Superior Capsular Reconstruction Provides Sufficient Biomechanical Outcomes for Massive, Irreparable Rotator Cuff Tears: A Systematic Review

Preoperative magnetic resonance imaging rotator cuff tendon stump classification correlates with the surgical outcomes following superior capsular reconstruction

HYPOTHESIS

This study aimed to investigate the correlation between rotator cuff stump classification and postoperative outcomes after superior capsular reconstruction (SCR).

METHODS

A total of 75 patients who underwent SCR between June 2013 and May 2021 were included in this study. Based on stump classification using the signal intensity ratio of the tendon rupture site to the deltoid muscle in the coronal view of preoperative T2-weighted, fat-suppressed magnetic resonance imaging scans, the patients were classified into types 1, 2, and 3 with ratios of <0.8, 0.8-1.3, and >1.3 (44, 17, and 14 patients, respectively). The American Shoulder and Elbow Surgeons (ASES), Constant, and visual analog scale (VAS) scores for pain and range of motion were evaluated at a minimum of 1 year of follow-up postoperatively. The acromiohumeral distance and rotator cuff arthropathy according to the Hamada classification were assessed on plain radiography. The graft integrity was evaluated by magnetic resonance imaging at 3 and 12 months postoperatively and annually thereafter.

RESULTS

Clinical and radiological outcomes were significantly improved after SCR. In comparison with type 2 and 3 patients, type 1 patients had significantly higher ASES scores (type 1, 2, and 3 = 84 ± 10, 75 ± 15, and 76 ± 14; all P = .014), Constant scores (type 1, 2, and 3 = 65 ± 5, 61 ± 9, and 56 ± 13; all P = .005), and forward flexion (type 1, 2, and 3 = 155 ± 10, 154 ± 15, and 145 ± 13; all P = .013). However, these statistical differences between groups were below the established minimum clinically important difference values for the ASES and Constant scores after rotator cuff repair. The graft failure rate after surgery was lower in the type 1 group than that in the other 2 groups; however, the difference was not statistically significant (P = .749).

CONCLUSION

Patients with stump classification type 1 showed significantly better functional scores (ASES and VAS scores) and forward flexion; however, the clinical importance of these differences may be limited. Stump classification may be useful for predicting postoperative clinical outcomes.

Rate of graft retear is higher in over-the-top superior capsular reconstruction for massive posterosuperior rotator cuff tears with subscapularis tear

PURPOSE

To compare side-to-side superior capsular reconstruction (SCR) with over-the-top SCR in terms of functional outcomes, pain relief and allograft survival rates.

METHODS

Patients who had undergone arthroscopic dermal allograft SCR for massive irreparable rotator cuff tears and clinical follow-up for ≥2 years were recruited. All patients underwent postoperative assessment with routine radiographic analysis for acromiohumeral distances, ultrasound imaging 1 and 3 months after SCR and magnetic resonance imaging (MRI) at least 12 months after SCR. The outcome measures were visual analogue scale (VAS), American Shoulder and Elbow Surgeons (ASES), Constant and Single Assessment Numeric Evaluation (SANE) scores.

RESULTS

SCR was performed in 56 patients including side-to-side SCR in 32 and over-the-top SCR in 24. Postoperative MRI showed that the grafts were intact in 46 patients (82.1%; 26 who underwent side-to-side SCR and 20 who underwent over-the-top SCR). The proportion of nonhealing grafts in the over-the-top group was significantly higher with concomitant subscapularis tears (60% vs. 5.3%; p = 0.02). VAS scores and functional outcomes improved postoperatively in both groups and postoperative VAS (1.4 vs. 1.7; n.s.), Constant (74.8 vs. 76.0; n.s.), mean ASES (87.4 vs. 89.1; n.s.) and mean SANE (81.7 vs. 84.3; n.s.) scores did not differ significantly.

CONCLUSION

For massive rotator cuff tears, over-the-top and side-to-side SCR achieve similar pain relief and functional improvement, and the rate of healing allografts is high. However, over-the-top SCR is not recommended for massive posterosuperior rotator cuff tears with repairable subscapularis tendon tears due to a higher nonhealing rate.

