Superior Capsule Reconstruction for Reinforcement of Arthroscopic Rotator Cuff Repair Improves Cuff Integrity

Abstract

Background: Retear of repaired rotator cuff tendons worsens patient outcome and decreases patient satisfaction. Superior capsule reconstruction (SCR) was developed to center the humeral head and thus restore the force couple for patients with rotator cuff tears. Purpose: To evaluate whether SCR for reinforcement before arthroscopic rotator cuff repair (ARCR) improves cuff integrity. Study Design: Cohort study; Level of evidence, 3. Methods: Thirty-four consecutive patients (mean age, 69.1 years) with severely degenerated but reparable rotator cuff tears underwent SCR with fascia lata autografts for reinforcement before ARCR. All tears were medium (1-3 cm) or large (3-5 cm), and the number of torn tendons was 2 (supraspinatus and infraspinatus) in 29 shoulders and 3 (supraspinatus, infraspinatus, subscapularis) in 5 shoulders. To assess the benefit of SCR for reinforcement, all data were compared with those after ARCR alone among 91 consecutive patients with medium or large rotator cuff tears (mean age, 63.6 years). The American Shoulder and Elbow Surgeons (ASES) and Japanese Orthopaedic Association (JOA) scores, active shoulder range of motion, and cuff integrity (Sugaya magnetic resonance imaging classification) were compared ( t test and chi-square test) between ARCR with and without SCR, as well as before surgery and at final follow-up. Results: All 34 patients who underwent SCR before ARCR had neither postoperative retear nor type III cuff integrity, whereas those treated with ARCR alone had a 4% incidence (4 of 91) of retear and 8% incidence of type III cuff integrity. ASES and JOA scores, active elevation, active external rotation, and active internal rotation increased in both treatment groups ( P < .001). Postoperative ASES score and active range of motion did not differ between groups, although the Goutallier grade of the supraspinatus was higher for ARCR with SCR (mean, 2.8) than ARCR alone (mean, 2.1; P < .0001). Conclusion: SCR for reinforcement prevented retear at 1 year after ARCR and improved the quality of the repaired tendon on magnetic resonance imaging. Functional outcomes were similar between groups, even though degeneration of the torn tendons was greater among patients who underwent ARCR with SCR.

Editorial Commentary: Superior Capsule Reconstruction: Grafts for Superior Capsular Reconstruction Must Be Thick and Stiff

“…I n their review, "Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears: A Systematic Review," Zastrow, London, Parsons, and Cagle acknowledge that autograft of fascia lata [1][2][3][4][5][6][7][8][9][10] and acellular dermal allografts 2,[11][12][13][14][15][16] are the materials used most often in superior capsule reconstruction (SCR) for irreparable rotator cuff tears. Importantly, however, they also mention several alternative graft materials for reconstructive surgery.…”

Arthroscopic Rotator Cuff Repair Combined With Modified Superior Capsule Reconstruction as Reinforcement by the Long Head of the Biceps

“…SCR in a massive RCT is crucial to prevent upward translation and maintain a constant restraint on the glenohumeral joint. 1,4,9 Our technique effectively uses the bicep tendon as an autograft without donor site morbidity. The biceps tendon can be easily transposed from the intra-articular space without much of a challenge, and the process does not require extra incisions for extra portals.…”

“…2 Studies have shown that SCR in massive irreparable RCTs results in better clinical scores and significant short-term improvements without significant complications. 3,4 Since the introduction of rotator cuff repairs with SCR, different methods of reconstruction have been done by either biologic augmentations or autografts; however, these techniques have obtained mixed results. 5,6 In this study, we propose an SCR technique that can restore glenohumeral stability by using the long head of the biceps tendon (LHBT), which provides closer anatomic attachments to the original superior capsule without sacrificing other autografts.…”

Editorial Commentary: SCR: Substantial Confusion Remains

“…If not, we will soon be grafting every large rotator cuff repair to reduce our tear rate from 4% to 0%. 15…”