Superior Capsule Reconstruction Technique Using an Acellular Dermal Allograft

Patients With Graft Tears Leaving the Tuberosity Covered Have Similar Functional Outcomes to Those With an Intact Graft After Superior Capsular Reconstruction

BACKGROUND

Studies to date of superior capsular reconstruction (SCR) comparing outcomes of healed grafts versus torn grafts do not separate graft tears based on location of the tear, rather they combine and report all tears as a single group.

PURPOSE/HYPOTHESIS

The purpose of this study was to correlate functional outcome with graft integrity and graft tear location after SCR with a dermal allograft. It was hypothesized that the functional outcomes of patients with an intact graft would be equivalent to those with graft tears leaving the tuberosity covered.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent SCR with an acellular dermal allograft at a single institution were included. Pre- and postoperative American Shoulder and Elbow Surgeons (ASES), Oxford Shoulder Score, visual analog scale (VAS) for pain, and postoperative Single Assessment Numeric Evaluation (SANE) scores were recorded. A magnetic resonance imaging scan was performed postoperatively to assess graft integrity.

RESULTS

A total of 39 patients met inclusion criteria. Mean age of patients was 60.4 ± 8.7 years; mean follow-up was 53.3 ± 25 months (range, 14-98 months). Magnetic resonance imaging performed at a mean of 17.5 months (range, 6-66 months) demonstrated an intact graft in 14 (36%); tear from the glenoid in 11 (28%), from midsubstance in 4 (10%), and from the tuberosity in 8 (21%); and complete graft absence in 2 (5%). Patients were divided into group 1 (intact graft), group 2 (tuberosity covered: tears from glenoid and midsubstance tears), and group 3 (tuberosity bare: tears from the tuberosity and dissolved or absent grafts). In group 1, there was significant improvement in ASES (37.9 to 88.5; P < .001), Oxford (25.2 to 46.2; P < .001), and VAS (6.8 to 0.9; P < .001). In group 2, there was significant improvement in ASES (32.2 to 86.1; P < .001), Oxford (23.4 to 44.2; P < .001), and VAS (7.3 to 1.3; P < .001). In group 3, there was no significant improvement in ASES (40.3 to 45.8; P = .50) or Oxford (33.5 to 31.4; P = .81), but there was a significant reduction in VAS (7.1 to 5.4; P = .03). There was no significant difference between group 1 and 2 in postoperative ASES (88.5 vs 86.1; P = .59), Oxford (46.2 vs 44.2; P = .07), VAS (0.9 vs 1.3, P = .42) and SANE (85.4 vs 83.2; P = .92) scores. However, group 3 had significantly lower ASES (45.8; P < .001), lower Oxford (31.4; P < .001), lower SANE (45.4; P < .001), and higher VAS (5.4; P < .001) scores than groups 1 and 2. There were no differences in outcomes based on sex (P = .72), previous surgery (P = .06), preoperative acromiohumeral distance (P = .57), and preoperative Goutallier stage of the supraspinatus (P = .16).

CONCLUSION

Patients who underwent SCR with a dermal allograft and developed a graft tear leaving the tuberosity covered had equivalent functional outcomes to those with an intact graft.

A biomechanical study to optimize superior capsular reconstruction operative technique

Background

The goals of this study were to optimize superior capsular reconstruction by assessing the relative fixation strength of 4 suture anchors; evaluating 3 glenoid neck locations for fixation strength and bone mineral density (BMD); determining if there is a correlation between BMD and fixation strength; and determining which portal sites have optimal access to the posterosuperior and anterosuperior glenoid neck for anchor placement.

Methods

Twenty cadaveric specimens were randomized into 4 groups: all-suture anchor (FiberTak), conventional 3.0-mm knotless suture anchor (SutureTak), 3.9-mm knotless PEEK (polyetheretherketone) Corkscrew anchor, and 4.5-mm Bio-Corkscrew anchor. Each specimen was prepared with 3 anchors into the glenoid: an anterosuperior anchor, superior anchor, and posterosuperior anchor. All anchors were inserted into the superior glenoid neck 5 mm from the glenoid rim. A materials testing system performed cyclic testing (250 cycles) followed by load-to-failure testing at 12.5 mm/s. Cyclic elongation, first cycle excursion, maximum load, and stiffness were recorded. Using custom software, BMD was calculated at each anchor location. This software was also used to assess access to the posterosuperior and anterosuperior glenoid neck from standard arthroscopic portal positions.

Results

There was no significant difference in cyclic elongation (P = .546), first cycle excursion (P = .476), maximum load (P = .817), or stiffness (P = .309) among glenoid anchor positions. Cyclic elongation was significantly longer in the PEEK Corkscrew group relative to the other implants (P ≤ .002). First cycle excursion was significantly greater in the FiberTak group relative to all other implants (P ≤ .008). For load-to-failure testing, the Bio-Corkscrew group achieved the highest maximum load (P ≤ .001). No other differences in cyclic or failure testing were observed between the groups. No differences in stiffness testing were observed (P = .133). The superior glenoid rim had the greatest BMD (P = .003), but there was no correlation between BMD and cyclic/load outcomes. The posterior portal (80% of specimens) and the anterior portal (60% of specimens) demonstrated the best access to the posterosuperior and anterosuperior glenoid neck, respectively.

Conclusion

The 4.5-mm Bio-Corkscrew anchor provided the most robust fixation to the glenoid during superior capsular reconstruction as it demonstrated the strongest maximum load, had minimal elongation, had minimal first cycle excursion, and did not fail during cyclic testing. The superior glenoid neck had the highest BMD; however, there was no correlation between BMD or glenoid anchor location and biomechanical outcomes. The posterior portal and anterior portal provided optimal access to the posterosuperior glenoid neck and anterosuperior glenoid neck, respectively.

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.

Anterior capsular reconstruction with acellular dermal allograft for subscapularis deficiency: a report of two cases

Anterior glenohumeral instability with an irreparable subscapularis tear is a challenging problem for the orthopedic shoulder surgeon. Current techniques, including tendon transfers, yield inconsistent results with high rates of recurrent instability. Acellular dermal allografting has been used in young patients with massive superior rotator cuff tears with early success, but acellular dermal allografting is comparatively unstudied in anterior deficiency. We present two cases of anterior capsular reconstruction with an acellular dermal allograft in patients ages 66 and 58 years with irreparable subscapularis tendon tears. Follow-up for both patients exceeded 4 years, with forward flexion >140°, external rotation exceeding 60°, a Single Assessment Numeric Evaluation score >90 points, a visual analog scale score of 0 points, and an American Shoulder and Elbow Score of 98 points. In conclusion, acellular dermal allografting can be used to reconstruct the anterior capsule in patients with massive irreparable subscapularis tears, similar to its use in superior capsular reconstruction in patients with massive posterosuperior rotator cuff tears.

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.

Better functional outcomes and a lower infection rate can be expected after superior capsular reconstruction in comparison with latissimus dorsi tendon transfer for massive, irreparable posterosuperior rotator cuff tears: a systematic review

BACKGROUND

Massive, irreparable rotator cuff tears, if left untreated, may result in cuff tear arthropathy, which causes shoulder disability and pain. The primary outcome of this systematic review was to evaluate differences in functional outcomes between the arthroscopic superior capsular reconstruction (SCR) and latissimus dorsi tendon transfer (LDTT) for the treatment of massive, irreparable posterosuperior rotator cuff tears without arthritis. The secondary outcome was to compare complication and reoperation rates between the 2 surgical procedures.

METHODS

The PubMed, MEDLINE, Scopus, and Cochrane Central databases were searched using keywords, and 20 studies were included in this review. Data extracted for quantitative analysis included the American Shoulder and Elbow Surgeons score, the Constant-Murley score, the subjective shoulder value, the range of motion, the visual analog scale for pain, numbers and types of complications, and reoperation rate. The preoperative fatty degeneration of the muscles and the preoperative and follow-up acromiohumeral distance and glenohumeral osteoarthritis according to the Hamada grading system were also reported.

