Superior Capsular Reconstruction Using Acellular Dermal Allograft Combined With Remaining Rotator Cuff Augmentation Improved Shoulder Pain and Function at 1 Year After The Surgery

Improved Acromiohumeral Distance Independently Predicts Better Outcomes After Arthroscopic Superior Capsular Reconstruction Graft Tears

PURPOSE

To identify independent factors responsible for poor outcomes after a graft tear after arthroscopic superior capsular reconstruction (ASCR).

METHODS

Patients who underwent ASCR for massive rotator cuff tears between January 2013 and July 2021were reviewed. On the basis of the achievement of the minimal clinically important differences for clinical outcome measures at the final follow-up, patients were divided into the good outcome (GO) and poor outcome (PO) groups. The minimal clinically important differences were calculated as the value equal to one-half of the standard deviation of the changes in outcome scores between the preoperative baseline and the latest follow-up. Pre- and final follow-up variables included demographics, American Shoulder and Elbow Surgeons score, Constant score, visual analog scale score, and range of motion. Preoperative and postoperative 1-year radiologic variables were analyzed using magnetic resonance imaging, including anteroposterior and mediolateral tear sizes, subscapularis tear, acromiohumeral distance (AHD), and degree of fatty degeneration. Logistic regression analysis was performed to identify the significant predictors of poor outcomes.

RESULTS

A total of 33 patients who underwent ASCR presented with graft tears, which were confirmed by postoperative 1-year magnetic resonance imaging, and had a minimum follow-up duration of 2 years after surgery were enrolled. The GO group demonstrated significantly greater improvements in functional outcomes compared with the PO group (American Shoulder and Elbow Surgeons score: 83.5 ± 11.8 vs 64.0 ± 20.4, P = 0.004; Constant: 67.6 ± 5.7 vs 57.1 ± 9.8, P < .001; and visual analog scale score: 0.9 ± 1.2 vs 2.4 ± 2.0, P = .026). The postoperative 1-year AHD showed significant improvement in the GO group (3.1 ± 1.2 vs 6.1 ± 1.4, P < .001) but no change in the PO group (3.4 ± 1.3 vs 4.2 ± 0.9, P = .074) postoperatively. Multivariate logistic regression analysis indicated that a decreased postoperative 1-year AHD (odds ratio, 0.145; P = .019) was associated with a poor outcome after a graft tear.

CONCLUSIONS

A narrow postoperative 1-year AHD was identified as the most important independent risk factor indicating poor clinical outcomes after a graft tear post-ASCR, which was related to a larger tear and loss of integrity between the grafts and infraspinatus at 1-year postoperatively.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Combined cuff repair and superior capsular reconstruction reinforcement in patients with massive rotator cuff (re)tears: a minimum 2-year clinical and radiological follow-up

BACKGROUND

Due to the ageing population, the number of symptomatic degenerative rotator cuff tears has increased substantially, and some are challenging to repair due to poor tendon quality with significant retraction. In order to optimize repair integrity and function, rotator cuff repair reinforcement with a superior capsule reconstruction has been proposed. This study presents the results of a technique combining cuff repair and capsular reconstruction (CRACR) using acellular dermal allograft in patients with massive rotator cuff tears and retears.

METHODS

From December 2017 to July 2019, 50 consecutive patients with previous failed rotator cuff repairs or primary surgery on poor tendon quality defined as massive rotator cuff tear (full thickness rotator cuff tears with 2 or more tendons involved), were treated with the CRACR technique and enrolled prospectively. Contraindications for the CRACR procedure were Hamada stage ≥3 cuff tear arthropathy and patient's preference for reverse total shoulder arthroplasty. Patients were reviewed at 3, 6, 12, and 24 months (American Shoulder and Elbow Surgeons scores, Constant Murley Scores, Visual Analogue Scores, Oxford Shoulder Score, QuickDASH). Postoperative magnetic resonance imaging scans were requested at 6 weeks, 3 months, 6 months, 12 months, and 24 months postoperatively, to assess repair integrity.

RESULTS

Mean age at surgery was 58.0 years (SD 8.1, range 41-79). Of the 50 patients, 14 patients (28.0%) had previous failed rotator cuff repair. From the 36 primary cases, 28 (77.8%) had massive rotator cuff tears and one (2.8%) a perioperative irreparable tear, while 28 (77.8%) patients had a subscapularis tear. At 2 years of follow-up all scores improved significantly (Visual Analogue Scores 6.3 to 1.5; American Shoulder and Elbow Surgeons 34.0 to 79.0; Constant Murley Scores 30.9 to 68.0; OSS 23.3 to 40.1; QuickDASH 56.2 to 20.3; all P < .001). Magnetic resonance imaging scans were conducted at a mean of 14.4 months (SD 7.0, range 3-26) after surgery showing 6 isolated superior capsular reconstruction failures and 5 isolated rotator cuff retears.

