Association Between the Postoperative Condition of the Subscapularis Tendon and Clinical Outcomes After Superior Capsular Reconstruction Using Autologous Tensor Fascia Lata in Patients With Pseudoparalytic Shoulder

Abstract

Background: Superior capsular reconstruction (SCR) has been performed for irreparable rotator cuff tear and pseudoparalytic shoulder (PPS); however, poor clinical outcomes have occasionally been reported. Previous studies have shown that the cause of poor clinical results was mainly graft rupture; however, poor clinical outcomes have also been observed in some cases even though the graft was not ruptured. Hypothesis/Purpose: We hypothesized that the subscapularis (SSC) tendon would be an important factor affecting clinical outcomes after SCR. The purpose was to clarify the correlation between the condition of the SSC tendon and clinical outcomes after SCR in patients with PPS. Study Design: Cohort study; Level of evidence, 3. Methods: This retrospective cohort study included 27 patients who had undergone SCR for PPS performed by 1 surgeon between June 2014 and July 2017. The 27 patients were divided into 3 groups for evaluation: group A (n = 12), irreparable supraspinatus (SSP) and infraspinatus (ISP) tears but intact SSC tendon; group B (n = 11), irreparable SSP and ISP tears and repairable SSC tear; and group C (n = 4), irreparable SSP, ISP, and SSC tears. We evaluated the preoperative and postoperative ranges of motion (ROMs; active flexion, abduction, external rotation, and internal rotation), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, and graft condition on magnetic resonance imaging at 12 months postoperatively. All data were analyzed using the Mann-Whitney U, Wilcoxon signed-rank test, and Fisher exact tests, and P < .05 was considered significant. Results: Postoperative flexion, abduction, and internal rotation ROMs were significantly lower in group C than in groups A and B (flexion: 70.0° ± 17.8° vs 153.3° ± 14.3° and 154.5° ± 14.3°, P = .003 and P = .003, respectively; abduction: 67.5° ± 15° vs 148.3° ± 22.5° and 140° ± 29.3°, P = .003 and P = .004, respectively; internal rotation: L4 vs Th10 and Th11, P = .005 and P = .008, respectively). All 23 patients in groups A and B were able to recover from PPS; however, no patient recovered from PPS in group C. Conclusion: The present study suggests that the SSC tendon is the important factor for achieving good clinical outcomes after SCR in patients with PPS. When the SSC tendon was irreparable, SCR was not an effective treatment for patients with PPS.

Consensus statement on the treatment of massive irreparable rotator cuff tears: a Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons

“…2). This preference aligns with current literature as a recent study by Takayama et al 36 investigated the importance of the condition of the subscapularis with SCR and found that flexion, abduction, and internal rotation were worse in patients with an irreparable subscapularis than in those with an intact or repairable subscapularis. Additionally, none of the patients with an irreparable subscapularis had reversal of pseudoparalysis after SCR.…”

“…Additionally, none of the patients with an irreparable subscapularis had reversal of pseudoparalysis after SCR. 36 In another study, Gilat et al 11 found that subscapularis tears were positively associated with clinical failure following SCR. Although improvements in patient-reported outcome measures and return to sports have been exhibited, these studies yield the importance of patient factors to treatment selection.…”

“…Although improvements in patient-reported outcome measures and return to sports have been exhibited, these studies yield the importance of patient factors to treatment selection. 1,2,8,11,14,[21][22][23]36 In the setting of patients with pseudoparesis, absent or irreparable subscapularis tendons, and anterior-superior escape, the treatment algorithms point toward an RSA. 33,38 Overall, there were numerous clinical scenarios that reached the established levels of consensus for preferred, acceptable, and not acceptable/contraindicated treatments.…”

SCR 2021

“…Failure of pseudoparalysis to resolve was associated with SCR graft tear. Subsequent studies by Takayama et al 32 and Burkart and Hartzler 4 also report the resolution of pseudoparalysis after autograft or allograft SCR.…”

“…In the setting of large to massive rotator cuff tears, pseudoparalysis has been linked to the extent of the tear and specifically to the involvement of the subscapularis. 4,7,10,32 In the July 2020 AJSM , Takayama et al 32 reported success using SCR to reverse pseudoparalysis, except in patients with irreparable subscapularis tears. In the December 2020 AJSM , Mihata et al 21 compared outcomes after SCR in patients with and without subscapularis tears.…”