Orthopedics

Feature Article Supplemental Data

Arthroscopic Superior Capsular Reconstruction of the Shoulder Using Dermal Allograft

Daoud Makki, MD, FRCS (Tr&Orth); Quen O. Tang, MBChB, FRCS (Tr&Orth); Dilraj Sandher, MBChB, FRCS (Tr&Orth); Barnes W. Morgan, MBBS, MSc, FRCS (Tr&Orth); Matt Ravenscroft, MBBS, FRCS (Tr&Orth)

Abstract

Irreparable massive cuff tears in young patients pose a difficult problem for shoulder surgeons. Arthroscopic superior capsular reconstruction has shown promise in recent years in the treatment of this challenging patient population. The majority of the literature is limited to surgical techniques. The authors present the 2-year clinical outcomes of 25 patients undergoing arthroscopic superior capsular reconstruction with dermal allograft from a single center. The Oxford Shoulder Score and range of motion were assessed preoperatively and then at 3 to 6 months, 1 year, and 2 years following surgery. Patient satisfaction was recorded at final follow-up. Magnetic resonance imaging was performed at 3 months postoperatively to assess graft integrity. All patients were available at 1-year follow-up, and 23 were available at 2 years. The mean Oxford Shoulder Score improved by a minimum of 10 points at all time points compared with preoperatively. The mean forward flexion and abduction improved by 20° and external rotation by 7°. Revision to reverse shoulder arthroplasty was seen in 3 patients (12%). Graft failure was seen in 4 patients (16%). Overall, 20 patients had successful outcomes at 1 year (80%) and 18 patients had successful outcomes at 2 years (72%). Superior capsular reconstruction offers a safe and effective short-term bridging option for young patients with irreparable supraspinatus tears in the absence of glenohumeral arthritis. However, long-term outcome studies are required to evaluate the true clinical effectiveness and failure rates. [Orthopedics. 2020;43(x):xx–xx.]

Abstract

Irreparable massive cuff tears in young patients pose a difficult problem for shoulder surgeons. Arthroscopic superior capsular reconstruction has shown promise in recent years in the treatment of this challenging patient population. The majority of the literature is limited to surgical techniques. The authors present the 2-year clinical outcomes of 25 patients undergoing arthroscopic superior capsular reconstruction with dermal allograft from a single center. The Oxford Shoulder Score and range of motion were assessed preoperatively and then at 3 to 6 months, 1 year, and 2 years following surgery. Patient satisfaction was recorded at final follow-up. Magnetic resonance imaging was performed at 3 months postoperatively to assess graft integrity. All patients were available at 1-year follow-up, and 23 were available at 2 years. The mean Oxford Shoulder Score improved by a minimum of 10 points at all time points compared with preoperatively. The mean forward flexion and abduction improved by 20° and external rotation by 7°. Revision to reverse shoulder arthroplasty was seen in 3 patients (12%). Graft failure was seen in 4 patients (16%). Overall, 20 patients had successful outcomes at 1 year (80%) and 18 patients had successful outcomes at 2 years (72%). Superior capsular reconstruction offers a safe and effective short-term bridging option for young patients with irreparable supraspinatus tears in the absence of glenohumeral arthritis. However, long-term outcome studies are required to evaluate the true clinical effectiveness and failure rates. [Orthopedics. 2020;43(x):xx–xx.]

The treatment of irreparable supraspinatus tendon tears poses a challenge, particularly when dealing with young and active patients. Management options range from non-operative treatment to arthroscopic debridement, partial repair of the tendon, patch augmentation, and tendon transfers.1–7 Reverse shoulder arthroplasty (RSA) is considered the last option but is associated with increased risk of complications.8

Superior capsular reconstruction (SCR) was first introduced by Mihata et al9 to treat this challenging population. Although good clinical outcomes were reported, the use of fascia lata autograft raised concern over increased surgical time and donor site morbidity. As a result, the use of acellular dermal allograft as an alternative has become more popular.10 Biomechanical studies have shown that restoration of the superior capsule restrains proximal migration of the humeral head.9,11 This in turn restores force couples, optimizes the function of the deltoid, and prevents subacromial impingement.9 Based on the promising biomechanical advantages and reduced donor site morbidity, SCR using acellular dermal allograft has been advocated; however, the published literature regarding it is limited, with the majority relating to surgical techniques.

This article reports the 2-year clinical outcomes and patient satisfaction regarding arthroscopic SCR using acellular dermal allograft for irreparable rotator cuff tears.