RESULTS

A total of 1112 patients were identified, among whom 407 and 399 underwent SCR and LDTT, respectively. The SCR group showed a higher mean age at the time of operation (64.5 ± 7.8 vs. 62.1 ± 8.9 years; P < .001). The SCR group showed a lower rate of previous surgical procedures on the shoulder (35 out of 407 vs. 111 out of 399; P < .001) and a shorter mean follow-up (30.4 ± 7.5 vs. 36.3 ± 10.3 months; P < .001). Patients who underwent SCR reported significantly better functionality and residual pain as measured by the Constant-Murley score (75.5 ± 11.2 vs. 65.6 ± 22.8, P < .001), the American Shoulder and Elbow Surgeons score (84.3 ± 13 vs. 67.7 ± 23, P < .001), the subjective shoulder value (79.4 ± 13 vs. 64.4 ± 23, P < .001), and the visual analog scale (1.4 ± 2 vs. 2.8 ± 3, P < .001) than patients who underwent LDTT. A greater acromiohumeral distance (5.8 ± 2.5 vs. 7.6 ± 2.7, P < .001) was found in the SCR group. The SCR group showed a significantly lower infection rate (0.2% vs. 2.8%., P = .003) and a higher graft failure rate (12.3% vs. 6.8%, P = .012). No differences in terms of reoperation for graft failure (1% vs. 2.3% for SCR and LDTT, respectively; P = .172) or for conversion to reverse total shoulder arthroplasty (1.7% vs. 2% for SCR and LDTT, respectively; P = .800) were found.

CONCLUSION

Patients undergoing SCR report better functional outcomes and greater acromiohumeral distance than those undergoing LDTT. The LDTT group shows a significantly higher infection rate, while the SCR group shows a significantly higher graft failure rate, but there are no differences in terms of reoperation between the 2 surgical procedures.

Middle Trapezius Tendon Transfer for Augmentation of In Situ Superior Capsular Reconstruction-Reinforced Partial Rotator Cuff Repair: Short-term Outcomes of a Prospective Cohort Study

Background

Middle trapezius tendon (MTT) transfer has been described for dynamic reproduction of supraspinatus function. For management of irreparable rotator cuff (RC) tears, this procedure can be coupled with in situ (long head of the biceps tendon-based) superior capsular reconstruction (SCR) and partial RC repair.

Purpose

To investigate the functional outcomes of augmentation of in situ SCR-reinforced partial RC repair with MTT transfer for the management of irreparable posterosuperior RC tears.

Study Design

Cohort study; Level of evidence, 3.

Methods

Conducted between September 2014 and March 2022, this study included 24 patients with irreparable posterosuperior RC tears who were allocated into 2 groups: patients managed with 2-layer tendon construct (in situ SCR-reinforced partial RC repair) (group A; n = 15) and patients managed with 3-layer tendon construct (MTT transfer-augmented, in situ SCR-reinforced partial RC repair) (group B; n = 9). Outcome measures included 2-year postoperative pain, range of motion (ROM) in forward flexion and external rotation, and the American Shoulder and Elbow Surgeons (ASES) and the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores. For data comparison, independent and paired t tests were used for parametric quantitative variables, and Mann-Whitney and Wilcoxon signed-rank tests were used for nonparametric quantitative variables; Fisher exact and McNemar tests were used for qualitative variables.

Results

The mean age of the patients was 58.40 ± 4.54 years in group A and 59.22 ± 4.46 years in group B; there were no between-group differences in baseline patient characteristics. Patients in both groups had significant preoperative to postoperative improvement on all outcome measures (P < .05 for all). Group B had a significantly higher magnitude of postoperative improvement compared with group A in forward flexion ROM (88.88° ± 29.34° vs 46.66° ± 20.93°; P = .001), external rotation ROM (32.22° ± 14.81° vs 16.0° ± 9.10°; P = .002), ASES score (71.07 ± 8.26 vs 57.87 ± 8.39; P = .001), and QuickDASH score (-70.20 ± 6.95 vs -58.34 ± 12.52; P = .007).

Conclusion

Augmentation of in situ SCR-reinforced partial RC repair with MTT transfer in a 3-layer tendon construct led to significantly greater improvement in postoperative ROM and functional scores compared with a 2-layer construct.

Superior capsular reconstruction using hybrid graft for irreparable massive rotator cuff tear

PURPOSE

To evaluate the clinical and radiological outcomes of arthroscopic superior capsular reconstruction (SCR) using hybrid grafts composed of tensor fascia lata autografts and human dermal allografts.

METHODS

This study included 30 patients with chronic irreparable posterosuperior rotator cuff tears (RCTs) who underwent arthroscopic SCR using a hybrid graft composed of tensor fascia lata autograft and human dermal allograft. Clinical outcomes were evaluated using the pain visual analogue scale score, shoulder range of motion, American Shoulder and Elbow Surgeons score, constant score, University of California-Los Angeles score, and simple shoulder test score preoperatively and at least 2 years after surgery. Radiographic analysis included the Hamada classification grade, acromiohumeral distance (AHD), and graft integrity at 2 years after surgery.

RESULTS

All patients exhibited significant clinical improvement in all functional outcome measurements, except external rotation (all P < 0.05). The number of patients who exhibited pseudoparalysis decreased from 7 (23.3%) to 2 (6.7%) postoperatively. Complications were not observed. Radiologically, the mean postoperative AHD increased significantly from 6.9 ± 1.6 cm to 8.8 ± 2.1 cm at 2 years postoperatively (P < 0.001). Twenty five out of the 30 (83.3%) patients showed successful graft healing, and all healing failures occurred on the humeral side. The differences between the healed-graft and failed-graft groups were significantly lower graft thickness (P = 0.001) and smaller AHD (P < 0.001) in the failed-graft group. Every functional outcome scores were not statistically different between healed-graft and failed-graft groups.

CONCLUSIONS

An arthroscopic SCR technique using a hybrid graft consisting of a tensor fascia lata autograft and human dermal allograft showed satisfactory clinical outcomes in patients with irreparable RCTs.

LEVEL OF EVIDENCE

IV.

Acellular Dermal Allograft and Tensor Fascia Lata Autograft Show Similar Patient Outcome Improvement and High Rates of Complications and Failures at a Minimum Two-Year Follow-up: A Systematic Review

PURPOSE

To compare clinical and radiologic outcomes following superior capsular reconstruction (SCR) using dermal allograft versus tensor fascia lata (TFL) autograft for massive rotator cuff tears with a minimum 2-year follow-up.

METHODS

A literature search was performed by querying Scopus, EMBASE, and PubMed computerized databases from database inception through September 2022 in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies evaluating clinical and radiologic outcomes, as well as complications following SCR for the treatment of massive rotator cuff tears were included. Study quality was assessed via the Newcastle-Ottawa Scale and the National Institutes of Health Quality Assessment. The mean change from preoperative to postoperative values (delta) was calculated for each outcome.

RESULTS

Seventeen studies, consisting of 519 patients were identified. Mean duration of follow-up ranged from 24 to 60 months. Mean reduction in visual analog scale pain score ranged from 2.9 to 5.9 points following use of dermal allograft, and 3.4 to 7.0 points following TFL autograft reconstruction. Mean improvements in American Shoulder and Elbow Surgeons score were similar between groups (dermal allograft: 28.0-61.6; TFL autograft: 24.7-59.3). The mean increase in forward flexion ranged from 31° to 38° with dermal allograft, versus 19° to 69° with TFL autograft. Average improvement in active external rotation with dermal allograft ranged from -0.4° to 11° and from 2° to 22.4° using TFL autograft. A similar change in acromiohumeral distance following SCR (dermal allograft: 0.9-3.2 mm; TFL autograft: 0.3-3.6 mm) was appreciated. The rate of complications within the dermal allograft group ranged from 4.5% to 38.2% versus 13.3% to 86.4% following TFL autograft. Failure rate ranged from 4.5 to 38.2% following dermal allograft versus 4.5 to 86.4% with TFL autograft.

CONCLUSIONS

Acellular dermal allograft versus TFL autograft for SCR both demonstrate improved VAS and American Shoulder and Elbow Surgeons scores, with increased values in flexion and external rotation, and increased visual analog scale, although with high variability. Both grafts demonstrate high rates of complications and failures at minimum 2-year follow-up.

LEVEL OF EVIDENCE

IV; systematic review of level II-IV studies.

Arthroscopic Superior Capsular Reconstruction with Tensor Fascia Lata Allograft for Irreparable Rotator Cuff Tears: Clinical and Radiologic Outcomes for a Minimum 1-Year Follow-Up

PURPOSE

To confirm the radiologic and clinical outcomes after performing arthroscopic superior capsular reconstruction (ASCR) using a tensor fascia lata (TFL) allograft.

METHODS

Thirty-three patients with irreparable rotator cuff tears were treated with ASCR with a TFL allograft. The mean age and follow-up period were 62 years and 20.1 months, respectively. TFL allografts were used as 3, 4, and 6 layers, and the graft thickness was 3.7, 3.9, and 5.4 mm, respectively. Range of motion, visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons score, and Constant score were evaluated preoperatively and at the final follow-up. The pre-, postoperative, and final acromiohumeral distances (AHD) were compared. The graft integrity was checked through a follow-up magnetic resonance imaging at least 6 months after surgery.

