13.6 Postoperative Protocol

The arm is placed in a brace positioned in 15° of abduction and ER for 4 weeks. Passive forward flexion is started on the first postoperative day. The brace is discontinued after 4 weeks, and the patients undergo a physiotherapist-assisted rehabilitation program of passive and active mobilization and isometric strengthening exercises. After 8 weeks, isokinetic strengthening exercises are started.

13.7 Results

To the best of our knowledge, there are only five reports published on arthroscopic-assisted LDTT for irreparable RCTs [37, 38, 41, 43, 75]. Castricini et al. [38] reported on 27 patients with a mean age of 60 years (range, 46 to 67 years). The authors showed a significant improvement in the mean Constant and Murley score, pain score, muscle strength in forward elevation, and range of motion in ER (P < 0.05) at a mean follow-up of 27 months. The authors used a true anteroposterior radiograph to evaluate the grade of osteoarthritis in the shoulder pre- and postoperatively according to the Samilson and Prieto three-stage classification system [76]. They also assessed the proximal migration of the humeral head on true anteroposterior radiographs in neutral rotation, using a three-stage classification (stage 1, no proximal migration; stage 2, mild proximal migration; stage 3, severe proximal migration). The authors did not report significant osteoarthritis progression and proximal migration of the humeral head after surgery.

Grimberg et al. [41] evaluated the clinical (Constant and Murley score and subjective shoulder value), radiologic (acromiohumeral distance), and MRI (transferred tendon aspect) results of arthroscopic-assisted LDTT performed in 55 patients with a mean age at the time of surgery of 62 years (range, 31 to 75 years). The patients were evaluated at a mean follow-up of 29 months. The authors reported statistically significant improvement in Constant and Murley score, subjective shoulder value, and range of motion (P < 0.001) from preoperatively to postoperatively. The authors did not report any statistical difference in acromiohumeral distance and osteoarthritic stage between preoperative and final follow-up. However, four patients had a ruptured LDT on MRI at 1-year follow-up.

Paribelli et al. [75] compared clinical results in two groups of patients with irreparable RCTs treated surgically: one group (20 patients) received an arthroscopic-assisted LDTT and the other (20 patients) an arthroscopic partial rotator cuff repair. The patients were evaluated at a mean follow-up of 2.8 years (1–5, SD 3) using the following tools: University of California Los Angeles (UCLA) shoulder rating scale, range of motion, measurement of the strength, and the rotator cuff quality of life (RC-QOL) questionnaire. The authors reported statistically significant improvement (P < 0.05) in UCLA score results, strength, and RC-QOL questionnaire for patients treated with arthroscopic-assisted LDTT compared to patients treated with arthroscopic partial rotator cuff repair, with no differences found between groups for pain relief. One case of LDT rupture was reported (13 months after surgery) and the patient underwent a RTSA surgery.

Castricini et al. [37] evaluated the functional outcomes (Constant and Murley score) and checked for possible outcome predictors of arthroscopic-assisted LDTT in 86 patients (aged 59.8 ± 5.9 years). Of these, 14 patients (16.3%) sustained an irreparable, massive RCT after a failed arthroscopic rotator cuff repair. The patients were evaluated at a mean follow-up of 36.4 ± 9 months. The authors reported statistically significant improvement (P < 0.001) in Constant and Murley score at final follow-up. Patients with lower preoperative CMS and a history of failed rotator cuff repair have a greater likelihood of having a lower clinical result. Interestingly, gender and age did not affect the clinical outcomes.

Kanatli et al. [43] clinically (range of motion, UCLA, Constant and Murley score, and visual analog scale pain score) and radiologically (acromiohumeral distance) evaluated a modified technique for arthroscopic-assisted LDTT in 15 patients with irreparable RCTs and pseudoparalysis. The mean patient age was 61.53 ± 6.24 years (range, 52–71 years). The patients were evaluated at a mean follow-up of 26.4 ± 2.58 months (range, 24–31 months). The authors reported statistically significant improvement (P < 0.001) in UCLA, Constant and Murley score, visual analog scale pain score, active forward flexion, active abduction, and active ER. The authors reported a statistically significant difference in acromiohumeral distance from preoperatively (3.13 ± 1.40 mm) to postoperatively (5.67 ± 1.67 mm) (P < 0.001).