Original Research

Superior Capsular Reconstruction: Clinical Outcomes After Minimum 2-Year Follow-Up

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Superior capsular reconstruction (SCR) is performed to reduce the pain and disability caused by irreparable supraspinatus rotator cuff tears (RCTs). In this article, we discuss 9 cases of irreparable rotator cuff tears managed with arthroscopic SCR with dermal allograft. At minimum 2-year follow-up (mean, 32.38 months), the patients were prospectively evaluated on the American Shoulder and Elbow Surgeons (ASES) shoulder index, a visual analog scale (VAS) for pain, acromial-humeral distance, and ultrasonography. Patients were compared before and after surgery and against historical controls who underwent repair of massive RCTs.

From before surgery to 2 years after surgery, mean ASES score improved significantly (P < .00002), from 43.54 to 86.46, and mean VAS pain score decreased significantly (P < .00002), from 6.25 to 0.38. For the historical controls at final follow-up, mean ASES score was 70.71 (P = .11), and mean VAS pain score was 3.00 (P < .05). Mean acromial-humeral distance improved from 4.50 mm before surgery to 8.48 mm immediately after surgery (P < .0008) and 7.60 mm 2 years after surgery (P < .05). Ultrasonography revealed pulsatile vessels within the allograft tissue between 4 and 8 months after surgery. One patient underwent reverse total shoulder arthroplasty (RTSA) for anterior escape; another had the graft rupture after a motor vehicle accident.

Our data showed SCR with dermal allograft effectively restored the superior restraints in the glenohumeral joint and yielded outstanding clinical outcomes even after 2 years, making it an excellent viable alternative to RTSA.


 

References

Take-Home Points

  • The SCR is a viable treatment option for massive, irreparable RCTs.
  • Arm position and exact measurement between anchors will help ensure proper graft tensioning.
  • Anterior and posterior tension and margin convergence are critical to stabilizing the graft.
  • Acromial-humeral distance, ASES, and VAS scores are improved and maintained over long-term follow-up.
  • The dermal allograft should be 3.0 mm or thicker.

Conventional treatments for irreparable massive rotator cuff tears (RCTs) have ranged from nonoperative care to débridement and biceps tenotomy, 1,2 partial cuff repair, 3,4 bridging patch grafts, 5 tendon transfers, 6,7 and reverse total shoulder arthroplasty (RTSA). 8,9 Superior capsular reconstruction (SCR), originally described by Mihata and colleagues, 10 has been developed as an alternative to these interventions. Dr. Hirahara modified the technique to use dermal allograft instead of fascia lata autograft. 10,11

Biomechanical analysis has confirmed the integral role of the superior capsule in shoulder function. 10,12-14 In the presence of a massive RCT, the humeral head migrates superiorly, causing significant pain and functional deficits, such as pseudoparalysis. It is theorized that reestablishing this important stabilizer—centering the humeral head in the glenoid and allowing the larger muscles to move the arm about a proper fulcrum—improves function and decreases pain.

Using ultrasonography (US), radiography, magnetic resonance imaging (MRI), clinical outcome scores, and a visual analog scale (VAS) for pain, we prospectively evaluated minimum 2-year clinical outcomes of performing SCR with dermal allograft for irreparable RCTs.

Methods

Except where noted otherwise, all products mentioned in this section were made by Arthrex.

Surgical Technique

The surgical technique used here was described by Hirahara and Adams. 11 ArthroFlex dermal allograft was attached to the greater tuberosity and the glenoid, creating a superior restraint that replaced the anatomical superior capsule ( Figures 1A, 1B ). Some cases included biceps tenotomy, subscapularis repair, or infraspinatus repair.

Figure 1.
Mean number of anchors used was 6.13 (range, 4-8). A SpeedBridge construct, which was used for the greater tuberosity, had 2 medial anchors with FiberWire and FiberTape attached. The medial and lateral anchors typically used were 4.75-mm BioComposite Vented SwiveLocks; in 1 case, significant bone defects were found after removal of previous anchors, and 6.5-mm corkscrew anchors were medially augmented with QuickSet cement. A double pulley using the FiberWire eyelet sutures from the medial row anchors was fixated into the anterior anchor in the lateral row.

Medial fixation was obtained with a PASTA (partial articular supraspinatus tendon avulsion) bridge-type construct 15 that consisted of two 3.0-mm BioComposite SutureTak anchors (placed medially on the glenoid rim, medial to the labrum) and a 3.5-mm BioComposite Vented SwiveLock. In some cases, a significant amount of tissue was present medially, and the third anchor was not used; instead, a double surgeon knot was used to fixate the double pulley medially.

Posterior margin convergence (PMC) was performed in all cases. Anterior margin convergence (AMC) was performed in only 3 cases.

Clinical Evaluation

All patients who underwent SCR were followed prospectively, and all signed an informed consent form. Between 2014 and the time of this study, 9 patients had surgery with a minimum 2-year follow-up. Before surgery, all patients received a diagnosis of full-thickness RCT with decreased acromial-humeral distance (AHD). One patient had RTSA 18 months after surgery, did not reach the 2-year follow-up, and was excluded from the data analysis. Patients were clinically evaluated on the 100-point American Shoulder and Elbow Surgeons (ASES) shoulder index and on a 10-point VAS for pain—before surgery, monthly for the first 6 months after surgery, then every 6 months until 2 years after surgery, and yearly thereafter. These patients were compared with Dr. Hirahara’s historical control patients, who had undergone repair of massive RCTs. Mean graft size was calculated and reported. Cases were separated and analyzed on the basis of whether AMC was performed. Student t tests were used to determine statistical differences between study patients’ preoperative and postoperative scores, between study and historical control patients, and between patients who had AMC performed and those who did not ( P < .05).

Imaging

For all SCR patients, preoperative and postoperative radiographs were obtained in 2 planes: anterior-posterior with arm in neutral rotation, and scapular Y. On anteroposterior radiographs, AHD was measured from the most proximal aspect of the humeral head in a vertical line to the most inferior portion of the acromion ( Figures 2A, 2B ).

Figure 2.
Student t tests were used to identify statistical differences ( P < .05) between preoperative and postoperative groups for radiographs obtained immediately after surgery and most

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