LEVEL OF EVIDENCE

Level III.

Glenohumeral Superior Translation and Subacromial Contract Pressure Are Both Improved With Superior Capsular Reconstruction: A Systematic Review and Meta-analysis of Biomechanical Investigations

PURPOSE

To review cadaveric studies evaluating the biomechanical outcomes of superior capsular reconstruction (SCR) with different graft types for the treatment of irreparable rotator cuff (RTC) tears.

METHODS

PubMed, Cochrane, and Embase were queried in January 2022 to conduct this meta-analysis using the following key words: "superior capsule reconstruction," "superior capsular reconstruction," and "biomechanics." Articles were included if they reported glenohumeral superior translation or subacromial contact pressure following SCR in cadaveric RTC tears. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. Number of shoulders, graft types, and biomechanical outcomes were recorded and analyzed with forest plots.

RESULTS

Twelve studies (95 shoulders) were included in the statistical analysis. There was a significant reduction in glenohumeral superior translation following SCR compared with RTC tear across 10 studies (79 shoulders) with standardized mean difference (SMD) -2.48 mm; confidence interval (CI) -3.28 mm, -1.69 mm. The SMD between fascia lata graft and RTC tear was -3.84 mm (CI -4.82 mm, -2.86 mm) and between dermal allograft and RTC tear was -2.05 mm (CI -3.10 mm, -1.00 mm). There was a significant reduction in subacromial contact pressure following SCR compared with RTC tear across 5 studies (55 shoulders) with SMD -3.49 MPa (CI -4.54 MPa, -2.44 MPa). The SMD between fascia lata graft and RTC tear was -3.21 MPa (CI -5.08 MPa, -1.34 MPa) and between dermal allograft and RTC tear was -3.89 MPa (CI -5.91 MPa, -1.87 MPa).

CONCLUSIONS

Independent of graft type, biomechanical studies suggest that SCR improves glenohumeral superior translation and subacromial contact pressure in comparison with RTC tear at time zero. There was no definitive evidence identified in this study to suggest a biomechanically superior SCR graft option.

CLINICAL RELEVANCE

Investigating the biomechanical outcomes of several graft types for superior capsular reconstruction will help surgeons better understand the efficacies of different graft types for use in superior capsule reconstruction surgery.

Patients With Intact Shoulder Superior Capsular Reconstruction Grafts on Ultrasound Show Significant Improvement in Functional Outcomes at Minimum 2-Year Follow-up

Purpose

To assess the utility of using dynamic ultrasound for postoperative evaluation after superior capsular reconstruction (SCR) by evaluating graft integrity and its correlation with clinical outcomes at a minimum 2-year follow-up.

Methods

A retrospective chart review was conducted to identify patients who underwent SCR between July 2015 and July 2020 with a minimum 2-year clinical and ultrasound follow-up. Clinical outcome measures included Simple Shoulder (SS) and American Shoulder and Elbow Surgeon (ASES) scores. Integrity of the SCR graft was evaluated by dynamic ultrasound.

Results

We evaluated 22 shoulders in 21 patients with a mean follow-up of 44.8 months (range, 24-71 months). The graft was found to be intact by ultrasound evaluation in 82% (18/22). Patients with intact grafts had higher mean SS (11.6 vs 7.8, P = .00079) and ASES (91.2 vs 64.1, P = .0296) scores at latest follow-up compared to those with failed grafts. Those with intact grafts also had significant improvement in SS (3.7 vs 11.6, P < .00001) and ASES (23.2 vs 91.2, P < .00001) scores at latest follow-up compared to their preoperative scores. In contrast, patients with graft failure had no significant improvement in SS (6.3 vs 9.0, P = .123) and ASES (40.4 vs 58.3, P = .05469) scores at latest follow-up compared to their preoperative scores. There was no difference between clinical outcomes at 6 to 12 months vs latest follow-up for both SS (P = .11, P = .5) and ASES (P = .27, P = .21) scores.

