Arthroscopic Superior Capsular Reconstruction: Indications and Outcomes

Does arthroscopic superior capsule reconstruction using porcine dermal xenograft represent a viable option in case of massive irreparable posterosuperior rotator cuff tear?

INTRODUCTION

The aim of the present study was to evaluate clinical and structural outcomes of patients with a massive irreparable rotator cuff tear treated with arthroscopic superior capsule reconstruction using an acellular porcine dermal xenograft. We hypothesized that this procedure would lead to improvement in clinical and functional results and that structural failure would not influence the final clinical results.

MATERIALS AND METHODS

A retrospective analysis on arthroscopic superior capsule reconstruction performed from October 2016 to January 2019 was conducted. The procedure was performed in patients with a massive irreparable posterosuperior rotator cuff tear without a severe glenohumeral arthropathy (Hamada I and II) and complaining a painful pseudoparalysis. Clinical evaluation and MRI study were performed before surgery and after at least 14 months.

RESULTS

A comprehensive group of 21 patients with 11 females and 10 males and a mean age of 57 ± 8.5 years underwent arthroscopic superior capsule reconstruction. The graft had a thickness of 1.5 mm in the first 9 cases (43%) since it was used in a single layer. The graft was thereafter doubled for technique evolution in the following 12 cases (57%) achieving a graft thickness of 3 mm. Active ROM significantly improved with a mean increase of active forward flexion from 72.8° ± 7.5° to 120.6° ± 4.5°, active abduction from 68.3° ± 10.2° to 140.2° ± 8.8° and external rotation from 38.2° ± 11.2° to 56.7° ± 6.8° at the last follow-up. The mean Constant score significantly improved from 40.4 ± 6.7 to 73.3 ± 8.2. A graft tear revealed in 52% (11/21) of overall patients was significantly more frequent in single layer graft when compared to double layer (77% vs 33%, p < 0.05). Location and type of graft tear significantly influenced final outcomes. Patients with a healed (graft continuity with bone at medial and lateral insertion) or medial graft tear showed statistically significant better outcomes when compared with patients in which the graft was completely reabsorbed or torn on humeral side (p < 0.05).

CONCLUSION

Arthroscopic superior capsule reconstruction using an acellular porcine dermal xenograft may be a viable alternative to treat massive posterosuperior rotator cuff tear in patients with a painful pseudoparalysis without anterosuperior escape. Structural failure may strongly influence final outcomes with significant role played by tear location.

A Biomechanical Analysis of Shoulder Muscle Excursions During Abduction, After the Treatment of Massive Irreparable Rotator Cuff Tears Using Superior Capsular Reconstruction (SCR), Bursal Acromial Reconstruction (BAR), and SCR with BAR

Introduction

Current understanding of the biomechanical effects of treatment options for irreparable rotator cuff (RC) tears is lacking. This study examines how shoulder muscle lengths and excursions are affected by superior capsular reconstruction (SCR), bursal acromial reconstruction (BAR), and SCR with BAR, following a complete supraspinatus tear.

Method

Six fresh-frozen cadaveric shoulders were examined. Deltoid and RC muscle lengths were measured at 0, 30, 45, 60, and 90° of shoulder abduction under six conditions: (1) intact, (2) partially torn supraspinatus, (3) completely torn supraspinatus, (4) SCR, (5) SCR with BAR, and (6) BAR. Muscle excursions from 0–90° of abduction were then calculated.

Results

Subscapularis muscle lengths after SCR, BAR, and SCR with BAR were significantly greater (post-hoc Tukey HSD test; p < .01) compared to the other conditions. Supraspinatus, infraspinatus, teres minor, and deltoid lengths were not significantly different (ANOVA test; p > .01) between the conditions. All muscle excursions remained statistically similar between the conditions (ANOVA test; p > .01).

Conclusion

These findings demonstrate that the use of SCR, BAR, or SCR with BAR for a complete supraspinatus tear, may increase subscapularis muscle length while maintaining other shoulder muscle lengths. An increase in subscapularis length can allow for more effective subscapularis muscle strengthening and increased compensatory function in the long term. Additionally, all shoulder muscle excursions are preserved after partial or complete supraspinatus tears and after SCR, BAR, or SCR with BAR. Therefore, these surgical treatments can initially normalize shoulder muscle function during 0–90° of abduction, after an irreparable supraspinatus tear.