RESULTS

Torn grafts were identified in 6 cases (19%). AHD significantly increased from 5.0 to 8.0 mm postoperatively (P < .0001). However, there was no significant difference of 5.0 mm at the final follow-up AHD. Five cases (83%) of torn grafts were induced in the 3-layered graft sheet group, but the difference was not statistically significant (P = .067). Visual analog scale, forward elevation, internal rotation, American Shoulder and Elbow Surgeons, and Constant scores significantly improved at the last follow-up. Two cases of early infection were confirmed and the graft materials were all removed.

CONCLUSIONS

Despite the possibility of early infection, ASCR using TFL allograft is a reliable procedure for the irreparable rotator cuff tear. In particular, if the number of layers of TFL allograft increases, it is judged that it could become a more effective graft.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Study of arthroscopic superior capsule reconstruction in the treatment of irreparable rotator cuff tears

Background

The objective of this study was to investigate the clinical outcome and radiographic findings after arthroscopic superior capsule reconstruction (ASCR) with a new augmented autograft technique for irreparable rotator cuff tears.

Methods

Between 2018 and 2020, 11 patients whose shoulders had irreparable rotator cuff tears underwent ASCR using a fascia lata weaving mesh. Physical examination, radiography, and magnetic resonance imaging (MRI) were performed before surgery and the average follow-up was 20 months (18-24 months) after surgery. Clinical outcome scores were recorded.

Results

Average clinical outcome scores improved significantly at the final follow-up, with 94.7 points scored on the American Shoulder and Elbow Surgeons scale (range, 85-100 points) and 34.5 points on the University of California, Los Angeles scale (33-35 points) (P < 0.05). Mean active elevation increased significantly from 30.1° to 150° (P < 0.05) and external rotation increased from 30° to 59.2° (P < 0.05). The acromiohumeral distance (AHD) increased from 3.9 ± 0.6 mm preoperatively to 10.1 ± 0.7 mm postoperatively (P < 0.05). No patient had graft tear or tendon retear during follow-up.

Conclusions

ASCR with a new augmented autograft can restore the function of the shoulder joint with irreparable rotator cuff tears. Our results suggest that this reconstruction technique can help obtain good clinical and radiographic outcomes, which can provide a reliable method for the treatment of irreparable rotator cuff tears.

Level of Evidence

Level IV, therapeutic case series.

Longitudinal efficacy of acellular dermal allograft following superior capsular reconstruction of irreparable rotator cuff tears

Background

Superior capsular reconstruction (SCR) remains an option for irreparable rotator cuff tears, especially for active patients. While fascia lata grafts were first used with SCRs, acellular dermal allografts have demonstrated similar postoperative outcomes and complication rates. Few studies report long-term clinical outcomes following use of acellular dermal allografts. The aim of the current study is to evaluate long-term efficacy of allograft usage in SCR through patient reported clinical outcomes.

Methods

A retrospective review of patients undergoing SCR with use of dermal allografts from 2015 to 2021 was performed. Exclusion criteria included patients lost to follow up, revision or removal of graft, and inadequate follow up timepoints. Demographics and operative characteristics were collected. To evaluate efficacy of graft, numerical rating scale (NRS), American Shoulder and Elbow Score (ASES) were assessed postoperatively. Shoulder range of motion (ROM) was also evaluated by the 6-month postoperative timepoint. Improvement in NRS, ASES, and shoulder ROM from baseline values were evaluated using a t-test.

Results

The final cohort was 21 patients with two patients undergoing revision and removal of the graft. Mean follow up time was 36.9 months. No major postoperative complications were recorded. Mean preoperative NRS and ASES score was 5.7 and 38.4, which both significantly improved postoperatively (p < 0.001). Patients demonstrated improvements in forward flexion, abduction in 90° rotation, and external and internal rotation.

Conclusion

Use of acellular dermal grafts in SCR procedures for irreparable rotator cuff tears remains a viable long-term solution to restore shoulder function.

Outcomes of arthroscopic-assisted middle trapezius tendon transfer for isolated irreparable supraspinatus tendon tears: minimum 2-year follow-up

INTRODUCTION

Middle trapezius tendon (MTT) transfer has been proposed as a feasible option for managing isolated irreparable supraspinatus tears (IISTTs). However, no clinical study has been attempted. This study aimed to evaluate clinical and radiologic outcomes of arthroscopic-assisted MTT transfer in patients with IISTTs.

METHODS

This retrospective study included patients who underwent arthroscopic-assisted MTT transfer using fascia lata autograft for IISTTs. Clinical outcomes, including pain visual analog scale (VAS), Constant, American Shoulder and Elbow Society (ASES), University of California Los Angeles (UCLA) shoulder scores and active range of motion (aROM), were assessed. Radiographic analyses included the acromiohumeral distance (AHD), Hamada grade, and transferred tendon integrity at the final follow-up.

RESULTS

Twenty-two patients (mean age: 63.3 ± 6.8 [51‒74] years; mean follow-up period: 28.9 ± 4.9 [24‒44] months) met the study criteria. The mean VAS, Constant, ASES, and UCLA scores improved postoperatively at the final follow-up (p < 0.001). The mean aROMs for forward flexion and abduction were significantly increased postoperatively. No significant changes of AHD (p = 0.105) and Hamada grade (p = 0.815) were observed postoperatively. One patient had a re-tear of the transferred tendon at the footprint site at the final follow-up.

CONCLUSION

In this minimum 2-year follow-up study of the novel aMTT transfer using fascia lata autograft, we found significant improvement in pain relief, clinical scores, and active forward flexion and abduction. Additionally, no significant progression of cuff tear arthropathy was observed at the final follow-up. Therefore, aMTT transfer could be a promising treatment option for patients with IISTTs. However, further multicenter and long-term trials are needed to verify its effectiveness.

LEVEL OF EVIDENCE

Retrospective case series, level IV.

Shoulder Superior Capsular Reconstruction Hybrid Graft Thickness Greater Than Preoperative Acromiohumeral Distance Increases Graft Retear Rate and Subacromial Erosion

PURPOSE

To evaluate the impact of graft thickness on clinical outcomes and graft retear after superior capsular reconstruction (SCR) using a hybrid graft combining both fascia lata autograft and dermal allograft in patients with massive rotator cuff tear (MRCT).

METHODS

Between January 2017 and February 2019, this study enrolled 58 patients with MRCT who underwent SCR using a hybrid graft combining both fascia lata autograft and dermal allograft. We evaluated clinical outcomes and compared differences between the graft intact and the graft retear group. Moreover, subgroup analysis was performed for patients having a preoperative acromiohumeral distance (AHD) less than or equal to the used graft thickness (group 1) and the results were compared with those for preoperative AHD greater than the used graft thickness (group 2).

RESULTS

Fifty-five patients who underwent MRCT with a mean age of 65.1 ± 5.7 years old were followed up during a mean period of 30.5 ± 6.5 (range, 24-37) months. There were significant differences in clinical outcome measures preoperatively and postoperatively (P < .05). There were no significant differences in clinical outcomes between the graft intact and graft retear groups (P > .05). The subgroup analysis revealed that the retear (68.6% vs 30.4%, P = .004) and subacromial erosion rates (91.4% vs 60.9%, P = .005) were significantly greater in for patients having a preoperative AHD less than or equal to the used graft thickness (group 1).

CONCLUSIONS

SCR using a hybrid graft combining both fascia lata autograft and dermal allograft is promising with improved clinical scores (P < .05) irrespective of the graft integrity. The use of a graft with a thickness greater than a patient's preoperative AHD could increase graft retear and subacromial erosion rates after SCR. However, there was no significant difference in clinical outcomes according to the relationship between used graft thickness and preoperative AHD.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Donor-Site Morbidity After Autologous Fascia Lata Harvest for Arthroscopic Superior Capsular Reconstruction: A Midterm Follow-up Evaluation

Background:

Autologous fascia lata (AFL) graft use in arthroscopic superior capsular reconstruction (ASCR) is effective for the treatment of irreparable rotator cuff tears (RCTs). Although donor-site morbidity (DSM) is a recurrent argument against AFL graft use, scientific evidence for this argument is lacking.

Purpose:

To report the midterm clinical follow-up evaluation of DSM in ASCR using minimally invasively harvested AFL grafts and compare thigh function and patient satisfaction with those of an unharvested control group.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Of 66 consecutive patients who underwent ASCR using a minimally invasively harvested AFL graft, 39 patients with a minimum follow-up of 24 months were retrospectively evaluated (ASCR group) and compared with 39 randomly selected patients who underwent arthroscopic RCT repair by the same surgeons (control group). The functional outcomes of both thighs were evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Patient satisfaction was evaluated using the Patient Scar Assessment Questionnaire (PSAQ) and a subjective questionnaire. Pain was quantified using a visual analog scale (VAS).