Conclusions

SCR grafts were found by ultrasound to be intact in 82% of cases. Patients with intact grafts on ultrasound had significant improvement in functional outcome scores while those with graft failure did not. Functional outcome scores suggest that maximal recovery from this procedure occurs by 6 to 12 months.

Level of Evidence

Level IV, therapeutic case series.

Interposition Grafting Using Fascia Lata Autograft for Failed Rotator Cuff Repairs

Massive rotator cuff tears are a huge challenge for orthopaedic surgeons, as the patients may be in need of multiple operations, even including reverse total shoulder arthroplasty. The various repair methods for the rotator cuff, such as partial rotator cuff repair, patch-augmented rotator cuff repair, bridging rotator cuff reconstruction with graft interposition, tendon transfer, and superior capsular reconstruction, have always been the focus of research. During surgical intervention for failed rotator cuff repairs, complexity of tears, poor tissue quality, retained hardware, and adhesions are the problems routinely encountered. In this Technical Note, we describe the technique of interposition grafting using fascia lata autograft to reconstruct the rotator cuff after failed primary repair.

Superior capsular reconstruction for irreparable rotator cuff tear: a review of current methods

Irreparable massive rotator cuff tears can significantly impact daily life; and these types of tears can be difficult to repair completely, especially in younger patients who are more active and have higher functional requirements. Since its introduction by Mihata and the colleagues, superior capsular reconstruction (SCR) has gained popularity in the treatment of irreparable massive rotator cuff tears and has shown promising short-term results. A variety of studies have focused on the clinical and biomechanical outcomes of this procedure. This article reviews the biomechanics, indications for the surgical procedure, graft options, surgical technique, and rehabilitation from SCR.

Editorial Commentary: Superior Capsular Reconstructions in Cases of Irreparable Rotator Cuff Tendons Only Partially Restore Anatomy, Yet Significantly Normalize Biomechanics-Without Resorting to Reverse Anatomy

The goal of shoulder superior capsular reconstruction and/or anterior cable reconstructions, at least in terms of biomechanics, is to primarily restore a fulcrum to assist with pain control and functional optimization, with the secondary hope of maintaining cartilage. Fully restoring glenohumeral joint loads with SCR cannot be expected in the setting of persistent tendon insufficiency. Biomechanical studies characterizing shoulder capsular reconstructions have demonstrated anatomic and functional restorations toward normalization when tested with standard biomechanical methods. Glenohumeral abduction, superior humeral head migration, deltoid forces, and glenohumeral contact pressure and area, can be optimized toward the normal intact condition, as measured by motion tracking and pressure mapping in real time, using dynamic actuators. Insofar as restoring normal native anatomy is considered a fundamental priority, with the idea that joint functional longevity is enhanced by preserving anatomy, as surgeons, we should not lose sight of reconstruction over replacement (such as nonanatomic reverse total shoulder arthroplasty) as a favored goal. Anatomy-based reconstructions such as superior capsule or anterior cable reconstruction, may prove over time to be the best primary treatment as knowledge and innovations (technical and medical) develop, with nonanatomic arthroplasty truly being a last resort (yet a clinically viable option when indicated).

Editorial Commentary: Superior Capsular Reconstruction Employing Allograft Heals and Functions Well if the Graft Is Sufficiently Thick and Stiff

Superior capsular reconstruction (SCR) has fallen into disrepute, and the numbers performed appear to be on the decline because it is technically demanding and time-consuming, requires a long postoperative recovery, and does not always heal or function as expected. In addition, two "new kids on the block," the subacromial balloon spacer and the lower trapezius tendon transfer, have emerged as viable alternatives for low-demand patients who cannot tolerate a lengthy recovery and for high-demand patients who lack external rotation strength, respectively. However, carefully selected patients continue to do well after SCR, when surgery is meticulously performed using a graft that is sufficiently thick and stiff. The clinical results and healing rates after SCR using allograft tensor fascia lata are comparable with those after SCR using tensor fascia lata autograft and without donor-site morbidity. Robust comparative clinical study is needed to sort out the optimal graft type and thickness for SCR and the precise indications for each of the surgical treatment options for the irreparable rotator cuff tear, but let's not "throw the baby out with the bathwater" and abandon SCR altogether.

