Anterior Capsule Reconstruction Technique With an Acellular Dermal Allograft

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.

Management of irreparable subscapularis tears: Current concepts

Primary repair of acute subscapularis (SSC) tears provides excellent results, but tendon retraction, muscle atrophy, fatty infiltration, and humeral head migration may render a more chronic tear irreparable. These irreparable SSC tears present a diagnostic and treatment challenge for orthopaedic surgeons. Careful physical examination and imaging evaluation can help to distinguish those with reparable versus irreparable tears, but they are still not very reliable due to the methodological limitations of current evidence. Therefore, future research using 3D and quantitative measurement techniques is necessary to better predict the irreparability of the SSC. When conservative treatment of an irreparable SSC tear fails, reversed shoulder arthroplasty has been established as the preferred treatment option for older, low-demand patients with arthropathy, providing reliable improvements in pain and function. In younger patients without significant arthropathy, musculotendinous transfers are the treatment of choice. The pectoralis major transfer is historically the most frequently performed procedure and provides improved range of motion and pain relief, but fails to adequately restore strength and shoulder function. The latissimus dorsi transfer has gained increased interest over the last few years due to its biomechanical superiority, and early clinical studies suggest improved outcomes as well. More recently, anterior capsular reconstruction has been proposed as an alternative to musculotendinous transfers, but clinical data are completely lacking. Future high-quality randomised controlled trials are necessary to reliably compare the different musculotendinous transfers and anterior capsular reconstruction.

Management of Subscapularis Insufficiency After Total Shoulder Arthroplasty

The functional success of anatomic total shoulder arthroplasty (TSA) relies heavily on the healing integrity of the subscapularis tendon. Access to the glenohumeral joint is performed through a deltopectoral approach, and takedown of the subscapularis tendon is necessary in most surgeons' hands. Although initially described as a tenotomy, lesser tuberosity osteotomy and subscapularis peel are two techniques more commonly used today. Both of these options offer good results as long as proper repair is done. A subscapularis-sparing approach has more recently been advocated but is technically demanding. Failure of tendon repair can lead to early failure of anatomic total shoulder arthroplasty with accelerated glenoid loosening, decreased function, and anterior instability. Treatment options for subscapularis insufficiency include nonsurgical management, revision tendon repair, tendon reconstruction or transfer, or conversion to reverse shoulder arthroplasty. As shoulder arthroplasty continues to become increasingly prevalent, subscapularis insufficiency, too, will become more common. Accordingly, a surgeon's knowledge of subscapularis management in an arthroplasty setting must encompass treatment options for postoperative subscapularis insufficiency.

Current concepts review in the management of subscapularis tears

Subscapularis (SSc) is the prime internal rotator of shoulder. It is the most powerful rotator cuff muscle, maintaining the anterior force couple of shoulder. The tears in SSc as any other rotator cuff muscles might result from a traumatic event or more commonly from intrinsic degeneration. With the advent and widespread use of shoulder arthroscopy, SSc tears, which were once considered as "forgotten or hidden lesions" are now being increasingly recognized. Isolated SSc tears are relatively rare. They occur in combinations. Clinically internal rotation can be near normal because of the compensation provided by other internal rotators. It is not uncommon for patients with SSc tear to be normal on routine physical examination. The Bear Hug test (BHT) has high sensitivity and accuracy in the diagnosis of SSc tear. The combined use of BHT with Belly Press Test has been found optimal for diagnosis. US is an accurate and reliable method for diagnosing SSc tears and outperformed MRI in diagnosing partial-thickness SSc tears. The MRI is currently the most advanced imaging available for diagnosis. The specificity is up to 100%. However, the sensitivity is between 36 and 40%. The earliest classification system for SSc tears was by Fox et al. The commonly used classification is by Lafosse et al. The recent system by Yoo et al. is based on the insertion of SSc. The comma sign is gaining importance not only in arthroscopic diagnosis but also in MRI identification and repair of SSc. The mode of management is mainly arthroscopic. The techniques of repair of SSc are continuously progressing. However, there is no clear consensus on the double vs single-row repairs, biceps tendon management, and the role of coracoplasty. Future research must focus on these areas. Reserve shoulder arthroplasty is reserved for salvage in older age groups. Tendon transfers are performed in young active individuals with irreparable tears.