Results:

The ASCR group had a mean age of 65 years (range, 51-77 years) and a mean follow-up of 47 months (range, 24-66 months). The WOMAC score in the harvested thigh differed by 0.8% from that in the contralateral thigh ( P = .002). The mean PSAQ score differed by 6 points from the minimum PSAQ score ( P < .001). Overall, 95% of the patients indicated that they would undergo the same surgery again and that the shoulder outcome compensated for the thigh symptoms. There was no significant association between the presence of residual thigh symptoms and the willingness to undergo the same surgery again ( P = .354). The mean VAS score in the harvested thigh was 0.6 (range, 0-5). There was no significant difference in the average WOMAC score or VAS score between groups ( P = .684 and P = .148, respectively).

Conclusion:

Despite the proportion of residual symptoms, the associated functional effects were small and not clinically significant, and the vast majority of patients were accepting of the harvest symptoms given the improvement in shoulder function.

Effect of human dermal allograft thickness on glenohumeral stability for superior capsular reconstruction in irreparable supraspinatus tears: A biomechanical analysis of the superior capsular reconstruction - A cadaveric study

PURPOSE

The objective of this study was to compare the biomechanics of using a double layered human dermal allograft to a single layered human dermal allograft in superior capsular reconstruction.

METHODS

Five cadaveric shoulders were tested. The superior translation of the humerus and the subacromial contact pressure were measured at 0°, 30° and 60° of glenohumeral abduction in the following six conditions: (1) intact rotator cuff, (2) irreparable supraspinatus tear, (3) superior capsular reconstruction using a double layered human dermal allograft with and (4) without posterior suturing, (5) superior capsular reconstruction using a single human dermal allograft with and (6) without posterior suturing.

RESULTS

There was a significant increase in superior translation of the humerus and subacromial contact pressure when comparing torn supraspinatus to intact shoulder. All superior capsular reconstruction repairs lead to a reduction in superior translation and subacromial contact pressures compared to after the supraspinatus tear except for single layered superior capsular reconstruction repair without posterior suturing. There was no difference in superior translation and subacromial contact pressures comparing the intact shoulder to any of the superior capsular reconstruction constructs.

CONCLUSION

Superior capsular reconstruction using a single or double layered human dermal allograft improves superior translation after supraspinatus repair. There is some biomechanical benefit of a double layered human dermal allograft technique over a single layered graft technique in superior capsular reconstruction.

LEVEL OF EVIDENCE

IV.

Classification system of graft tears following superior capsule reconstruction

OBJECTIVE

Superior capsule reconstruction (SCR) is a treatment option for irreparable massive rotator cuff tears (MRCT). The purpose of this study is to describe a classification system for graft integrity and tear location.

METHODS

Patients who underwent SCR at a single institution were included. Pre-operative age, gender, prior surgery, Hamada grade, and Goutallier stage were recorded. An MRI was performed postoperatively to assess graft integrity and tear location.

RESULTS

53 patients met inclusion criteria. Mean age was 60.1 ± 7.9 years. A post-operative MRI was performed in 42 (80%) patients at a mean of 14 ± 7 months (range, 6-40 months). MRIs demonstrated an intact graft in 16 (38%) shoulders. Of the 26 graft tears, 14 (54%) were from the glenoid, 5 (19%) mid-substance, 6 (23%) from the tuberosity, and 1 (3.8%) had complete graft absence.

CONCLUSION

Graft tears are common following SCR. We describe four different graft tear locations and submit a classification system that can be used in future studies to better compare outcomes based on graft integrity and tear location. Clinical correlation with graft integrity and graft tear location needs to be further investigated.

[The short-term effectiveness of superior capsular reconstruction using autologous fascia lata graft for irreparable massive rotator cuff tears]

OBJECTIVE

To observe and evaluate the short-term effectiveness of superior capsular reconstruction using autologous fascia lata graft for irreparable massive rotator cuff tears.

METHODS

The clinical data of 9 patients with irreparable massive rotator cuff tears treated with arthroscopic superior capsular reconstruction by using autologous fascia lata graft between September 2019 and April 2020 were retrospectively analysed. There were 4 males and 5 females with a median age of 66 years (range, 55-70 years). The disease duration was 6-60 months with an average of 19.1 months. According to Hamada classification, the patients were classified as grade 1 in 2 cases, grade 2 in 2 cases, grade 3 in 2 cases, and grade 4 in 3 cases. Before and after operation, the visual analogue scale (VAS) score was used to evaluate the improvement of shoulder joint pain, the American Shoulder and Elbow Surgeons (ASES) score, Constant score, and the University of California Los Angeles (UCLA) shoulder function score were used to evaluate the improvement of shoulder joint function. The active range of motion of shoulder joint was recorded, including forward flexion, abduction, lateral external rotation, and internal rotation. The changes of subacromial space were recorded by anteroposterior X-ray film of shoulder joint. Sugaya classification was used to judge the integrity of rotator cuff immediately after operation and at last follow-up.

RESULTS

The operation time was 210-380 minutes, with an average of 302.3 minutes. All incisions healed by first intention after operation, and there was no complication such as infection and nonunion of incisions. Two patients had numbness of the upper limbs on the surgical side after operation, and the numbness completely relieved at 6 weeks after operation; 5 cases with preoperative pseudoparalysis symptoms recovered after operation. Nine patients were followed up 12-17 months, with an average of 14.1 months. At last follow-up, the patient's active range of motion of shoulder joint (forward flexion, abduction, lateral external rotation, and internal rotation), subacromial space distance, VAS score, ASES score, Constant score, and UCLA score significantly improved when compared with preoperative ones ( P<0.05). There was no significant difference in the Sugaya classification between at last follow-up and immediately after operation ( Z=-1.633, P=0.102).

CONCLUSION

Superior capsular reconstruction using autologous fascia lata graft can restore the superior stability and achieve a good short-term effectiveness for irreparable massive rotator cuff tears.

Tratamento das rupturas irreparáveis do manguito rotador: Reconstrução capsular superior com aloenxerto de fáscia lata

Objective  The objective of the present study was to evaluate the efficacy and safety of superior capsular reconstruction (SCR) using fascia lata allograft.

Methods  A prospective case series of 15 patients with irreparable supraspinatus tear who underwent SCR using fascia lata allograft. The American Shoulder and Elbow Surgeons (ASES) scale at 12 months after surgery was the primary outcome. The University of California Los Angeles (UCLA), Constant-Murley, and Single Assessment Numeric Evaluation (SANE) scales, in addition to the range of motion, were secondary outcomes. Radiological parameters were also evaluated by simple radiographs and magnetic resonance imaging (MRI).

Results  Fifteen patients completed 12 months of postoperative follow-up. The ASES score increased from 34.0 to 73.0 ( p  = 0.005). The UCLA, Constant-Murley, and SANE scales also showed statistically significant differences ( p  = 0.001; p  = 0.005; and p  = 0.046). In the evaluation of range of motion, there was improvement in elevation and in external rotation (95 to 140°, p  = 0.003; 30 to 60°, p  = 0.007). Six patients (40%) had complete graft healing. The clinical outcomes were significantly higher in the patients who presented graft healing.

Conclusions  Superior capsular reconstruction using a fascia lata allograft is a safe and effective procedure in short follow-up. Level of Evidence IV; Therapeutic Study; Case Series.

Current Options in Tendon Transfers for Irreparable Posterosuperior Rotator Cuff Tears

Massive irreparable posterosuperior rotator-cuff tears are debilitating lesions that usually require surgical treatment. Even though there is no consensus regarding the best surgical technique, tendinous transfers around the shoulder are the most commonly performed procedures. The latissimus dorsi tendon remains the most commonly used, but different modifications to the original technique have been shown to minimize complications and to improve functional results and satisfaction. Other techniques, such as the transfer of the lower trapezius tendon, are promising and should be considered, especially for patients with isolated loss of external rotation. The present paper is a literary review regarding tendon transfers for irreparable posterosuperior rotator-cuff tears.

Arthroscopic Superior Capsular Reconstruction for Management of Massive Irreparable Rotator Cuff Tears: A Simple Alternative Technique

The use of acellular dermal allograft in arthroscopic superior capsular reconstruction is a promising treatment option for massive irreparable rotator cuff tears. However, indications are limited to a subset of patients, so it is not routinely performed. Therefore, the surgery is technically demanding, although it has evolved in recent years. The authors present a simple alternative technique that addresses common pitfalls. [Orthopedics. 2021;44(3):e458-e462.].

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.