Superior Capsular Reconstruction Partially Restores Native Glenohumeral Joint Loads In A Dynamic Biomechanical Shoulder Model

PURPOSE

To evaluate the effect of an irreparable posterosuperior rotator cuff tear (PSRCT) on glenohumeral joint loads and to quantify improvement following superior capsular reconstruction (SCR) using an acellular dermal allograft.

METHODS

Ten fresh-frozen cadaveric shoulders were tested using a validated dynamic shoulder simulator. A pressure mapping sensor was placed between the humeral head and glenoid surface. Each specimen underwent the following conditions: (1) native, (2) irreparable PSRCT, (3) SCR using a 3mm-thick acellular dermal allograft. Glenohumeral abduction angle (gAA) and superior humeral head migration (SM) were measured using 3D motion tracking software. Cumulative deltoid force (cDF) and glenohumeral contact mechanics, including contact area (gCA) and contact pressure (gCP), were assessed at rest,15°,30°,45°, and maximum angle of glenohumeral abduction.

RESULTS

The PSRCT resulted in a significant decrease of gAA along with an increase in SM, cDF, and gCP (P<.001, respectively). SCR did not restore native gAA (P<.001), however, SM was significantly reduced (P<.001). Further, SCR significantly reduced deltoid forces at 30° (P=.007) and 45° of abduction (P=.007) when compared to the PSRCT. SCR did not restore native cDF at 30°(P=.015), 45°(P<.001), and maximum angle (P<.001) of glenohumeral abduction. Compared to the PSRCT, SCR resulted in a significant decrease of gCP at 15°(P=.008), 30°(P=.002), and 45°(P=.006). However, SCR did not completely restore native gCP at 45° (P=.038) and maximum abduction angle (P=.014).

CONCLUSION

In this dynamic shoulder model, SCR only partially restored native glenohumeral joint loads. However, SCR significantly decreased glenohumeral contact pressure, cumulative deltoid forces, and superior migration, while increasing abduction motion, when compared to the posterosuperior rotator cuff tear.

CLINICAL RELEVANCE

These observations raise concerns regarding the true joint preserving potential of SCR for an irreparable posterosuperior rotator cuff tear, along with its ability to delay progression of cuff tear arthropathy and eventual conversion to reverse shoulder arthroplasty.

Editorial Commentary: Shoulder Superior Capsular Reconstruction Remains to Be Proven Superior to Partial Repair of the Rotator Cuff for Active Patients With Irreparable Tears and Without Osteoarthritis

The management of irreparable rotator cuff tears in active patients without severe osteoarthritis is challenging. Retracted tears of the superior cuff result in devastating glenohumeral kinematics and decreased shoulder function. Surgical solutions such as superior capsular reconstruction (SCR) or tendon transfers may improve shoulder function. Regarding SCR, the superior capsule has been described as a static stabilizer allowing for the centering of the humeral head. However, some bases for SCR are based on biomechanical studies that should be regarded as time zero, absent healing, and generally oversimplified as ball-and-socket research rather than replicating complex functional shoulder kinematics. SCR may be waning in popularity. SCR using autograft may, or may not, prove effective in the long run. For now, it remains to be seen whether SCR is superior to partial repair of the rotator cuff.

Management of Irreparable Posterosuperior Rotator Cuff Tears-A Current Concepts Review and Proposed Treatment Algorithm by the AGA Shoulder Committee

