Superior Capsular Reconstruction With the Addition of an Acromial Acellular Dermal Allograft Spacer

Editorial Commentary: Bursal Acromial Resurfacing Offers Improved Biomechanics in Laboratory Studies but There Is No Consensus on Indications, Technique, or Graft Type, and Clinical Results Are Lacking

Bursal acromial reconstruction/resurfacing, acromiograft, and biologic tuberoplasty are all terms used to describe the concept of fixing a graft (human dermal allograft or fascia lata) to the undersurface of the acromion or onto the greater tuberosity with the aim of achieving pain relief and improved function in patients with massive irreparable cuff tears. The rationale for these procedures is based on the biomechanical concept that an interpositional spacer can reverse superior migration of the humeral head, increase acromiohumeral distance, reduce subacromial contact pressure, and limit painful bone-on-bone contact. These types of procedures are postulated to offer potential advantages (cost savings related to use of implants, long-term biologic solution, technical ease of surgery, and short surgical time) over other options for massive irreparable cuff tears, particularly superior capsule reconstruction and in some respects the subacromial balloon. However, these advantages remain unproven because published clinical studies are sparse. Furthermore, there is no current consensus on indications, technique, or optimum graft choice.

Surgical Management of Massive Irreparable Cuff Tears: Superior Capsule Reconstruction and Rotator Cable Reconstruction

PURPOSE OF REVIEW

Massive irreparable rotator cuff tears (MIRCTs) present treatment challenges. Recently, superior capsule reconstruction (SCR) and anterior cable reconstruction have emerged as surgical options, but no single approach is superior. This review provides an overview of SCR and cable reconstruction techniques, including biomechanical studies, clinical outcomes, and surgical considerations.

RECENT FINDINGS

Biomechanical studies show SCR with autografts or allografts improves glenohumeral stability and mechanics. Clinical outcomes of SCR demonstrate improved range of motion, function scores, and pain relief in short-term studies. Anterior cable reconstruction reduces superior humeral head translation and subacromial pressures in biomechanical models. Early clinical studies report improved rotator cuff healing and outcomes for cable reconstruction in specific irreparable tear patterns. SCR and cable reconstruction are viable surgical options for MIRCTs based on early encouraging results. However, higher-level comparative studies with long-term follow-up are still needed. Careful consideration of tear pattern, patient factors, and surgical goals is required to optimize treatment of MIRCTs. Further research is necessary to determine the optimal role for these procedures.

Yoke procedure as a salvage treatment option for failed reverse total shoulder arthroplasty with irreconstructible glenoid

BACKGROUND

Glenoid bone loss is a known challenge in primary and revision reverse total shoulder arthroplasty. In severe deficiency, even placing the baseplate in alternative centerline or using an augmented baseplate may be insufficient. This study reports on the use of a soft tissue resurfacing technique using Achilles tendon allograft, coined Yoke procedure, for salvage treatment of glenoid deficient shoulder requiring reconstruction.

MATERIALS AND METHODS

All patients who underwent the Yoke procedure between 2014 and 2020 by a single surgeon at a single academic center were identified and had their charts retrospectively reviewed. Demographics and surgical information were recorded. Preoperative X-rays and 3D-computed tomography scans were reviewed to classify patient glenoid types, evaluate glenoid medialization, and measure shoulder angles. Preoperative and postoperative range of motions and patient-reported outcome scores were evaluated, including anterior elevation, external rotation, internal rotation, visual analog scale, subjective shoulder value score, Simple Shoulder Test, and American Shoulder and Elbow Surgeons (ASES) scores. Postoperative radiographs and follow-up notes were reviewed to evaluate postoperative complication profiles at 1 year.

RESULTS

Seven patients with a median age of 69 years (range, 54-77 years) underwent Yoke procedure and had a median 12-month follow-up (range, 9-56 months). All patients were female and had a median of 2 prior shoulder surgeries (range, 0-13). Of all the patients, the most common comorbidity was osteoporosis (6) followed by rheumatoid arthritis (3). Of the 5 patients who had previous arthroplasty, the most common indications were baseplate failure (4), followed by instability (3) and infection (3). The median visual analog scale score improved from 8 (range, 3-9) to 2 (range, 1-4). The median Simple Shoulder Test improved from 8% (range, 0%-42%) to 33% (range, 17%-83%). The median ASES score improved from 15 (range, 5-38) to 52 (range, 40-78). The median anterior elevation and external rotation improved from 20° (range, 0°-75°) to 100° (range, 40°-145°) and 10° (range, 0°-20°) to 20° (range, 0°-55°), respectively. There was no change in median internal rotation. As of the last follow-up, one patient reported postoperative complications of anterior-superior implant escape, heterotopic ossification, and scapular notching.

