Arthroscopic Superior Capsule Reconstruction With Doubled Autologous Semitendinosus Tendon Graft

Interposition Grafting Using Fascia Lata Autograft for Failed Rotator Cuff Repairs

Massive rotator cuff tears are a huge challenge for orthopaedic surgeons, as the patients may be in need of multiple operations, even including reverse total shoulder arthroplasty. The various repair methods for the rotator cuff, such as partial rotator cuff repair, patch-augmented rotator cuff repair, bridging rotator cuff reconstruction with graft interposition, tendon transfer, and superior capsular reconstruction, have always been the focus of research. During surgical intervention for failed rotator cuff repairs, complexity of tears, poor tissue quality, retained hardware, and adhesions are the problems routinely encountered. In this Technical Note, we describe the technique of interposition grafting using fascia lata autograft to reconstruct the rotator cuff after failed primary repair.

Combined Arthroscopic-Assisted Lower Trapezius Tendon Transfer and Superior Capsule Reconstruction for Massive Irreparable Posterior-Superior Rotator Cuff Tears: Surgical Technique

Primary or revision irreparable rotator cuff tears remain a challenge. Clear algorithms do not exist. Several joint-preserving options are available, but no technique has been definitely proven to be better than another. Although superior capsule reconstruction has been shown to be effective in restoring motion, lower trapezius transfer can provide strong external rotation and abduction moment. The aim of the present article was to describe an easy and reliable technique to combine both options in 1 surgery, aiming to maximize the functional outcome by getting motion and strength back.

Reliability of a Novel Preoperative Protocol for Determining Graft Sizes for Superior Capsular Reconstruction Using Plain Film Radiography

BACKGROUND

Superior capsular reconstruction (SCR) for massive, irreparable rotator cuff tears involves anchoring a graft between the superior glenoid and the greater tuberosity of the humerus. Optimizing the graft size is important. We aimed (1) to evaluate the reliability of plain film radiography in determining graft size for SCR and (2) to create a database to help predict future graft sizes.

METHODS

An inter- and intra-rater reliability trial was conducted on 10 and 6 subjects with healthy shoulders, respectively, using plain film radiography to measure the distance between the superior glenoid and the supraspinatus footprint. The subjects were positioned upright with an abduction pillow modified to hold the shoulder at 30° abduction and 45° external rotation, afterwhich a true antero-posterior shoulder radiograph was captured. Thirty subjects were recruited for the database and grouped using the aforementioned protocol.

RESULTS

The inter-rater and intra-rater trial agreement was excellent, with intraclass correlation coefficients of 0.94 (95% CI) and 0.76 (95% CI), respectively. Three medio-lateral patch sizes, of 33 mm, 38 mm, and 47 mm, were proposed based on the protocol in 30 subjects.

CONCLUSIONS

Plain film radiography demonstrated excellent reliability in measuring the distance between the superior glenoid and the supraspinatus footprint. Three ordinal patch sizes are proposed.

Biomechanical Comparison of Synthetic Polytetrafluoroethylene (PTFE) vs Human Dermal Allograft (HDA), 2 vs 3 Glenoid Anchors, and Suture vs Minitape in Superior Capsule Reconstruction

Background: Superior capsule reconstruction (SCR) is an option for the treatment of massive, irreparable rotator cuff tears. However, which materials yield the strongest constructs remains undetermined. Purposes: We sought to investigate whether SCR with polytetrafluoroethylene (PTFE) or human dermal allograft (HDA), 2 or 3 glenoid anchors, and suture or minitape resulted in better failure load properties at the patch-glenoid interface. Methods: We conducted a biomechanical study in 30 glenoid-sided SCR repairs in Sawbones models divided into 5 groups. Each was pulled to failure to assess mode of failure, peak load (N), stiffness (N/mm), yield load (N), peak energy (N m), and ultimate energy (N m). The 5 groups were as follows: group 1-PTFE, 2 anchors, and suture; group 2-PTFE, 2 anchors, and minitape; group 3-HDA, 2 anchors, and suture; group 4-HDA, 2 anchors, and minitape; group 5-PTFE, 3 anchors, and minitape. Results: Repairs failed by button-holing of suture/minitape. Group 5 had greater peak load, stiffness, yield load, and peak energy (384 ± 62 N; 24 ± 3 N/mm; 343 ± 42 N; 4 ± 2 N m) than group 3 (226 ± 67 N; 16 ± 4 N/mm; 194 ± 74 N; 2 ± 1 N m) or group 4 (274 ± 62 N; 17 ± 4 N/mm; 244 ± 50 N; 2 ± 1 N m) and greater ultimate energy (8 ± 3 N m) than all other groups. Conclusions: This biomechanical study of SCR repairs in Sawbones models found that yield load was greater in PTFE than HDA, 3 anchors were better than 2, and minitape was no better than suture.