CONCLUSION

In the short term, the CRACR technique is a valid option for patients with massive rotator cuff tears and retears with a high chance of a postoperative retear due to poor tendon quality. Clinical results and repair integrity are promising. Longer term follow-up is ongoing to establish the efficacy of this procedure.

The Relationship Between Achieving the Minimal Clinically Important Difference and Patient-Reported Satisfaction After Arthroscopic Superior Capsular Reconstruction With a Fascia Lata Autograft for Irreparable Massive Rotator Cuff Tears

Background

Surgeons used the minimal clinically important difference (MCID) to interrogate outcomes-using patient-reported outcomes-to determine whether a patient can achieve clinical benefit after orthopaedic surgery. However, it is proposed to be crucial to separate the idea of meeting a clinically established threshold of patient-reported outcome measures (PROMs), which could truly predict patient-reported satisfaction with that outcome.

Purpose

To investigate the association between achieving MCID and patient-reported satisfaction after arthroscopic superior capsular reconstruction with fascia lata autografts for irreparable massive rotator cuff tears.

Study Design

Case-control study; Level of evidence, 3.

Methods

A total of 62 patients with ≥2-year follow-up and receiving questionnaires were included. PROMs were collected pre- and postoperatively, including pain visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES), and Single Assessment Numeric Evaluation (SANE) scores. MCIDs were determined using the sensitivity- and specificity-based approaches. Patient-reported satisfaction was evaluated with the following question: "Are you satisfied with your superior capsular reconstruction surgery (yes/no)?" The association between achieving MCID and patient-reported satisfaction was evaluated.

Results

All 3 scores had acceptable area under the curve values (>0.7) for MCID. The MCID values were 4.5, 14.5, and 25.0 for the VAS, ASES, and SANE scores, respectively. Patients achieving MCID for PROMs had significantly greater improvement levels in the other clinical outcome scores than their counterparts (P < .05), except for the VAS score that demonstrated no difference between patients achieving and not achieving the MCID for SANE score (P = .07). Achieving MCID for PROMs was associated with a significantly higher proportion of patients feeling satisfied with the outcomes than the group failing to achieve the MCID (all P < .05). However, the percentages of patients who failed to achieve MCID for pain VAS, ASES, and SANE scores reported satisfaction with their results at 63.3%, 54.5%, and 59.1%, respectively.

Conclusion

Achieving MCID thresholds on the VAS, ASES, and SANE scores were predictive of patient-reported satisfaction after arthroscopic superior capsular reconstruction 2 years postoperatively. However, half of the patients who failed to achieve MCID were still satisfied, regardless of clinical outcome improvements. Surgeons may need to be careful when consulting patients about expected outcomes, and patients need to set reasonable expectations based on their preoperative condition.

Efficacy of reverse shoulder arthroplasty compared with superior capsular reconstruction in patients with posterosuperior irreparable rotator cuff tears without arthritis: a propensity score matching study

INTRODUCTION

Superior capsular reconstruction (SCR) and reverse shoulder arthroplasty (RSA) are viable treatment options for active patients with posterosuperior irreparable rotator cuff tears (PSIRCTs). In this study, we aimed to compare the clinical outcomes and recovery of muscle strength following RSA and SCR in PSIRCTs patients without arthritis.

MATERIAL AND METHODS

Fifteen patients were included in the RSA and SCR groups using propensity score matching, which was performed to minimize selection bias among the surgical treatments, RSA or SCR. Clinical outcomes were evaluated based on the degree of pain and patient-reported clinical scores. Functional outcomes were assessed with active range of motion of the shoulder and muscle strength. Radiological outcomes were assessed with acromiohumeral distance and Hamada grade.

RESULTS

Both groups showed significant improvement in postoperative clinical and functional outcomes; there was no significant difference between the groups. However, mean improvement in the Constant score, American Shoulder and Elbow Surgeons (ASES) score, University of California Los Angeles (UCLA) score, forward elevation, and abduction was significantly better in the RSA group. Moreover, the achievement of MCID for ASES score and UCLA score was significantly better in the RSA group (p = 0.001 and 0.009, respectively). Although the muscle strength was improved following SCR or RSA, it was not statistically significant. In the SCR group, five patients (30%) showed postoperative progression of arthritic change, and seven patients (46.7%) had graft re-tear.

CONCLUSIONS

Our findings suggest that RSA provides greater improvements in functional outcomes and a higher likelihood of achieving MCID compared to SCR in patients with PSIRCTs without arthritis. However, given the small sample size, the potential for indication bias, and the high variability in patient selection criteria, these results should be interpreted with caution.

LEVEL OF EVIDENCE

III.

