:34.780 --> 00:38:37.809 be a risk during this procedure. Whilst large 00:38:37.809 --> 00:38:39.670 comparative studies looking at these different 00:38:39.670 --> 00:38:42.650 techniques are perhaps scarce, authors like Resch 00:38:42.650 --> 00:38:45.210 and Galatz have reported generally satisfactory 00:38:45.210 --> 00:38:48.329 clinical outcomes following PMA transfer. They 00:38:48.329 --> 00:38:50.429 show significant improvements in pain and functional 00:38:50.429 --> 00:38:54.250 scores, including increases in AC scores, demonstrating 00:38:54.250 --> 00:38:57.289 restored internal rotation strength, and improved 00:38:57.289 --> 00:39:00.159 overall shoulder function. So it seems like an 00:39:00.159 --> 00:39:02.280 effective option for restoring that lost internal 00:39:02.280 --> 00:39:04.519 rotation provided the patient selection is right. 00:39:04.800 --> 00:39:06.840 Are there any other transfer options for these 00:39:06.840 --> 00:39:09.599 anterior superior tears? Yes, the pectoralis 00:39:09.599 --> 00:39:12.980 minor transfer PMI has also been used. This is 00:39:12.980 --> 00:39:15.360 sometimes used in conjunction with a graft or 00:39:15.360 --> 00:39:17.619 perhaps as a smaller transfer option depending 00:39:17.619 --> 00:39:20.579 on the tear pattern. Wirth and Rockwood were 00:39:20.579 --> 00:39:23.219 among the first to describe using the PMI tendon 00:39:23.219 --> 00:39:26.539 either as a graft or as a direct transfer for 00:39:26.539 --> 00:39:30.000 irreparable subscapularis tears. And when might 00:39:30.000 --> 00:39:33.139 that specific transfer be indicated? It's typically 00:39:33.139 --> 00:39:35.320 considered for tears that involve mainly the 00:39:35.320 --> 00:39:37.539 upper two -thirds of the subscapularis tendon 00:39:37.539 --> 00:39:40.460 rather than the entire tendon. Palladini and 00:39:40.460 --> 00:39:42.579 colleagues described a specific technique involving 00:39:42.579 --> 00:39:44.840 transferring the pectoralis minor along with 00:39:44.840 --> 00:39:47.119 a small piece of the coracoid bone where it attaches 00:39:47.119 --> 00:39:49.820 onto the superior two -thirds of the subscapularis 00:39:49.820 --> 00:39:52.400 footprint. They often use this for combined irreparable 00:39:52.400 --> 00:39:55.699 tears involving both superior cuff, supraspinitis, 00:39:56.119 --> 00:39:58.739 and the upper subscapularis. Their study reported 00:39:58.739 --> 00:40:00.929 good outcomes at a two -year follow -up. with 00:40:00.929 --> 00:40:02.789 significant improvements in constant scores, 00:40:03.190 --> 00:40:04.969 and also a high rate of patients being able to 00:40:04.969 --> 00:40:06.949 return to their previous daily and even recreational 00:40:06.949 --> 00:40:09.429 activities. So it suggests this can be a viable 00:40:09.429 --> 00:40:11.750 option for certain specific patterns of complex 00:40:11.750 --> 00:40:14.300 anterior superior tears. It's really remarkable, 00:40:14.380 --> 00:40:16.280 isn't it, how many different muscle surgeons 00:40:16.280 --> 00:40:19.159 can potentially repurpose to try and restore 00:40:19.159 --> 00:40:21.920 lost function around the shoulder. Beyond these 00:40:21.920 --> 00:40:24.800 muscle transfers, the sources also discuss using 00:40:24.800 --> 00:40:27.519 different types of grafts, biological or synthetic 00:40:27.519 --> 00:40:30.840 materials, to either augment repairs or bridge 00:40:30.840 --> 00:40:34.179 large defects. Absolutely. Graft augmentation 00:40:34.179 --> 00:40:36.400 techniques represent another important strategy 00:40:36.400 --> 00:40:40.000 in the armamentarium for massive or irreparable 00:40:40.000 --> 00:40:42.460 tears. This is particularly relevant where there's 00:40:42.460 --> 00:40:44.920 a large gap in the tendon tissue that simply 00:40:44.920 --> 00:40:47.780 cannot be closed, even partially, without creating 00:40:47.780 --> 00:40:50.380 excessive tension. Right. The idea here is to 00:40:50.380 --> 00:40:52.739 use biological materials, or sometimes synthetic 00:40:52.739 --> 00:40:55.079 ones, to provide structural support, essentially 00:40:55.079 --> 00:40:57.599 bridge the defect, or potentially even enhance 00:40:57.599 --> 00:40:59.699 the biological healing environment. What kind 00:40:59.699 --> 00:41:02.159 of materials are typically used for these grafts? 00:41:02.360 --> 00:41:04.420 Well, they can be interpositional grafts, meaning 00:41:04.420 --> 00:41:06.440 they're placed between the torn edges to bridge 00:41:06.440 --> 00:41:08.679 the gap, and they can come from various sources. 