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Address correspondence to Teruhisa Mihata, M.D., Ph.D., Department of Orthopedic Surgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka 569-8686, Japan.
Affiliations
Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Osaka, JapanOrthopaedic Biomechanics Laboratory, VA Healthcare System, Long Beach; and the University of California, Irvine, CA, U.S.A.
The objective of this study was to investigate the clinical outcome and radiographic findings after arthroscopic superior capsule reconstruction (ASCR) for symptomatic irreparable rotator cuff tears.
Methods
From 2007 to 2009, 24 shoulders in 23 consecutive patients (mean, 65.1 years) with irreparable rotator cuff tears (11 large, 13 massive) underwent ASCR using fascia lata. We used suture anchors to attach the graft medially to the glenoid superior tubercle and laterally to the greater tuberosity. We added side-to-side sutures between the graft and infraspinatus tendon and between the graft and residual anterior supraspinatus/subscapularis tendon to improve force coupling. Physical examination, radiography, and magnetic resonance imaging (MRI) were performed before surgery; at 3, 6, and 12 months after surgery; and yearly thereafter. Average follow-up was 34.1 months (24 to 51 months) after surgery.
Results
Mean active elevation increased significantly from 84° to 148° (P < .001) and external rotation increased from 26° to 40° (P < .01). Acromiohumeral distance (AHD) increased from 4.6 ± 2.2 mm preoperatively to 8.7 ± 2.6 mm postoperatively (P < .0001). There were no cases of progression of osteoarthritis or rotator cuff muscle atrophy. Twenty patients (83.3%) had no graft tear or tendon retear during follow-up (24 to 51 months). The American Shoulder and Elbow Surgeons (ASES) score improved from 23.5 to 92.9 points (P < .0001).
Conclusions
ASCR restored superior glenohumeral stability and function of the shoulder joint with irreparable rotator cuff tears. Our results suggest that this reconstruction technique is a reliable and useful alternative treatment for irreparable rotator cuff tears.
Level of Evidence
Level IV, therapeutic case series.
Chronic large to massive rotator cuff tears are challenging to repair completely because of the development of tendon retraction with inelasticity,
Arthroscopic debridement and decompression for selected rotator cuff tears. Clinical results, pathomechanics, and patient selection based on biomechanical parameters.
However, none of these approaches is considered optimal for irreparable rotator cuff tears because any alternative to complete repair has proved inferior in terms of clinical outcome and postoperative complications.
These signs result mainly from a loss of the superior stability of the glenohumeral joint because of dysfunction of the rotator cuff muscles. Patients with irreparable rotator cuff tears have a defect of the superior capsule, which is located on the inferior surface of the supraspinatus and infraspinatus tendons. Therefore, we developed a new surgical treatment, arthroscopic superior capsule reconstruction (ASCR) (Figs 1 and 2, and Video 1 [available at www.arthroscopyjournal.org]) to restore superior stability of the shoulder joint because the shoulder capsule plays a role in stabilizing the glenohumeral joint.
Fig 1(Left) Conventional patch graft surgery. The graft is attached medially to the torn tendon and laterally to the greater tuberosity. (Right) Superior capsule reconstruction. The graft is attached medially to the superior tubercle of the glenoid and laterally to the greater tuberosity.
The objective of this study was to investigate the clinical outcome and radiographic findings after use of this technique on irreparable posterosuperior rotator cuff tears. Our hypothesis was that reconstruction of the superior capsule could increase acromiohumeral distance (AHD) and improve functional outcomes even when the torn tendons could not be repaired.
Methods
We retrospectively reviewed our database, which was collected prospectively. From 2007 to 2009, 223 consecutive patients with rotator cuff tears for which conservative treatment had failed underwent arthroscopic surgery by a single surgeon. The patients signed an informed consent form approved by the Institutional Review Board at our university (Osaka Medical College, No. 0893). Twenty-four patients had partial-thickness tears, and 174 patients with full-thickness tears underwent arthroscopic rotator cuff repair. The remaining 25 patients with irreparable rotator cuff tears were managed with ASCR. Two patients moved away and were lost to follow-up. The inclusion criterion was an irreparable rotator cuff tear that was evaluated during shoulder arthroscopy. When the torn tendon cannot reach to the original footprint, the rotator cuff tear is defined as an irreparable tear. The exclusion criteria included severe bone deformity such as Hamada classification type V, severe superior migration of the humeral head that does not move by traction of the arm, cervical nerve palsy, axillary nerve palsy, deltoid muscle dysfunction, and infection. One patient underwent ASCR in both shoulders. Consequently, 24 shoulders in 23 patients were enrolled in the study.