Posterosuperior rotator cuff tears range among the most common causes of shoulder complaints. While non-operative treatment is typically reserved for the elderly patient with low functional demands, surgical treatment is considered the gold standard for active patients. More precisely, an anatomic rotator cuff repair (RCR) is considered the most desirable treatment option and should be generally attempted during surgery. If an anatomic RCR is impossible, the adequate choice of treatment for irreparable rotator cuff tears remains a matter of debate among shoulder surgeons. Following a critical review of the contemporary literature, the authors suggest the following evidence- and experience-based treatment recommendation. In the non-functional, osteoarthritic shoulder, treatment strategies in the management of irreparable posterosuperior RCT include debridement-based procedures and reverse total shoulder arthroplasty as the treatment of choice. Joint-preserving procedures aimed at restoring glenohumeral biomechanics and function should be reserved for the non-osteoarthritic shoulder. Prior to these procedures, however, patients should be counseled about deteriorating results over time. Recent innovations such as the superior capsule reconstruction and the implantation of a subacromial spacer show promising short-term results, yet future studies with long-term follow-up are required to derive stronger recommendations.

Dermal Tuberoplasty for Irreparable Supraspinatus Tears Using Self-Punching, Knotless Fixation

Superior capsular reconstruction has become an accepted treatment option for the irreparable rotator cuff tear in the nonarthritic shoulder. Widespread adoption of this technique has been limited, however, because of the technical difficulty of performing this procedure. Recently, allograft interpositional grafting of the greater tuberosity has gained popularity as a simpler alternative to superior capsular reconstruction and provides similar joint preservation advantages. We describe a technique for allograft interpositional tuberoplasty that simplifies graft delivery, graft fixation, and suture management by using a graft inserter and self-punching, knotless soft anchors.

Early Treatment of Shoulder Pathology Is Necessary but Not Enough Is Being Performed

Delayed treatment of shoulder instability results in bone loss requiring more-complicated surgery, in turn resulting in less-optimal outcomes. Similarly, delayed treatment of repairable rotator cuff tears results in irreparable tears requiring more-complicated surgery and resulting in less-optimal outcomes. Delayed treatment of shoulder pathology is a problem. Solutions include education and research investigation.

Infraspinatus Muscle Fiber Moment Arms During Abduction: A Biomechanical Comparison of Values for Intact Rotator Cuff, Supraspinatus Tear, Superior Capsular Reconstruction, and Reverse Total Shoulder Arthroplasty

Background:

Lines of action of the superior, middle, and inferior infraspinatus muscle fibers work together to produce moment arms that change throughout abduction in an intact shoulder, after a supraspinatus tear, and after superior capsular reconstruction (SCR) and reverse total shoulder arthroplasty (rTSA).

Purpose:

To use moment arm values to indicate the efficacy of SCR and rTSA to restore infraspinatus function during shoulder abduction.

Study Design:

Descriptive laboratory study.

Methods:

A total of 5 human cadaveric shoulders placed in a testing apparatus were each actively abducted (0°-90°) under the following 4 conditions: intact, complete supraspinatus tear, SCR, and rTSA. The 3-dimensional coordinates of points were tracked along the origin and insertion of the superior, middle, and inferior infraspinatus fibers during abduction. Moment arm values were calculated using the origin-insertion method to determine abduction contribution of infraspinatus fiber sections. Analysis of variance and post hoc Tukey testing were used to compare differences in moment arms between the 4 conditions and between fiber sections.

Results:

In the intact condition, the superior infraspinatus fibers had an abduction moment that decreased with elevation until shifting to adduction. Conversely, the middle and inferior fibers had an adduction moment that turned to abduction (mean moment arm values from 0° to 90°: inferior, from –5.9 to 19.4 mm; middle, from –4.7 to 15.9 mm; superior, from 5.6 to –5.1 mm; P < .05). After a supraspinatus tear, superior fibers lacked any torque, and inferior and middle fibers lost adduction potential (inferior, from 4.8 to 14.0 mm; middle, from –0.2 to 9.6 mm; superior, from 1.0 to 0.7 mm; P < .05). SCR restored the initial superior fiber abduction moment (5.6 mm at 0°; P < .05); middle and inferior fibers had some restoration but were weaker than intact fibers. Loss of abduction moment in all fibers was seen with rTSA (inferior, from –9.6 to –1.6 mm; middle, from –10.5 to –3.6 mm; superior, from –1.7 to –4.6 mm; P < .05).

