Superior Capsular Reconstruction for Massive Rotator Cuff Tears

Abstract

A massive rotator cuff tear is defined as a tear involving .2 tendons or .5 cm of retraction.» Superior capsular reconstruction is done with either a folded fascia lata autograft (6 to 8 mm in thickness) or acellular dermal allograft (3 to 4 mm in thickness). The graft is secured arthroscopically with anchors on the superior glenoid rim and multiple anchors on the humeral head with use of a transosseous-equivalent repair technique.» Superior capsular reconstruction is indicated for younger patients with massive and irreparable rotator cuff tears involving the supraspinatus and infraspinatus with minimal arthritis, intact subscapularis, and a functional deltoid. Contraindications include bone defects, stiffness, and moderate to severe arthropathy.» Arthroscopic superior capsular reconstruction with fascia lata autograft or humeral dermal allograft is a surgical option, with multiple studies showing statistically significant improvement in short-term outcomes for both pain and function among younger patients with massive irreparable rotator cuff tears. The long-term clinical effectiveness and value have yet to be determined. » Biomechanical data suggest improved restoration of superior glenohumeral stability with decreased subacromial contact pressures in association with the use of the 8-mm fascia lata graft as compared with the 4-mm acellular humeral dermal allograft. In addition, fascia lata graft has shown less elongation and thinning than humeral dermal graft.» Either fascia lata autograft or humeral dermal allograft may be used clinically for arthroscopic superior capsular reconstruction; however, a graft thickness of at least 3 mm is recommended to decrease the risk of radiographic and clinical failure.» No comprehensive quality-of-life or cost-comparison analyses are available to compare superior capsular reconstruction, reverse total shoulder arthroplasty (rTSA), tendon transfer, and partial rotator cuff repair for the treatment of massive irreparable rotator cuff tears. However, the potential higher cost of superior capsular reconstruction and the lack of long-term clinical outcomes or revision data suggest Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked "yes" to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/ JBJSREV/A465).

Complete Repair of Massive, Retracted, and “Non-Repairable” Tears of the Rotator Cuff: The Anatomic Vector Repair

“…The technique of SCR uses facia lata autograft or dermal allograft tissue to treat massive and retracted tears of the supraspinatus or infraspinatus. 8 Regarding the technique of SCR, long-term clinical outcome studies are lacking, which is a concern given the avascular nature of the tissues used in this reconstructive procedure. Regarding the biomechanical benefits of SCR in cases of massive tear injury involving the supraspinatus and infraspinatus, complete or partial repair of massive rotator cuff tears is likely to provide similar or superior clinical benefit compared with SCR, even in cases of less-robust repair tissue.…”

Editorial Commentary: Shoulder Superior Capsule Reconstruction: Should We Suture Leftover Dermal Allograft to the Inferior Acromion?

“…9 SCR by itself restores humeral head migration and stability is a matter of SCR graft thickness. 3,6,10 That said, my hypothesis also requires evaluation, and the authors must be congratulated for thinking outside the box; yet, their results may not support clinical adaptation. Translational research may be most successful when it fails.…”

“…S uperior capsular reconstruction (SCR) is a hot and controversial topic. In 2019 alone, 4 systematic reviews were published, [1][2][3][4] and their conclusions were all very similardshort-term improvements, further studies are needed to delineate clinical indications, survivorship, and risk factors for failure 1 ; significant improvement in patient-reported outcomes and shoulder range of motion with low graft failure, complication, and reoperation rates at short-term follow-up in fair-quality studies 2 ; restoration of superior glenohumeral stability with decreased contact pressures depends on graft thickness, significant improvement in short-term outcomes for both pain and function 3 ; biomechanical studies suggest that the humeral head-stabilizing effect appears to translate into improved clinical outcomes, and future research should focus on further defining the indications, limitations, and optimal technique. 4 In 2018, the Tokish group published a technique introducing the concept of an additional subacromial spacer using left over dermal allograft when performing SCR with dermal allograft.…”

Superior Capsular Reconstruction with Achilles Tendon Allograft

“…1 While partial rotator cuff repair, arthroscopic debridement and tendon transfer including latissimus dorsi, trapezius, and pectoralis major have been described, high failure rates and patient dissatisfaction are associated. 2 Reverse total shoulder arthroplasty has demonstrated favorable outcomes in patients older than 60 years of age; however, variable long-term implant survivorship and limited revision options make joint-preserving alternatives ideal, especially among younger patients. 3 Thus, superior capsular reconstruction (SCR) has become an increasingly popular choice and has early encouraging outcomes.…”