Arthroscopic Superior Capsular Reconstruction With a Minimally Invasive Harvested Fascia Lata Autograft Produces Good Clinical Results

Abstract

Background:Painful dysfunctional shoulders with irreparable rotator cuff tears (IRCTs) in active patients are a challenge. Arthroscopic superior capsular reconstruction (ASCR) is a new treatment option originally described using a fascia lata autograft harvested through an open approach. However, concerns about donor site morbidity have discouraged surgeons from using this type of graft.Hypothesis:ASCR using a minimally invasive harvested fascia lata autograft produces good 6-month and 2-year shoulder outcomes in IRCTs, with low-impact thigh morbidity at 2 years.Study Design:Case series; Level of evidence, 4.Methods:From 2015 to 2016, a total of 22 consecutive patients (mean age, 64.8 ± 8.6 years) with chronic IRCTs (Hamada grade 1-2; Goutallier cumulative grade ≥3; Patte stage 1: 2 patients; Patte stage 2: 6 patients; Patte stage 3: 14 patients) underwent ASCR using a minimally invasive harvested fascia lata autograft. All patients completed preoperative and 6-month evaluations consisting of the Simple Shoulder Test (SST), subjective shoulder value (SSV), Constant score (CS), range of motion (ROM), acromiohumeral interval (AHI), and magnetic resonance imaging. Twenty-one patients completed the 2-year shoulder and donor site morbidity assessments.Results:The mean active ROMs improved significantly (P < .001): elevation, from 74.8° ± 55.5° to 104.5° ± 41.9° (6 months) and 143.8° ± 31.7° (2 years); abduction, from 53.2° ± 43.3° to 86.6° ± 32.9° (6 months) and 120.7° ± 37.7° (2 years); external rotation, from 13.2° ± 18.4° to 27.0° ± 16.1° (6 months) and 35.6° ± 17.3° (2 years); and internal rotation, from 1.2 ± 1.5 points to 2.6 ± 1.5 points (6 months) and 3.8 ± 1.2 points (2 years). The mean functional shoulder scores improved significantly (P < .001): SST, from 2.1 ± 2.9 to 6.8 ± 3.5 (6 months) and 8.6 ± 3.5 (2 years); SSV, from 33.0% ± 17.4% to 55.7% ± 25.6% (6 months) and 70.0% ± 23.0% (2 years); CS, from 17.5 ± 13.4 to 42.5 ± 14.9 (6 months) and 64.9 ± 18.0 (2 years). The mean shoulder abduction strength improved significantly (P < .001) from 0.0 to 1.1 ± 1.4 kg (6 months) and 2.8 ± 2.6 kg (2 years). The mean AHI improved from 6.4 ± 3.3 mm to 8.0 ± 2.5 mm (6 months) and decreased to 7.1 ± 2.5 mm (2 years). This 0.7 ± 1.5–mm overall decrease was statistically significant (P = .042). At 6 months, 20 of 22 patients (90.9%) had no graft tears. At 2 years, 12 of 21 patients (57.1%) were bothered by their harvested thigh, 16 (76.2%) noticed donor site changes, 16 (76.2%) considered that the shoulder surgery’s end result compensated for the thigh’s changes, and 18 (85.7%) would undergo the same surgery again.Conclusion:ASCR using a minimally invasive harvested fascia lata autograft produced good 6-month and 2-year shoulder outcomes in IRCTs, with low-impact thigh morbidity at 2 years.

Arthroscopic superior capsular reconstruction using a human dermal allograft in patients with and without preoperative pseudoparalysis

“…Similar to our study, four recent publications about SCR with human dermal allografts reported failure rates between 40 and 60% with mainly humeral side ruptures [4,11,15,25], while recent data on SCR with fascia lata autografts described failure rates between 5 and 10% [3,18]. Although the literature on SCR with fascia lata is limited, the healing rate of autografts seems to be far better.…”

“…However, when using autografts, donor site morbidity, especially when taking a long fascia lata graft, needs to be considered. In fact, Azevedo et al [3] reported that at the 2-year follow-up, 57% of patients were still bothered by their harvested thigh and 76% noticed donor site changes. However, Plachel et al [26,27] in their case report showed that there is ingrowth of vessels and expression of growth factors in the acellular human dermal allograft patch after 6 months, which led them to the conclusion that healing of the graft to the native tissue may be facilitated.…”

“…Moderate-to-severe pseudoparalysis does not seem to represent a contraindication for SCR according to this and other recently published studies (. Table 5; [1,3,4,15,18,19,25]). For patients with irreparable rotator cuff tear with no or mild arthritis, SCR seems to have the potential to become a valuable tool in the armamentarium of shoulder surgeons; however, long-term results are required to judge the true benefits of the procedure.…”

Editorial Commentary: Off the Hip or Off the Shelf? An Analysis of Autograft and Allograft as a Graft Source for Shoulder Superior Capsular Reconstruction

“…His ingenious solution was the SCR, which was a minimally invasive, joint-preserving option that the rest of the world would soon adopt as a legitimate alternative to the RSA and tendon transfers. [3][4][5][6][7][8] To further complicate the issue, stringent regulation and lack of tissue banks limit the availability of allograft tissue in Japan. To meet this challenge, Mihata used fascia lata autograft to reconstruct the superior capsule.…”

Superior Capsular Reconstruction Using 3-layered Fascia Lata Autograft Reinforced with a Nonresorbable Suture Mesh

“… 29 These individual variations in the thickness of FLA and technical challenges related to preparation of the graft makes standard FLA not always reproducible and a reliable option. 25 , 29 , 30 , 31 In our quest to find an improved biological autograft with higher structural strength, stiffness, and thickness, we designed a new graft based on the FL and reinforced with a nonresorbable suture mesh. We aimed to make a stiffer graft with right thickness, but without harvesting a large portion of the FL or disrupting the superior attachment of the tensor fascia lata muscle.…”