Use of Gracile and semi-tendinosus tendons (GRAST) for the reconstruction of irreparable rotator cuff tears

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.

Superior capsular reconstruction for irreparable rotator cuff tears: Autografts versus allografts

AIMS

Superior capsular reconstruction (SCR) is a treatment option for patients with massive irreparable rotator cuff tears. Different types of grafts from various donor sites have been described. There are no clinical studies comparing the different grafts available. The aim of this study is to compare the early clinical outcomes of patients who have undergone arthroscopic SCR with different types of grafts (allograft vs. autograft).

MATERIAL AND METHODS

This study is a retrospective analysis of data collected prospectively, from patients who underwent arthroscopic SCR with either a long head of biceps autograft (LHB) (n=40) or an acellular dermal allograft (n=40), between March 2015 and April 2018. The pre- and postoperative clinical data were compared between the 2 groups, as well as the incidence and type of complications.

RESULTS

All patients were monitored with a minimum follow-up of one year. Three patients (7.5%) in the autograft group, and 14 (35%) in the allograft group (p=0.005) had a complication, of which 2 (5%) and 5 (12.5%) respectively, required revision surgery (p=0.432). Linear regression ruled out any significant difference between the 2 groups, with respect to clinical scores. However, patients with a history of prior rotator cuff surgery had poorer results with regard to active elevation (β, -29.3; p=0.020), internal rotation (β, -3.4; p=0.003) and Subjective Shoulder Value (SSV) (β, -17.2; p=0.023). Older patients, as well as men, are associated with poorer postoperative internal rotation (β, -0.1; p=0.003 and β, -1.9; p=0.039 respectively), and type D lesions are associated with poorer external rotation and postoperative SSV (β, -11.3; p=0.012 and β, -12.4; p=0.048 respectively), compared to type C lesions. Postoperative graft integrity was improved in the autograft group compared to the allograft group. (Grade 1: 65.8% vs. 2.9%; Grade 5: 5.3% vs. 28.6%; p<0.001).

CONCLUSIONS

In both groups, clinical scores improved after SCR in patients with irreparable rotator cuff tears. Fewer complications and revisions were observed with the autograft compared to the allograft. If the LHB was still in place during surgery, its use appears valid, given the reasonable cost and low rate of complications associated with it. If absent, an allograft is also an option, considering the potential clinical improvement.

LEVEL OF EVIDENCE

III; Case-control study.