Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears: A Systematic Review

Mid-term Outcome of Superior Capsular Reconstruction Using Fascia Lata Autograft (At Least 6 mm in Thickness) Results in High Retear Rate and No Improvement in Muscle Strength

PURPOSE

(1) To report and evaluate clinical and radiologic outcomes of superior capsular reconstruction (SCR) using fascia lata autograft in patients with irreparable rotator cuff tears (IRCTs) over a mid-term duration and (2) to assess the overall survival rate of the graft.

METHODS

We retrospectively reviewed patients who underwent SCR with fascia lata autograft between June 2017 and August 2018. The graft, folded 3 or 4 times, achieved a minimum thickness of 6 mm during the surgical procedure. The inclusion criteria encompassed patients with isolated supraspinatus IRCTs or posterosuperior IRCTs exhibiting poor muscle quality (Goutallier grade ≥3) and without arthritis (Hamada grade ≤ 2). The exclusion criteria included lack of follow-up data or magnetic resonance imaging. Clinical assessments included the visual analog scale score, Constant score, and American Shoulder and Elbow Surgeons (ASES) score; active range of motion; and strength. Radiographic analysis included the acromiohumeral distance, Hamada grade, and graft integrity at final follow-up. A Kaplan-Meier curve was generated to depict SCR graft survivorship.

RESULTS

In total, 45 patients (mean age, 64.8 ± 5.7 years) were included, and the average follow-up duration was 63.2 ± 5.9 months (range, 50-79 months). There was significant improvement in pain (visual analog scale score of 4.4 ± 1.3 preoperatively vs 1.4 ± 0.4 at final follow-up, P < .001). Yet, 18 patients (40.0%) and 17 patients (37.7%) achieved the minimal clinically important difference in the ASES score and Constant score, respectively. Active forward elevation increased from 119° ± 23° to 137° ± 23° (P < .001), and external rotation at the side improved from 29° ± 11° to 36° ± 12° (P = .002). However, strength did not exhibit improvement in any direction. The acromiohumeral distance decreased from 8.5 ± 1.7 mm to 6.5 ± 1.9 mm (P < .001), and the Hamada grade increased from 1.1 ± 0.3 to 1.8 ± 1.1 (P < .001). Finally, the infection rate was 13.3% (n = 6).

CONCLUSIONS

Despite a substantial graft retear rate of 62.2%, SCR led to a significant improvement in pain. Nonetheless, 18 patients (40.0%) and 17 patients (37.7%) achieved the minimal clinically important difference in the ASES score and Constant score, respectively. Forward elevation and external rotation at the side showed significant improvement, but no improvement in muscle strength was observed. Finally, significant arthritis progression was observed.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Radiologic and clinical outcomes of an arthroscopic bridging graft for irreparable rotator cuff tears with a modified MasonAllen stitch using a plantaris tendon autograft: a case series with minimum 2-year outcomes

BACKGROUND

Surgical management of a massive rotator cuff tear (RCT) is always challenging. This study describes the clinical and radiological outcomes of patients who underwent bridging grafts using a plantaris tendon for an irreparable RCT.

METHODS

Thirteen patients with a massive RCT were treated with arthroscopic interposition of a folded plantaris tendon autograft between June 2017 and January 2020. For clinical evaluation, a visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, Constant-Murley score, and range of motion values were collected. For radiographic evaluation, standardized magnetic resonance imaging and ultrasonography were performed to check the integrity of the interposed tendon.

RESULTS

A statistically significant improvement at the final follow-up was evident in scores for the VAS (-3.0, P=0.003), ASES (24.9, P=0.002), D ASH (-20.6, P=0.001), and Constant-Murley values (14.2, P=0.010). In addition, significant improvement was shown in postoperative flexion (17.3°, P=0.026) and external rotation (27.7°, P<0.001). In postoperative radiologic evaluations, the interposed tendons were intact at the last examination in 12 of the 13 patients. No complications related to donor sites were reported.

CONCLUSIONS

An arthroscopic bridging graft for irreparable RCTs using a modified Mason-Allen stitch and a plantaris autograft resulted in improved short-term radiological and clinical outcomes. Graft integrity was maintained for up to 2 years in most patients. Level of evidence: IV.

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.

