Reconstrucción de la cápsula superior en las roturas irreparables del manguito mediante injerto autógeno de isquiotibiales

Revascularization character of autologous fascia lata graft following shoulder superior capsule reconstruction by enhanced magnetic resonance imaging

Background

Fascia lata has been used for arthroscopic superior capsule reconstruction (ASCR) and verified to achieve a good clinical outcome. However, it is still not known about revascularization character of the fascia lata after ASCR. This study was performed to evaluate the revascularization of autologous fascia lata grafts after ASCR by enhanced magnetic resonance imaging (MRI).

Methods

A prospective study of 19 patients with irreparable rotator cuff tears underwent ASCR with autologous fascia lata grafts from September 2019 to April 2021. Radiography examinations and clinical evaluations were performed preoperatively and postoperatively at 6 weeks and 3, 6, and 12 months. The signal-to-noise quotient (SNQ) value and enhancement index (EI) of autologous fascia lata grafts in the great tubercle insertion (GTI), midpoint of the graft (MG), and glenoid insertion (GI) were compared for radiography examination. Clinical evaluation included the American Shoulder and Elbow Surgeons (ASES) score, University of California Los Angeles (UCLA) shoulder score, and Visual Analog Scale (VAS) score.

Results

The SNQ values in T1WI enhancement at GI and GTI were significantly higher than those at the plain MRI scan at all postoperative observation timepoints; however, the SNQ values in T1WI enhancement at MG did not show a significant difference until 3 months postoperation. EI values at GTI and GI were significantly higher than those at MG at 6 weeks and 3 months postoperation, while there was no significant difference in the EI value between GTI and GI. At 6 months postoperation, the EI value at GI was significantly higher than those at MG. At 12 months postoperation, the EI value at GI was significantly higher than those at MG and GTI; however, there was no significant difference between GTI and MG. The EI values at GTI and MG peaked at 3 months and 6 months postoperation, respectively, and then plateaued at 12 months postoperation. However, there was no significant difference in the EI value among the different postoperative timepoints at GI. The EI value did not correlate with the VAS and ASES, UCLA scores at any time point or any postoperative observation location.

Conclusion

Revascularization of the fascia lata was dependent on the location of the fascia lata and plateaus at 12 months postoperation. The EI value did not correlate with the VAS and ASES, UCLA scores during12 months postoperation.

Arthroscopic superior capsule reconstruction using semitendinosus tendon autograft for irreparable rotator cuff tears: Preliminary results

Background

To examine prospectively the functional and structural results of arthroscopic superior capsule reconstruction using semitendinosus tendon autograft for irreparable superior rotator cuff tears.

Methods

5 patients (40.8 months average follow-up) were evaluated clinical preoperatively and at the end of the follow-up. Magnetic resonance imaging (MRI) was used preoperatively and at 12 months.

Results

The mean ASES and the Constant scores increased from 56.2 to 92 and 46.8 to 82.8. The MRI showed continuity of the ligamentoplasty.

Conclusions

Given the small number of cases, few conclusions can be drawn. Nonetheless, the results regarding this technique may be considered promising.

Level of evidence

Level IV; Case series; Treatment Study.

[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.

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.

Arthroscopic Superior Capsular Reconstruction for Older Patients With Irreparable Rotator Cuff Tears: A Comparative Study With Younger Patients

BACKGROUND

Arthroscopic superior capsular reconstruction (ASCR) is a method for treating irreparable chronic rotator cuff tears. However, the extent to which ASCR can be performed with regard to the patient's age has yet to be determined.

PURPOSE

To compare the surgical outcomes of ASCR for the treatment of irreparable rotator cuff tears (IRCTs) in patients aged <65 years versus patients aged ≥65 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Of 105 patients with IRCTs who underwent ASCR between March 2013 and June 2020, 73 patients were enrolled in this study based on the selection criteria. Polypropylene mesh augmentation to the graft was used in 18 of 36 patients in the younger adults group (age, <65 years) and 20 of 37 patients in the older adults group (age, ≥65 years). The clinical and radiological outcomes were evaluated preoperatively and at the final clinical follow-up. The graft integrity status was evaluated using serial magnetic resonance imaging and set as the primary endpoint. Furthermore, subgroup analysis was performed based on age group and graft type.

RESULTS

The mean age of the patients was 59.2 ± 3.8 years in the younger adults group and 70.5 ± 4.1 years in the older adults group. Both groups showed improvement based on the clinical and radiological outcomes at the final follow-up. The mean American Shoulder and Elbow Surgeons scores improved from 52.3 ± 15.4 to 77.3 ± 13.5 in the younger adults group (P < .001) and from 45.7 ± 16.1 to 76.6 ± 11.4 in the older adults group (P < .001). The mean visual analog scale for pain scores improved from 5.5 ± 1.2 to 2.1 ± 0.9 in the younger adults group (P < .001) and from 5.5 ± 1.4 to 2.1 ± 1.2 in the older adults group (P < .001). The graft healing rate was significantly higher in the younger adults group (81%) than in the older adults group (65%) (P = .049). Subgroup analysis showed that after mesh augmentation, the healing rate in the younger adults group (84%) was similar to that in the older adults group (85%) (P = .299).