Early failure of superior capsule reconstruction with human dermal allograft (Epiflex) in patients with massive rotator cuff tears: a clinical and radiological analysis

BACKGROUND

Massive rotator cuff tears (MRCT) are one of the major challenges in reconstructive shoulder surgery and the therapeutic concepts are still controversial. Using conventional reconstruction techniques rotator cuff re-tear rates still occur up to 52%-94% according to the recent literature. Therefore, superior capsule reconstruction (SCR) using acellular human dermal allografts (AHDG) are currently a frequently applied alternative treatment option for MRCT. Although the functional outcome improves, there is some discrepancy in survival time of the graft. The purpose of this study was to evaluate the structural graft integrity by magnetic resonance imaging (MRI) scans and the functional status of the shoulder early after surgery.

MATERIALS AND METHODS

Twenty-nine patients with conventionally irreparable MRCT were treated with an arthroscopic SCR utilized an AHDG (Epiflex, DIZG). Pre- and postoperative MRIs were used to evaluate the rotator cuff and graft configuration. The mean MRI follow-up was 9.8 ± 3.9 (6-21) weeks. The functional status was recorded regarding the Constant Score (CS) and active range of motion. General complications were noted. The clinical follow-up (FU) was 9.4 ± 2.9 (6-17) weeks and 1 year postoperatively at 42.5 ± 5.7 (36-58) weeks.

RESULTS

The presence of a total graft failure rate of 59% type 3 according to Mirzayan after SCR with AHDG did not negatively influence the functional outcome during the observation period. There was the main effect of time on all directions of range of motion and all categories of the CS-Score (pain: P < .001, activity: P = .01 and motion: P = .04) except for CS-force value (P = .28) at the first FU and the improvement remained constant until the last FU. There were no significant differences in clinical outcome between the group with graft failure and the group with intact graft at the first and last FU.

CONCLUSIONS

The SCR with AHDG in MRCT shows high rate of structural graft failures in early postoperative MRI. However, this does not correlate with the functional outcome in early and mid-term FU. Further studies focusing to elucidate the underlying complex process of in vivo AHDG regeneration and recent developments of biological graft healing and surgery techniques may improve the structural integrity of the SCR construct.

Rate of graft retear is higher in over-the-top superior capsular reconstruction for massive posterosuperior rotator cuff tears with subscapularis tear

PURPOSE

To compare side-to-side superior capsular reconstruction (SCR) with over-the-top SCR in terms of functional outcomes, pain relief and allograft survival rates.

METHODS

Patients who had undergone arthroscopic dermal allograft SCR for massive irreparable rotator cuff tears and clinical follow-up for ≥2 years were recruited. All patients underwent postoperative assessment with routine radiographic analysis for acromiohumeral distances, ultrasound imaging 1 and 3 months after SCR and magnetic resonance imaging (MRI) at least 12 months after SCR. The outcome measures were visual analogue scale (VAS), American Shoulder and Elbow Surgeons (ASES), Constant and Single Assessment Numeric Evaluation (SANE) scores.

RESULTS

SCR was performed in 56 patients including side-to-side SCR in 32 and over-the-top SCR in 24. Postoperative MRI showed that the grafts were intact in 46 patients (82.1%; 26 who underwent side-to-side SCR and 20 who underwent over-the-top SCR). The proportion of nonhealing grafts in the over-the-top group was significantly higher with concomitant subscapularis tears (60% vs. 5.3%; p = 0.02). VAS scores and functional outcomes improved postoperatively in both groups and postoperative VAS (1.4 vs. 1.7; n.s.), Constant (74.8 vs. 76.0; n.s.), mean ASES (87.4 vs. 89.1; n.s.) and mean SANE (81.7 vs. 84.3; n.s.) scores did not differ significantly.

CONCLUSION

For massive rotator cuff tears, over-the-top and side-to-side SCR achieve similar pain relief and functional improvement, and the rate of healing allografts is high. However, over-the-top SCR is not recommended for massive posterosuperior rotator cuff tears with repairable subscapularis tendon tears due to a higher nonhealing rate.

LEVEL OF EVIDENCE

Level III.

Arthroscopic Partial Repair of Large to Massive Rotator Cuff Tears Shows Clinical Outcomes and Survivorship at Minimum 10-Year Follow-Up Comparable to Those of Arthroscopic Complete Repair

PURPOSE

To compare the survival rate (revision surgery) and clinical and radiologic outcomes of arthroscopic partial versus complete repair for large to massive rotator cuff tears over a minimum 10-year follow-up period.

METHODS

We conducted a retrospective analysis of patients who underwent arthroscopic partial or complete repair of large to massive rotator cuff tears between 2008 and 2013, with minimum 10-year follow-up. Functional outcomes were measured using the visual analog scale pain score, Subjective Shoulder Value, American Shoulder and Elbow Surgeons score, University of California, Los Angeles shoulder score, and passive range of motion preoperatively and at the last follow-up. Failure was defined as the need for revision surgery (reverse shoulder arthroplasty) owing to significant pain and functional loss. Radiographic assessments included radiography (preoperatively and at the latest follow-up) and magnetic resonance arthrography (preoperatively and at 6 months postoperatively). The groups were compared regarding subjective and objective outcomes.