CONCLUSION

The Yoke procedure is a promising salvage treatment that can offer patients consistent pain reduction and moderate functional improvements at short-term follow-up. In the setting of poor bone quality and severe glenoid deficiency, glenoid baseplate implantation may not be absolutely necessary for a pain-relieving, functionally acceptable outcome.

Arthroscopic Superior Capsule Reconstruction with Combined Fascia Lata Autograft and Synthetic Scaffold Patch Graft for the Treatment of Irreparable Rotator Cuff Tears Yields Favorable Clinical and Radiographic Outcomes at Minimum Two-Year Follow-Up

PURPOSE

To report the results of the arthroscopic superior capsule reconstruction (ASCR) technique with a combined fascia lata autograft and synthetic scaffold patch graft for irreparable massive rotator cuff tears (RCTs).

METHODS

The period for this retrospective study was between December 2016 and December 2020. The criteria for inclusion were patients treated arthroscopically for an incompletely reparable massive RCT (dimension > 5 cm and two tendons fully torn, intact or reparable subscapularis tendons and teres minor tendon with or without irreparable infraspinatus, a radiological Hamada classification between grade 0 and 4, and a minimum 24-month postoperative follow-up).. Clinical outcomes were evaluated pre-operatively and at a final follow-up by a visual analog scale (VAS) for pain and range of motion along with the American Shoulder and Elbow Surgeons score (ASES), the University of California Los Angeles score (UCLA), and the Constant-Murley score (CMS). Radiological outcomes were assessed according to the rotator cuff arthropathy (RCA) and the acromiohumeral distance (AHD) stages. Graft integrity and muscle fatty infiltration were evaluated by magnetic resonance imaging (MRI).

RESULTS

A total of 43 patients were enrolled in the study with a mean follow-up duration of 45.6 months (range 24 to 64). All clinical scores also improved at the two-year follow-up (mean VAS 0.7 [SD 0.7] vs. 5.4 [SD 1.1], P < 0.001; mean ASES 92.6 [SD 8.0] vs. 34.8 [SD 13.4], P < 0.001; mean UCLA 31.5 [SD 3.9] vs. 11.0 [SD 3.2], P < 0.001; and mean CMS 86.6 [SD 7.2] vs. 40.0 [SD 11.6], P < 0.001), and 39 of 43 fascia lata grafts were fully intact on MRI (91%).

CONCLUSIONS

ASCR with a combined fascia lata autograft and synthetic scaffold patch graft resulted in good functional outcomes, with a high rate of graft healing at the two-year follow-up. All patients achieved clinically relevant improvement (met minimal clinically important differences (MCID)) on ASES, UCLA, and VAS with improved abduction strength restoration.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

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.

Arthroscopic Acromiograft for Large-to-Massive Rotator Cuff Tears: A Rescue Technique for Restoring Shoulder Stability

A large-to-massive rotator cuff tear is a complicated disease for an orthopedic surgeon to get the best results and prevent complications like retears or progression to arthropathy. Although there are several surgical options for managing these tears, there is still no gold standard treatment. The key point in the solution would be preventing the upward migration of the humeral head to create a biomechanically stable joint to promote rotator cuff healing. In this article, we introduced a technique called an acromiograft, in which the allograft is attached to the undersurface of the acromion.

Latissimus dorsi transfer vs. lower trapezius transfer for posterosuperior irreparable rotator cuff tears

BACKGROUND

Latissimus dorsi transfer (LDT) and lower trapezius transfer (LTT) are effective treatment options for posterosuperior irreparable rotator cuff tears (IRCTs) in relatively young patients and elderly high-demand patients without arthritic changes. However, the optimal treatment option for patients with posterosuperior IRCT remains a subject of ongoing debate. This study aimed to compare clinical and radiologic short-term outcomes between arthroscopic-assisted LDT (aLDT) and arthroscopic-assisted LTT (aLTT) in patients with posterosuperior IRCT.