CONCLUSION

ASCR resulted in a favorable surgical outcome for both younger and older adult patients with IRCT. The younger patients had lower graft failure rates and superior surgical outcomes. In older patients, ASCR using polypropylene mesh augmentation may reduce graft failure and result in surgical outcomes similar to those in younger patients.

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.

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.

Failure Rate After Superior Capsular Reconstruction With Achilles Tendon-Bone Allograft for Irreparable Rotator Cuff Tears

Background

Superior capsular reconstruction (SCR) is an alternative to reverse shoulder arthroplasty for irreparable rotator cuff tears (IRCTs). The reconstructed capsule acts as a static restraint to prevent superior migration of the humeral head. Traditional SCR uses a fascia lata autograft, which has shown failure at the greater tuberosity. An Achilles tendon-bone allograft has been proposed to improve the failure rate.

Purpose

To evaluate the surgical outcomes of SCR using an Achilles tendon-bone allograft for the treatment of IRCTs.

Study Design

Case series; Level of evidence, 4.

Methods

We retrospectively evaluated 6 patients with massive IRCTs who underwent SCR using an Achilles tendon-bone allograft between January 2017 and January 2018. Clinical outcomes were assessed using range of motion, the American Shoulder and Elbow Surgeons score, and the visual analog scale for pain. The acromiohumeral distance and the status of graft integrity were evaluated using serial magnetic resonance imaging. Second-look arthroscopy surgery was performed to evaluate graft integrity at the mean of 7.5 months postoperative.

Results

The mean ± SD clinical follow-up period was 14.5 months (range, 12-17 months). The American Shoulder and Elbow Surgeons and visual analog scale scores improved from 42.8 ± 11.9 and 4.0 ± 1.2 to 62.1 ± 14.7 and 2.8 ± 1.4, respectively. Forward flexion and external rotation improved from 98° ± 36° and 58° ± 4° to 123° ± 20° and 39° ± 8°, respectively. The acromiohumeral distance improved from 3.9 ± 0.8 mm to 6.4 ± 2.2 mm at final follow-up. However, second-look arthroscopy at a mean of 7.6 months postoperatively confirmed a graft failure rate of 83.3%.

Conclusion

SCR using an Achilles tendon-bone allograft for the treatment of IRCTs had a high graft failure rate among patients in this case series.

[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.

Arthroscopic superior capsular reconstruction of the shoulder: a narrative review

Irreparable rotator cuff tears (IRCTs) in young and considerably active patients are difficult to treat because it is mostly associated with poor outcome which may lead to a painful and dysfunctional shoulder. Most of the IRCTs are encountered in massive size rotator cuff tears which associated with high failure rate following surgical repair. Thus, the IRCTs was considered challenging for its poor healing rate following repair which may induce the arthritic changes. Since the advent of arthroscopic superior capsular reconstruction (ASCR) of the shoulder in 2013, it has gained its popularity. The procedure has become the most popular option for joint-preserving shoulder surgery for patients with IRCTs. It works by providing a static restraint to the superior humeral head migration to optimize the rotator cuff force couples, hence improving joint kinematics. The acceptance of superior capsular reconstruction has made it rapidly evolving in terms of a wider variety of procedures and broader surgical indications. Despite the enthusiasm and widely acceptance towards the procedure, there are still many queries that exist regarding the best indications, surgical technique particularly graft of choice, the long-term outcome, and the complication and risk of the superior capsular reconstruction (SCR). This narrative review provide the current evidence of SCR in an attempt to provide a state-of-the-art knowledge.

Clinical Outcomes of Superior Capsular Reconstruction for Massive, Irreparable Rotator Cuff Tears: A Systematic Review Comparing Acellular Dermal Allograft and Autograft Fascia Lata

Purpose

To investigate clinical outcomes after superior capsular reconstruction (SCR) for the treatment of massive and/or irreparable rotator cuff tears treated with either allograft or autograft.

Methods

Using the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines, in April 2020 a systematic review was performed using PubMed, MEDLINE, EMBASE, and Cochrane databases. Clinical studies were assessed for patient-reported outcomes and range of motion, comparing dermal allografts to fascia lata autografts, with a minimum follow-up of 12 months.

Results

A total of 16 clinical studies involving 598 patients (606 shoulders) were included for data analysis, with a weighted mean follow-up of 36.9 months (range 12 to 60). Visual analogue scale (VAS) pain scores decreased from 4.0 to 6.9 mm preoperatively to 0 to 2.5 mm postoperatively. American Shoulder & Elbow Surgeons score increased from 20.3 to 54.5 preoperatively to 73.7 to 97.0 postoperatively. Forward flexion increased from 27.0° to 142.7° preoperatively to 134.5° to 167.0° postoperatively. External rotation increased from 13.2° to 41.0° preoperatively to 30.0° to 59.0° postoperatively. Acromiohumeral distance increased from 3.4 to 7.1 mm preoperatively to 6.0 to 9.7 mm postoperatively. The total rates of complications, graft failure, and revision surgery were 5.6%, 13.9%, and 6.9%, respectively.