Conclusion:

Infraspinatus fiber groups had different and inverse moment arms during scapular plane elevation. SCR most closely resembled the intact shoulder, whereas rTSA transformed the infraspinatus into an adductor.

Clinical Relevance:

These results support the efficacy of SCR at restoring biomechanical muscle function and suggest that the changes in moment arms for each fiber group be considered when choosing treatment modalities and rehabilitation protocols after rotator cuff tear.

Anterior Cable Reconstruction: Prioritize Rotator Cable and Tendon Cord When Considering Superior Capsular Reconstruction

Although distinct in name, the anterior cable of the superior capsule and tendon cord of the supraspinatus are structurally one in the same at the attachment on the greater tuberosity footprint. Force transmission through both structures where they converge and interdigitate at this location is disproportionately high, which has implications on functional impact. Superior capsule reconstruction, and, specifically, the anterior cable of the superior capsule, has been shown to assist in maintaining superior stability and a functional fulcrum of the glenohumeral joint, without overconstraining range of motion. Anterior cable reconstructions have been described for specific indications, including full-thickness tears of the supraspinatus and anterior one-half of the infraspinatus. Cord-like grafts, including long head biceps tendon autografts and semitendinosus allografts, can provide relative technical ease during surgery compared to sheet-like grafts for this indication. Side-to-side sutures between anterior cable reconstruction graft and posterosuperior capsule retension the native capsule to optimize its natural functional role. Accounting for abduction and rotation at the time of fixation and employing "loop-around" fixation sutures (no sutures through the graft), are critical concepts to consider in terms of kinematics and limiting graft failure. With both the biomechanically and clinically based literature demonstrating functionality with maintenance of the superior capsule (and specifically the anterior cable of the capsule), despite rotator cuff tendon insufficiency or irreparability, the anterior cable of the superior capsule should be prioritized when considering full-thickness rotator cuff tears that naturally involve both the capsular cable and the supraspinatus tendon cord. LEVEL OF EVIDENCE: Level V (expert opinion).

Editorial Commentary: Determination of Meaningful, Clinically Significant Outcome Thresholds for Superior Capsular Reconstruction of the Shoulder: Predicting Those Patients Who Improve and Those Who Don't!

Since the introduction of superior capsular reconstruction (SCR) for the treatment of irreparable rotator cuff tears nearly 10 years ago, we have witnessed widespread adoption by the arthroscopic shoulder community alongside an exponential increase in use within North America. To date, more than 42,000 acellular dermal allografts have been implanted in the United States alone, and our indications and surgical technique have been progressively refined in response to the evolving body of clinical outcomes research. However, with P values set aside, the real question still remains: how do our patients actually do after SCR? With the advent of clinically significant outcomes such as the patient acceptability symptomatic state and substantial clinical benefit, investigators have sought to establish more practical, patient-centered benchmarks for success after an intervention. Rather than just seeking the baseline expectations via the minimally clinically important difference (i.e., "I am better"), substantial clinical benefit (i.e., "I am so much better") and patient acceptability symptomatic state (i.e., "I am 'okay' with how I feel") truly clarify patient satisfaction and provide measurable units of patient improvement. These must be assessed on an individual basis, as aggregated averages introduce outliers that can distort the outcomes. Based on these end points, prognostic factors may allow a more concrete assessment of surgical risk while equipping physicians with appropriate information to guide ideal patient selection and optimize chances of success. Patients of female sex, older age, worker's compensation status, and those with subscapularis involvement are less likely to achieve clinically significant outcomes at minimum 1-year follow-up after SCR. Based on the current study, surgeons should exercise caution in recommending SCR for patients of advancing chronological age and significant subscapularis involvement, particularly if irreparable or untreated.

Superior Capsular Reconstruction: A Salvage Option for Massive Irreparable Rotator Cuff Tears with Pseudoparalysis or Subscapularis Insufficiency

PURPOSE

We sought to examine superior capsular reconstruction (SCR) outcomes after minimum 2-year follow-up and determine risk factors that were predictive of outcomes.