Superior capsular reconstruction for irreparable rotator cuff tears: A literature review and specialist practice report

BACKGROUND

Recent evidence continues to confirm the effectiveness of arthroscopic superior capsular reconstruction (SCR) in relieving pain and improving function in an irreparable cuff deficient shoulder. This paper presents an up-to-date literature review on SCRand a tertiary referral unit experience in the United Kingdom.

METHODS

Data was prospectively collected on patients undergoing SCR for irreparable rotator cuff tears using a dermal allograft. Patients with already established arthritis were excluded. The first 49 consecutive cases performed by 3 surgeons over 3 years (including their learning curve) with average follow-up of 19 months (range 3-37 months) were analysed. The outcomes assessed were re-operation rates, patient satisfaction and complications. The study group was analysed to identify the factors predicting outcomes.

RESULTS

The average age of the cohort was 56 years. The re-operation rate in this group was 12.2% with each of these 6 patients subsequently undergoing a reverse total shoulder arthroplasty. Forty (82%) patients were satisfied with the outcome of the procedure with 35 (72%) of them showing complete pain relief, 5 (10%) having dull aches and clicks and the remaining 9 (18%) unsatisfied due to pain. There was no difference in satisfaction rates between different age groups (p > 0.05). The pre-operative factors associated with poor outcomes included patients with multiple previous surgeries on the same shoulder (p = 0.02) and teres minor atrophy or tear (p = 0.03). The other factors that showed a trend towards inferior outcomes (but not statistically significant) included patients with degenerative tears, symptoms of longer duration (>24 months) and subscapularis tear/atrophy. No serious adverse effects such as graft rejection, infection or neuro-vascular injury were observed.

CONCLUSION

Early results of superior capsular reconstruction are promising and may offer an answer to a challenging group of patients with symptomatic irreparable rotator cuff tears. It is likely that the relatively low re-operation rates can be further improved by considering the negative prognostic factors in defining indications for surgery.

Load-to-failure characteristics of patellar tendon allograft superior capsule reconstruction compared with the native superior capsule

Background

The potential use of a patellar tendon allograft for superior capsular reconstruction has been demonstrated biomechanically; however, there are concerns regarding compromised fixation strength owing to the longitudinal orientation of the fibers in the patellar tendon. Therefore, the purpose of this study was to compare the fixation strength of superior capsule reconstruction using a patellar tendon allograft to the intact superior capsule.

Methods

The structural properties of the intact native superior capsule (NSC) followed by superior capsular reconstruction using a patellar tendon allograft (PT-SCR) were tested in eight cadaveric specimens. The scapula and humerus were potted and mounted onto an Instron testing machine in 20 degrees of glenohumeral abduction. Humeral rotation was set to achieve uniform loading across the reconstruction. Specimens were preloaded to 10 N followed by cyclic loading from 10 N to 50 N for 30 cycles, then load to failure at a rate of 60 mm/min. Video digitizing software was used to quantify the regional deformation characteristics.

Results

During cyclic loading, there was no difference found in stiffness between PT-SCR and NSC (cycle 1 - PT-SCR: 12.9 ± 3.6 N/mm vs. NSC: 22.5 ± 1.6 N/mm; P = .055 and cycle 30 - PT-SCR: 27.3 ± 1.4 N/mm vs. NSC: 25.4 ± 1.7 N/mm; P = .510). Displacement at the yield load was not significantly different between the two groups (PT-SCR: 7.0 ± 1.0 mm vs. NSC: 6.5 ± 0.3 mm; P = .636); however, at the ultimate load, there was a difference in displacement (PT-SCR: 20.7 ± 1.1 mm vs. NSC: 8.1 ± 0.5 mm; P < .001). There was a significant difference at both the yield load (PT-SCR: 71.4 ± 2.2 N vs. NSC: 331.6 ± 56.6 N; P = .004) and the ultimate load (PT-SCR: 217.1 ± 26.9 N vs. NSC: 397.7 ± 62.4 N; P = .019). At the yield load, there was a difference found in the energy absorbed (PT-SCR: 84.4 ± 8.9 N-mm vs. NSC: 722.6 ± 156.8 N-mm; P = .005), but no difference in energy absorbed was found at the ultimate load.

Conclusions

PT-SCR resulted in similar stiffness to NSC at lower loads, yield displacement, and energy absorbed to ultimate load. The ultimate load of the PT-SCR was approximately 54% of the NSC, which is comparable with the percent of the ultimate load in rotator cuff repair and the intact supraspinatus at time zero.

Superior Capsule Reconstruction Using Fascia Lata Allograft Compared With Double- and Single-Layer Dermal Allograft: A Biomechanical Study

PURPOSE

To biomechanically characterize superior capsule reconstruction (SCR) using fascia lata allograft, double-layer dermal allograft, and single-layer dermal allograft for a clinically relevant massive irreparable rotator cuff tear involving the entire supraspinatus and 50% of the infraspinatus tendons.

METHODS

Eight cadaveric specimens were tested in 0°, 30°, and 60° abduction for (1) intact, (2) massive rotator cuff tear, (3) SCR using fascia lata, (4) SCR using double-layer dermis, and (5) SCR using single-layer dermis. Superior translation and subacromial contact pressure were measured. Statistical analysis was conducted using repeated measures ANOVA or paired t test with P < .05.

RESULTS

Massive rotator cuff tear significantly increased superior translation of the humeral head at all abduction angles (P < .05). At 0° abduction, all SCR conditions significantly decreased superior translation compared with the massive tear but did not restore translation (P < .05) to intact. Fascia lata and double-layer dermis SCR restored superior translation to intact at 30° and 60° of abduction, but single-layer dermis did not. Subacromial contact pressure at 0° of abduction significantly decreased with SCR with fascia lata and double-layer dermis compared with tear. At 30°, all SCR conditions significantly decreased subacromial contact pressure. Single-layer dermis graft thickness significantly decreased more than fascia lata during testing (P = .02).

CONCLUSION

For SCR tensioned at 20° glenohumeral abduction, all 3 graft types may restore superior translation and subacromial contact pressure depending on the glenohumeral abduction angle; fascia lata and double-layer dermis may be more effective than single-layer dermis.

CLINICAL RELEVANCE

If a dermal graft is to be used for SCR, consideration should be given to doubling the graft for increased thickness and better restorative biomechanical properties, which may improve clinical outcomes following SCR.

Comparison of Superior Capsular Reconstruction and Partial Infraspinatus Repair: A Matched-Pair Analysis of Irreparable Rotator Cuff Tears

Background

Superior capsular reconstruction (SCR) represents a new option for the treatment of irreparable rotator cuff tears.

Purpose/Hypothesis

This study aimed to evaluate the clinical and radiologic outcomes of SCR and compare them with the outcomes of partial repair (PR) of the infraspinatus tendon. The hypothesis was that there would be no significant differences between the clinical and radiologic outcome parameters of SCR and PR after a minimum follow-up of 2 years.

Study Design

Cohort study; Level of evidence, 3.

Methods

Of 21 patients who underwent SCR, 20 patients were matched in a 1:1 ratio according to sex, age, and tear configuration with 20 of 60 patients who had undergone PR; all patients were prospectively evaluated for a minimum follow-up of 2 years. The investigated outcome measures included the Constant score; Western Ontario Rotator Cuff (WORC) index; Disabilities of the Arm, Shoulder and Hand (DASH) score; and radiologic analysis of acromiohumeral distance (AHD) and humeral head centralization (HHC).

Results

There were no differences in the demographic data between the SCR and PR groups. The mean age of both groups was 62.3 years (range, 47-79 years), the mean tear configuration was Bateman 3.0 and Patte 2.8, and the mean follow-up period was 29.4 months (range, 24-53 months). At final follow-up, no significant differences were seen between the SCR and PR groups with regard to Constant score (77.1 vs 82.7), age- and sex-adapted Constant score (85.5% vs 91.4%), DASH score (15.6 vs 7.8), or WORC index (81.1 vs 90.4). No significant differences in the AHD or HHC were seen between the groups. The reoperation rate was 4.8% (1/21) in the SCR cohort and 15% (9/60) in the PR cohort.

Conclusion

Both SCR and PR resulted in significant improvements in patient-reported outcomes at 2-year follow-up, with no significant differences in clinical outcomes between the 2 techniques. Further follow-up is needed to determine whether there are long-term differences in HHC and development of cuff tear arthropathy. Further investigations should also focus on the cost-effectiveness of the respective procedures.