00:41:09.769 --> 00:41:11.650 Allografts, which are derived from human donors, 00:41:12.289 --> 00:41:14.389 include materials like human dermal allograft 00:41:14.389 --> 00:41:18.550 skin, or fascialata allograft, a tough connective 00:41:18.550 --> 00:41:20.909 tissue from the thigh. Autografts are harvested 00:41:20.909 --> 00:41:23.789 from the patient themselves, most commonly fascialata 00:41:23.789 --> 00:41:27.010 from their own thigh, or perhaps a strip of iliotibial 00:41:27.010 --> 00:41:30.010 band, also from the leg. Synthetic grafts and 00:41:30.010 --> 00:41:32.650 also extracellular matrix products exist too, 00:41:32.929 --> 00:41:34.829 although the provided literature seems to focus 00:41:34.829 --> 00:41:37.230 more heavily on the biological grafts for this 00:41:37.230 --> 00:41:39.929 purpose, for interposition. A review by Sunwoo 00:41:39.929 --> 00:41:42.449 and Merle looked specifically at the biomechanical 00:41:42.449 --> 00:41:44.989 properties of these different graft types. They 00:41:44.989 --> 00:41:47.190 found that biological grafts like the allografts 00:41:47.190 --> 00:41:49.889 and autografts from Fasciolata or Iliotibial 00:41:49.889 --> 00:41:52.429 band tend to have quite similar stiffness and 00:41:52.429 --> 00:41:54.869 maximal load to failure compared to the native 00:41:54.869 --> 00:41:57.550 rotator cuff tendons themselves. Synthetic grafts, 00:41:57.550 --> 00:41:59.710 they found, might have similar load capacity 00:41:59.710 --> 00:42:02.489 but were often less stiff. And extracellular 00:42:02.489 --> 00:42:05.630 matrix grafts were typically lower in both stiffness 00:42:05.630 --> 00:42:09.139 and load capacity. This biomechanical understanding 00:42:09.139 --> 00:42:10.760 is quite important, isn't it, for predicting 00:42:10.760 --> 00:42:13.440 how well a particular graft might function under 00:42:13.440 --> 00:42:15.679 the stresses experienced in the shoulder. Absolutely. 00:42:16.420 --> 00:42:19.300 And clinically, do these grafts actually improve 00:42:19.300 --> 00:42:22.409 outcomes for patients? Well, the clinical evidence 00:42:22.409 --> 00:42:25.050 presented in the sources is generally quite positive, 00:42:25.369 --> 00:42:27.769 suggesting that grafts can indeed be a valuable 00:42:27.769 --> 00:42:30.469 adjunct in selected cases. Yeah. Demetrio's et 00:42:30.469 --> 00:42:32.829 al., for instance, reported improvements in pain 00:42:32.829 --> 00:42:35.809 and constant scores using a fascialata allograft 00:42:35.809 --> 00:42:38.210 for inner position, and they noted relatively 00:42:38.210 --> 00:42:41.010 low re -tier rates in their series. Okay. Panday 00:42:41.010 --> 00:42:42.949 et al. conducted a study where they found that 00:42:42.949 --> 00:42:45.130 using a dermal allograft to augment a partial 00:42:45.130 --> 00:42:47.809 repair actually improved outcomes measured by 00:42:47.809 --> 00:42:50.449 the Oxford shoulder score and constant score. 00:42:50.409 --> 00:42:52.670 compared to just doing the partial repair alone 00:42:52.670 --> 00:42:54.849 for symptomatic irreparable tears. So adding 00:42:54.849 --> 00:42:57.050 the graft actually improved the results compared 00:42:57.050 --> 00:42:59.110 to just doing the partial repair on its own. 00:42:59.250 --> 00:43:02.050 That was their specific finding, yes. It suggests 00:43:02.050 --> 00:43:04.130 the graft provided some beneficial structural 00:43:04.130 --> 00:43:06.909 support or perhaps enhanced the healing process. 00:43:08.090 --> 00:43:12.210 Morial's study using fascia lata autograft highlighted 00:43:12.210 --> 00:43:15.230 an interesting point. Its efficacy seemed to 00:43:15.230 --> 00:43:17.530 be linked to the degree of fatty degeneration 00:43:17.530 --> 00:43:20.239 already present in the remaining muscle. The 00:43:20.239 --> 00:43:22.199 grafts appeared to perform better when the fatty 00:43:22.199 --> 00:43:25.170 infiltration was less severe. Which makes sense 00:43:25.170 --> 00:43:27.389 biologically, doesn't it? The muscle has to be 00:43:27.389 --> 00:43:28.949 functional enough to actually load the graft 00:43:28.949 --> 00:43:32.230 effectively for it to work. And Mahara et al. 00:43:32.429 --> 00:43:34.929 described using an iliotibial band autograft, 00:43:35.250 --> 00:43:38.050 which had a bone block still attached. This bone 00:43:38.050 --> 00:43:40.150 block was then fixed directly to the humerus 00:43:40.150 --> 00:43:42.889 bone. They reported good pain relief, functional 00:43:42.889 --> 00:43:45.349 scores, and range of motion improvements. They 00:43:45.349 --> 00:43:47.530 also noted that the bone block successfully united 00:43:47.530 --> 00:43:49.769 to the humerus, and importantly, they reported 00:43:49.769 --> 00:43:52.469 no significant donor site morbidity from harvesting 00:43:52.469 --> 00:43:55.300 the graft. It sounds like these biological graphs 00:43:55.300 --> 00:43:58.059 show quite a bit of promise then, particularly 00:43:58.059 --> 00:44:00.539 according to that Sunrew and Merle review, which, 00:44:00.559 --> 00:44:03.739 as you mentioned, noted promising two -year outcomes 00:44:03.739 --> 00:44:06.179 regardless of the specific biological graph type 00:44:06.179 --> 00:44:09.139 used, and with relatively few complications reported. 