METHODS

Forty consecutive patients (mean age 57.3 years, 87.5% male) who underwent SCR for massive irreparable rotator cuff tears (RCT) met the inclusion criteria. Minimum 2-year follow-up was obtained for 32 patients (80% follow-up). Patient demographics and preoperative clinical findings were collected. Postoperative data, including complications, patient satisfaction, strength and range-of-motion (ROM), and patient-reported outcomes were collected.

RESULTS

The Hamada score was ≤2 in 88% with average acromiohumeral interval distance of 6.8 mm. Preoperatively, 6 patients had external rotation lag (19%) and 6 had pseudoparalysis (19%). Intraoperative assessment of the subscapularis demonstrated true insufficiency in 38%. There was significant improvement in forward elevation (FE) (31° increase; P = .007) and strength in all planes (all P < .05). Patient-reported outcomes significantly improved (American Shoulder and Elbow Surgeon [ASES] 34-point increase; visual analog scale [VAS] 2.9-point decrease; single alpha-numeric evaluation [SANE] 48-point increase; all P < .05). Twenty-six patients (81%) were completely or somewhat satisfied with surgery. At time of final follow-up, 3/32 patients (9%) failed SCR and converted to reverse total shoulder arthroplasty. There were 4 (13%) reported complications (2 patients had postoperative falls; 1 patient had persistent severe pain; 1 had persistent stiffness). One patient was deceased. Patients with pseudoparalysis (n = 6) had significant improvement in post-operative FE (28 vs 154°; P < .0001) and SANE score (P = .016) with 66% patient satisfaction. However, outcome scores overall remained lower than SCR without pseudoparalysis. Regarding subscapularis insufficiency (n = 12), significant improvement was seen in postoperative FE (108 vs 158°; P = .019) and patient-reported outcome scores (P < .005). In patients converted from SCR to reverse total shoulder arthroplasty (n = 3), there were no distinguishing characteristics present.

CONCLUSION

Superior capsular reconstruction is an effective salvage operation for massive irreparable RCT. Patients with pseudoparalysis or subscapularis insufficiency demonstrate significant postoperative improvement in FE and patient-reported outcomes.

LEVEL OF EVIDENCE

IV, retrospective cohort.

Editorial Commentary: Clinical Improvements of Superior Capsular Reconstruction Are Not Due to Maintained Dynamic Acromiohumeral Distance

Biomechanical data often help inform clinical decision-making in orthopaedic surgery. However, there are times when the biomechanical data and clinical data do not align. This is seen in cases of statistical but clinically irrelevant differences. This is also seen at times in cases of demonstrated clinical improvements with a poorly understood mechanism. Superior capsular reconstruction has gained significant traction since the original description in 2012. It has taken a central role in the armamentarium of treatment options of irreparable rotator cuff tears. There is robust published literature on the time zero biomechanics of superior capsular reconstruction and its stabilizing effects on the glenohumeral joint, especially with regards to superior migration of the humeral head. There also is demonstrated good early patient-reported outcomes with superior capsular reconstruction. However, the cause and effect may not be as simple as the biomechanical studies may suggest, and the underlying mechanism of why the superior capsular reconstruction appears to improve early outcomes remains poorly understood. These mechanisms are important to understand in order to inform technique changes and improvements and help us optimize treatment of the patient with an irreparable rotator cuff tear.

Superior Capsular Reconstruction: Proposed Biomechanical Advantages

The intact rotator cuff provides dynamic stability for the glenohumeral joint through range of motion by compressing the humeral head to the center of the glenoid. Maintenance of articular congruity provides a stable fulcrum for the more forceful muscles of the shoulder girdle. Massive rotator cuff tears disrupt the concavity-compression mechanism and lead to unopposed superior pull of the deltoid. As a result, superior migration of the humerus, abutment of the acromion, and, in some cases, progression to cuff tear arthropathy occur. Arthroscopic superior capsular reconstruction has emerged as an effective treatment in select indications. Several potential biomechanical advantages to SCR have been described on the basis of cadaver studies. By tethering the greater tuberosity to the glenoid, superior migration is resisted, and the center of rotation is stabilized. The interpositional spacer effect describes reduced subacromial contact pressure, and the reduction is greater with thicker grafts. Side-to-side suturing of the graft to residual tendon and capsule achieves capsular continuity and may further improve the stabilizing function of the residual capsule and prevent medial-lateral elongation of the graft. Although these biomechanical principles overlap to some degree, their summation offers an explanation for the improved pain and function seen in patients who undergo superior capsular reconstruction.