RESULTS

The study included 90 participants, 34 in the partial repair group (group P) and 56 in the complete repair group (group C). At the latest follow-up, no significant differences in clinical scores were found and the percentage of participants exceeding the minimal clinically important difference was comparable in both groups for all variables. Groups P and C showed forward flexion of 133° ± 7° and 136° ± 10°, respectively (P = .319); external rotation of 41° ± 5° and 42° ± 6°, respectively (P = .465); and internal rotation of 11 ± 1 and 11 ± 2, respectively (P = .284). Despite differences in retear size at 6 months (P < .001) and acromiohumeral distance at the latest follow-up (4.5 ± 1.1 mm in group P vs 5.8 ± 0.7 mm in group C), the survival rates at 10 years were similar: 77% (n = 8) in group P and 84% (n = 11) in group C (P = .674).

CONCLUSIONS

Although radiologic outcomes were inferior in the partial repair group, both groups had comparable survival rates and clinical outcomes over the 10-year follow-up period.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Patients With Graft Tears Leaving the Tuberosity Covered Have Similar Functional Outcomes to Those With an Intact Graft After Superior Capsular Reconstruction

BACKGROUND

Studies to date of superior capsular reconstruction (SCR) comparing outcomes of healed grafts versus torn grafts do not separate graft tears based on location of the tear, rather they combine and report all tears as a single group.

PURPOSE/HYPOTHESIS

The purpose of this study was to correlate functional outcome with graft integrity and graft tear location after SCR with a dermal allograft. It was hypothesized that the functional outcomes of patients with an intact graft would be equivalent to those with graft tears leaving the tuberosity covered.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent SCR with an acellular dermal allograft at a single institution were included. Pre- and postoperative American Shoulder and Elbow Surgeons (ASES), Oxford Shoulder Score, visual analog scale (VAS) for pain, and postoperative Single Assessment Numeric Evaluation (SANE) scores were recorded. A magnetic resonance imaging scan was performed postoperatively to assess graft integrity.

RESULTS

A total of 39 patients met inclusion criteria. Mean age of patients was 60.4 ± 8.7 years; mean follow-up was 53.3 ± 25 months (range, 14-98 months). Magnetic resonance imaging performed at a mean of 17.5 months (range, 6-66 months) demonstrated an intact graft in 14 (36%); tear from the glenoid in 11 (28%), from midsubstance in 4 (10%), and from the tuberosity in 8 (21%); and complete graft absence in 2 (5%). Patients were divided into group 1 (intact graft), group 2 (tuberosity covered: tears from glenoid and midsubstance tears), and group 3 (tuberosity bare: tears from the tuberosity and dissolved or absent grafts). In group 1, there was significant improvement in ASES (37.9 to 88.5; P < .001), Oxford (25.2 to 46.2; P < .001), and VAS (6.8 to 0.9; P < .001). In group 2, there was significant improvement in ASES (32.2 to 86.1; P < .001), Oxford (23.4 to 44.2; P < .001), and VAS (7.3 to 1.3; P < .001). In group 3, there was no significant improvement in ASES (40.3 to 45.8; P = .50) or Oxford (33.5 to 31.4; P = .81), but there was a significant reduction in VAS (7.1 to 5.4; P = .03). There was no significant difference between group 1 and 2 in postoperative ASES (88.5 vs 86.1; P = .59), Oxford (46.2 vs 44.2; P = .07), VAS (0.9 vs 1.3, P = .42) and SANE (85.4 vs 83.2; P = .92) scores. However, group 3 had significantly lower ASES (45.8; P < .001), lower Oxford (31.4; P < .001), lower SANE (45.4; P < .001), and higher VAS (5.4; P < .001) scores than groups 1 and 2. There were no differences in outcomes based on sex (P = .72), previous surgery (P = .06), preoperative acromiohumeral distance (P = .57), and preoperative Goutallier stage of the supraspinatus (P = .16).

CONCLUSION

Patients who underwent SCR with a dermal allograft and developed a graft tear leaving the tuberosity covered had equivalent functional outcomes to those with an intact graft.

Effect of Medial or Lateral Graft Failure on Graft Volume and Clinical Outcomes After Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears

BACKGROUND

Graft failure is a common complication after superior capsule reconstruction (SCR). The graft in SCR is fixed on the greater tuberosity and superior glenoid, and graft failure has been reported on both sides.