00:44:09.480 --> 00:44:11.880 Yes. That review certainly provided a positive 00:44:11.880 --> 00:44:14.659 outlook on the potential role of biological graphs, 00:44:15.099 --> 00:44:17.719 either for augmentation or interposition, in 00:44:17.719 --> 00:44:20.159 selected cases of irreparable tiers, at least 00:44:20.159 --> 00:44:22.980 in the medium term. Building on that concept 00:44:22.980 --> 00:44:25.260 of using graphs, another technique that's received 00:44:25.260 --> 00:44:28.360 significant attention in recent years is superior 00:44:28.360 --> 00:44:32.539 capsular reconstruction, or SCR. This seems specifically 00:44:32.539 --> 00:44:34.940 designed to address a fundamental biomechanical 00:44:34.940 --> 00:44:37.480 problem caused by these large tears. It is, yes. 00:44:37.860 --> 00:44:40.760 The rationale for SCR, which was really pioneered 00:44:40.760 --> 00:44:43.619 and popularized by Dr. Teruhizo Meata in Japan 00:44:43.619 --> 00:44:46.139 is based on the concept that these massive irreparable 00:44:46.139 --> 00:44:48.860 tears often result in a deficiency not just of 00:44:48.860 --> 00:44:50.980 the rotator cuff canons themselves, but also 00:44:50.980 --> 00:44:53.739 the superior capsule of the shoulder joint. This 00:44:53.739 --> 00:44:57.099 superior capsular defect is thought to contribute 00:44:57.099 --> 00:44:59.460 significantly to the glenohumeral instability 00:44:59.460 --> 00:45:02.260 and that upward migration of the humeral head 00:45:02.260 --> 00:45:05.329 that we keep talking about. It's part of what 00:45:05.329 --> 00:45:07.909 Mihata termed the circle concept of instability 00:45:07.909 --> 00:45:10.210 that occurs in the setting of rotator cuff deficiency. 00:45:10.590 --> 00:45:12.989 So the tear isn't just a hole in the tendons, 00:45:13.090 --> 00:45:15.989 it actually compromises a key stabilizing structure 00:45:15.989 --> 00:45:18.489 right on top of the joint itself. Exactly that. 00:45:18.789 --> 00:45:21.570 The goal of SER is therefore to reconstruct that 00:45:21.570 --> 00:45:24.050 deficient superior capsule in order to restore 00:45:24.050 --> 00:45:26.969 passive stability to the joint and prevent that 00:45:26.969 --> 00:45:29.590 superior translation or upward movement of the 00:45:29.590 --> 00:45:32.039 humeral head. The original Mihata technique involved 00:45:32.039 --> 00:45:34.920 using a folded graft, typically fascia latae, 00:45:34.940 --> 00:45:37.000 either harvested as an autograft from the patient's 00:45:37.000 --> 00:45:40.159 thigh or using an allograft. This graft is then 00:45:40.159 --> 00:45:43.380 meticulously fixed medially to the superior aspect 00:45:43.380 --> 00:45:46.039 of the glenoid rim, the edge of the socket, and 00:45:46.039 --> 00:45:48.400 laterally to the greater tuberosity footprint 00:45:48.400 --> 00:45:50.440 on the humerus where the supraspinatus would 00:45:50.440 --> 00:45:52.719 normally attach. It essentially creates a new 00:45:52.719 --> 00:45:54.539 superior constraint, like putting a roof back 00:45:54.539 --> 00:45:57.219 on. It's also often sutured to any remaining 00:45:57.219 --> 00:45:59.360 viable rotator cuff tissue at the front or back. 00:45:59.420 --> 00:46:02.400 And what's the specific biomechanical goal of 00:46:02.400 --> 00:46:05.840 this complex reconstruction? Well, by restoring 00:46:05.840 --> 00:46:08.440 that superior constraint, the procedure aims 00:46:08.440 --> 00:46:11.019 to recreate the normal force couple mechanics 00:46:11.019 --> 00:46:13.920 around the shoulder. It aims to significantly 00:46:13.920 --> 00:46:16.519 increase the concurrently humeral distance by 00:46:16.519 --> 00:46:19.639 effectively pushing the humeral head back down 00:46:19.639 --> 00:46:22.739 into a more centered position. And thereby, it 00:46:22.739 --> 00:46:25.239 aims to improve the instability caused by the 00:46:25.239 --> 00:46:28.369 underlying cuff deficiency. And were the reported 00:46:28.369 --> 00:46:30.849 outcomes impressive? It sounds like a big procedure. 00:46:31.090 --> 00:46:33.690 They were indeed, yes, and they generated considerable 00:46:33.690 --> 00:46:36.780 excitement within the orthopedic community. Mahata's 00:46:36.780 --> 00:46:39.440 original studies, primarily using the Fascialata 00:46:39.440 --> 00:46:41.960 autograft, showed really quite dramatic improvements 00:46:41.960 --> 00:46:44.360 in clinical scores. Things like the AC score, 00:46:44.719 --> 00:46:47.099 the JOA, Japanese Orthopedic Association score, 00:46:47.519 --> 00:46:50.320 and the UCLA score. They also showed significant 00:46:50.320 --> 00:46:52.679 gains in active range of motion, and importantly, 00:46:53.099 --> 00:46:54.820 objective evidence on post -operative imaging 00:46:54.820 --> 00:46:57.480 of corrected instability, and that increased 00:46:57.480 --> 00:47:00.260 chromiohumeral distance. That sounds like a potential 00:47:00.260 --> 00:47:02.739 major breakthrough for certain types of patients, 00:47:02.940 --> 00:47:05.719 then. Who is the ideal candidate for an SCR procedure? 