Treatment options for massive irreparable rotator cuff tears: a review of arthroscopic surgical options

While functional reconstruction of massive irreparable rotator cuff tears remains a challenge, current techniques aimed at recentering and preventing superior migration of the humeral head allow for clinical and biomechanical improvements in shoulder pain and function. Recentering of the glenohumeral joint reduces the moment arm and helps the deltoid to recruit more fibers, which compensates for insufficient rotator cuff function and reduces joint pressure. In the past, the concept of a superior capsular reconstruction with a patch secured by suture anchors has been used. However, several innovative arthroscopic treatment options have also been developed. The purpose of this article is to present an overview of new strategies and surgical techniques and if existing present initial clinical results. Techniques that will be covered include rerouting the long head of the biceps tendon, utilization of the biceps tendon as an autograft to reconstruct the superior capsule, utilization of a semitendinosus tendon allograft to reconstruct the superior capsule, superior capsular reconstruction with dermal allografts, and subacromial spacers.

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.

Biomechanical Assessment of a V-Shaped Semitendinosus Allograft Anterior Cable Reconstruction for Irreparable Rotator Cuff Tears

PURPOSE

The purpose of this study was to biomechanically assess superior stability, subacromial contact pressures, and glenohumeral kinematics of a V-shaped anterior cable reconstruction with semitendinosus allograft (VST) in a massive rotator cuff tear (MCT) model.

METHODS

Eight cadaveric shoulders (mean age, 66 years; range, 48 to 72 years) were tested with a custom testing system used to evaluate superior translation, subacromial contact pressure, and glenohumeral kinematics at 0°, 20°, and 40° glenohumeral abduction and 0°, 30°, 60°, and 90° of external rotation (ER). Conditions tested included (1) native state, (2) MCT (complete supraspinatus and ½ infraspinatus), a (3) VST. The VST was secured medially on the glenoid with 1 anchor and on the greater tuberosity with a double-row configuration using 4 anchors.

RESULTS

The VST significantly decreased superior translation compared to the MCT at 0° and 20° glenohumeral abduction for 0°, 30°, and 60° humeral rotation and at 40° abduction and 0° degrees humeral rotation (P < .05). Superior translation following the VST remained significantly greater than the intact state at 0° abduction and 60° and 90° ER (P = .039 and 0.007, respectively) and 20° abduction and 30°, 60°, and 90° ER (P = .048, .003, and .004, respectively). The VST restored peak subacromial contact pressure to intact levels for all positions except 40° abduction and 60° ER. The VST did not statistically affect humeral head kinematics compared to the intact condition.

CONCLUSIONS

In a biomechanical model, a VST anterior cable reconstruction partially restores superior stability and reduces peak subacromial contact pressure associated with an MCT, without affecting glenohumeral kinematics. The technique may be a consideration in the treatment of an irreparable MCT with isolated anterior cable disruption.

CLINICAL RELEVANCE

The VST may provide an option for treatment of irreparable MCTs with anterior rotator cable disruption.

Minimal graft site morbidity using autogenous semitendinosus graft from the uninjured leg: a randomised controlled trial

PURPOSE

To quantify the effect on strength of semitendinosus (ST) graft harvest by comparing isokinetic and isometric muscle strength.

METHODS

A cohort of 140 patients underwent anterior cruciate ligament (ACL) reconstruction (ACLR) and were randomized to ipsilateral or contralateral ST graft harvest. Isokinetic and isometric muscle strength testing using a dynamometer were collected for the operated and non-operated leg. Patients were assessed pre-surgery and at 6, 12 and 24 months after reconstruction.

RESULTS

ST graft harvest reduced isokinetic flexion muscle strength for 6 months. At 12 months follow up there was no significant difference between the two groups and they were all stronger than pre-injury. No other significant differences were found in any primary or secondary outcome measurements.

CONCLUSION

Solitary ST graft harvest does not appear to result in a permanent reduced isometric or isokinetic quadriceps muscle strength on the side where the graft is harvested. A reduction in hamstring muscle strength of less than 10% can be seen at short-term follow-up with full recovery by 12 months. Most patients report little or no donor site pain. Given these findings, ST autograft is an alternative graft choice that could be used for various reconstructions in terms of donor site morbidity.

LEVEL OF EVIDENCE

Level II.

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.

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.