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

Background

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

Purpose

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

Study Design

Cohort study; Level of evidence, 3.

Methods

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

Results

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

Conclusion

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level IV, therapeutic case series.

Outcomes of reverse shoulder arthroplasty following failed superior capsular reconstruction

BACKGROUND

Superior capsular reconstruction (SCR) can be used for massive irreparable rotator cuff tears in the absence of significant degenerative changes; however, those who fail an SCR may require reverse shoulder arthroplasty (RSA). The effect of a previously performed SCR on outcomes following RSA remains unknown.

METHODS

Subjects who underwent RSA from May 2015 to January 2021 at 2 separate institutions were retrospectively identified through prospectively collected databases. Patients who underwent RSA after failed SCR were matched to those who underwent RSA after failed rotator cuff repair (RCR) based on the number of previous ipsilateral shoulder procedures (n = 1, 2, ≥3) and secondarily by age within 5 years. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain, and Western Ontario Osteoarthritis of the Shoulder index (WOOS) scores were compared between groups. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) thresholds were calculated to determine clinically relevant differences between groups.

RESULTS

Forty-five patients were included (32 RSA following RCR, 13 following SCR). There were more smokers (P = .001) and worker's compensation cases (P = .034) in the SCR group. The RCR cohort was older (P = .007) and had a greater incidence of mental health (P > .999) and somatic disorders (P = .698), although these did not reach statistical significance. The mean follow-up for the RCR and SCR groups were 24.2 ± 23.3 and 20.4 ± 14.9 months following RSA, respectively (P = .913). The time from index RCR or SCR to RSA were 94.4 ± 22.2 and 89.2 ± 5.3 months, respectively (P = .003). Pre- and postoperative range of motion were similar between groups, as was the overall change in forward flexion (P = .879), abduction (P = .971), and external rotation (P = .968) following RSA. The RCR group had lower postoperative VAS pain (P = .009), higher SANE (P = .015), higher ASES (P = .008), and higher WOOS (P = .018) scores. The percentage achieving the MCID (P = .676) and SCB (P > .999) were similar; however, 56.7% of the RCR group met the SANE PASS threshold compared with 0.0% in the SCR group (P = .005). There were no differences in postoperative complications (P = .698) or revision rates (P = .308) following RSA between cohorts.

CONCLUSION

When matched for number of previous procedures to the ipsilateral extremity and age, patients who underwent RSA following failed SCR had worse clinical outcome scores than their RSA following failed RCR counterparts. No patient in the SCR group met the SANE PASS threshold, whereas more than half of the RCR group did.

Does subscapularis integrity influence outcome following latissimus dorsi tendon transfer for irreparable cuff tears? A comparative series of 48 patients

Background

Latissimus dorsi tendon transfer (LDTT) remains a surgical option for massive irreparable rotator cuff tears. Despite a lack of comparative studies, subscapularis insufficiency has been reported as a contraindication. This study investigated the clinical outcome at a minimum 2-years post-surgery, in patients undergoing LDTT with varied subscapularis integrity.

Methods

This retrospective study included 48 patients, of which 22 underwent LDTT with an intact subscapularis (age 56.9 years, review time 79.6 months, males 68.2%) and 26 with partial (16 patients) or full-thickness (10 patients) subscapularis tearing (age 57.4 years, review time 73.3 months, males 73.1%) between 2004 and 2018. Pre-operative imaging ascertained subscapularis status. Outcomes included the Upper Extremity Functional Index (UEFI), Global Rating of Change (GRC) and patient satisfaction.

Results

No significant group differences were observed in age (p = 0.617) or review time (p = 0.555), nor the UEFI (intact 69.6, not intact 67.0, p = 0.265) or GRC (intact 3.6, not intact 2.9, p = 0.265). High levels of patient satisfaction were observed in both groups for pain relief, improving the ability to undertake daily and recreational activities, and overall satisfaction (intact 95.5-100.0%, not intact 92.3-96.2%).

Conclusion

LDTT resulted in encouraging clinical scores and high satisfaction levels, irrespective of the degree of untreated, underlying subscapularis integrity.

Level of evidence

Therapeutic Level III.

Superior Capsule Reconstruction Is a Viable Option for Patients with Symptomatic, Isolated, and Irreparable Supraspinatus Tears

Purpose

Methods

Results

Conclusions

Level of Evidence

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.