Bursal Acromial Reconstruction (BAR) Using an Acellular Dermal Allograft as a Surgical Solution for the Treatment of Massive Irreparable Rotator Cuff Tears

Massive, irreparable rotator cuff tears in patients without severe signs of osteoarthritis remains a major challenge for orthopaedic surgeons. These can be a source of significant pain and functional loss occurring most commonly in a relatively frail, elderly patient population. A plethora of surgical techniques covering minimally invasive, arthroscopic techniques and open, salvage procedures have been described for this challenging patient cohort. Continuous evolvement of arthroscopic techniques has led to all-arthroscopic superior capsular reconstruction techniques using allografts, thereby reducing donor side morbidity along with decreased soft tissue dissection. However, conventional superior capsular reconstruction is noted to be a technically complex, time-consuming, and high-cost surgery, which may put this technique beyond the confidence of many shoulder surgeons. The subacromial balloon spacer has emerged as a potential solution in these patients, providing interposition between the humeral head and acromion. However, the subacromial balloon biodegrades rapidly and its effect is only temporary. Thus this technique article presents using an acellular human dermal allograft to reconstruct the bursal layer, which is normally interposed between the humeral head and the acromion. The proposed technique provides a permanent interposition graft preventing humeral acromial contact, which does not undergo rapid biodegradation. The surgical technique is technically feasible, both minimizing surgical time and therefore operative risk to the patient.

Patient Factors Associated With Clinical Failure Following Arthroscopic Superior Capsular Reconstruction

PURPOSE

To identify demographic, clinical, and radiographic factors associated with failure after superior capsular reconstruction (SCR).

METHODS

Prospectively collected data were analyzed from patients who underwent SCR using a decellularized dermal allograft for an irreparable rotator cuff tear. Demographic characteristics, radiographic findings, concomitant procedures, and patient-reported outcomes (PROs) were recorded. Failure was defined by ≥1 of the following criteria: (1) conversion to reverse total shoulder arthroplasty (RTSA), (2) a decrease in 1-year postoperative shoulder-specific PROs compared with preoperative scores, or (3) patient reports at final follow-up that the shoulder was in a worse condition than before surgery. Preoperative variables were compared between patients meeting the criteria for clinical failure and those who did not.

RESULTS

Fifty-four patients (mean age 56.3 ± 5.8 years, range 45 to 70) who underwent SCR, with minimum 1-year follow-up, were included in the analysis. Mean follow-up after surgery was 24 months (range 12 to 53). Eleven patients (20.4%) met criteria for clinical failure. Of the 11, 8 reported decreased American Shoulder and Elbow Surgeons (ASES) or Constant scores or indicated that the operative shoulder was in a worse condition than before surgery. Three patients underwent RTSA in the 6 to 12 months after SCR. Female sex and the presence of a subscapularis tear were associated with failure (P = .023 and P = .029, respectively). A trend toward greater body mass index (BMI), lower preoperative forward flexion, and lower preoperative acromiohumeral distance (AHD) was found in patients with clinical failure (P = .075, P = .088, and P = .081, respectively). No other variable included in the analysis was significantly associated with failure.

CONCLUSION

The proportions of female patients and those with subscapularis tear were greater among patients with clinical failure after SCR. Greater BMI, lower preoperative forward flexion, and lower preoperative AHD trended toward association with clinical failure of SCR.

LEVEL OF EVIDENCE

4, case series.

Arthroscopic Superior Capsule Reconstruction with a Doubled-Over (6 mm) Dermal Allograft

Superior capsule reconstruction has gained popularity as a treatment option for massive rotator cuff tears. The initial graft described was a tensor fascia lata. In the United States, acellular dermal matrix or dermal allograft has gained popularity. The results from published reports have been promising, but graft tear on postoperative imaging has been reported in several studies. Strives are being made to reduce the graft tear rate. One such way is to increase the thickness of the graft. Biomechanical studies have shown that thicker and stiffer grafts perform better in restoring superior stability. We present a technique of doubling a commercially available 3 mm dermal allograft and making it into a 6 mm graft for superior capsule reconstruction.

Biomechanics of tensor fascia lata allograft for superior capsular reconstruction

BACKGROUND

We hypothesized that in a cadaveric massive rotator cuff tear (MCT) model, a fascia lata (FL) allograft superior capsular reconstruction (SCR) would restore subacromial contact pressure and humeral head superior translation without limiting range of motion (ROM). Therefore, the objective of this study was to compare these parameters between an intact rotator cuff, MCT, and allograft FL SCR.

METHODS

Eight fresh cadavers were studied using a custom shoulder testing system. ROM, superior translation, and subacromial contact pressure were measured in each of 3 states: (1) intact rotator cuff, (2) MCT, and (3) MCT with SCR.

RESULTS

Total ROM was increased in the MCT state at 60° of abduction (P = .037). FL SCR did not restrict internal or external rotational ROM. Increased superior translation was observed in the MCT state at 0° and 30° of humeral abduction, with no significant difference between the intact cuff and FL SCR states. The MCT state significantly increased mean subacromial contact pressure at 0° of abduction with 30° and 60° of external rotation, and FL SCR restored this to intact levels. Peak subacromial contact pressure was increased for the MCT state at 0° of abduction with 30° and 60° of external rotation, as well as 30° of abduction with 30° of external rotation.

CONCLUSION

This study demonstrates a tensor FL allograft preparation technique for use in SCR. After MCT, FL SCR restores ROM, superior translation, and subacromial contact pressure to the intact state.

Anterior Capsular Reconstruction with Dermal Allograft in Combination With Anatomic Glenohumeral Arthroplasty: A Case Report

CASE

A 43-year-old man with chronic right shoulder pain and dysfunction due to recurrent anterior instability, irreparable subscapularis tear, and glenohumeral arthritis presented to our practice. After workup and counseling, he was treated with anatomic total shoulder arthroplasty augmented by anterior capsular reconstruction using human acellular dermal allograft. At 15 months postoperatively, his forward elevation, external rotation, and internal rotation were 160, 45, and T12, nearly equal to contralateral values. His glenohumeral joint remained reduced, and no complications were encountered.

CONCLUSION

We report the first known anterior capsular reconstruction performed in combination with anatomic shoulder arthroplasty.

Augmented Repair of Large to Massive Delaminated Rotator Cuff Tears With Autologous Long Head of the Biceps Tendon Graft: The Arthroscopic "Cuff-Plus" Technique

An anatomic and tension-free repair is the goal of arthroscopic rotator cuff repair. However, this purpose is not always achievable in large and massive tears, and sometimes, even when intraoperative results seem acceptable, clinical and radiologic outcomes can be disappointing shortly afterward. Superior capsule reconstruction has been claimed as a valid and viable joint-preserving option for treating irreparable rotator cuff tears. However, the role of the superior capsule in repairable cuff tears has also been questioned. The aim of this article is to present the so-called arthroscopic cuff-plus technique. This technique consists of superior capsule reconstruction using the proximal part of the long head of the biceps tendon associated with a tension-free repair of the rotator cuff tendons in large to massive delaminated tears.

Arthroscopic Superior Capsule Reconstruction With Doubled Autologous Semitendinosus Tendon Graft

Massive and irreparable rotator cuff tears remain a difficult condition to treat. Fatty infiltration of the muscles and excessive retraction of the tendons predispose to high failure rates of arthroscopic repair techniques. In recent years, studies on the superior capsule have shown that it plays a key role in reducing superior humeral head translation and restoring balance to the force couples required for dynamic shoulder function. Superior capsule reconstruction has become common in clinical practice. Several techniques with different types of grafts have been described, such as fascia lata autograft, dermal allograft patch, and long head of the biceps tendon autograft. More recently, an open technique with semitendinosus tendon autograft has been proposed. Our aim is to describe an all-arthroscopic technique for superior capsule reconstruction using a doubled semitendinosus tendon autograft in a box-shaped configuration. We believe that the technique can combine the advantages of other techniques, such as graft availability, low harvest-site morbidity, limited cost, and mechanical strength.

Graft Tensioning in Superior Capsular Reconstruction Improves Glenohumeral Joint Kinematics in Massive Irreparable Rotator Cuff Tears: A Biomechanical Study of the Influence of Superior Capsular Reconstruction on Dynamic Shoulder Abduction

Background:

Superior capsular reconstruction (SCR) for massive, irreparable rotator cuff tears has become more widely used recently; however, ideal tensioning of the graft and the influence on joint kinematics remain unknown.

Purpose/Hypothesis:

The purpose of this study was to assess the effects of graft tensioning on glenohumeral joint kinematics after SCR using a dermal allograft. The hypothesis was that a graft fixed under tension would result in increased glenohumeral abduction motion and decreased cumulative deltoid forces compared with a nontensioned graft.

Study Design:

Controlled laboratory study.

