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.
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.
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.
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.
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 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.
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).
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
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.
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.
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.
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.
- Liem D, Lengers N, Dedy N, Poetzl W, Steinbeck J, Marquardt B. Arthroscopic debridement of massive irreparable rotator cuff tears. Arthroscopy. 2008;24(7):743–748. doi:10.1016/j.arthro.2008.03.007 [CrossRef] PMID:18589261
- Lee BG, Cho NS, Rhee YG. Results of arthroscopic decompression and tuberoplasty for irreparable massive rotator cuff tears. Arthroscopy. 2011;27(10):1341–1350. doi:10.1016/j.arthro.2011.06.016 [CrossRef] PMID:21873021
- Kim SJ, Lee IS, Kim SH, Lee WY, Chun YM. Arthroscopic partial repair of irreparable large to massive rotator cuff tears. Arthroscopy. 2012;28(6):761–768. doi:10.1016/j.arthro.2011.11.018 [CrossRef] PMID:22317798
- Mihata T, Lee TQ, Watanabe C, et al. Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy. 2013;29(3):459–470. doi:10.1016/j.arthro.2012.10.022 [CrossRef] PMID:23369443
- Mori D, Funakoshi N, Yamashita F. Arthroscopic surgery of irreparable large or massive rotator cuff tears with low-grade fatty degeneration of the infraspinatus: patch autograft procedure versus partial repair procedure. Arthroscopy. 2013;29(12):1911–1921. doi:10.1016/j.arthro.2013.08.032 [CrossRef] PMID:24169146
- Wellmann M, Lichtenberg S, da Silva G, Magosch P, Habermeyer P. Results of arthroscopic partial repair of large retracted rotator cuff tears. Arthroscopy. 2013;29(8):1275–1282. doi:10.1016/j.arthro.2013.05.006 [CrossRef] PMID:23906267
- Grimberg J, Kany J, Valenti P, Amaravathi R, Ramalingam AT. Arthroscopic-assisted latissimus dorsi tendon transfer for irreparable posterosuperior cuff tears. Arthroscopy. 2015;31(4):599–607.e591. doi:10.1016/j.arthro.2014.10.005 [CrossRef]
- Ek ET, Neukom L, Catanzaro S, Gerber C. Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen years. J Shoulder Elbow Surg. 2013;22(9):1199–1208. doi:10.1016/j.jse.2012.11.016 [CrossRef] PMID:23385083
- Mihata T, McGarry MH, Pirolo JM, Kinoshita M, Lee TQ. Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: a biomechanical cadaveric study. Am J Sports Med. 2012;40(10):2248–2255. doi:10.1177/0363546512456195 [CrossRef] PMID:22886689
- 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
- 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
- Koo SS, Burkhart SS, Ochoa E. Arthroscopic double-pulley remplissage technique for engaging Hill-Sachs lesions in anterior shoulder instability repairs. Arthroscopy. 2009;25(11):1343–1348. doi:10.1016/j.arthro.2009.06.011 [CrossRef] PMID:19896057
- Hirahara AM, Adams CR. Arthroscopic superior capsular reconstruction for treatment of massive irreparable rotator cuff tears. Arthrosc Tech. 2015;4(6):e637–e641. doi:10.1016/j.eats.2015.07.006 [CrossRef] PMID:26870638
- Burkhart SS, Denard PJ, Adams CR, Brady PC, Hartzler RU. Arthroscopic superior capsular reconstruction for massive irreparable rotator cuff repair. Arthrosc Tech. 2016;5(6):e1407–e1418. doi:10.1016/j.eats.2016.08.024 [CrossRef] PMID:28149739