Patient Assessment
The patients provided a standard history and underwent physical examination that consisted of measurement of the shoulder range of motion and muscle strength by a single surgeon before surgery; at 3, 6, and 12 months after surgery; and yearly thereafter. We measured shoulder elevation, external rotation with the arm at the side, and internal rotation both actively and passively. We measured internal rotation as the highest vertebral body that the patient was able to reach with the thumb of the affected arm. We determined muscle strength by manual muscle testing (MMT) on a scale of 0 to 5, where 5 = normal amount of resistance to applied force; 4 = resistance between 5 and 3; 3 = ability to move the segment (the arm) through its range of motion against gravity; 2 = ability to move the segment through its range of motion but not against gravity; 1 = presence of contraction in the muscle without joint motion; and 0 = no muscle contraction.
Grades 3 and 4 were further divided into 3 grades (grades 3−, 3, and 3+ and grades 4−, 4, and 4+), and grade 5 was divided into 2 grades (grades 5− and 5).
We assessed all patients preoperatively by using the scoring systems of the shoulder index of the American Shoulder and Elbow Surgeons (ASES, a 100-point scoring system),
; we reassessed the patients at the time of the final follow-up. The average time to final follow-up was 34.1 months (range, 24 to 51 months). We believe that the variability of the follow-up period did not affect the current result, because the clinical results did not change after 2 years postoperatively.
Radiography and Magnetic Resonance Imaging
We obtained preoperative and follow-up radiographs in 3 planes (anteroposterior view with the arm in neutral rotation, axial view, and scapular Y view) in all patients. AHD was measured on standard anteroposterior radiographs by the method described by Ellman et al.
Magnetic resonance imaging (MRI) was performed with a 1.5-T closed-type scanner (MRT-2000/V2, Toshiba, Tokyo, Japan). Oblique coronal, oblique sagittal, and axial T2-weighted MR images were acquired for structural and qualitative assessment of the rotator cuff tendons, and repair integrity was determined. We evaluated fatty degeneration of the rotator cuff by using the grading system of Goutallier et al.
in 5 stages: Stage 0 corresponds to a completely normal muscle, without any fatty streak; in stage 1 the muscle contains some fatty streaks; in stage 2 the fatty infiltration is substantial, but there is still more muscle than fat; in stage 3 there is as much fat as muscle; and in stage 4 there is more fat than muscle. Radiography and MRI were performed by a single surgeon before surgery; at 3, 6, and 12 months after surgery; and yearly thereafter, and this study used the final data. Average follow-up was 34.1 months (range, 24 to 51 months) after surgery.
Surgical Technique
We performed all procedures using general anesthesia with the patient in the lateral decubitus position. Normal pump pressure was set between 30 and 50 mm Hg. We examined shoulder range of motion and laxity with the patient under general anesthesia. Three portals were typically required for the ASCR. We established a posterior portal for initial assessment of the glenohumeral joint. We established an anterior portal through the rotator interval as the working portal for treatment of intra-articular lesions, such as labral tear and biceps tear, or subluxation. We then removed the arthroscope from the glenohumeral joint and redirected it into the subacromial space. We also established a lateral portal. We removed any pathologic bursal tissue that impeded clearance of the space. We performed arthroscopic subacromial decompression to create a flat acromial undersurface. We also removed bony spurs in the inferior part of the acromioclavicular joint and at the distal end of the clavicle. We debrided the superior glenoid and rotator cuff footprint of the greater tuberosity to expose cortical bone. We completely repaired the torn subscapularis tendon and partially repaired the torn infraspinatus and teres minor tendons with fully threaded titanium suture anchors (diameter, 5 mm; Corkscrew II Suture Anchor, Arthrex, Naples, FL). We evaluated the size of the superior capsular defect by using a measuring probe in both the anteroposterior and mediolateral direc-tions at 45° shoulder abduction.
