Systematic review of reversing pseudoparalysis of the shoulder due to massive, irreparable rotator cuff tears

https://doi.org/10.1016/j.jse.2020.04.039Get rights and content

Background

Correcting pseudoparalysis of the shoulder due to massive rotator cuff tear is challenging. The most reliable treatment for restoring active shoulder elevation is debatable. Therefore, the purpose of this systematic review was to evaluate the success of various treatment options for reversing pseudoparalysis due to massive rotator cuff tear.

Methods

A search was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines of the MEDLINE database, Cochrane database, Sportdiscus, and Google Scholar database for articles evaluating shoulder pseudoparalysis due to massive rotator cuff tears.

Results

Nine articles evaluating reverse total shoulder arthroplasty (RTSA), superior capsular reconstruction (SCR), and rehabilitation programs were included in the study. Though there was variability, the definition of pseudoparalysis was active forward elevation (AFE) less than 90° with preserved passive range of motion (ROM). Reversal of pseudoparalysis was defined as restoration of AFE greater than 90°. The overall rate of reversal of pseudoparalysis across studies was similar for RTSA (96% ± 17%) and SCR (94% ± 3%). However, there was a difference in average improvement in AFE for RTSA (56° ± 11°) and SCR (106° ± 20°). A progressive rehabilitation program described improvements in a single study with 82% reversal of pseudoparalysis.

Conclusion

The available Level IV evidence suggests that RTSA and SCR reliably reverse pseudoparalysis in most patients with massive, irreparable rotator cuff tears. However, the dissimilar improvements in ROM suggest that a more consistent definition of pseudoparalysis is warranted. Future randomized controlled trials are needed to determine the best treatment approach for patients with massive irreparable rotator cuff tears.

Section snippets

Methods

A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Our search was performed by using the MEDLINE, Cochrane, SportDiscus, and Google Scholar databases; it included all years through January 2019. Search terms / key words for the literature review included pseudoparalysis, pseudoparesis, irreparable rotator cuff tear, reverse total shoulder arthroplasty, and superior capsular reconstruction. The initial search was

Results

The initial key term search identified 1901 potential articles. A key term and title review of each article was performed reducing the initial search to 69 articles. After abstract review of these 69 articles for inclusion and exclusion criteria, 20 articles met the criteria. These articles were analyzed and cross-referenced to ensure no additional articles should be included. After full-text review, 9 articles were included in the final analysis. The key term literature search, abstract

Discussion

Although many treatment strategies exist when caring for patients with pseudoparalysis, operative treatment strategies appear to have a superior reversal rate when compared to nonoperative management. Comparing surgical options is more difficult. Both SCR and RTSA appear reliable in re-establishing ROM and reversing pseudoparalysis. The results from this review suggest that SCR may achieve better overall improvement in AFE than RTSA. However, this requires further study and longer-term

Conclusion

The available Level IV evidence suggests that both RTSA and SCR can reliably reverse pseudoparalysis in patients with irreparable rotator cuff tears. A more consistent definition of pseudoparalysis would help clarify the success of treatments. Future randomized controlled trials with modern techniques and indications are needed to determine the best treatment approach for patients who present with pseudoparalysis due to massive irreparable rotator cuff tearing in the absence of advanced

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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      Based on these results, we suggest that the LDTT should not be performed in presence of true pseudoparalysis. Both, superior capsular reconstruction and reverse shoulder arthroplasty appear more reasonable in reversing pseudoparalysis.25 Another relevant finding of the current study is the significant effect of the AHI reversibility on the patient satisfaction after arthroscopic-assisted LDTT.

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      The clinical importance of the shrugging and active scapulothoracic motion during initiation of abduction when clarifying PP was recently emphasized by Ernstbrunner et al,17 who also demonstrated the structural importance of the subscapularis integrity, which was not separately analyzed in this study. The term “irreparable” rotator cuff tears has not been standardized across the literature,12 but we have used the magnetic resonance imaging findings of tendon retraction and fatty infiltration as our main predictors of rotator cuff “reparability.”25 The natural course of PP is still poorly understood as some cases will occasionally demonstrate recovery with time, but rehabilitation to train the anterior deltoid has shown its effectiveness as well.30

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    This systematic review did not require institutional review board approval.

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