00:47:06.039 --> 00:47:08.579 It's typically indicated for younger, more active 00:47:08.579 --> 00:47:12.059 patients who have massive, irreparable, post 00:47:12.059 --> 00:47:15.059 or superior rotator cuff tears, but who do not 00:47:15.059 --> 00:47:19.260 have significant pre -existing glenohumeral osteoarthritis. 00:47:19.420 --> 00:47:22.059 No arthritis. Correct. They often have specific 00:47:22.059 --> 00:47:25.400 patterns of fatty degeneration and tendon retraction. 00:47:26.190 --> 00:47:28.750 But crucially, their humeral head should not 00:47:28.750 --> 00:47:30.789 be rigidly fixed in a high -riding position. 00:47:31.309 --> 00:47:33.329 It needs to be reducible. How do you actually 00:47:33.329 --> 00:47:35.989 know if it's fixed high -riding? Well a key clinical 00:47:35.989 --> 00:47:38.030 test often performed is the sulcus maneuver. 00:47:38.280 --> 00:47:41.159 If the surgeon can apply gentle downward traction 00:47:41.159 --> 00:47:43.980 on the patient's arm and the humeral head visibly 00:47:43.980 --> 00:47:47.000 translates inferiorly, creating a sulcus or dimple 00:47:47.000 --> 00:47:49.699 just below the acromion bone, it suggests that 00:47:49.699 --> 00:47:52.579 the head is still mobile and reducible, not fixed 00:47:52.579 --> 00:47:55.000 rigidly in its superiorly migrated position. 00:47:55.179 --> 00:47:57.500 This indicates there's enough mobility left in 00:47:57.500 --> 00:47:59.860 the joint and the surrounding soft tissues for 00:47:59.860 --> 00:48:02.360 the SCR graft to potentially be effective in 00:48:02.360 --> 00:48:04.820 stabilizing the head in a better position. If 00:48:04.820 --> 00:48:06.480 the head is already fixed high and cannot be 00:48:06.480 --> 00:48:09.219 reduced, then SCR is generally contraindicated. 00:48:09.840 --> 00:48:11.780 And are there variations or evolutions of the 00:48:11.780 --> 00:48:14.599 technique being used now? Yes, definitely. Other 00:48:14.599 --> 00:48:17.099 graft sources are being explored. For instance, 00:48:17.179 --> 00:48:19.599 using the long head of the biceps tendon as an 00:48:19.599 --> 00:48:22.139 autograft after performing a tenotomy has been 00:48:22.139 --> 00:48:24.719 described by Chalami and others. This potentially 00:48:24.719 --> 00:48:26.679 eliminates the need for a separate donor site 00:48:26.679 --> 00:48:29.320 harvest from the leg. Different techniques for 00:48:29.320 --> 00:48:32.059 graft introduction and fixation are also continually 00:48:32.059 --> 00:48:34.340 being refined to try and improve the procedure 00:48:34.340 --> 00:48:36.739 and outcomes. This leads us naturally, I think, 00:48:37.480 --> 00:48:39.840 to perhaps the most definitive surgical option 00:48:39.840 --> 00:48:42.559 for many of these complex irreparable tears, 00:48:43.300 --> 00:48:47.539 reverse total shoulder arthroplasty or... RTSA. 00:48:47.900 --> 00:48:50.880 Yes, RTSA has truly transformed the management 00:48:50.880 --> 00:48:53.079 of these complex shoulder problems over the past 00:48:53.079 --> 00:48:56.099 couple of days. It's now often considered a primary 00:48:56.099 --> 00:48:58.539 first -line treatment for very specific indications 00:48:58.539 --> 00:49:01.139 related to irreparable rotator cuff deficiency. 00:49:01.539 --> 00:49:04.000 What are those key indications where RTSA is 00:49:04.000 --> 00:49:05.949 considered upfront? Well, the most prominent 00:49:05.949 --> 00:49:08.050 indication is probably patients who have a true 00:49:08.050 --> 00:49:10.269 pseudo -paralytic shoulder resulting from an 00:49:10.269 --> 00:49:12.590 irreparable tear. That means they simply cannot 00:49:12.590 --> 00:49:14.769 actively elevate their arm effectively because 00:49:14.769 --> 00:49:16.809 the rotator cuff is completely non -functional 00:49:16.809 --> 00:49:19.369 as a prime mover. Another major indication is 00:49:19.369 --> 00:49:22.389 the combination of an irreparable rotator cuff 00:49:22.389 --> 00:49:25.690 tear with significant pre -existing glenohumeral 00:49:25.690 --> 00:49:29.030 osteoarthritis. This specific condition is often 00:49:29.030 --> 00:49:33.530 termed cuff tear arthropathy. Okay. RTSA is also 00:49:33.530 --> 00:49:35.349 often considered for patients who are perhaps 00:49:35.349 --> 00:49:38.130 not ideal candidates for arthroscopic procedures 00:49:38.130 --> 00:49:41.130 or tendon transfers, maybe due to their age, 00:49:41.289 --> 00:49:43.550 their general health, or the specific nature 00:49:43.550 --> 00:49:46.250 of their tear and resulting dysfunction. And 00:49:46.250 --> 00:49:48.429 remind us why it's called reverse arthroplasty. 00:49:48.610 --> 00:49:51.849 Yes. Well, unlike a conventional or anatomical 00:49:51.849 --> 00:49:54.650 total shoulder replacement, where a metal ball 00:49:54.650 --> 00:49:56.469 is placed on the humerus side and the plastic 00:49:56.469 --> 00:49:59.099 socket is put on the glenoid side, mimicking 00:49:59.099 --> 00:50:02.360 normal anatomy. In a reverse replacement, the 00:50:02.360 --> 00:50:05.400 geometry is flipped or reversed. A metal hemisphere 00:50:05.400 --> 00:50:07.780 called the glenosphere is fixed onto the glenoid 00:50:07.780 --> 00:50:10.619 bone, the socket side, and a plastic socket or 00:50:10.619 --> 00:50:13.099 cup within the humeral component is placed on 00:50:13.099 --> 00:50:15.800 the top of the humerus, the arm bone side. This 00:50:15.800 --> 00:50:18.480 design effectively lateralizes and distalizes 00:50:18.480 --> 00:50:20.320 the center of rotation of the shoulder joint. 