We made a vertical skin incision over the lateral thigh around the greater trochanter of the femur and harvested a section of fascia lata 2 to 3 times the size of the superior capsular defect, after which we fashioned a graft 6 to 8 mm thick by folding the fascia lata twice or thrice (average graft size after folding: 6.1 cm mediolaterally and 3.0 cm anteroposteriorly) and stitched to keep it from unfurling. We inserted the graft into the subacromial space through the lateral portal and then attached the medial side of the fascia lata to the superior glenoid by using 2 fully threaded titanium suture anchors (diameter, 5 mm; Corkscrew II Suture Anchor, Arthrex) each with 2 No. 2 FiberWire nonabsorbable sutures (Arthrex), which we inserted into the superior glenoid at the 10 to 11 o'clock and 11 to 12 o'clock positions on the glenoid of the right shoulder (or the 1 to 2 o'clock and 12 to 1 o'clock positions of the left shoulder). We attached the lateral side of the fascia lata to the rotator cuff footprint on the greater tuberosity by using the compression double-row technique, which is a combination of the conventional double-row technique and the suture bridge,
at 45° shoulder abduction. To achieve this, we placed Corkscrew II suture anchors medially at the edge of the articular cartilage and laterally 5 to 10 mm inferior to the highest tip of the greater tuberosity to minimize the possibility of the anchors pulling out. We placed the sutures through the fascia lata by using either a suture shuttle (SutureLasso, Arthrex) or a suture-passing device (Scorpion Suture Passer, Arthrex). Finally, we added side-to-side sutures between the graft and the infraspinatus tendon and between the graft and the residual anterior supraspinatus tendon or subscapularis tendon to improve force coupling in the shoulder joint. We made a couple of stitches with No. 2 FiberWire nonabsorbable sutures in the anterior and posterior sides. Careful attention should be paid to overtightening of the side-to-side suture in the anterior side to avoid shoulder contracture after surgery. When the graft is attached in the medial, lateral, and posterior side very well, the anterior suture may not be necessary. Technical pearls and pitfalls of ASCR are noted in Table 1.
Table 1Technical Pearls and Pitfalls of ASCR
•
Acromioplasty is recommended to avoid abrasion of the graft under the acromion after surgery.
•
Subscapularis tear should be repaired.
•
The capsular defect may be underestimated because the probe is straight and the surface of the greater tuberosity is curved.
•
Thick and large grafts are better. In particular, when the torn infraspinatus tendon is severely degenerated, a large-sized fascia lata should be grafted with or without repair of the torn infraspinatus tendon.
•
Careful attention should be paid to over-tightening of the side-to-side suture in the anterior side to avoid shoulder contracture after surgery. When the graft is attached in the medial, lateral, and posterior side very well, the anterior suture may not be necessary.
•
For a revision case which has many suture anchors inserted in the greater tuberosity, we recommend attaching the graft to the greater tuberosity with a transosseous procedure.
•
If a surgeon is not familiar with arthroscopic surgery, the superior capsule reconstruction can be performed with open procedure.
•
At least 6-12 months of postoperative rehabilitation is necessary.
•
To improve shoulder function after ASCR, the deltoid muscle force has to be kept normal.
We recommend the use of an abduction pillow (Airbags, Nakamura Brace, Shimane, Japan) for 4 weeks after the reconstruction. After the immobilization period, passive and active-assisted exercises were initiated to promote “scaption” (scapular plane elevation). Eight weeks after surgery, patients began to perform exercises to strengthen the rotator cuff and the scapula stabilizers. Physical therapists assisted all patients.
Statistical Analysis
To calculate the average of MMT grade, we converted each grade to a scale of 0 to 10, where MMT 5 = 10, MMT 5− = 9, MMT 4+ = 8, MMT 4 = 7, MMT 4− = 6, MMT 3+ = 5, MMT 3 = 4, MMT 3− = 3, MMT 2 = 2, MMT 1 = 1, and MMT 0 = 0. We compared the shoulder scores, shoulder range of motion, and converted MMT scale before surgery with the values at final follow-up using the Wilcoxon matched-pairs test. To compare the shoulder scores between the group with intact repairs and the group with retears, we used the Mann-Whitney U test. A significant difference was defined as P < .05.
Results
The 12 men and 11 women had an average age of 65.1 years (range, 52 to 77 years) at the time of surgery. Mean duration of symptoms before surgery was 21.8 months (3 to 120 months). The preoperative tear size was evaluated during arthroscopic surgery. Eleven tears were large (3 to 5 cm) and 13 were massive (>5 cm). All patients had labral fraying, and 13 patients had pathologic processes of the biceps long head, including 2 partial tears, 7 complete tears, one subluxation, and 3 dislocations. The labral fraying and biceps partial tears were debrided. One subluxation and 2 dislocations of the biceps tendon were repositioned after subscapularis repair. For one patient with biceps dislocation, we performed biceps tenodesis. The stage of osteoarthritis before surgery was classified by using the system of Hamada et al.