Materials and Methods

The authors present a retrospective consecutive case series of 25 patients during a 2-year period from April 2015 to April 2017 with an irreparable supraspinatus tear. The patients were treated by a single surgeon (M.R.) from a single center. Outcome measures were collected retrospectively and prospectively. Inclusion criteria for SCR were as follows: (1) irreparable supraspinatus tear; (2) grossly intact glenohumeral joint with minimal evidence of degenerative change; (3) pain on attempted active arm elevation with obvious clinical signs of proximal migration of the humeral head (this included patients with clinical pseudoparalysis defined as inability of active elevation beyond 45° as a result of an absent superior cuff); and (4) full passive range of movement of the glenohumeral joint.

All patients underwent clinical assessment preoperatively and cross-sectional magnetic resonance imaging that outlined the size of the tear and the quality of muscle belly. Patients who had more than one irreparable tendon were excluded. However, concomitant infraspinatus tears that were deemed reparable at the time of surgery were included.

Nine patients had pseudoparalysis on clinical assessment. The remaining 16 patients had a painful arc, with 13 having limited abduction with sensation of locking of the shoulder and 3 having clicking but maintaining range of motion.

Outcome Measures

Patients' Oxford Shoulder Score (OSS) was obtained preoperatively and then at 3 to 6 months, 1 year, and 2 years postoperatively. Active range of motion (flexion, external rotation, and abduction) of all patients was also recorded at all time points postoperatively. Patient satisfaction with the procedure was evaluated at final follow-up. Magnetic resonance imaging was routinely performed at 3 months postoperatively to assess for graft integrity.

Surgical Technique

An all-arthroscopic technique was used once patients had received general anesthesia and suprascapular nerve block in the beach chair position. Assessment of the glenohumeral joint and all tendons following bursal clearance was performed through posterior and lateral viewing portals. Tenotomy of the long head of the biceps was routinely performed in all cases. On confirmation of the inclusion criteria, the decision was made to proceed to SCR. Concomitant tears involving the infraspinatus or subscapularis were repaired first.

Soft Tissue Release and Footprint Preparation

A 10-mm cannula (PassPort Cannula; Arthrex, Naples, Florida) was inserted into the lateral portal. The residual supraspinatus tendon stump was released from the glenoid and preserved. Any suture anchors from previous repair were removed, followed by bony preparation of both the glenoid and humeral head footprint.

Medial and Lateral Anchor Placement

Two double-loaded glenoid anchors (3.0-mm BioComposite SutureTak; Arthrex) were placed at the 11:00- and 1:00-o'clock positions through percutaneous anterior and posterior portals.

Two medial row humeral anchors (4.75-mm BioComposite Vented SwiveLock; Arthrex) were placed using anterior and posterior superolateral portals. The anchors were loaded with attached swedged FiberTapes (Arthrex).

Graft Measurement and Preparation

Graft dimensions were determined using an arthroscopic measurement probe (220 mm, 60°; Arthrex). An additional 5 mm was added to the medial, anterior, and posterior measurement and 10 mm to the lateral measurement. The 3.5-mm acellular dermal allograft (ArthroFlex; Arthrex) was cut to the required size. The desired suture points were marked on the graft with a sterile marker, and an arrow indicated orientation.

Glenoid Fixation Technique

Graft passage into the joint was achieved using the double-pulley technique12 (Figure 1) for the first 8 patients. For the rest of the patients, a modification of the technique was used whereby one simple and one cinch loop suture were passed through the graft from each anchor (Figure 2). The medial suture limbs were rolled in the graft to facilitate passage through the cannula. Shuttling of the graft onto the glenoid was achieved by pulling on the simple suture limbs from each anchor. The two corresponding suture limbs were then tied. The retention sutures were passed through the supraspinatus stump and tied.

Model photographs illustrating the original glenoid fixation technique using the double-pulley technique.

Figure 1:

Model photographs illustrating the original glenoid fixation technique using the double-pulley technique.

Clinical (A) and model (B) photographs illustrating the modified glenoid fixation technique.

Figure 2:

Clinical (A) and model (B) photographs illustrating the modified glenoid fixation technique.

Humeral Fixation and Margin Convergence

Graft fixation to the humerus was performed using a standard double-row knotless transosseous equivalent technique (SpeedBridge Implant System; Arthrex). The swedged FiberTapes from the medial row anchors were first passed through the graft and then separated. One FiberTape from each anchor was then passed into a 4.75-mm SwiveLock lateral row anchor. The process was repeated for the second lateral row anchor, creating equal compression of the graft footprint (Figure 3). Posterior margin convergence of the infraspinatus to the posterior margin of the graft was performed in all cases. Anterior margin convergence was not performed due to resultant stiffness.