00:50:20.599 --> 00:50:22.639 And how does that change in geometry help patients 00:50:22.639 --> 00:50:25.320 who have a non -functioning rotator cuff? By 00:50:25.320 --> 00:50:28.420 changing that center of rotation, The deltoid 00:50:28.420 --> 00:50:30.360 muscle, which is usually intact and strong in 00:50:30.360 --> 00:50:32.460 these patients, becomes a much more effective 00:50:32.460 --> 00:50:35.460 lever arm for elevating the arm. It simply bypasses 00:50:35.460 --> 00:50:38.539 the need for a functional rotator cuff to lift 00:50:38.539 --> 00:50:41.320 the arm overhead, allowing the powerful deltoid 00:50:41.320 --> 00:50:44.219 muscle to take over this crucial role. That's 00:50:44.219 --> 00:50:46.519 quite an ingenious biomechanical solution, isn't 00:50:46.519 --> 00:50:49.800 it? And what about the outcomes for RTSA? How 00:50:49.800 --> 00:50:52.460 well does it work? Systematic reviews, like the 00:50:52.460 --> 00:50:55.409 one by Petrillo et al. that you provided consistently 00:50:55.409 --> 00:50:57.769 show statistically significant improvements in 00:50:57.769 --> 00:51:00.409 clinical scores and also an active range of motion, 00:51:00.829 --> 00:51:03.050 particularly in forward elevation and abduction. 00:51:03.389 --> 00:51:05.329 Patients who were previously pseudo -paralytics 00:51:05.329 --> 00:51:07.489 often regain quite functional elevation of their 00:51:07.489 --> 00:51:11.230 arm. However, these reviews also often note limitations, 00:51:11.789 --> 00:51:14.789 particularly in reliably restoring active external 00:51:14.789 --> 00:51:17.949 rotation, which can sometimes remain weak even 00:51:17.949 --> 00:51:21.170 after a successful RTSA. And the wall -it -all 00:51:21.170 --> 00:51:24.019 review... specifically highlighted that the best 00:51:24.019 --> 00:51:26.199 functional results from RTSA are typically seen 00:51:26.199 --> 00:51:27.960 in those patients with established cuff tear 00:51:27.960 --> 00:51:30.679 arthropathy. That's where the combination of 00:51:30.679 --> 00:51:32.420 pain relief from the arthritis and the restored 00:51:32.420 --> 00:51:34.780 elevation function leads to the most dramatic 00:51:34.780 --> 00:51:37.159 improvements, often showing very significant 00:51:37.159 --> 00:51:40.199 increases in constant scores. So it's particularly 00:51:40.199 --> 00:51:42.480 effective at restoring the ability to lift the 00:51:42.480 --> 00:51:44.519 arm, especially when there's significant arthritis 00:51:44.519 --> 00:51:47.239 involved as well. What's the main downside then 00:51:47.239 --> 00:51:50.949 or the major concern with RTSA? The primary concern, 00:51:51.030 --> 00:51:52.829 which is consistently highlighted in the literature, 00:51:53.309 --> 00:51:56.329 is the risk of significant perioperative complications 00:51:56.329 --> 00:51:58.570 compared to some of the less invasive procedures 00:51:58.570 --> 00:52:01.130 we've discussed. That Petrillo review, for instance, 00:52:01.710 --> 00:52:03.909 compiled complication rates for multiple studies. 00:52:04.389 --> 00:52:07.449 They reported figures like 2 .4 % for mechanical 00:52:07.449 --> 00:52:10.630 failure of the implants themselves, 2 .7 % for 00:52:10.630 --> 00:52:13.070 fractions of the acromion or scapular spine occurring 00:52:13.070 --> 00:52:15.989 after the surgery, almost 1 % for deep infections 00:52:15.989 --> 00:52:19.070 requiring further treatment, and around 6 .6%. 00:52:18.989 --> 00:52:21.849 for heterotopic ossification that's abnormal 00:52:21.849 --> 00:52:24.250 bone formation around the new joint. Those numbers 00:52:24.250 --> 00:52:27.570 do sound... quite significant. They are, yes. 00:52:28.130 --> 00:52:30.050 And whilst revision surgery might eventually 00:52:30.050 --> 00:52:32.590 be needed for any shoulder procedure, the risk 00:52:32.590 --> 00:52:35.250 with RTSA is generally considered higher and 00:52:35.250 --> 00:52:37.889 revision RTSA surgery can be particularly complex 00:52:37.889 --> 00:52:40.409 and challenging. These potential complications 00:52:40.409 --> 00:52:43.429 require very careful patient counseling and consideration, 00:52:43.909 --> 00:52:45.789 especially perhaps in younger or healthier patients 00:52:45.789 --> 00:52:48.489 where other less definitive options might still 00:52:48.489 --> 00:52:50.670 be preferred initially if possible. It's also 00:52:50.670 --> 00:52:52.820 worth noting going back to that issue of external 00:52:52.820 --> 00:52:56.219 rotation, that for patients where restoring external 00:52:56.219 --> 00:52:59.079 rotation remains a major functional goal, some 00:52:59.079 --> 00:53:01.539 surgeons have explored combining the RTSA procedure 00:53:01.539 --> 00:53:04.239 with a latissimus dorsi, or perhaps a lopiscopal 00:53:04.239 --> 00:53:06.780 transfer at the same time. Authors like Boyleau 00:53:06.780 --> 00:53:08.860 and Bouibri have reported on this, attempting 00:53:08.860 --> 00:53:12.019 to address that specific rotational deficit concurrently 00:53:12.019 --> 00:53:15.340 with the joint replacement. OK, wow. We have 00:53:15.340 --> 00:53:17.699 covered an absolutely vast spectrum of options 00:53:17.699 --> 00:53:20.239 here, haven't we? Ranging from potentially encouraging 00:53:20.239 --> 00:53:22.360 results with just physiotherapy right through 00:53:22.360 --> 00:53:25.420 to complex muscle transfers and joint replacement. 