The Biomechanical and Histological Processes of Rerouting Biceps to Treat Chronic Irreparable Rotator Cuff Tears in a Rabbit Model

BACKGROUND

Recently, the biceps was rerouted into a newly fabricated bicipital groove for in situ superior capsular reconstruction (SCR), resulting in promising time-zero cadaveric and clinical outcomes. However, no studies have determined the in vivo biomechanical and histological processes after the biceps is transposed to a nonanatomic position.

PURPOSE

To explore the in vivo biomechanical and histological processes of the rerouting biceps tendon to treat chronic irreparable rotator cuff tears (IRCTs) in a rabbit model.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 94 skeletally mature male rabbits were used to create a chronic IRCT model in the supraspinatus tendon. Then, the biceps rerouting procedures were performed in rabbits with chronic IRCT. Eighteen rabbits were sacrificed at 1, 3, 6, 9, and 12 weeks postoperatively for biomechanical testing, micro-computed tomography scanning, and histological analysis. The biomechanical and histological changes of intra- and extra-articular portions of the rerouting biceps were evaluated at each time point, with the contralateral native superior capsule (NSC) and the native biceps (NB) as controls, respectively. The morphology and bone formation of the fabricated bicipital grooves were evaluated, with native grooves as controls.

RESULTS

The intra-articular rerouting biceps tendon was progressively remodeled over time, displaying denser fibers and more mature collagen than those of the NSC, with gradual improvements in the tendon-to-bone healing interface from 6 to 12 weeks. Consequently, the failure load and stiffness of the intra-articular rerouting biceps portion increased with time and were significantly higher than those of the NSC from 9 weeks. Similarly, the extra-articular portion of the rerouting biceps progressively healed into a new bicipital groove, as demonstrated by a smaller tendon-to-bone interface from 6 to 12 weeks, resulting in greater failure load and stiffness at 9 and 12 weeks than those of the NB attachment. The newly fabricated bicipital groove showed similar morphology to that of the native groove with sufficient trabecular bone formed underneath.

CONCLUSION

The rerouting biceps could progressively remodel and heal into the newly fabricated bicipital groove over time, resulting in greater biomechanical performances in intra- and extra-articular portions than the NSC and the NB attachment.

CLINICAL RELEVANCE

The biceps rerouting technique may be a feasible procedure to perform in situ SCR to treat IRCT in the future clinical practice; however, more clinical evidence is required.

Classification system of graft tears following superior capsule reconstruction

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Complications of Superior Capsule Reconstruction for the Treatment of Functionally Irreparable Rotator Cuff Tears: A Systematic Review

PURPOSE

The purpose of this systematic review is to characterize the complications associated with superior capsule reconstruction (SCR) for the treatment of functionally irreparable rotator cuff tears (FIRCTs).

METHODS

This systematic review was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Two independent reviewers completed a search of PubMed, Embase, and Medline databases. Studies were deemed eligible for inclusion if they reported postoperative outcomes of arthroscopic SCR for FIRCTs and considered at least 1 postoperative complication. Statistical heterogeneity was quantified via the I² statistic. Due to marked heterogeneity, pooled proportions were not reported. All complications and patient-reported outcomes were described qualitatively.

RESULTS

Fourteen studies met the inclusion/exclusion criteria. The overall complication rate post-SCR ranged from 5.0% to 70.0% (I² = 84.9%). Image-verified graft retear ranged from 8% to 70%, I² = 79.4%), with higher rates reported when SCR was performed using allograft (19%-70%, I² 76.6%) compared to autograft (8%-29%, I² = 66.1%). Reoperation (0%-36%, I² = 73.4%), revision surgeries (0%-21%, I² = 81.2%), medical complications (0%-5%, I² = 0.0%), and infections (0%-5%, I² = 0.0%) were also calculated.

CONCLUSIONS

SCR carries a distinct complication profile when used for the treatment of FIRCTs. The overall rate of complications ranged from 5.0% to 70.0%. The most common complication is graft retear with higher ranges in allografts (19%-70%) compared to autografts (8%-29%). The majority of studies reported at least 1 reoperation (range, 0%-36%), most commonly for revision to reverse shoulder arthroplasty.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV or better investigations.