Arthroscopic view of the right shoulder showing the final position of the humeral side fixation using a standard double-row knotless transosseous equivalent technique.

Figure 3:

Arthroscopic view of the right shoulder showing the final position of the humeral side fixation using a standard double-row knotless transosseous equivalent technique.

Rehabilitation

Patients were immobilized in a sling for 6 weeks postoperatively, but passive-assisted flexion (restricted to 90°) and external rotation (restricted to 30°) commenced immediately. At 6 weeks, full passive range of motion was permitted. At 3 months, strengthening was initiated with progression to full active range of motion. Return to full activity was permitted at 6 months, including all sports activities without restriction. All patients received guidance from a dedicated shoulder physiotherapist.

Statistical Analysis

Statistical analysis was performed with SPSS for Windows version 12.0 (SPSS Inc, Chicago, Illinois). Categorical variables (eg, number of failures in each medial fixation technique) were compared using Fisher's exact test. Continuous data (eg, change in the mean of the OSS, range of motion between before and after the procedure) were compared using the paired Student's t test (t test for two dependent means). All tests were two sided, with statistical significance set as P<.05.

Results

A total of 25 patients (25 shoulders) were reviewed. Patient demographics are summarized in Table 1. A detailed overview is provided in Table A (available in the online version of the article).

Patient Demographics

Table 1:

Patient Demographics

Detailed outcome on individuals within patient cohort.Detailed outcome on individuals within patient cohort.

Table A.

Detailed outcome on individuals within patient cohort.

All patients were available for follow-up at 3 to 6 months and 1 year postoperatively. At 2 years, 23 patients were available and 2 had been lost to follow-up.

The mean OSS improved by a minimum of 10 points at all follow-up intervals. The mean active forward elevation and abduction improved by at least 20° at all time points and were clinically and statistically significant. Improvement in mean external rotation was seen at 1 year and 2 years postoperatively; despite being statistically significant, this was considered marginal (7°) (Table 2).

Comparison of Outcome Measures

Table 2:

Comparison of Outcome Measures

There were no cases of postoperative infection. Exacerbation of preexisting cervical myelopathy was seen in 1 patient, leading to a poor outcome. Four graft failures were observed: 3 occurred at the glenoid side at the graft/suture interface, being identified on magnetic resonance imaging routinely performed at 3 months postoperatively; and 1 occurred in the mid-substance, being identified at the time of revision surgery. All 3 of the glenoid side failures were observed among the 8 initial patients who had graft fixation using the double-pulley technique. Following modification of the technique to a double cinch loop, no further failures at the glenoid were observed (P=.04, Fisher's exact test); however, 1 failure of the graft in the mid-substance was observed in this group. Examples of intact and failed grafts on magnetic resonance imaging are illustrated in Figure 4 and Figure 5, respectively. Three of the 4 graft failures underwent revision to RSA for ongoing pain. The time intervals between the primary procedure and the RSA were 6, 7, and 15 months.

T1-weighted coronal (A) and sagittal (B) magnetic resonance images illustrating the final position of an intact superior capsular reconstruction dermal allograft. Abbreviations: Ac, acromion; GI, glenoid; Gr, graft; HH, humeral head; ISp, infraspinatus; SSc, subscapularis; Tm, teres minor.

Figure 4:

T1-weighted coronal (A) and sagittal (B) magnetic resonance images illustrating the final position of an intact superior capsular reconstruction dermal allograft. Abbreviations: Ac, acromion; GI, glenoid; Gr, graft; HH, humeral head; ISp, infraspinatus; SSc, subscapularis; Tm, teres minor.

T2-weighted coronal magnetic resonance image illustrating graft failure at the glenoid (arrow). Abbreviations: Gl, glenoid; Gr, graft; HH, humeral head.

Figure 5:

T2-weighted coronal magnetic resonance image illustrating graft failure at the glenoid (arrow). Abbreviations: Gl, glenoid; Gr, graft; HH, humeral head.

At 3 to 6 months, 5 patients had no improvement in their OSS compared with preoperatively. Three patients had failure of the graft medially (1 declined any further surgery, and the other 2 were revised to RSA). One patient had exacerbation of preexisting cervical myelopathy. The other patient, with a history of multiple sclerosis, had deterioration of overall functional ability after surgery. Of the 9 patients with pseudoparalysis preoperatively, 6 had restoration postoperatively. Two had little improvement in range of motion, but their pain significantly improved. One patient had a poor outcome. At 1 year postoperatively, 1 patient had deterioration in pain and function as a result of failure of the graft at the glenoid and was therefore revised to RSA.