00:53:25.960 --> 00:53:29.139 Given this huge range, how does a surgeon actually 00:53:29.139 --> 00:53:32.059 navigate this and decide which procedure is the 00:53:32.059 --> 00:53:34.949 right one? for a given patient presenting with 00:53:34.949 --> 00:53:37.130 an irreparable tear. Yes. This is absolutely 00:53:37.130 --> 00:53:38.710 the crux of the challenge, isn't it? And it brings 00:53:38.710 --> 00:53:40.710 us right back to the idea of a decision pathway, 00:53:41.070 --> 00:53:43.570 which is hinted at in the sources. The reality 00:53:43.570 --> 00:53:46.630 is there's no single simple algorithm that applies 00:53:46.630 --> 00:53:49.110 perfectly to every single patient. It requires 00:53:49.110 --> 00:53:51.769 really careful consideration of multiple factors, 00:53:52.349 --> 00:53:54.389 starting fundamentally with the patient themselves 00:53:54.389 --> 00:53:56.489 and what their goals are. Let's try and walk 00:53:56.489 --> 00:53:58.630 through that decision process logically, then. 00:53:58.769 --> 00:54:01.010 OK. Well, it really begins with a thorough patient 00:54:01.010 --> 00:54:04.260 assessment. We need to know their age, their 00:54:04.260 --> 00:54:07.039 activity level, their functional demands. What 00:54:07.039 --> 00:54:08.659 do they need and want to do with their shoulder? 00:54:09.119 --> 00:54:11.980 Their overall health and any comorbidities are 00:54:11.980 --> 00:54:15.059 crucial. And critically, what is their primary 00:54:15.059 --> 00:54:18.340 complaint? Is it mainly pain? Is it weakness? 00:54:19.000 --> 00:54:21.539 Or is it that inability to lift the arm, the 00:54:21.539 --> 00:54:24.199 pseudo -paralysis? Then on clinical examination 00:54:24.199 --> 00:54:26.860 and looking at the imaging, x -rays, MRI, the 00:54:26.860 --> 00:54:29.019 surgeon assesses the specific tear pattern which 00:54:29.019 --> 00:54:31.500 tendons are involved. How retracted are they? 00:54:31.860 --> 00:54:33.380 What's the quality of the muscle? What are like 00:54:33.380 --> 00:54:35.599 how much atrophy and fatty infiltration is there? 00:54:35.920 --> 00:54:38.099 What's the acromiohumeral distance? Is the giant 00:54:38.099 --> 00:54:40.920 stable? And importantly, is there any osteoarthritis 00:54:40.920 --> 00:54:44.400 present? And if so, how severe is it? So gathering 00:54:44.400 --> 00:54:46.280 all those different pieces of information together 00:54:46.280 --> 00:54:49.800 first is key. Exactly. Then the initial approach, 00:54:49.800 --> 00:54:52.260 as we discussed right at the beginning, is often 00:54:52.260 --> 00:54:54.320 conservative management, especially for those 00:54:54.320 --> 00:54:56.460 patients who don't have significant superior 00:54:56.460 --> 00:54:59.519 migration of the humeral head yet. Physiotherapy 00:54:59.519 --> 00:55:01.820 focused on strengthening the remaining muscles, 00:55:02.260 --> 00:55:04.519 particularly that anterior deltoid, is really 00:55:04.519 --> 00:55:07.179 key here. Right. If pseudo -paralysis is present, 00:55:07.719 --> 00:55:10.539 sometimes a diagnostic injection of local anesthetic 00:55:10.539 --> 00:55:13.679 into the joint can be helpful. It can help differentiate 00:55:13.679 --> 00:55:16.679 if the inability to lift the arm is purely due 00:55:16.679 --> 00:55:19.699 to pain inhibition. in which case blocking the 00:55:19.699 --> 00:55:21.980 pain might temporarily restore some movement 00:55:21.980 --> 00:55:25.579 or if it's due to an absolute mechanical deficiency 00:55:25.579 --> 00:55:28.019 of the cuff. And if that conservative care fails 00:55:28.019 --> 00:55:30.760 to provide adequate relief, particularly for 00:55:30.760 --> 00:55:33.320 ongoing pain, then the arthroscopic options come 00:55:33.320 --> 00:55:35.900 into consideration. Arthroscopic debridement 00:55:35.900 --> 00:55:37.920 and brosectomy are often the primary choices 00:55:37.920 --> 00:55:40.599 specifically for pain relief, especially perhaps 00:55:40.599 --> 00:55:43.019 in older or lower demand patients where function 00:55:43.019 --> 00:55:46.050 might be less of a concern than comfort. Adjuncts 00:55:46.050 --> 00:55:48.650 like a biceps tenotomy might be added if there's 00:55:48.650 --> 00:55:51.269 clear evidence of biceps pathology contributing 00:55:51.269 --> 00:55:54.409 to the pain. A partial rotator cuff repair could 00:55:54.409 --> 00:55:56.429 be attempted if it seems that a functional repair, 00:55:56.670 --> 00:55:59.550 restoring those key force couples, might be achievable 00:55:59.550 --> 00:56:02.010 based on the remaining tissue quality and its 00:56:02.010 --> 00:56:05.710 mobility. And suprascapular nerve release would 00:56:05.710 --> 00:56:08.309 only be considered if there's specific evidence 00:56:08.309 --> 00:56:10.809 pointing towards nerve involvement causing pain 00:56:10.809 --> 00:56:14.389 or weakness. Where does the subacromial spacer 00:56:14.389 --> 00:56:17.369 fit into this decision pathway now, given the 00:56:17.369 --> 00:56:20.050 recent evidence? Oh, that's a good question. 00:56:20.590 --> 00:56:23.050 And its place is perhaps less clear -cut now 00:56:23.050 --> 00:56:25.590 than it might have seemed a few years ago. Based 00:56:25.590 --> 00:56:27.590 on some of the initial reports, the spacer was 00:56:27.590 --> 00:56:29.409 often positioned in the pathway as an option 00:56:29.409 --> 00:56:31.309 for patients who had failed conservative care, 00:56:31.630 --> 00:56:33.550 but perhaps weren't deemed suitable candidates 00:56:33.550 --> 00:56:35.929 for a partial repair or more complex transfers. 00:56:36.469 --> 00:56:38.750 The idea was it could restore some subacromial 00:56:38.750 --> 00:56:41.989 height and facilitate therapy. But... As we've 00:56:41.989 --> 00:56:44.030 highlighted, the more recent conflicting evidence, 00:56:44.389 --> 00:56:46.469 particularly regarding its questionable impact 00:56:46.469 --> 00:56:48.610 on radiographic progression and perhaps lower 00:56:48.610 --> 00:56:51.949 functional outcomes, coupled with that non -negligible 00:56:51.949 --> 00:56:54.530 complication risk, makes its precise role in 00:56:54.530 --> 00:56:57.789 the decision pathway much more debated now and 00:56:57.789 --> 00:57:00.610 probably quite surgeon dependent. It's fair to 00:57:00.610 --> 00:57:02.349 say it's a procedure where the clinical indication 00:57:02.349 --> 00:57:05.489 is currently undergoing significant reevaluation 00:57:05.489 --> 00:57:08.019 based on this evolving data. That's a really 00:57:08.019 --> 00:57:10.360 important point of nuance to understand. What 00:57:10.360 --> 00:57:12.579 about the more involved transfers then? When 00:57:12.579 --> 00:57:15.760 do they come in? The tendon transfers are typically 00:57:15.760 --> 00:57:17.940 reserved for those younger, more active patients 00:57:17.940 --> 00:57:21.079 who have specific, significant functional deficits 00:57:21.079 --> 00:57:23.800 resulting from chronic irreparable tears, but 00:57:23.800 --> 00:57:26.320 crucially, who have minimal or no arthritis. 00:57:26.699 --> 00:57:29.340 The choice of which transfer to perform is dictated 00:57:29.340 --> 00:57:31.500 primarily by the location of the irreparable 00:57:31.500 --> 00:57:36.019 tear and the resulting functional loss. So, latissimus 00:57:36.019 --> 00:57:38.199 dorsi, or perhaps the lapiscopal modification, 00:57:38.820 --> 00:57:41.579 for posterior superior tears, where there's significant 00:57:41.579 --> 00:57:44.639 external rotation weakness, provided that the 00:57:44.639 --> 00:57:47.239 subscapularis at the front is intact and functional. 00:57:47.800 --> 00:57:50.780 Pectoralis major, or maybe minor, transfer for 00:57:50.780 --> 00:57:53.599 androsuperior tears, causing internal rotation 00:57:53.599 --> 00:57:56.039 weakness, provided the posterior cuff is intact. 00:57:56.480 --> 00:57:58.300 But remember, these are generally considered 00:57:58.300 --> 00:58:00.820 salvage procedures for severe functional loss, 00:58:01.300 --> 00:58:04.440 not routine operations. And the graft augmentation 00:58:04.440 --> 00:58:07.340 or the SCR procedure, where do they fit? Grafts 00:58:07.340 --> 00:58:09.559 used for augmentation or interposition are options 00:58:09.559 --> 00:58:11.820 when there's a large tissue defect, potentially 00:58:11.820 --> 00:58:14.260 to improve the outcomes of impartial repair or 00:58:14.260 --> 00:58:16.340 to bridge a gap that simply can't be closed otherwise. 00:58:16.889 --> 00:58:19.670 Superior Captular Reconstruction, SCR, is a much 00:58:19.670 --> 00:58:21.889 more specific reconstructive technique. It's 00:58:21.889 --> 00:58:23.989 typically considered for younger, non -arthritic 00:58:23.989 --> 00:58:26.550 patients who have massive postural superior tears 00:58:26.550 --> 00:58:29.289 where the humeral head is reducible but demonstrably 00:58:29.289 --> 00:58:32.150 unstable superiorly. It's a complex procedure 00:58:32.150 --> 00:58:34.769 aimed squarely at restoring that superior stability. 00:58:35.130 --> 00:58:39.670 And finally, the RTSA, the reverse replacement. 