PURPOSE

To evaluate the clinical manifestations of patients with graft failure after SCR and identify the clinical and radiological differences between medial and lateral graft failure.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent SCR with a dermal allograft for symptomatic irreparable rotator cuff tears between March 2018 and September 2021 were retrospectively reviewed. All patients had minimum 2-year follow-up and underwent magnetic resonance imaging at 6 months postoperatively. Patients with graft failure were divided into 2 groups: those with lateral graft failure on the greater tuberosity side (group I) and those with medial graft failure on the glenoid side (group II). Patients with intact grafts were included in group III as a control group. Intergroup differences in clinical and radiological characteristics were analyzed, and multiple regression analysis was performed.

RESULTS

Among the 93 patients included, there were 18 patients in group I, 15 in group II, and 60 in group III. Overall, 11 patients (61.1%) in group I and 9 patients (60.0%) in group II had a partial graft rupture at one anchor. The postoperative graft volume was significantly lower in group I than in groups II and III (2514.0 ± 564.3 mm3, 3183.5 ± 547.1 mm3, and 3198.0 ± 584.8 mm3, respectively; P = .002 for group I vs II; P < .001 for group I vs III). The acromiohumeral distance (AHD) was significantly increased at 6 months postoperatively compared with before surgery in group I (6.6 ± 1.6 mm vs 4.3 ± 1.9 mm, respectively; P < .001) and group II (7.4 ± 1.3 mm vs 5.7 ± 1.7 mm, respectively; P = .002). However, group I exhibited a significantly greater decrease in the AHD over time than group II (P < .001) and a significantly lower AHD at the final follow-up than the other groups (P < .001). The postoperative American Shoulder and Elbow Surgeons score was significantly lower in group I than in the other groups (P < .001). On multiple regression analysis, fatty infiltration of the infraspinatus muscle, Hamada grade, and graft width were independent factors for lateral graft failure.

CONCLUSION

Patients with lateral graft failure had inferior clinical outcomes and lower postoperative graft volumes than those with medial graft failure after SCR using a dermal allograft. The AHD of patients with lateral graft failure improved postoperatively; however, it deteriorated over time.

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

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 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.

Clinical and radiological outcomes between superior capsule reconstruction using allografts or xenografts: a 2-year retrospective comparison study

BACKGROUND

Treating symptomatic, massive, irreparable rotator cuff tears remains challenging and controversial. Superior capsule reconstruction (SCR) using the tensor fascia lata has shown promising clinical results; however, due to donor site morbidity, interest in SCR using other grafts has increased. Yet, no studies have compared allografts with xenografts. In addition, the clinical results of graft tears remain controversial. This study compared the clinical and radiological outcomes of SCR between those with allografts and xenografts.

METHODS

Sixty-seven patients who had undergone SCR with allografts or xenografts between January 2016 and December 2020 were included in this retrospective study. Furthermore, 62 patients were evaluated 2 years postsurgery, with five patients excluded due to loss to follow-up or conversion to reverse shoulder arthroplasty. The Constant, American Shoulder and Elbow Surgeons, and visual analog scale scores, range of motion, and radiological outcomes were evaluated before the surgery and at 6 and 24 months after surgery.

RESULTS

The graft tear rate was 23.08% in the allograft group and 42.86% in the xenograft group at 6 months after surgery; at 2 years postsurgery, the gap further widened to 32.43% and 64%, respectively, showing a significant difference. The graft in the allograft group was thicker than that in the xenograft group, and there were significant differences on the humeral side and in the midsubstance area. The allograft group showed significantly better visual analog scale, Constant, and American Shoulder and Elbow Surgeons scores than the xenograft group 2 years postsurgery. However, the difference in clinical outcomes between the two groups did not surpass minimal clinically important differences.

CONCLUSION

Although arthroscopic SCR using xenografts had significantly lower clinical outcome than allografts, this difference did not reach minimal clinically important differences. Arthroscopic SCR using xenografts showed higher graft tear rates than allografts. Even with partial tears, better results were obtained if the graft continuity was maintained. Additionally, after surgery, the xenograft showed less thickness than the allograft and resulted in more tears, specifically in the midsubstance area.

Superior capsular reconstruction for irreparable posterosuperior rotator cuff tears

Although the superior portion of the shoulder joint capsule is a clearly distinct structure, its ability to prevent vertical humeral head translation in irreparable rotator cuff tears remains controversial. The clinical results of superior capsule reconstruction (SCR) in this context are satisfactory but the radiological outcomes are poor in up to two-thirds of patients. Moreover, there is no proof that SCR is more beneficial than simply doing a subacromial debridement, a partial repair or a tenotomy of the long head of biceps. Furthermore, graft healing is not predictive of success. Given the lack of comparative studies with high level of evidence (level 1 or 2), we cannot conclude that this surgical technique (and its many variants) has a place in our treatment paradigm. Also, it seems that xenografts are no longer being used given the high rate of structural failure seen on MRI and the large number of complications. If the long head of biceps tendon is still intact at the time of surgery, it is a feasible option for SCR given the reasonable cost and minimal complications. If it is not - but the subscapularis tendon is intact or repairable - an allograft or a non-local autograft should be considered, despite its unpredictable clinical results. Surgeons should inform patients of the high rate of radiological repair failure and the worse results if a reverse shoulder arthroplasty should be needed subsequently. Level of evidence: 4.