In this system, stage 1 is associated with minimal radiographic changes, stage 2 is characterized by narrowing of the subacromial space to ≤5 mm, stage 3 is defined as erosion and so-called acetabulization of the acromion caused by superior migration of the humeral head, stage 4 is associated with glenohumeral arthritis and is subdivided into stage 4a (without acetabulization) and stage 4b (with acetabulization), and stage 5 is characterized by the presence of humeral head osteonecrosis. Patients with Hamada stage 1, 2, or 3 were considered to have rotator cuff tear without arthritis, and patients with Hamada stage 4 or 5 were considered to have cuff tear arthropathy according to the definition given by Neer et al.
The average preoperative scores were 23.5 points by ASES (range, 3.3 to 63.3 points), 48.3 points by JOA (26.5 to 68.5 points), and 9.9 points by UCLA (4 to 18 points). Average clinical outcome scores all improved significantly after ASCR at the final follow-up (mean, 34.1 months; range, 24 to 51 months after surgery; ASES, 92.9 points; JOA, 92.6 points; UCLA, 32.4 points) (P < .00001) (Table 3). Postoperative clinical outcome scores in the healed patients (ASES, 96.0 points; JOA, 94.9 points; UCLA, 34.0 points) were significantly better than in the unhealed patients who had graft tears or retears of the repaired rotator cuff tendon (ASES: 77.1 points, P < .0001; JOA: 81.1, P < .001; UCLA: 24.8, P < .00001). All 5 manual workers and all 3 carpenters returned to the same jobs.
Table 3Summary of Patients' Shoulder Functional Scores
Shoulder
ASES Score
JOA Score
UCLA Score
Preoperative
Postoperative
Preoperative
Postoperative
Preoperative
Postoperative
1
43.3
100
63.5
100
18
35
2
13.3
100
28.5
100
5
35
3
10
100
26.5
97
4
35
4
16.7
100
44
97
10
34
5
16.7
95
43
92
7
34
6
21.7
100
49.5
97
12
34
7
8.3
100
30
95
6
35
8
26.7
100
35.5
100
5
35
9
13.3
95
43.5
93
9
33
10
28.3
100
49.5
95
13
35
11
20
100
58
99.5
13
35
12
43.3
100
68.5
100
18
35
13
20
88.3
37.5
92.5
7
31
14
18.3
96.7
44
94
8
34
15
51.7
96.7
70.5
92
17
34
16
21.7
95
49.5
95
7
35
17
33.3
78.3
65.5
76.5
17
25
18
15
76.7
32
83
5
22
19
10
70
38
79.5
5
28
20
63.3
100
56.5
100
15
35
21
18.3
100
64
100
12
35
22
28.3
100
57
100
11
35
23
20
65
54.5
72.5
9
21
24
3.3
71.7
49.5
71.5
4
28
Average
23.5
92.9
48.3
92.6
9.9
32.4
SD
14.4
11.3
13.0
9.0
4.7
4.3
ASES, American Shoulder and Elbow Surgeons; JOA, Japanese Orthopaedic Association; UCLA, University of California, Los Angeles. Postoperative = at the final follow-up.
The shoulder active range of motion improved significantly after ASCR at the final follow-up (mean, 34.1 months; range, 24 to 51 months after surgery)—by 64° for elevation (P < .001), by 14° for external rotation (P < .01), and by 2 vertebral bodies for internal rotation (P < .01) (Fig 3 and Table 4). Postoperative active elevation in the healed patients (157° ± 22°) was significantly greater than in the unhealed patients who had graft tears or retears of the repaired rotator cuff tendon (100° ± 44°; P < .001). Internal rotation decreased in 3 patients after surgery. Shoulder muscle strength improved significantly as well (abduction: 3+ to 5−, P < .001; external rotation: 3+ to 5−, P < .001; internal rotation: 4+ to 5, P < .001) (Table 5).
Fig 3Patient 3, 4 years after arthroscopic superior capsule reconstruction. (Left) The range of elevation and (right) external rotation have been restored to nearly normal.
Range of motion and strength were measured at 3, 6, and 12 months and yearly thereafter. However, there was no significant change beyond 2 years after surgery.
There were no surgical complications—such as neural injury, infection, or suture anchor problems—in this series. Also we did not see any complications with the harvest site.