Conclusions

Irrespective of tissue source, SCR serves as a reasonable joint-preserving option for massive, irreparable rotator cuff tears, with favorable short- to midterm improvements in patient-reported outcomes and range of motion.

Level of Evidence

IV, systematic review of level III and IV studies.

Arthroscopic Superior Capsular Reconstruction With Mesh Augmentation for the Treatment of Irreparable Rotator Cuff Tears: A Comparative Study of Surgical Outcomes

BACKGROUND

Arthroscopic superior capsular reconstruction (ASCR) is an alternative to open surgery for irreparable chronic rotator cuff tears (RCTs). This approach can provide static restraint while avoiding upward migration of the humeral head. However, graft tears and their effect on clinical outcomes after ASCR remain a debated topic.

PURPOSE

To evaluate the clinical outcomes of ASCR with mesh augmentation for the treatment of irreparable RCTs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The data of 72 patients with irreparable RCTs who underwent ASCR between 2013 and 2018 were retrospectively evaluated. Among them, 64 patients who met the inclusion and exclusion criteria were enrolled in this study. Fascia lata grafts augmented with a polypropylene mesh were used for 30 patients (mesh group), and grafts without mesh augmentation were used for 34 patients (control group). Clinical outcomes were evaluated using range of motion, the American Shoulder and Elbow Surgeons (ASES) questionnaire, and visual analog scale for pain. Radiological outcomes were evaluated according to acromiohumeral distance and stage of rotator cuff arthropathy. The status of fatty infiltration and graft integrity was evaluated using magnetic resonance imaging. Outcomes were assessed preoperatively and at the final follow-up.

RESULTS

Both groups showed improvement in clinical and radiological outcomes at the final follow-up. The mesh group demonstrated a larger improvement in ASES score (mean ± SD, 29.1 ± 15.8) than the control group (18.1 ± 15.9) (P = .006). The mean improvement in active forward flexion was significantly higher in mesh group (40°± 26°) than in control group (28°± 23°) (P = .003). The mean improvement in active external rotation was also significantly higher in the mesh group (11°± 5°) than in the control group (6°± 3°) (P = .004). Graft healing rate was significantly higher in the mesh group (83.3%) than in the control group (58.8%) (P = .039), and acromiohumeral distance was significantly greater in the mesh group (9.1 ± 2.4 mm) than in the control group (6.3 ± 1.8 mm) at the final follow-up (P = .001). Subgroup analysis revealed that patients with graft failure generally showed progression of fatty infiltration without improvement in the stage of rotator cuff arthropathy. Patients with intact grafts demonstrated a more substantial improvement in functional outcomes (ASES score and forward flexion motion).

CONCLUSION

ASCR with mesh augmentation reduced graft failure rate to restore superior shoulder joint stability.

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.

Comparison Between Autografts and Allografts in Superior Capsular Reconstruction: A Systematic Review of Outcomes

BACKGROUND

The treatment of irreparable rotator cuff tears (IRCTs) is a significant challenge, and various treatment options have emerged. Superior capsular reconstruction (SCR) is a promising procedure for patients with IRCTs.

PURPOSE

To investigate the clinical outcomes of SCR and compare allografts with autografts.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A search for relevant articles was carried out using the PubMed, Cochrane Library, Embase, Scopus, and Google Scholar databases. We used medical subject heading (MeSH) terms and natural keywords (superior AND (capsule OR capsular) AND reconstruction). Also, we filtered for high-quality articles using the Methodological Index for Non-Randomized Studies (MINORS). We summarized the characteristic data and commonly used outcome measures of each included study and performed a descriptive analysis using an evidence-based tendency concept as proposed by Huisstede et al (2013).

RESULTS

A total of 10 articles (374 shoulders) with a mean follow-up of 27.2 months were selected and analyzed. There were 4 articles on SCR with an autograft, 4 on SCR with an allograft, and 2 on SCR with both an autograft and allograft. For autografts and allografts, respectively, the mean gain in forward elevation (FE) was 48.7° and 33.3°, the visual analog scale for pain score improved by 3.5 and 3.3, the American Shoulder and Elbow Surgeons (ASES) score increased by 47.3 and 31.9, and the acromiohumeral distance increased by 1.2 and 1.8 mm. In addition, the number of graft tears was 16 (10.0%) and 17 (12.9%), the number of other complications was 12 (7.5%) and 6 (3.9%), and the number of reoperations was 5 (3.1%) and 14 (8.2%) for autografts and allografts, respectively.

CONCLUSION

Both autografts and allografts improved clinical outcomes. Although the graft tear rate appeared similar between the autograft and allograft groups, the autograft group had no cases of conversion to reverse total shoulder arthroplasty. In addition, we found 3 evidence-based tendencies: (1) a tendency for both autografts and allografts to have significantly improved FE and clinical scores, (2) a tendency that autografts improved internal rotation and allografts improved abduction, and (3) a weak tendency that autografts improved abduction and allografts improved internal and external rotation. Although it was not possible to compare the groups statistically, the differences in ASES scores might be clinically important and will need to be explored in future comparative studies.