Methods:

A total of 10 fresh-frozen cadaveric shoulders were tested using a dynamic shoulder simulator. Each shoulder underwent the following 4 conditions: (1) native, (2) simulated irreparable supraspinatus (SSP) tear, (3) SCR using a nontensioned acellular dermal allograft, and (4) SCR using a graft tensioned with 30 to 35 N. Mean values for maximum glenohumeral abduction and cumulative deltoid forces were recorded. The critical shoulder angle (CSA) was also assessed.

Results:

Native shoulders required a mean (±SE) deltoid force of 193.2 ± 45.1 N to achieve maximum glenohumeral abduction (79.8° ± 5.8°). Compared with native shoulders, abduction decreased after SSP tears by 32% (54.3° ± 13.7°; P = .04), whereas cumulative deltoid forces increased by 23% (252.1 ± 68.3 N; P = .04). The nontensioned SCR showed no significant difference in shoulder abduction (54.1° ± 16.1°) and required deltoid forces (277.8 ± 39.8 N) when compared with the SSP tear state. In contrast, a tensioned graft led to significantly improved shoulder abduction compared with the SSP tear state (P = .04) although abduction and deltoid forces could not be restored to the native state (P = .01). A positive correlation between CSA and maximum abduction was found for the tensioned-graft SCR state (r = 0.685; P = .02).

Conclusion:

SCR using a graft fixed under tension demonstrated a significant increase in maximum shoulder abduction compared with a nontensioned graft; however, abduction remained significantly less than the intact state. The nontensioned SCR showed no significant improvement in glenohumeral kinematics compared with the SSP tear state.

Clinical Relevance:

Because significant improvement in shoulder function after SCR may be expected only when the graft is adequately tensioned, accurate graft measurement and adequate tension of at least 30 N should be considered during the surgical procedure. SCR with a tensioned graft may help maintain sufficient acromiohumeral distance, improve clinical outcomes, and reduce postoperative complications.

Superior Capsular Reconstruction: Fascia Lata Versus Acellular Dermal Allograft: A Systematic Review

Purpose

We systematically reviewed the literature to compare the clinical and radiologic outcomes and retear rates of superior capsular reconstruction (SCR) using fascia lata autograft (FLA) versus human dermal allograft (HDA) in cases of massive irreparable rotator cuff tears.

Methods

Searches of Pub Med and Cochrane Library identified clinical studies addressing SCR using FLA and HDA. Two reviewers independently screened the titles, abstracts and full texts to extract data from eligible studies. Reported outcome measures were descriptively analyzed.

Results

A total of 6 studies with 2 study groups satisfied the inclusion criteria. The number of shoulders in the HDA group was 155, and in the FLA group, the number was 140 shoulders. The mean age at time of surgery for the HDA group and the FLA group was 60.49 years and 65.8 years, respectively, and the mean follow-up was 15.2 months and 44.6 months, respectively. Active elevation improved from of 121°-130° to 158°-160° in the HDA group and from 74.8°-133° to 130.4°-146° in the FLA group. Active external rotation improved from 36°-45° in the HDA group and from 13°-28° to 30°-43° in the FLA group. The Visual Analog Scale for pain improved from 4-6.25 to 0.38-1.7 points in the HDA group, whereas in the FLA group, it improved from 6-2.5 points. In the HDA group, American Shoulder and Elbow Surgeons scores improved from 42-52 to 77.5-86.5, whereas in the FLA group scores improved from 35-54.4 to 73.7-94.3. The acromiohumeral distance improved in both groups. The retear rate was 3.4%-55% in the HDA group and 4.5%-29% % in the FLA group.

Conclusions

Arthroscopic SCR for massive, irreparable rotator cuff tears using both fascia lata allograft and human dermal allograft leads to improvement in clinical outcomes and radiologic outcomes. There is a lower retear rate in fascia lata allografts. The current literature is heterogeneous and has low levels of evidence.

Level of Evidence

Level IV, systematic review of level IV studies.

Arthroscopic superior capsular reconstruction versus latissimus dorsi transfer for irreparable rotator cuff lesions: a systematic review

INTRODUCTION

The present systematic review compared arthroscopic superior capsular reconstruction (ASCR) and latissimus dorsi transfer (ALDT) for the management of massive irreparable rotator cuff lesions.

SOURCES OF DATA

We performed a systematic review searching the literature on Medline, Cochrane and Scopus databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

AREAS OF AGREEMENT

We included a total of 20 articles, 10 on ASCR and 10 on ALDT (12 retrospective and 8 prospective studies), all published between 2013 and 2019.

AREAS OF CONTROVERSY

ASCR and ALDT are technical demanding procedures. When compared to each other, they do not produce significantly different improvements in clinical outcome.

GROWING POINTS

Both ASCR and ALDT are valid options for surgical management of MIRCLs. Although ALDT has shown a greater complication rate and a less improvement in acromion-humeral distance, its clinical outcomes overlap those obtained with ASCR.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further comparative prospective and retrospective studies with longer follow-up could confirm which surgical procedure can lead to better outcomes with a lower complication rate.

The Superior Capsular Reconstruction: Lessons Learned and Future Directions

The ideal solution for the irreparable rotator cuff tear remains in question. A recent innovative technique, superior capsular reconstruction (SCR), has demonstrated promising results with some early clinical outcomes demonstrating statistically notable improvements in active forward flexion and American Shoulder and Elbow Surgeons scores. Multiple biomechanical studies have also demonstrated its ability to reduce superior translation of the humerus after massive rotator cuff tear. Even so, these results are still early and durability of the reconstruction over time needs to be determined. Although more than 15,000 SCRs have been done worldwide, there remains a paucity of outcome data and one must be vigilant to not allow enthusiasm to overtake critical evaluation. The potential mechanisms of action, including tenodesis effect, force coupler, or subacromial spacer, need further elucidation and the ideal indications for this procedure, as well as its technical optimization, and limitations have yet to be fully determined. The purpose of this review is to critically evaluate the biomechanical and clinical literature that has assessed SCR, along with the controversies and considerations encountered with this procedure.

Arthroscopic Superior Capsular Reconstruction of the Shoulder Using Dermal Allograft

Irreparable massive cuff tears in young patients pose a difficult problem for shoulder surgeons. Arthroscopic superior capsular reconstruction has shown promise in recent years in the treatment of this challenging patient population. The majority of the literature is limited to surgical techniques. The authors present the 2-year clinical outcomes of 25 patients undergoing arthroscopic superior capsular reconstruction with dermal allograft from a single center. The Oxford Shoulder Score and range of motion were assessed preoperatively and then at 3 to 6 months, 1 year, and 2 years following surgery. Patient satisfaction was recorded at final follow-up. Magnetic resonance imaging was performed at 3 months postoperatively to assess graft integrity. All patients were available at 1-year follow-up, and 23 were available at 2 years. The mean Oxford Shoulder Score improved by a minimum of 10 points at all time points compared with preoperatively. The mean forward flexion and abduction improved by 20° and external rotation by 7°. Revision to reverse shoulder arthroplasty was seen in 3 patients (12%). Graft failure was seen in 4 patients (16%). Overall, 20 patients had successful outcomes at 1 year (80%) and 18 patients had successful outcomes at 2 years (72%). Superior capsular reconstruction offers a safe and effective short-term bridging option for young patients with irreparable supraspinatus tears in the absence of glenohumeral arthritis. However, long-term outcome studies are required to evaluate the true clinical effectiveness and failure rates. [Orthopedics. 2020;43(4):215-220.].

Arthroscopic Single-Row Superior Capsular Reconstruction for Irreparable Rotator Cuff Tears

Massive, irreparable rotator cuff tears are challenging to manage. Often, these tears are not amenable to primary repair and necessitate additional treatment options. This is especially true in patients with absent glenohumeral arthritis in the setting of a massive, irreparable rotator cuff tear. Superior capsular reconstruction (SCR), originally described by Mihata using a fascia lata autograft, has grown in popularity for the treatment of irreparable rotator cuff tears as a salvage option with good clinical outcomes. More recently, SCR techniques have been described using dermal allograft. Biomechanical studies and reported clinical series show promising results, with favorable postoperative clinical outcomes. The procedure, however, may be technically challenging, especially when performed using an all-arthroscopic technique. This article describes an all-arthroscopic technique using a predetermined graft size, unique medial fixation to ease graft passage, and knotless single-row lateral fixation to optimize suture management and efficiency.

Anterior Capsular Reconstruction Using a Dermal Allograft for an Irreparable Subscapularis Tear After Shoulder Arthroplasty: A Case Report

CASE

A 51-year-old man was noted to have an irreparable subscapularis tear after total shoulder arthroplasty (TSA). Owing to positive reported results with superior capsular reconstruction, his insufficiency was addressed with anterior capsular reconstruction with use of a dermal allograft. Two-year follow-up results demonstrate good functional outcomes, no recurrent instability, and excellent patient satisfaction.