Postoperative Graft Volume Reduction Is Associated With Inferior Clinical Outcomes of Superior Capsule Reconstruction Using an Acellular Dermal Matrix Allograft

PURPOSE

To evaluate whether postoperative graft volume reduction is associated with clinical outcomes after superior capsule reconstruction (SCR) and to identify factors related to graft volume change.

METHODS

Between May 2018 and June 2021, patients who underwent SCR with acellular dermal matrix allograft for irreparable rotator cuff tear with a minimum 1-year follow-up and who had intact graft continuity in postoperative 6-month magnetic resonance imaging were retrospectively reviewed. The lateral half to the medial half of the graft volume ratio was defined as lateral half graft volume ratio. The difference between the preoperative and postoperative lateral half graft volume ratio was defined as lateral half graft volume change. Patients were divided into 2 groups: those with preserved graft volume (group I) and those with reduced graft volume (group II). Intergroup differences in clinical and radiological characteristics were analyzed.

RESULTS

A total of 81 patients were included, with 47 (58.0%) in group I and 34 (42.0%) in group II. Group I showed significantly lower lateral half graft volume change (0.018 ± 0.064 vs 0.370 ± 0.177; P < .001) than group II. Group II showed significantly greater preoperative Hamada grade (1.3 ± 0.5 vs 2.2 ± 0.6, P < .001), an anteroposterior distance of the graft at the greater tuberosity (APGT) (30.3 ± 4.8 vs 35.2 ± 3.8, P < .001), and fatty infiltration of infraspinatus (2.3 ± 0.9 vs 3.1 ± 0.8, P < .001) and subscapularis (0.9 ± 0.9 vs 1.6 ± 1.3, P = .009) than group I. Group II had a significantly lower proportion of patients achieving MIC in Constant score than group I (70.2% vs 47.1%, P = .035). The Hamada grade, APGT, and fatty infiltration of infraspinatus and subscapularis were independent factors of graft volume change.

CONCLUSIONS

Although SCR improved pain and shoulder function, postoperative graft volume reduction was related to a lower rate of minimal important change achievement in the Constant score compared with preserved graft volume. The preoperative Hamada grade, APGT, and fatty infiltration of infraspinatus and subscapularis were associated with graft volume reduction.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

When and how much does the muscle strength recover after arthroscopic superior capsular reconstruction?

BACKGROUND

Recently, arthroscopic superior capsular reconstruction (SCR) has been performed for irreparable large to massive rotator cuff tears and excellent clinical results have been reported. Although the muscle strength is reported to recover, it has not yet been clarified when and how much it recovers. The purpose of this study was to determine the recovery pattern of muscle strength after SCR.

METHODS

We retrospectively reviewed 35 patients (mean age, 65 years) who met the following inclusion criteria: (1) patients with large to massive irreparable tears of the rotator cuff including the supraspinatus and infraspinatus tendons; (2) those with severe muscle atrophy and fatty change; (3) those who underwent assessment of muscle quality and strength by magnetic resonance imaging and dynamometry at 6 months, 1 year, and 2 years; (4) those with a minimum follow-up period of 2 years; and (5) those without severe osteoarthritis. The isometric muscle strength of scaption (ie, scapular-plane elevation), internal rotation, and external rotation in adduction was measured twice for each motion by a dynamometer.

RESULTS

Relative to the muscle strength on the uninvolved side, the involved side showed 61% ± 21% in scaption, 63% ± 20% in external rotation, and 103% ± 29% in internal rotation at 2 years after surgery. Whereas no significant differences were observed between the 1-year and 2-year follow-up assessments, a significant difference in muscle strength of scaption was found between 6 months and 1 year (P = .0174). Graft retear was seen in 5 cases (14%). There was a trend that the muscle strength of scaption and external rotation in the no-retear group was greater than that in the retear group despite no significant difference (P = .0717 and P = .0824, respectively).

CONCLUSION

The recovery of the muscle strength after SCR was observed until 1 year after surgery, and the muscle strength of scaption and external rotation returned to 60% of that on the uninvolved side at 2 years.

Definition of irreparable rotator cuff tear: a scoping review of prospective surgical therapeutic trials to evaluate current practice

BACKGROUND

The definition of irreparable rotator cuff tear (IRCT) is controversial. This scoping review provides definitions used to describe IRCT in the literature. This scoping review (1) identified criteria used in the definition of IRCT and (2) investigated the current state of those criteria in prospective surgical therapeutic trials.