METHODS

This retrospective crossover study included patients who underwent aLDT or aLTT for posterosuperior IRCT and who had a minimum clinical follow-up time of 2 years after undergoing surgical procedures between January 2012 and June 2019. A total of 90 patients with posterosuperior IRCT were divided into 2 groups according to the surgical procedure: group D underwent aLDT (n = 48) and group T underwent aLTT (n = 42). Clinical outcomes comprised the visual analog scale score for pain, active shoulder range of motion (ROM), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, and activities of daily living that require active external rotation (ADLER) score. Radiologic outcomes included acromiohumeral distance (AHD). The progression of arthritis was evaluated using Hamada grade. Graft integrity was assessed using postoperative magnetic resonance imaging.

RESULTS

Significant improvements in clinical outcomes were observed in both groups. Active shoulder external rotation (P < .001), postoperative ASES score (P < .001), and ADLER score (P < .001) were significantly higher in group T than in group D. AHD at 2-year follow-up was significantly higher in group T than in group D (P < .001). The rate of progression of arthritis was significantly higher in group D (31.3%) than in group T (7.1%) (P = .031).

CONCLUSIONS

Although both LDT and LTT improved the overall clinical outcomes of patients with posterosuperior IRCT, LTT was superior to LDT in terms of shoulder ROM, functional improvement, and progression of arthritis. Our findings indicate that LTT may be the preferred treatment option for posterosuperior IRCT in relatively active and young patients.

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.

Bursal Acromial Reconstruction (BAR) Using an Acellular Dermal Allograft for Massive, Irreparable Posterosuperior Rotator Cuff Tears: A Dynamic Biomechanical Investigation

PURPOSE

To investigate the effect of bursal acromial reconstruction (BAR) using an acellular dermal allograft on glenohumeral joint kinematics including maximum abduction angle, glenohumeral superior translation, cumulative deltoid force, and subacromial contact pressure.

METHODS

In this dynamic biomechanical cadaveric shoulder study, 8 fresh-frozen cadaveric shoulders (age 53.4 ± 14.2 years, mean ± standard deviation) were tested using a dynamic shoulder testing system. Maximum abduction angle (MAA), glenohumeral superior translation (ghST), maximum cumulative deltoid force (cDF), and subacromial peak contact pressure (sCP) were compared across 3 conditions: (1) intact shoulder; (2) massive retracted irreparable posterosuperior rotator cuff tear (psRCT) according to Patte III; and (3) BAR. Additionally, humeral head containment was measured using contact pressure.

RESULTS

Compared with the simulated psRCT, BAR significantly increased mean MAA and significantly decreased ghST (P < .001, respectively) and cDF (P = .017) Additionally, BAR was found to significantly decrease sCP compared with psRCT (P = .024).

CONCLUSION

In a dynamic biomechanical cadaveric shoulder simulator, resurfacing the undersurface of the acromion using the BAR technique leads to significantly improved ghST, MAA, cDF, and sCP compared with the irreparable rotator cuff tear.

CLINICAL RELEVANCE

With the BAR technique, native humeral containment may be restored, which can potentially delay progressive subacromial and glenoidal abrasive wear and improve overall shoulder function. As such, the proposed BAR technique can be considered as a technically feasible and potentially cost- and timesaving procedure, as no bone anchors are needed, glenoidal or humeral side graft ruptures can be avoided, and postoperative rehabilitation can be started immediately. However, future clinical studies are needed.

Combining fascia lata autograft bridging repair with artificial ligament internal brace reinforcement : a novel healing-improvement technique for irreparable massive rotator cuff tears

AIMS

The aim of this study is to provide a detailed description of cases combining bridging patch repair with artificial ligament "internal brace" reinforcement to treat irreparable massive rotator cuff tears, and report the preliminary results.