Fifteen patients had previous rotator cuff repair surgery; the rest did not. There were 2 graft failures before 1 year resulting in revision to RSA (1 patient in each group). Of the 14 patients who had previous rotator cuff repair surgery, 11 (79%) showed improvement in their OSS by at least 10 points (mean, 18 points) at 1 year. Similarly, of the 9 patients for whom SCR was the primary procedure, 7 (78%) showed improvement in their OSS by at least 10 points (mean, 15 points) at 1 year. There was no difference in OSS at 1 year (P=.99, Fisher's exact test) between patients undergoing SCR who had a history of previous rotator cuff surgery and patients who underwent SCR as a primary procedure.

Superior capsular reconstruction led to a successful outcome in 21 of 25 patients at 3 to 6 months (84%), 20 of 25 patients at 1 year (80%), and 18 of 23 patients at 2 years (72%).

Of the 23 patients at the final follow-up, 19 (83%) were satisfied and 4 were dissatisfied. Of the dissatisfied patients, 2 had revision to RSA, 1 had global deteriorations secondary to multiple sclerosis, and 1 had failure of the graft but declined further surgery. The last patient who had revision to RSA reported satisfaction, with symptomatic improvement achieved for 1 year.

Discussion

Restoration of the superior capsule provides a static restraint to superior migration of the humeral head in the presence of a massive rotator cuff tear. This in turn optimizes force couples, enhancing the function of the deltoid. Initial outcomes of SCR reported by Mihata et al4 using fascia lata autografts were promising. The use of acellular dermal allograft has increased due to reduced donor site morbidity and surgical time; however, reports have been limited to surgical techniques10,13–17 and case series.18,19

In a prospective case series, Denard et al18 reviewed the outcomes of SCR using acellular dermal allograft in 59 patients with minimum follow-up of 12 months (mean, 17.7 months). They reported similar improvement in range of flexion and abduction—a minimum of 20° for each. Similarly, the rate of revision of failed cases to RSA was 11.8% (7 of 59 patients), comparable to the current series, which had a revision rate of 12% (3 of 25 patients). A marginally lower success rate of 70% at a minimum of 1 year was also reported, compared with 80% of patients achieving a successful outcome at 1 year and 72% at 2 years in the current study. However, success rates improved to 87% at 1 year and 86% at 2 years on exclusion of the 2 patients who had underlying global conditions (cervical myelopathy and multiple sclerosis) that impacted their OSS. The observed difference may be attributable to the variability in graft thickness (range, 1–3 mm) in the study by Denard et al.18 Mihata et al11 demonstrated that a significant decrease in superior translation can only be seen with an 8-mm–thick graft, suggesting that ultimately a thicker graft may be necessary. Although there is no consensus on graft thickness, the current authors found that the 3.5-mm graft used in all of their cases achieved a promising rate of success even at 2 years.

In a larger retrospective case series, Pennington et al19 reviewed 86 patients with a minimum follow-up of 1 year (range, 16 to 28 months). Thirty-six patients had follow-up of 2 years. These authors found a statistically significant improvement in American Shoulder and Elbow Surgeons scores and range of motion at 1 and 2 years. Significant improvement in strength was also observed at 6 months but not beyond. Graft failure was reported in 4.4% of patients. Although not directly comparable to American Shoulder and Elbow Surgeons scores, a significant improvement in OSS was also seen in 80% and 72% of the current patients at 1 and 2 years, respectively. Graft failure was observed in a higher proportion in the current series—16% (4 of 25 patients). All patients in the current series underwent magnetic resonance imaging at 3 months postoperatively in a standardized protocol. Conversely, Pennington et al19 did not routinely perform magnetic resonance imaging unless patient dissatisfaction or significant trauma was reported. However, patients may not immediately report symptoms following graft failure due to the interposition effect of the graft in the subacromial space. This in turn offers some initial restraint to superior migration of the humeral head, allowing optimal deltoid function and minimizing pain. This may be explained by the similar effect of interposition arthroplasty.20 It is therefore possible that graft failures are underdiagnosed if routine magnetic resonance imaging is not performed. The current authors acknowledge that, in this series, graft failures may have been underidentified at final follow-up because further imaging was not routinely perform at that point.

The authors observed a total of 4 graft failures. Interestingly, 3 occurred at the glenoid in patients who had fixation via a double-pulley technique originally described for rotator cuff repairs21 and subsequently popularized for SCR.10,13,14 With the double cinch loop technique being adopted for glenoid fixation, 1 mid-substance failure was diagnosed at the time of revision to arthroplasty. There were no significant differences in demographics between the cohorts of patients undergoing each glenoid fixation technique, suggesting that failures were attributable to the technique rather than patient factors.