Clinical outcomes and temporal changes in the range of motion following superior capsular reconstruction for irreparable rotator cuff tears: comparison based on the Hamada classification, presence or absence of shoulder pseudoparalysis, and status of the subscapularis tendon

BACKGROUND

Superior capsular reconstruction (SCR) has recently gained popularity as a surgical solution for patients with massive rotator cuff tears or shoulder pseudoparalysis (PPS). Good clinical outcomes have been reported after SCR; however, the factors that influence its clinical outcomes remain unclear. Therefore, in this study, we aimed to clarify the factors influencing postoperative outcomes after SCR using tensor fascia lata graft, for which we evaluated the Hamada grade, patients with or without PPS, and the status of the subscapularis tendon (SSC).

METHODS

In total, 54 consecutive patients with irreparable rotator cuff tears or PPS who underwent SCR between June 2014 and October 2018 were included. The enrolled patients were grouped and compared as follows: (1) Hamada grade 2 (11 patients) and Hamada grade 3 (43 patients) and (2) non-PPS (22 patients), moderate PPS (16 patients), and severe PPS (16 patients). For subanalysis, the 32 PPS patients were divided into 3 groups: intact SSC (11 patients), repairable SSC (16 patients), and irreparable SSC (5 patients). To assess shoulder function, the American Shoulder and Elbow Surgeons (ASES) score was evaluated before surgery and at 24 months postoperatively; shoulder range of motion was evaluated at 2, 3, 4, 5, 6, 8, 10, 12, and 24 months postoperatively.

RESULTS

No significant differences in postoperative ASES scores and shoulder range of motion were observed between the Hamada grade 2 and grade 3 groups or between the non-PPS, moderate PPS, and severe PPS groups. However, significant differences in postoperative shoulder elevation and ASES scores were observed between the intact SSC and irreparable SSC groups (P = .006) and between the repairable SSC and irreparable SSC groups (P = .003).

CONCLUSIONS

This study demonstrated that the status of the SSC, rather than the Hamada grade or the presence or absence of PPS, influences the clinical outcomes after SCR. Therefore, reparability or intactness of the SSC is an important factor in considering the surgical indication for SCR.

Clinical effectiveness of mini-open superior capsular reconstruction using autologous tensor fascia lata graft

BACKGROUND

When one is performing superior capsular reconstruction (SCR), graft thickness is an important factor for achieving sufficient glenohumeral stability. However, when a graft of sufficient length and thickness is prepared and inserted into the subacromial space, it is often challenging to secure the field of view arthroscopically. To solve this problem, we devised a mini-open SCR technique. This study aimed to compare the clinical effectiveness of this technique with that of arthroscopic SCR.

METHODS

This retrospective cohort study included 46 consecutive patients with Hamada classification grade 2-3b who were treated between June 2014 and February 2018 with SCR performed by a single surgeon for irreparable rotator cuff tears (grade 3 or higher according to the Goutallier classification) using autologous tensor fascia lata. We evaluated the duration of the operation, length of the skin incision of the lateral portal used to insert the graft, graft size (length, width, and thickness), American Shoulder and Elbow Surgeons score, range of motion, and graft retear rate.

RESULTS

This study included 46 patients who underwent arthroscopic SCR (n = 20) or mini-open SCR (n = 26). The mean follow-up period was 36.5 months (range, 24-66 months). The operative duration was significantly longer in the arthroscopic SCR group than in the mini-open SCR group (175 ± 48 minutes vs. 133 ± 25 minutes, P < .001); however, no significant difference was noted in the length of the skin incision (2.4 ± 0.2 cm vs. 2.5 ± 0.1 cm) and graft size. At the final follow-up, no significant differences were observed in American Shoulder and Elbow Surgeons scores, all ranges of motion (flexion, P = .60; abduction, P = .60; external rotation, P = .20; and internal rotation, P = .54), and graft retear rates (5% [1 case] vs. 3.8% [1 case], P > .999).

CONCLUSIONS

Good clinical outcomes were obtained in both the arthroscopic and mini-open SCR groups. The surgical stress experienced by the patients who underwent mini-open SCR was similar to that experienced by those who underwent the arthroscopic technique, as no significant difference was noted in the length of the skin incision. This study shows that mini-open SCR, which contributes to reductions in operative duration and difficulty associated with the surgical technique, is an effective and alternative method to arthroscopic 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.