METHODS

This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. PubMed, Scopus, and Web of Science were searched in March 2023. Studies were screened against predetermined inclusion and exclusion criteria. Criteria regarding clinical symptoms, preoperative images, and intraoperative findings were captured respectively.

RESULTS

A total of 41 prospective studies were eligible for inclusion, and 35 studies (85.4%) defined IRCT. IRCT was defined on the basis of the following main criteria: preoperative image findings (28/35), intraoperative findings (24/35), and symptoms (16/35). With regard to preoperative images, IRCT was mainly defined on the basis of retraction of the tendon in the coronal plane (22/28), the severity of fatty degeneration (19/28), and ruptured tendon number or width of the defect in the sagittal plane (17/28).

CONCLUSION

This scoping review highlights the lack of a standardized definition for IRCT in clinical practice, with common predictive criteria including a duration of over 6 months, retraction beyond 5 cm, Goutallier grade 3 fatty infiltration, and the rupture of two or more tendons. However, surgeons should apply more than one criterion when examining preoperative images and confirm reparability during surgery. A more objective manner of evaluating intraoperative reparability is necessary.

Time required to achieve clinically significant outcomes after arthroscopic superior capsular reconstruction

PURPOSE

To investigate the time-dependent nature of clinically significant outcomes, including the minimal clinically important difference (MCID), substantial clinical benefit, and Patient Acceptable Symptomatic State (PASS) after arthroscopic superior capsular reconstruction, and the factors contributing to the achievement of early clinically significant outcomes.

METHODS

Patients who underwent ASCR between March 2015 and September 2020 with complete preoperative and postoperative 6-month, 1-year, and 2-year patient-reported outcome measures (PROMs) were retrospectively analysed. Threshold values for MCID, substantial clinical benefit, and PASS were obtained from the previous literature for the PROMs. The time required to achieve clinically significant outcomes was calculated using Kaplan-Meier analysis. Multivariate Cox regression was performed to evaluate the variables predictive of an earlier or delayed achievement of MCID.

RESULTS

Fifty-nine patients with a mean age of 64.5 ± 8.7 years old were included. The time of mean achievement of MCID, substantial clinical benefit, and PASS for VAS was 11.2 ± 0.9, 16.3 ± 1.1, and 16.6 ± 0.9 months, respectively. The time of mean achievement of MCID, substantial clinical benefit, and PASS for ASES was 13.2 ± 1.0, 16.8 ± 1.0, and 18.3 ± 0.9 months, respectively. The time of mean achievement of MCID, substantial clinical benefit, and PASS for the Constant score was 11.6 ± 0.9, 15.1 ± 1.0, and 14.7 ± 0.9 months, respectively. The time of mean achievement of MCID, substantial clinical benefit, and PASS for SANE was 14.4 ± 1.0, 16.1 ± 1.0, and 15.5 ± 0.8 months, respectively. Patients with a higher preoperative VAS score achieved an earlier MCID for VAS (P = 0.014). However, patients with a higher preoperative ASES and SANE scores achieved delayed MCID for ASES and SANE (P = 0.026, and P < 0.001, respectively).

CONCLUSION

Most patients achieved MCIDs around 1 year after arthroscopic superior capsular reconstruction. A higher preoperative VAS score favours faster MCID achievement, while higher preoperative ASES and SANE scores contribute to delayed MCID achievement.

STUDY DESIGN

Cohort study LEVEL OF EVIDENCE: Level IV.

Long head of biceps tendon transposition for massive and irreparable rotator cuff tears: A systematic review and meta-analysis

BACKGROUND

Superior capsular reconstruction (SCR) with long head of biceps tendon (LHBT) transposition was developed to massive and irreparable rotator cuff tears (MIRCTs); however, the outcomes of this technique remain unclear.

AIM

To perform a systematic review of biomechanical outcomes and a meta-analysis of clinical outcomes after LHBT transposition for MIRCTs.

METHODS

We performed a systematic electronic database search on PubMed, EMBASE, and Cochrane Library. Studies of SCR with LHBT transposition were included according to the inclusion and exclusion criteria. Biomechanical studies were assessed for main results and conclusions. Included clinical studies were evaluated for quality of methodology. Data including study characteristics, cohort demographics, and outcomes were extracted. A meta-analysis was conducted of the clinical outcomes.

RESULTS

According to our inclusion and exclusion criteria, a total of six biomechanical studies were identified and reported an overall improvement in subacromial contact pressures and prevention of superior humeral migration without limiting range of motion (ROM) after LHBT transposition for MIRCTs. A total of five clinical studies were included in the meta-analysis of LHBT transposition outcomes, consisting of 253 patients. The results indicated that compared to other surgical methods for MIRCTs, LHBT transposition had advantages of more significant improvement in ROM (forward flexion mean difference [MD] = 6.54, 95% confidence interval [CI]: 3.07-10.01; external rotation [MD = 5.15, 95%CI: 1.59-8.17]; the acromiohumeral distance [AHD] [MD = 0.90, 95%CI: 0.21-1.59]) and reducing retear rate (odds ratio = 0.27, 95%CI: 0.15-0.48). No significant difference in American Shoulder and Elbow Surgeons score, visual analogue scale score, and University of California at Los Angles score was demonstrated between these two groups for MIRCTs.