Medical Journals Should Be a Forum for Disruptive Research

Disruptive innovation completely changes the traditional way that we operate and may only be realized in retrospect. For example, shoulder superior capsule reconstruction (SCR) is a complete change from the traditional methods of treating massive, irreparable rotator cuff tears and pseudoparalysis. Classic examples of disruptions in orthopaedic surgery include distraction osteogenesis, total hip joint replacement arthroplasty, and modern orthopaedic trauma care. Orthopaedic technologies that promise future disruption include artificial intelligence, surgical simulation, and orthopaedic biologics, including mesenchymal stromal cell (MSC) and gene therapy. Most of all, arthroscopic surgery completely changed the way we operate by using new methods and technology. Many never saw it coming. The challenge going forward is to motivate and foster new ideas and research that result in innovation and progress. Skepticism has a place, but not at the expense of transformative ideas, particularly as medical journals offer the alternative of prospective hypothesis testing using the scientific method, followed by unbiased peer review, and publication. Medical journals should be a forum for disruptive research.

Combined Arthroscopic Superior and Anterior Capsular Reconstruction of the Glenohumeral Joint: A Case Report

CASE

A 57-year-old male automobile mechanic presented with 1 year of atraumatic, bilateral shoulder pain and progressive loss of motion. Three months of physical therapy and nonsteroidal anti-inflammatory medications did not offer pain relief or increase his motion. He opted for right-sided dermal allograft superior capsular reconstruction (SCR) and anterior capsular reconstruction (ACR) with subsequent left-sided SCR and subscapularis repair 3 months later.

CONCLUSION

At the 18 months follow-up, combined SCR/ACR was effective in restoring motion and relieving pain. Although promising, additional studies are needed to determine the efficacy of this combined procedure.

The best options in superior capsular reconstruction

Irreparable massive rotator cuff tears cause pain, loss of function, and a decrease in range of motion, which cause serious disturbances in daily life. Young patients, in particular, are active and have relatively high functional requirements, and their surgical options are limited. Superior capsular reconstruction (SCR) was first proposed for irreparable massive rotator cuff tears, good clinical results have been reported in short-term follow up. Since then, SCR has been used increasingly worldwide for irreparable massive rotator cuff tears, and various studies have been published on clinical outcomes, biomechanical outcomes, surgical techniques, and graft types. This article reviews the optimal graft and surgical options for improving clinical outcomes in SCR.

Editorial Commentary: Superior Capsular Reconstruction Works Biomechanically but Should Be Used Selectively for Genuinely Irreparable Tears

Superior capsular reconstruction (SCR) has undergone extensive biomechanical and clinical study. Systematic review of biomechanical studies has shown that SCR functions to depress the humeral head and improve the glenohumeral register, which provides proof of concept. Clinical studies have shown the short-term effectiveness of SCR, but this is influenced by graft type and thickness, as well as surgical technique. These studies are mostly flawed because follow-up is brief, postoperative imaging is often lacking, and the results may not be generalizable. Multiple systematic reviews pooling the results of these various clinical studies have mostly produced diluted conclusions that are not clinically helpful. To date, there is a dearth of comparative studies to help guide the selection of SCR over other treatment options such as subacromial balloon spacer, partial repair with or without augmentation, tendon transfer, reverse shoulder arthroplasty, or even continued nonoperative care. Additionally, SCR is a salvage operation rather than an expedient alternative to careful mobilization of a rotator cuff tear for primary repair. Ultimately, large-scale, long-term imaging-based comparative clinical studies, rather than additional systematic clinical or biomechanical reviews, must provide the evidence needed to determine the precise indications and optimal technique for SCR.