00:58:40.000 --> 00:58:41.980 The first total shoulder arthroplasty is often 00:58:41.980 --> 00:58:44.639 the go -to or perhaps the default option for 00:58:44.639 --> 00:58:46.659 patients who have that combination of significant 00:58:46.659 --> 00:58:49.340 osteoarthritis and an irreparable tear -the -cuffed 00:58:49.340 --> 00:58:52.340 tear -arthropathy patients. Or for older patients 00:58:52.340 --> 00:58:54.639 who present with a true pseudo -paralytic shoulder 00:58:54.639 --> 00:58:56.739 and aren't really suitable candidates for transfers 00:58:56.739 --> 00:58:59.420 or other reconstructive procedures. It's also 00:58:59.420 --> 00:59:01.519 used when other surgical options have failed. 00:59:01.880 --> 00:59:04.380 Its main strength, as we said, is reliably restoring 00:59:04.380 --> 00:59:06.559 elevation, particularly in the presence of arthritis, 00:59:07.039 --> 00:59:09.400 but that higher potential complication rate always 00:59:09.400 --> 00:59:11.420 has to be factored into the decision -making 00:59:11.420 --> 00:59:14.329 and patient selection process. So you can see 00:59:14.329 --> 00:59:16.570 the surgeon is essentially weighing up the patient's 00:59:16.570 --> 00:59:18.590 age, their functional goals, their overall health, 00:59:19.010 --> 00:59:21.130 the specific anatomy and muscle quality relating 00:59:21.130 --> 00:59:23.369 to the tear, the presence and severity of any 00:59:23.369 --> 00:59:25.929 arthritis, and then the relative risks and benefits 00:59:25.929 --> 00:59:28.769 of each potential procedure. They're moving along 00:59:28.769 --> 00:59:30.969 this continuum from simple interventions towards 00:59:30.969 --> 00:59:33.630 more complex ones, really aiming to match the 00:59:33.630 --> 00:59:35.769 right solution to that individual patient specific 00:59:35.769 --> 00:59:38.409 problem. It's truly a complex puzzle, isn't it? 00:59:38.409 --> 00:59:40.670 It requires such a deep understanding of both 00:59:40.670 --> 00:59:43.389 the pathology itself and all the available tools 00:59:43.389 --> 00:59:45.670 in the surgical toolbox, as you've so clearly 00:59:45.670 --> 00:59:48.449 laid out for us. Absolutely. And the literature 00:59:48.449 --> 00:59:50.610 really reflects this complexity. The ongoing 00:59:50.610 --> 00:59:53.349 research, as we saw very clearly with the differing 00:59:53.349 --> 00:59:55.949 findings on the subacromial spacer, continues 00:59:55.949 --> 00:59:58.050 to refine our understanding of which procedure 00:59:58.050 --> 01:00:00.909 works best for which patient and under exactly 01:00:00.909 --> 01:00:03.730 what circumstances. The challenge, really, of 01:00:03.730 --> 01:00:06.219 selecting the correct indication for each procedure 01:00:06.219 --> 01:00:08.940 remains absolutely paramount in this field. Well, 01:00:09.000 --> 01:00:11.039 what a comprehensive deep dive into a really 01:00:11.039 --> 01:00:13.440 challenging area of orthopedics. So just wrapping 01:00:13.440 --> 01:00:15.500 this all up and perhaps thinking about the future. 01:00:16.239 --> 01:00:18.179 Given the variable outcomes we've heard about 01:00:18.179 --> 01:00:20.579 for some procedures and that crucial need for 01:00:20.579 --> 01:00:23.000 meticulous patient selection and surgical technique, 01:00:23.559 --> 01:00:25.780 how might future innovations potentially move 01:00:25.780 --> 01:00:27.820 beyond the current strategies of compensation 01:00:27.820 --> 01:00:30.800 and reconstruction? Could we perhaps look towards 01:00:30.800 --> 01:00:33.420 more predictable long -term solutions or even 01:00:33.420 --> 01:00:36.059 biological regeneration for patients who are 01:00:36.059 --> 01:00:39.019 facing these complex irreparable tiers? Ah, that's 01:00:39.019 --> 01:00:40.940 the really compelling question, isn't it? That's 01:00:40.940 --> 01:00:42.719 what drives the continued research in this field. 01:00:43.380 --> 01:00:46.210 Will we see perhaps more effective biological 01:00:46.210 --> 01:00:48.530 scaffolds that truly integrate with the host 01:00:48.530 --> 01:00:52.590 tissue and actively promote healing? Will advances 01:00:52.590 --> 01:00:55.329 in things like gene therapy or the use of specific 01:00:55.329 --> 01:00:58.050 growth factors help us to improve muscle quality 01:00:58.050 --> 01:01:01.809 before or after surgery? Or will entirely new 01:01:01.809 --> 01:01:04.050 biomechanical solutions emerge that we haven't 01:01:04.050 --> 01:01:06.349 even thought of yet? It's certainly an exciting 01:01:06.349 --> 01:01:08.659 frontier to watch. A fascinating thought to leave 01:01:08.659 --> 01:01:11.019 us with. Thank you so much for guiding us through 01:01:11.019 --> 01:01:13.300 this really intricate topic today. It's been 01:01:13.300 --> 01:01:16.320 my pleasure. And if you, listening, found this 01:01:16.320 --> 01:01:18.940 deep dive valuable, please do take just a moment 01:01:18.940 --> 01:01:21.039 to rate and perhaps share the show with someone 01:01:21.039 --> 01:01:23.639 else who might benefit from a clear evidence 01:01:23.639 --> 01:01:26.460 -based look at complex topics like this one. 01:01:26.699 --> 01:01:28.679 It really helps us to bring more insights like 01:01:28.679 --> 01:01:29.239 these to you.