METHODS

This is a retrospective review of patients with irreparable massive rotator cuff tears undergoing fascia lata autograft bridging repair with artificial ligament "internal brace" reinforcement technique between January 2017 and May 2018. Inclusion criteria were: patients treated arthroscopically for an incompletely reparable massive rotator cuff tear (dimension > 5 cm or two tendons fully torn), stage 0 to 4 supraspinatus fatty degeneration on MRI according to the Goutallier grading system, and an intact or reparable infraspinatus and/or subscapularis tendon of radiological classification Hamada 0 to 4. The surgical technique comprised two components: first, superior capsular reconstruction using an artificial ligament as an "internal brace" protective device for a fascia lata patch. The second was fascia lata autograft bridging repair for the torn supraspinatus. In all, 26 patients with a mean age 63.4 years (SD 6.2) were included.

RESULTS

All patients underwent more than two years of follow-up (mean 33.5 months (24 to 45)). All clinical scores were also improved at two-year follow-up (mean visual analogue scale 0.7 (SD 0.5) vs 6.1 (SD 1.2); p < 0.001; mean American Shoulder and Elbow Surgeons score 93.5 (SD 5.3) vs 42.5 (SD 10.8); p < 0.001; mean University of California, Los Angeles score, 31.7 (SD 3.7) vs 12.0 (SD 3.1); p < 0.001; and mean Constant-Murley score 88.7 (SD 3.5) vs 43.3 (SD 10.9); p < 0.001), and 24 of 26 fascia lata grafts were fully healed on MRI (92%). One patient had haematoma formation at the harvesting side of the fascia lata at two days postoperatively.

CONCLUSION

The fascia lata autograft bridging repair combined with artificial ligament internal brace reinforcement technique achieved good functional outcomes, with a high rate of graft healing at two-year follow-up. Although the short-term results are promising, further studies with a greater number of patients would provide clearer results. Cite this article: Bone Joint J 2021;103-B(10):1619-1626.

Advancement in Arthroscopic Superior Capsular Reconstruction for Irreparable Massive Rotator Cuff Tear

Irreparable massive rotator cuff tear (IMRCT) was one of the causes of shoulder dysfunction, despite technical improvement, the failure rate of IMRCT was still demonstrated to be high. Traditional treatments like non-surgical treatments, partial rotator cuff repair, and tendon transfers could only achieve a slight improvement. A potential cause for high failure rate was the fact that traditional treatments cannot restore the superior stability of glenohumeral joint, and thus restricted the movement of shoulder joint severely. Superior capsular reconstruction (SCR) using a variety of grafts (autograft, allograft, xenograft, or synthetic grafts) provided a promising option for IMRCT. In surgery, graft was fixed medially to superior glenoid and laterally to the footprint of humeral greater tuberosity. SCR could increase the stability of the superior glenohumeral joint, decrease the subacromial pressure and acromiohumeral distance. This review summarized the relevant literature regarding the alternative grafts, surgery indications, operative techniques and clinical outcomes of SCR. we compared the different grafts, key surgical steps, the advantages and disadvantages of different surgical methods to provide clinicians with new surgical insights into the treatments of IMRCT. In conclusion, IMRCT without severe glenohumeral arthritis was the best suitable indication for SCR. The clinical outcomes were positive in the short-term and middle-term following-up. More studies were necessary to determine long-term results of this surgical procedure.

Subacromial resurfacing with fascia lata autograft for irreparable cuff tears : JEO 2021 expert opinion short report & surgical technique with video

Massive and irreparable rotator cuff tears remain a major challenge for orthopaedic surgeons and several surgical options have been accepted for different patterns of irreparable cuff tears. However, the high-cost and technical complexity of some surgeries and the inconsistent clinical results of others, leave room for the search for surgical options that can offer a good balance between technical simplicity, a lower cost and an acceptable clinical result.The rationale behind some available techniques includes lowering the humeral head, which enables a more efficient balance of the force couples around the shoulder during rehabilitation. The interpositional arthroplasty with a biodegradable balloon, the Superior Capsule Reconstruction and, more recently, subacromial resurfacing with a dermal allograft have been presented as valid options to address that purpose.This technical note presents Subacromial Resurfacing with fascia lata as an option for the treatment of irreparable rotator cuff tears in the elderly population. Its low-cost and reasonable technical demand, along with the need for further elucidation of the ideal indications and technical optimization of other available techniques may open up room for the success of this option.