A new approach to superior capsular reconstruction with hamstring allograft for irreparable posterosuperior rotator cuff tears: a dynamic biomechanical evaluation

BACKGROUND

Superior capsular reconstruction (SCR) treatment of massive, symptomatic, irreparable rotator cuff tears (RCTs) has become a more recently used procedure. However, there is a lack of consensus surrounding optimal graft choice for the SCR technique, and current dermal grafts have increased cost and are technically challenging because of a need for multiple implants. The purpose of this study was to biomechanically investigate a biological lower-cost alternative as a support for the superior capsule reconstruction concept: an isolated semitendinosus tendon (STT) allograft and a combination graft with the long head of the biceps tendon (LHBT) in an established massive posterosuperior RCT cadaver model.

METHODS

Ten fresh-frozen cadaveric shoulders (53.3 ± 12.4 years: range: 26-65) were tested on an established dynamic shoulder simulator using dynamic muscle loading. Cumulative deltoid forces, maximum abduction angle, and superior humeral head translation were compared across 4 testing conditions: (1) intact state, (2) massively retracted (Patte III), irreparable posterosuperior RCT, (3) SCR repair using an STT allograft, and (4) SCR repair using a combined STT-LHBT repair.

RESULTS

Intact shoulders required a mean deltoid force of 154.2 ± 20.41 N to achieve maximum glenohumeral abduction (55.3° ± 2.3°). Compared with native shoulders, the maximum abduction angle decreased following a massively retracted posterosuperior RCT by 52% (28.3° ± 8.4°; P < .001), whereas the cumulative deltoid forces increased by 48% (205.3 ± 40.9 N; P = .001). The STT repair and the STT-LHBT repair improved shoulder function compared with the tear state, with a mean maximum abduction angle of 30.6° ± 9.0° and 31.8° ± 7.7° and a mean deltoid force of 205.3 ± 40.9 N and 201.0 ± 34.0 N, respectively, but this was not statistically significant (P > .05). The STT-LHBT repair significantly improved the range of motion with respect to the tear state (P = .04).

CONCLUSIONS

In a dynamic shoulder simulator model, both the STT and the STT-LHBT repair techniques improved glenohumeral joint kinematics in an amount similar to previously reported "traditional" SCR techniques for treatment of an irreparable posterosuperior RCT.

Arthroscopic Superior Capsule Reconstruction Using Three-Dimensional Preoperative Planning: Technique Description

We describe a technique using a fascia lata autograft with 3-dimensional (3D) printing to reconstruct the rotator cuff. Prototyping constitutes the construction of physical prototypes with high complexity after virtual studies. Such models increase the knowledge of the characteristics and size of rotator cuff injuries, thus improving the accuracy of determining the correct size of the graft to be used in superior capsule reconstruction. We present a case of superior capsule reconstruction using 3D printing for enhancing the accuracy of fascia lata allograft size and tension determination; 3D reconstruction has never been described in the literature for rotator cuff injuries.

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.

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.

Surface modification of the simvastatin factor-loaded silk fibroin promotes the healing of rotator cuff injury through β-catenin signaling

Rupture of the rotator cuff is a common injury of the shoulder joint in sports professionals. In addition, research on repair of the rotator cuff has gained popularity over the recent years. Given the high rate of re-tear after surgery, it is necessary to design and prepare biodegradable materials with good mechanical properties, for the management of the condition. Consequently, the present study conducted surface modification of the simvastatin factor-loaded silk fibroin for the repair of chronic rotator cuff injury in SD rats. The in vitro experiments were analyzed through scanning electron microscopy and the water contact angle. Additionally, the CCK-8 assay was used to observe the effect of the intervention on the proliferation of BMSCs. Moreover, the osteogenic differentiation of BMSCs was detected through the ALP and ARS assays while the expression of osteogenic genes was examined using qRT-PCR and Western blot analysis. Furthermore, a model for repairing chronic rotator cuff tears in SD rats was established in vivo. Thereafter, rotator cuff repair and healing were evaluated through HE staining while Masson and Sirius staining was used to detect the collagen formation ratio. Additionally, the study analyzed the mechanism underlying the effect of simvastatin-loaded silk fibroin. The results showed that the simvastatin-loaded silk fibroin membrane had better biocompatibility and the in vitro experiments confirmed that it could promote the proliferation and osteogenic differentiation of BMSCs. In addition, the in vivo HE staining experiments similarly confirmed that it could enhance tendon bone healing and alleviate inflammation in chronic rotator cuff injuries. On the other hand, Masson and Sirius staining showed that the simvastatin-loaded silk fibroin could promote the formation of collagen. Further analysis also revealed that it could promote the osteogenic differentiation of BMSCs by activating the β-catenin signaling pathway. In general, these findings suggested that surface modification of the simvastatin factor-loaded silk fibroin was a potential means of improving the healing of rotator cuff injuries and can be implemented in clinical practice in future.