Arthroscopic Anterior Capsule Reconstruction Using Fascia Lata Autograft and Knotless Fibretak: A Case Report

Introduction

Shoulder has multidirectional mobility with capsule and rotator cuff as stabilizers. Irreparable subscapularis tears are relatively uncommon. Anterior capsule reconstruction (ACR) is one of the different modalities of treatment for irreparable subscapularis tears. Anterior capsular reconstruction can be performed using hamstring autograft, tibialis anterior allograft, and human dermal allograft. Procedures using hamstring autograft and tibialis anterior allograft reported severe capsular deficiency, recurrent dislocation, and subluxations. Dermal allograft is routinely used for ACR anterior capsule reconstruction. But However, there are no reports of Fascia lata autograft being used for ACR anterior capsule reconstruction. As fascia lata is an autograft, it may have a better chance of healing than dermal allograft.

Case Report

A 60-year year-old male patient came with history of slip and fall at home 3 months ago and injured his left shoulder. Magnetic resonance imaging MRI is showing subscapularis tear retracted medial to glenoid and anterior supraspinatus tear with minimal retraction. The aim of this case report is to describe in detail the arthroscopic technique of ACR anterior capsule reconstruction using fascia lata autograft using the new knotless all suture anchors (fibereTak) on glenoid.

Conclusion

Fascia lata being an autograft may have better healing potential, but its superiority over dermal allografts in the setting of ACR anterior capsule reconstruction needs further studies.

Complex Shoulder Girdle Stabilization Using Allograft Capsular Reconstruction and Pectoralis Major Transfer: A Case Report

CASE

A 21-year-old woman with a history of multiple failed surgical and conservative management for recurrent involuntary shoulder instability presented with 1-year history of shoulder pain. Physical examination demonstrated intractable static anterior glenohumeral instability, deficient capsular tissue, with reducible scapular winging secondary to long thoracic nerve palsy. Allograft capsular reconstruction and open split pectoralis major tendon transfer were performed to salvage shoulder motion and stabilize her shoulder girdle.

CONCLUSION

This report presents a novel repair option for intractable shoulder instability and scapular winging. Surgeons should recognize potential causes of shoulder instability and familiarize themselves with multiple stabilization techniques as potential salvage options before glenohumeral fusion.

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.

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.

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.

Biomechanical analysis of anterior capsule reconstruction and latissimus dorsi transfer for irreparable subscapularis tears

BACKGROUND

Anterior capsule reconstruction (ACR) and latissimus dorsi transfers (LTs) have been proposed as solutions for irreparable subscapularis tears. The purpose of this study was to biomechanically assess the effects of ACR and LT separately and together for treatment of irreparable subscapularis tears.

MATERIALS AND METHOD

Eight cadaveric shoulders underwent 5 testing conditions: (1) intact, (2) irreparable subscapularis tear, (3) ACR, (4) ACR+LT, and (5) LT alone. Anteroinferior translation loads of 20, 30, and 40 N were applied. Range of motion and magnitudes of glenohumeral anterior and inferior translation at 0°, 30°, and 60° of abduction and at 30° and 60° of external rotation were measured for each testing condition.

RESULTS

At 30° of abduction and 60° of external rotation, ACR and ACR+LT restored anterior and inferior translation to intact (P > .702) for 30 and 40 N of anteroinferiorly directed force. LT alone did not restore anteroinferior stability at 30 N of distraction force at 30° of glenohumeral abduction and 60° of external rotation (P < .001). However, ACR and ACR+LT led to significant decreases in total range of motion compared to intact at 0° and 30° of abduction (P < .007).

CONCLUSIONS

ACR with dermal allograft was able to restore anteroinferior stability in the setting of irreparable subscapularis tears but resulted in decreased total range of motion. LT alone was less effective than ACR in restoring glenohumeral stability. The addition of LT as a dynamic restraint did not increase the efficacy of ACR.

Recent development and biomedical applications of decellularized extracellular matrix biomaterials

Decellularized matrix (dECM) is isolated extracellular matrix of tissues from its original inhabiting cells, which has emerged as a promising natural biomaterial for tissue engineering, aiming at support, replacement or regeneration of damaged tissues. The dECM can be easily obtained from tissues/organs of various species by adequate decellularization methods, and mimics the structure and composition of the native extracellular matrix, providing a favorable cellular environment. In this review, we summarize the recent developments in the preparation of dECM materials, including decellularization, crosslinking and sterilization. Also, we cover the advances in the utilization of dECM biomaterials in regeneration medicine in pre-clinic and clinical trials. Moreover, we highlight those emerging medical benefits of dECM beyond tissue engineering, such as cell transplantation, in vitro/in vivo model and therapeutic cues delivery. With the advances in the preparation and broader application, the dECM biomaterials could become the gold scaffold and pharmaceutical excipients in medical sciences.