Arthroscopic Biologic Interpositional Tuberosity Graft for the Treatment of Irreparable Rotator Cuff Tears

Massive, irreparable rotator cuff tears in younger, more active patients present a unique treatment challenge to shoulder surgeons. In the past few years, new techniques continue to emerge to address this challenging problem. The superior capsular reconstruction technique has been accepted as an option for addressing this problem. While initial results are encouraging, pitfalls remain regarding technical challenges, healing and protracted rehabilitation due to delayed motion protocols. We present an alternative approach to the massive, irreparable rotator cuff tears using a biologic interpositional humeral -based graft.

[Research progress of indication and treatment of graft in shoulder superior capsular reconstruction for rotator cuff tear]

Objective

To review the research progress of indication and treatment of graft in shoulder superior capsular reconstruction (SCR) for rotator cuff tear (RCT).

Methods

The literature related to shoulder SCR in recent years was extensively reviewed, and the anatomy, biomechanics, surgical indications, and treatment of graft in SCR were summarized.

Results

Superior capsule plays a role as a functional complex with rotator cuff, ligament, and whole capsule. SCR can effectively restore the superior stability of the shoulder. The indications of SCR include the irreparable massive RCT, massive RCT combined with pseudoparalysis shoulder, medium/large RCT with severe degenerative rotator cuff tissue, and dual-layer RCT. In order to achieve a better healing of tendon-bone in graft and decrease the rate of long-term graft retearing, it is essential to select an appropriate thickness graft, fix the graft in right intensity, and get a better capsular continuity.

Conclusion

The technique of SCR advanced to SCR for reinforcement and it is indicated from substantial massive RCT to severe degeneration of rotator cuff tissue. Graft treatment is the key step for a successful SCR.

Superior Capsular Reconstruction: A Systematic Review of Surgical Techniques and Clinical Outcomes

PURPOSE

To evaluate surgical techniques and clinical outcomes of arthroscopic superior capsular reconstruction (SCR) for the treatment of massive irreparable rotator cuff tears.

METHODS

A systematic review was registered with PROSPERO and performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The PubMed, Scopus, and Cochrane databases were searched. Studies investigating SCR with reported surgical techniques were included. Animal studies, cadaveric studies, review studies, and letters to the editor were excluded. The technical aspects of the surgical techniques for SCR were analyzed in each article, which included graft type, glenoid fixation method, greater tuberosity fixation method, graft passage technique, suture management, margin convergence, concomitant procedures, and postoperative rehabilitation protocol. Clinical outcomes, when available, were also analyzed.

RESULTS

We screened 365 articles, of which 29 described surgical techniques for SCR. According to the Modified Coleman Methodology Score, 24 articles were rated as poor (score < 55), 4 were rated as fair (score between 55 and 69), and 1 was rated as good (score between 70 and 84), with an average score of 25.8 ± 20.9. The most commonly performed technique for SCR used the following: an acellular dermal allograft, 2 biocomposite suture anchors for glenoid fixation, transosseous-equivalent double-row suture anchor fixation for greater tuberosity fixation with 2 biocomposite medial-row anchors and 2 biocomposite lateral-row anchors, the double-pulley technique combined with an arthroscopic grasper and/or pull suture to pass the graft into the shoulder, the performance of both anterior and posterior margin convergence, and a native rotator cuff repair when possible. Only 8 studies reported clinical outcomes, and they showed that SCR provides significant improvement in patient-reported outcomes, significant improvement in shoulder range of motion, variable graft failure rates, low complication rates, and variable reoperation rates. There were no studies comparing outcomes among the various surgical techniques.

CONCLUSIONS

Many surgical techniques exist for arthroscopic SCR. However, no superior technique was shown because there were no studies comparing clinical outcomes among these various techniques.

LEVEL OF EVIDENCE

Level V, systematic review of Level III, IV, and V studies.

Suture Tape-Reinforced Human Dermal Allograft Used for Superior Capsule Reconstruction Demonstrates Improved Ability to Withstand Elongation

Purpose

To investigate the potential for a suture tape-reinforcement technique to prevent elongation with repetitive use of a human dermal (HD) allograft traditionally used for superior capsule reconstruction in a biomechanical model.

Methods

Using 8 scapulae and humeri Sawbones models, the standard superior capsule reconstruction was performed using 8 HD allografts. Four grafts were tested in the native state, whereas 4 were tested using reinforcement. Allografts were reinforced using suture tape in a running 360° fashion around the allograft borders, maintaining 5 mm of space from the edges. Allografts were measured pre- and postdynamic testing for length, width, and thickness. All specimens were affixed to a materials testing machine that allowed for allograft orientation in a longitudinal plane throughout testing. Specimens were preloaded to 10 N and then cyclically loaded to 100 N at a rate of 15 mm/s for 30 cycles.