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

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

Rooting Rotator Cuff Reconstruction for Irreparable Posterior-Superior Rotator Cuff Tear

Irreparable posterior-superior rotator cuff tear is encountered quite often in clinical practice. Bridging the tendon defect with various materials is reasonable. However, optimal bridging structures and techniques are still being pursued. We introduce a rotator cuff bridging technique, rooting rotator cuff reconstruction. In this technique, autogenous tendon is used to make grafts. On the medial side, the graft tendons are suspended on the rotator cuff tendon. On the lateral side, the graft tendons are placed into tunnels through the tuberosities. The most critical steps of this technique are properly fabricating the humeral tunnels and suspending the graft tendons onto the rotator cuff tendon. We believe this technique will shed light on rotator cuff reconstruction.

Comparison of Different Fixation Techniques of the Long Head of the Biceps Tendon in Superior Capsule Reconstruction for Irreparable Posterosuperior Rotator Cuff Tears: A Dynamic Biomechanical Evaluation

BACKGROUND

In the past decade, superior capsular reconstruction has emerged as a potential surgical approach in young patients with irreparable posterosuperior rotator cuff tears (RCT) and absence of severe degenerative changes. Recently, the use of locally available and biological viable autografts, such as the long head of the biceps tendon (LHBT) for SCR has emerged, with promising early results.

PURPOSE/HYPOTHESIS

The purpose of this study was to investigate the effect of using the LHBT for reconstruction of the superior capsule on shoulder kinematics, along with different fixation constructs in a dynamic biomechanical model. The authors hypothesized that each of the 3 proposed fixation techniques would restore native joint kinematics, including glenohumeral superior translation (ghST), maximum abduction angle (MAA), maximum cumulative deltoid force (cDF), and subacromial peak contact pressure (sCP).

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight fresh-frozen cadaveric shoulders (mean age, 53.4 ± 14.2 years) were tested using a dynamic shoulder simulator. Each specimen underwent the following 5 conditions: (1) intact, (2) irreparable posterosuperior rotator cuff tear (psRCT), (3) V-shaped LHBT reconstruction, (4) box-shaped LHBT reconstruction, and (5) single-stranded LHBT reconstruction. MAA, ghST, cDF and sCP were assessed in each tested condition.

RESULTS

Each of the 3 LHBT techniques for reconstruction of the superior capsule significantly increased MAA while significantly decreasing ghST and cDF compared with the psRCT (P < .001 and P < .001, respectively). Additionally, the V-shaped and box-shaped techniques significantly decreased sCP (P = .009 and P = .016, respectively) compared with the psRCT. The V-shaped technique further showed a significantly increased MAA (P < .001, respectively) and decreased cDF (P = .042 and P = .039, respectively) when compared with the box-shaped and single-stranded techniques, as well as a significantly decreased ghST (P = .027) when compared with the box-shaped technique.

CONCLUSION

In a dynamic biomechanical cadaveric model, using the LHBT for reconstruction of the superior capsule improved shoulder function by preventing superior humeral migration, decreasing deltoid forces and sCP. As such, the development of rotator cuff tear arthropathy in patients with irreparable psRCTs could potentially be delayed.

CLINICAL RELEVANCE

Using a biologically viable and locally available LHBT autograft is a cost-effective, potentially time-saving, and technically feasible alternative for reconstruction of the superior capsule, which may result in favorable outcomes in irreparable psRCTs. Moreover, each of the 3 techniques restored native shoulder biomechanics, which may help improve shoulder function by preventing superior humeral head migration and the development of rotator cuff tear arthropathy in young patients with irreparable rotator cuff tears.