Acromiohumeral distance preoperatively and postoperatively was not routinely measured in the current series, unlike in other series.18,19 Originally described by Ellman et al22 using standard plain antero-posterior radiographs, the acromiohumeral distance is used to assess superior stability. However, the humerus is referenced to the acromion, which may be influenced by projection of the radiograph beam23 or by the routine acromioplasty performed at the time of SCR. As a result, error can be easily introduced in the true assessment of superior humeral head migration. Therefore, acromiohumeral distance measurement was omitted from the current study.

This study had several limitations. First, it was a retrospective case review (level IV evidence) with no comparative cohort (patients treated nonoperatively or other surgical options). Nonetheless, the prospective collection of outcome measures (range of motion and OSS), the length of follow-up, the standardized postoperative rehabilitation protocol, and the reassessment of range of motion and OSS at regular postoperative intervals allowed valuable conclusions to be drawn. Second, the number of included patients was small; however, the statistical significance observed between the preoperative and postoperative outcome scores added to the power of the study.

Conclusion

This study contributes to the body of evidence that SCR offers a safe and effective bridging option for patients with an irreparable supraspinatus tear in the absence of glenohumeral joint arthritis. However, several concerns are consistently raised,24 including optimal graft thickness, graft type, graft healing, and longer-term clinical outcomes. The existing literature is lacking. Randomized controlled trials comparing SCR with other treatment options (eg, debridement alone, margin convergence, or placebo) are required to justify the cost-effectiveness.

References

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  10. Tokish JM, Beicker C. Superior capsule reconstruction technique using an acellular dermal allograft. Arthrosc Tech. 2015;4(6):e833–e839. doi:10.1016/j.eats.2015.08.005 [CrossRef] PMID:27284520
  11. Mihata T, McGarry MH, Kahn T, Goldberg I, Neo M, Lee TQ. Biomechanical effect of thickness and tension of fascia lata graft on glenohumeral stability for superior capsule reconstruction in irreparable supraspinatus tears. Arthroscopy. 2016;32(3):418–426. doi:10.1016/j.arthro.2015.08.024 [CrossRef] PMID:26524937
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Patient Demographics

CharacteristicValue
Patients/shoulders, No.25/25
Age, mean (range), y66 (49–80)
Side, right/left, No.13/12
Sex, male/female, No.17/8
Previous rotator cuff surgery, No.
  None10
  Primary arthroscopic repair7
  Revision arthroscopic repair7
  Revision open repair1
Additional procedures with superior capsular reconstruction, No.
  Infraspinatus (partial tear repair)5
  Subscapularis0

Comparison of Outcome Measures

MeasurePreoperativePostoperative

3 to 6 Months1 Year2 Years
Oxford Shoulder Score, mean (SD), points17.88 (6.8)27 (10.2)36.5 (9.4)38.5 (9.2)
   Pa.00004.00001.00001
Flexion, mean80°105°117°118°
   Pa.00004.00004.00004
External rotation, mean30°30°37°37°
   Pa.99.017.019
Abduction, mean70°97°105°107°
   Pa.00001.00001.00001

Detailed outcome on individuals within patient cohort.

PatientAge/sexSideOSS PreopOSS 3–6 MonthsOSS 1 YearOSS 2 YearsRevision SurgeryComments
172FL12364540None
277ML28374044None
366FL192234-No data at 2 years
458MR522-NoneMRI: graft failed medially
565MR22334344None
668FR17194242None
768MR13252536None
849MR18344444None
972MR20344046None
1072MR26384144None
1152FL12323747None
1273ML20324040None
1361ML20151616NonePatient suffers from MS
1475FR15363927None
1551FR20202323None
1676ML3830--RSAMRI: graft failed medially
1765ML18273744None
1872MR13888NonePatient with cervical myelopathy
1962ML21364848None
2058ML24454747None
2156FR81212-RSAMRI: graft failed medially
2280FL1616--RSAGraft failed mid-substance
2364ML9283832None
2476MR12283830None
2577MR21323939None
Authors

The authors are from Watford General Hospital (DM, QOT), Watford; and Stepping Hill Hospital (DS, BWM, MR), Stockport, United Kingdom.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Quen O. Tang, MBChB, FRCS (Tr&Orth), 12A Sterne St, Shepherds Bush, London, W128AD, United Kingdom ( quentang@gmail.com).

Received: November 09, 2019
Accepted: February 24, 2020
Posted Online: May 05, 2020

10.3928/01477447-20200428-05

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