- Narvani AA, Consigliere P, Polyzois I, Sarkhel T, Gupta R, Levy O. The “pull-over” technique for arthroscopic superior capsular reconstruction. Arthrosc Tech. 2016;5(6):e1441–e1447. doi:10.1016/j.eats.2016.08.016 [CrossRef] PMID:28560141
- Laskovski JR, Boyd JA, Peterson EE, Abrams JS. Simplified technique for superior capsular reconstruction using an acellular dermal allograft. Arthrosc Tech. 2018;7(11):e1089–e1095. doi:10.1016/j.eats.2018.07.002 [CrossRef] PMID:30533353
- Pennington WT, Chen SW, Bartz BA, Pauli JM. Arthroscopic superior capsular reconstruction with acellular dermal allograft using push-in anchors for glenoid fixation. Arthrosc Tech. 2018;8(1):e51–e55. doi:10.1016/j.eats.2018.08.026 [CrossRef] PMID:30899651
- Denard PJ, Brady PC, Adams CR, Tokish JM, Burkhart SS. Preliminary results of arthroscopic superior capsule reconstruction with dermal allograft. Arthroscopy. 2018;34(1):93–99. doi:10.1016/j.arthro.2017.08.265 [CrossRef] PMID:29146165
- Pennington WT, Bartz BA, Pauli JM, Walker CE, Schmidt W. Arthroscopic superior capsular reconstruction with acellular dermal allograft for the treatment of massive irreparable rotator cuff tears: short-term clinical outcomes and the radiographic parameter of superior capsular distance. Arthroscopy. 2018;34(6):1764–1773. doi:10.1016/j.arthro.2018.01.009 [CrossRef] PMID:29456069
- Holschen M, Brand F, Agneskirchner JD. Subacromial spacer implantation for massive rotator cuff tears: clinical outcome of arthroscopically treated patients. Obere Extrem. 2017;12(1):38–45. doi:10.1007/s11678-016-0386-9 [CrossRef] PMID:28868086
- Arrigoni P, Brady PC, Burkhart SS. The double-pulley technique for double-row rotator cuff repair. Arthroscopy. 2007; 23(6):675.e1–e4. doi:10.1016/j.arthro.2006.08.016 [CrossRef]
- Ellman H, Hanker G, Bayer M. Repair of the rotator cuff: end-result study of factors influencing reconstruction. J Bone Joint Surg Am. 1986;68(8):1136–1144. doi:10.2106/00004623-198668080-00002 [CrossRef] PMID:3771595
- Burkhart SS. Superior capsule reconstruction with dermal allograft: achieving the goal of joint preservation. Arthroscopy.2018;34(6):1774–1775. doi:10.1016/j.arthro.2018.02.024 [CrossRef] PMID:29804601
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|Age, mean (range), y||66 (49–80)|
|Side, right/left, No.||13/12|
|Sex, male/female, No.||17/8|
|Previous rotator cuff surgery, No.|
| Primary arthroscopic repair||7|
| Revision arthroscopic repair||7|
| Revision open repair||1|
|Additional procedures with superior capsular reconstruction, No.|
| Infraspinatus (partial tear repair)||5|
Comparison of Outcome Measures
|3 to 6 Months||1 Year||2 Years|
|Oxford Shoulder Score, mean (SD), points||17.88 (6.8)||27 (10.2)||36.5 (9.4)||38.5 (9.2)|
|External rotation, mean||30°||30°||37°||37°|
Detailed outcome on individuals within patient cohort.
|Patient||Age/sex||Side||OSS Preop||OSS 3–6 Months||OSS 1 Year||OSS 2 Years||Revision Surgery||Comments|
|3||66F||L||19||22||34||-||No data at 2 years|
|4||58M||R||5||2||2||-||None||MRI: graft failed medially|
|13||61M||L||20||15||16||16||None||Patient suffers from MS|
|16||76M||L||38||30||-||-||RSA||MRI: graft failed medially|
|18||72M||R||13||8||8||8||None||Patient with cervical myelopathy|
|21||56F||R||8||12||12||-||RSA||MRI: graft failed medially|
|22||80F||L||16||16||-||-||RSA||Graft failed mid-substance|