Arthroscopic Middle Trapezius Transfer for Treatment of Irreparable Superior Rotator Cuff Tendon Tears

Irreparable supraspinatus tendon tears are challenging to treat, especially in a young and high-demanding patient population. Whereas interposition tendon grafting and partial repair are limited by the quality of the remaining rotator cuff tendons and muscles, superior capsular reconstruction and subacromial spacers do not provide the active biomechanical principle of a contracting supraspinatus. The purpose of this technical note is to introduce an arthroscopic middle trapezius transfer below the acromion to replace the former supraspinatus unit. This technique might combine the benefits of both the static concepts seen with subacromial spacers or superior capsular reconstruction and dynamic concepts such as interposition grafting and partial repairs.

Superior Capsule Reconstruction: A Glimpse into the Future?

The recent study by Mihata et al., [10] "Five-year follow-up of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears" (J Bone Joint Surg Am. 2019;101:1921-1930), was the first case series published examining long-term clinical and radiographic outcomes of superior capsule reconstruction (SCR) for irreparable rotator cuff tears. This article is a critical review of how the aforementioned study fits into a growing literature surrounding the use of SCR for irreparable rotator cuff tears and how these results may impact clinical and operative decision-making for this patient population. The series compares clinical and radiographic data taken pre-operatively with data taken at 1 year and 5 years post-operatively in a group of 30 patients who underwent SCR utilizing tensor fascia lata autograft. While the results of the study suggest that a healed SCR graft utilizing this specific technique successfully restored shoulder function and prevented progression of rotator cuff arthropathy, it is important to appreciate the limitations of this small, retrospective case series. Nonetheless, the study represents an important addition to the expanding literature surrounding this significant topic. In this report, we shed light on the current state of this novel operative technique and the ongoing controversies revolving around graft material and thickness.

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

Background:

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

Purpose/Hypothesis:

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

Study Design:

Controlled laboratory study.

Methods:

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

Results:

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

Conclusion:

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

Clinical Relevance:

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

"Strings" (Multiple Tendon Interposition Autografts) for Reconstruction of Presumably Irreparable Rotator Cuff Tears

Irreparable rotator cuff tears are challenging to treat. Especially in younger patients without concomitant osteoarthritic changes, joint-preserving procedures are warranted. To date, no treatment guideline exists because none of the available techniques has shown superiority over the others, and long-term survivorship data are missing. The aim of the "Strings" is to provide an arthroscopic solution to anatomically reconstruct presumably irreparable rotator cuff tears by bridging the gap with multiple string-like tendon interposition autografts.

The results of using a tendon autograft as a new rotator cable for patients with a massive rotator cuff tear: a technical note and comparative outcome analysis

BACKGROUND

Several surgical reconstructive options are available to treat massive rotator cuff tears (MRCTs). The rotator cable has an important function and we evaluated the clinical result after arthroscopic reconstruction of the rotator cable with an autograft tendon.

METHODS

A prospective pilot study was performed with inclusion of four patients, average age of 64 years, with an irreparable MRCT. The patients underwent an arthroscopic reconstruction of the rotator cable with the use of the long head of biceps tendon autograft, except for one which was reconstructed with a hamstring tendon. Pre- and postsurgically, the Constant-Murley Score (CMS), Western Ontario Rotator Cuff Index (WORC), Simple Shoulder Test (SST), visual analog scale (VAS) scores, and an MRI was performed. Clinical results of the study group were compared with clinical results of comparable cohort of patients with a MRCT, treated non-operatively with physiotherapy.

RESULTS

The CMS score increased after surgery in three of the four patients. The improvement of CMS score was comparable to the improvement of the CMS score encountered in a comparable cohort. The MRI at 12 months follow-up showed that the reconstructed rotator cable was disintegrated in all patients and the rotator cuff was detached and retracted.

CONCLUSIONS

In our pilot study, arthroscopic reconstruction of the rotator cable using a tendon autograft failed over time and showed no clinical benefit in comparison to the non-operative treatment with physiotherapy.

TRIAL REGISTRATION

The regional Medical Ethical Committee (Zwolle) gave approval at 14th of October 2016 and assigned no. 16.06100.

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

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