Results

After dynamic, cyclic loading, suture tape-reinforced allografts experienced a significantly smaller percent change in anterior length (6.36% vs 14.50%, P = .013), posterior length (6.00% vs 13.68%, P = .002), medial width (5.80% vs 21.05%, P = .001), lateral width (5.45% vs 19.29%, P < .001), medial thickness (4.38% vs 17.93%, P = .005), central thickness (7.03% vs 16.11%, P = .026), and lateral thickness (4.55% vs 20.80%, P < .001). Linear stiffness values obtained for suture tape -reinforced allografts were significantly greater than those for native allografts when measured at cycles 1 (21.18 ± 1.03 N/mm vs 17.69 ± 1.91 N/mm, P = .02), 15 (29.90 ± 1.45 vs 24.93 ± 2.79, P = .03), and 30 (32.13 ± 1.98 N/mm vs 25.72 ± 3.01 N/mm, P = .01) of dynamic testing.

Conclusions

The suture tape-reinforcement technique described decreased HD allograft elongation, maintained graft thickness, and improved linear stiffness values following uniplanar cyclic loading in a biomechanical Sawbones model.

Clinical relevance

Suture tape reinforcement of the HD allograft could serve as one strategy to overcome the issue of allograft elongation with time following superior capsule reconstruction.

Editorial Commentary: Shoulder Superior Capsule Reconstruction: Should We Suture Leftover Dermal Allograft to the Inferior Acromion?

Superior capsular reconstruction remains a controversial procedure, and long-term results still need to be established. Graft thickness seems crucial and fascia lata appears superior to dermal allograft. Using a subacromial spacer by suturing dermal allograft to the subacromial bone "increases graft thickness" and reduces superior humeral head migration but increases subacromial pressures in a static laboratory cadaver model. It remains to be seen whether clinical studies support this concept.

Superior Capsule Reconstruction With Subacromial Allograft Spacer: Biomechanical Cadaveric Study of Subacromial Contact Pressure and Superior Humeral Head Translation

PURPOSE

To investigate the biomechanical effects of superior capsule reconstruction with subacromial allograft spacer on superior humeral head translation and subacromial contact pressure.

METHODS

Eight cadaveric shoulder specimens were tested in 4 conditions: (1) intact rotator cuff, (2) supraspinatus tear and superior capsule excision, (3) superior capsule reconstruction with human dermal allograft, and (4) superior capsule reconstruction with subacromial resurfacing using human dermal allograft. In each condition, specimens were tested at 0, 30, 60, and 90° of shoulder abduction in balanced and unbalanced loaded states for subacromial contact pressure and superior humeral head translation. Statistical comparisons were made using a repeated-measures analysis of variance test, followed by a Tukey post hoc test for pairwise comparisons. A P value <.05 was set as statistically significant.

RESULTS

Superior humeral head translation and subacromial contact pressure were increased after irreparable rotator cuff tear (P = .001). There was no significant difference between superior capsule reconstruction and intact cuff in regard to superior humeral head translation and subacromial contact pressure at all abduction angles. Superior capsule reconstruction with subacromial resurfacing decreased superior humeral head translation relative to intact (0°, P = .004; 30°, P = .02; 60°, P = .08; 90°, P = .01), superior capsule reconstruction (0°, P = .001; 30°, P = .003; 60°, P = .019; 90°, P = .001), and cuff-deficient states (P = .001). Superior capsule reconstruction with subacromial resurfacing resulted in nonsignificant increases in subacromial contact pressure relative to intact cuff at 0 to 90° abduction angles.

CONCLUSIONS

Superior capsule reconstruction with subacromial resurfacing using human dermal allograft results in decreased superior humeral head translation relative to superior capsule reconstruction with human dermal allograft only, while increasing subacromial contact pressure.

CLINICAL RELEVANCE

Superior capsule reconstruction with subacromial resurfacing using human dermal allograft reduces superior humeral head translation while increasing subacromial contact pressure in a cadaveric model.

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.

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.