CONCLUSIONS

Anterior shoulder insufficiency after TSA can significantly alter glenohumeral function and is an important cause of patient morbidity. This novel technique exhibits a good outcome and provides an alternative to previous methods of repair.

Superior capsule reconstruction for irreparable rotator cuff tears: a systematic review of biomechanical and clinical outcomes by graft type

BACKGROUND

Superior capsular reconstruction (SCR) has recently been proposed as a surgical solution to the irreparable rotator cuff tear and has gained popularity because of promising early results. Therefore, the purpose of this study is to review the biomechanical and clinical outcomes in shoulders with this condition treated with SCR.

METHODS

A systematic review was conducted following PRISMA guidelines using PubMed, EMBASE, and Cochrane databases. Studies were included if they reported biomechanical, radiographic, or clinical outcomes data after undergoing SCR in shoulders with irreparable rotator cuff tears. Studies were broken down into 3 categories: cadaveric biomechanical studies, autograft clinical outcome studies, and allograft clinical outcome studies. Biomechanical, radiographic, patient-reported, and functional outcomes data were recorded for each study.

RESULTS

Eight cadaveric biomechanical studies, 5 autograft clinical studies, and 4 allograft clinical studies met inclusion criteria. In biomechanical studies, subacromial contact pressure and superior humeral translation were decreased in most tested scenarios. An increase in American Shoulder and Elbow Surgeons (ASES) scores, forward elevation and external rotation values, and acromiohumeral distance (AHD) were found in all autograft clinical studies reporting. Allograft clinical studies reported increases in ASES scores, forward elevation values, and AHD but decreases in visual analog scale scores in all studies reporting.

CONCLUSIONS

SCR is emerging as a viable surgical option to address the irreparable rotator cuff tear. Biomechanical studies suggest that the humeral head-stabilizing effect of SCR appears to translate into improved clinical outcomes. Future research should focus on further defining the indications, limitations, and optimal technique.

The Effect of Glenohumeral Fixation Angle on Deltoid Function During Superior Capsule Reconstruction: A Biomechanical Investigation

PURPOSE

To evaluate the effect of dermal allograft fixation at different angles of glenohumeral abduction on deltoid forces during superior capsule reconstruction (SCR).

METHODS

Fifteen cadaveric specimens were tested using a dynamic shoulder simulator. Following testing in the native state, shoulders underwent SCR in 2 of 5 possible fixation angles; 0°, 15°, 30°, 45°, or 60° of glenohumeral abduction, allowing for 6 specimens per group. Angles were measured radiographically with the glenoid fixed perpendicular to the floor. Maximum mean deltoid abduction force was compared among 5 separate conditions within each angle group: (1) native shoulder, (2) complete supraspinatus (SSP) and superior capsule tear, (3) SCR alone, (4) SCR with posterior margin sutured, and (5) SCR with anterior and posterior margins sutured.

RESULTS

SSP tears significantly increased the maximum deltoid forces for all 5 fixation angles compared with the native state (P < .05). Specimens repaired at 0°, 30°, and 45° were unable to restore deltoid forces compared with the native state in any condition (P < .05). SCR at 15° with anterior and posterior margin convergence showed similar abduction forces compared with the native state (P = .19). When fixed at 60° abduction, SCR alone significantly reduced deltoid forces compared to SSP (Δ143N, P < .001) and native (Δ48N, P < .001). No significant differences were found between the 3 repair subtypes (SCR ± anterior/posterior margin repair) in the 60° group.

CONCLUSIONS

SCR with anterior and posterior margin convergence tensioned at 15° of glenohumeral abduction showed similar deltoid abduction force requirements compared with the native state, whereas graft fixation in 60° significantly reduced deltoid force in all SCR conditions.

CLINICAL RELEVANCE

Increased graft tension with a greater abduction angle may provide greater functional outcome by placing less load on the deltoid. In contrast, graft fixation in lower abduction angles may require additional margin convergence to reproduce native forces.

Superior Capsular Reconstruction with Fascia Lata Allograft for Irreparable Supraspinatus Tendon Tears

Superior capsular reconstruction is a recently described procedure for the treatment of irreparable supraspinatus tendon tears. Graft options that have been previously described include autogenous fascia lata and decellularized dermal graft. No studies were published with the use of fascia lata allograft. The purpose of this technical note is to describe the surgical technique of superior capsular reconstruction using fascia lata allograft. The procedure is performed by arthroscopic visualization, with the patient positioned in the lateral decubitus position. The authors describe a technique based on the use of a double-pulley knot in the glenoid and greater tuberosity, facilitating the procedure and allowing the graft to be brought into the subacromial space in the definitive position, with the appropriate tension. The allografts are available from this institution's tissue bank, cryopreserved and submitted to microbiological and histopathological evaluation. Superior capsular reconstruction is a promising surgery. The technique described in the present technical note shows a viable arthroscopic alternative, with a smaller number of anchors when compared with other techniques.

Arthroscopic Superior Capsular Reconstruction Using "Sandwich" Patch Technique for Irreparable Rotator Cuff Tears

The technique of superior capsular reconstruction (SCR) using fascia lata autograft, described by Mihata et al. in 2012, has been an acceptable and effective method for treating irreparable massive rotator cuff tears, especially in cases with severe fatty infiltration and tendon retraction. After the SCR procedure of Mihata et al., it was found that some graft failure occurred with thinning and elongation during the follow-up time, which was called graft "creep." To avoid graft creep and reduce graft failure rates after SCR, we created an arthroscopic SCR technique with a "sandwich" patch augmented with polyethylene terephthalate scaffold interspaced between 2 folded layers of fascia lata autograft.

Irreparable Rotator Cuff Tears: A Biomechanical Comparison of Superior Capsuloligamentous Complex Reconstruction Techniques and an Interpositional Graft Technique

Background:

Irreparable rotator cuff tears lead to superior translation of the humeral head. Numerous surgical management options are available to treat the condition.

Purpose:

To compare superior capsule stability among different types of patch grafting in irreparable rotator cuff tears.

Methods:

Six cadaveric shoulders were tested in a custom-designed shoulder testing system. Superior translation of the humerus and subacromial contact pressure were quantified in an intact condition (condition 1), after cutting the supraspinatus tendon (condition 2), and after additionally cutting the superior capsuloligamentous complex (condition 3). The results were compared among 3 types of patch grafting, in which capsule reconstruction was achieved by glenoidal 3-point (condition 4) or 2-point (condition 5) fixation or by affixing a graft below the acromion (condition 6).

Results:

No significant difference in subacromial pressure was measured by reconstruction with 2 or 3 anchors compared with conditions 1 and 2 (P > .05). However, with 3-point fixation, lower levels of pressure were measured than with 2-point fixation. Moreover, superior translation values were lower with 3-point fixation; the same applied for values of the preserved capsule as compared with the torn capsule. In condition 6, a significant increase in pressure in the neutral position was documented (P < .05).

Conclusion:

The superior capsuloligamentous complex plays an important role in stabilizing the glenohumeral joint. The results suggest that with additional medial anchoring at the coracoid base, the depressing and centering effect of the superior complex can probably be regained in a more physiological way compared with a reconstructed capsule with 2 glenoid attachments or with an interpositional graft below the acromion.

Editorial Commentary: Superior Capsule Reconstruction: Grafts for Superior Capsular Reconstruction Must Be Thick and Stiff

To achieve a good functional outcome, including minimal graft tear, after superior capsule reconstruction, surgeons should carefully compare the biomechanical properties of all graft materials under consideration. In particular, graft stiffness affects postoperative stability in the glenohumeral joint, acromiohumeral distance, and graft healing. In my experience, a sufficiently stiff fascia lata graft is 6- to 8-mm thick and includes suture reinforcement and/or an augmentation patch. I believe that augmenting acellular dermal allografts in a similar way will decrease the incidence of graft elongation, persistent superior migration of the humoral head, and other complications after superior capsule reconstruction.

Evaluation of an Incorporated Superior Capsular Reconstruction Graft: A Case Report

CASE

A 66-year-old man presented with 2 years of atraumatic right shoulder pain and difficulty with overhead activities. Radiographs and magnetic resonance imaging demonstrated Hamada stage I changes and a massive irreparable rotator cuff tear involving the supraspinatus and infraspinatus. He underwent superior capsular reconstruction with acellular human dermal matrix (SCR with ADM) allograft. Diagnostic arthroscopy and humeral avulsion of the glenohumeral ligament repair 1 year postoperatively showed that the SCR appeared intact and vascularized.

CONCLUSIONS

This is the first study to confirm visually that SCR with ADM allograft is well-vascularized and intact 1 year post-operatively.