CONCLUSION

In general, SCR with LHBT transposition was a reliable and economical technique for treating MIRCTs, both in terms of biomechanical and clinical outcomes, with comparable clinical outcomes, improved ROM, AHD, and reduced the retear rates compared to conventional SCR and other established techniques. More high-quality randomized controlled studies on the long-term outcomes of SCR with LHBT transposition are required to further assess.

A survey on the usage of decellularized tissues in orthopaedic clinical trials

Orthopaedic surgery requires grafts with sufficient mechanical strength. For this purpose, decellularized tissue is an available option that lacks the complications of autologous tissue. However, it is not widely used in orthopaedic surgeries. This study investigated clinical trials of the use of decellularized tissue grafts in orthopaedic surgery. Using the ClinicalTrials.gov (CTG) and the International Clinical Trials Registry Platform (ICTRP) databases, we comprehensively surveyed clinical trials of decellularized tissue use in orthopaedic surgeries registered before 1 September 2022. We evaluated the clinical results, tissue processing methods, and commercial availability of the identified products using academic literature databases and manufacturers' websites. We initially identified 4,402 clinical trials, 27 of which were eligible for inclusion and analysis, including nine shoulder surgery trials, eight knee surgery trials, two ankle surgery trials, two hand surgery trials, and six peripheral nerve graft trials. Nine of the trials were completed. We identified only one product that will be commercially available for use in knee surgery with significant mechanical load resistance. Peracetic acid and gamma irradiation were frequently used for sterilization. Despite the demand for decellularized tissue, few decellularized tissue products are currently commercially available, particularly for the knee joint. To be viable in orthopaedic surgery, decellularized tissue must exhibit biocompatibility and mechanical strength, and these requirements are challenging for the clinical application of decellularized tissue. However, the variety of available decellularized products has recently increased. Therefore, decellularized grafts may become a promising option in orthopaedic surgery.

Superior Capsule Reconstruction Using an Acellular Dermal Matrix Allograft Combined With Remnant Tendon Augmentation for Irreparable Rotator Cuff Tear

Graft fixation sites on the greater tuberosity and the superior glenoid for superior capsule reconstruction (SCR) are prone to graft failure. The graft fixation procedure on the superior glenoid is challenging due to the limited working space, narrow graft attachment site, and difficulties in suture management. This technical note introduces the surgical technique of SCR using an acellular dermal matrix allograft combined with remnant tendon augmentation to enhance graft healing and the suture management technique to prevent suture tangling for the treatment of irreparable rotator cuff tear.

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.

Preliminary Outcomes of Arthroscopic Biologic Tuberoplasty in the Treatment of Massive Irreparable Rotator Cuff Tears

INTRODUCTION

Several treatment options exist for the treatment of massive, irreparable rotator cuff tears. A novel technique has been described whereby an acellular dermal allograft is secured to the greater tuberosity which acts as an interpositional tissue preventing bone-to-bone contact between the greater tuberosity and acromion. The preliminary results of this arthroscopic procedure are being presented.

METHODS

Patients who underwent a biologic tuberoplasty procedure between 2015 and 2022, by a single surgeon, were included in this study. Pre- and postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and visual analogue pain scores (VAS) were prospectively recorded and retrospectively reviewed. Postoperative MRI was obtained in some cases. Paired t-test was used to calculate significance set at <0.05.

RESULTS

Ten patients met the inclusion criteria. The mean age was 70.4+4.7 years (range 65-78). There were five males. The mean length of follow-up was 21+27 months (range six to 95 months). There was significant improvement in ASES (24.3+4 to 91.5+10.3, P<0.00001), SANE (22.5+10.3 to 88+11.6, P<0.00001), and VAS (8.8+0.6 to 1.1+2.5, P<0.00001). MRI was obtained in seven patients at a mean of 5.3+2.9 months and showed a healed graft to the tuberosity in all cases.

CONCLUSION

Biologic tuberoplasty is an effective procedure in improving pain and functional outcomes in patients with massive, irreparable rotator cuff tears.

Early Treatment of Shoulder Pathology Is Necessary but Not Enough Is Being Performed

Delayed treatment of shoulder instability results in bone loss requiring more-complicated surgery, in turn resulting in less-optimal outcomes. Similarly, delayed treatment of repairable rotator cuff tears results in irreparable tears requiring more-complicated surgery and resulting in less-optimal outcomes. Delayed treatment of shoulder pathology is a problem. Solutions include education and research investigation.