Radiographic Evaluation
The preoperative AHD was 4.6 ± 2.2 mm (range, 1.3 to 9.3 mm). The AHD in 14 of 24 shoulders (58.3%) was 5 mm or less (stages 2, 3, and 4b of the Hamada grading system); 2 of these patients had acetabulization. After ASCR, the AHD increased significantly by 4.1 ± 1.7 mm (P < .00001) at final follow-up (Table 6). The postoperative AHD in 22 shoulders (91.7%) was more than 5 mm. The shoulders that had AHDs of 5 mm or less postoperatively had undergone postoperative retears of the repaired infraspinatus tendon or graft tear. There was no change in AHD from 3 months to final follow-up (mean, 34.1 months; range, 24 to 51 months after surgery).
Table 6Acromiohumeral Distance and Magnetic Resonance Imaging Findings
Shoulder
AHD (mm)
Structural Integrity
Preoperative Goutallier Grading System
Postoperative Goutallier Grading System
Preop
Postop
SSP
SubS
ISP
Teres
SSP
SubS
ISP
Teres
1
5.0
9.8
Healed
4
0
2
0
4
0
2
0
2
4.6
8.0
Healed
4
0
0
0
4
0
0
0
3
4.1
10.7
Healed
3
1
2
0
3
1
2
0
4
41
8.3
Healed
4
0
4
0
4
0
4
0
5
6.2
10.5
Healed
4
2
2
0
4
1
1
0
6
3.1
10.4
Healed
4
0
2
0
4
0
2
0
7
5.7
12.4
Healed
3
1
1
0
2
0
1
0
8
5.5
10.5
Healed
3
4
2
0
3
4
2
0
9
2.4
7.2
Healed
3
2
3
0
3
2
3
0
10
5.0
9.1
Healed
4
2
3
0
4
2
3
0
11
5.9
10.2
Healed
4
1
3
0
4
1
3
0
12
9.3
13.2
Healed
4
0
2
0
4
0
2
0
13
1.3
8.0
ISP retear
4
0
4
2
4
0
4
2
14
2.9
6.3
Healed
4
3
4
0
4
3
4
0
15
1.4
6.3
Healed
4
4
4
0
4
4
4
0
16
6.0
8.9
Healed
4
2
4
0
4
2
4
0
17
1.4
2.3
ISP retear
4
2
4
1
3
2
4
1
18
5.4
8.4
ISP retear
4
2
4
0
4
2
4
0
19
3.6
7.7
Healed
4
3
3
0
4
3
3
0
20
7.2
10.3
Healed
3
2
2
0
3
2
2
0
21
3.7
9.6
Healed
4
1
1
0
4
1
1
0
22
8.2
10.7
Healed
4
0
2
0
4
0
2
0
23
1.7
2.4
Graft tear
4
0
2
0
4
0
2
0
24
7.1
8.9
Healed
3
0
2
0
3
0
2
0
Average
4.6
8.7
3.8
1.3
2.6
0.1
3.7
1.3
2.5
0.1
SD
2.2
2.6
0.4
1.3
1.1
0.4
0.6
1.3
1.2
0.4
NOTE. Postoperative designates the final follow-up (mean, 34.1 months; range, 24 to 51 months after surgery).
Twenty of 24 shoulders (83.3%) had no graft tears or no retears of the repaired rotator cuff tendon during the follow-up period (mean, 34.1 months; range, 24 to 51 months after surgery) (Fig 4 and Table 6). Three patients (12.5%) with severe fatty degeneration of the infraspinatus tendon had retears of the repaired infraspinatus tendon at 3 months after surgery. One patient (4.2%), whose surgery was a revision procedure, had a postoperative graft tear 3 months after surgery.
Fig 4Coronal MRI scans in patient 3. (Left) Preoperative scan. (Right) Four years after arthroscopic superior capsule reconstruction.
Supraspinatus muscle atrophy in 2 of 24 shoulders (8.3%), subscapularis atrophy in 2 of 24 shoulders (8.3%), and infraspinatus atrophy in one of 24 shoulders (4.2%) were improved after ASCR at the final follow-up (mean, 34.1 months; range, 24 to 51 months after surgery). Progression of muscle atrophy was not seen in this series (Table 6).
Discussion
There have been many clinical reports of patch graft surgery for irreparable rotator cuff tears. However, patch graft surgery in which the graft is attached medially to the stump of the torn rotator cuff tendons is not considered reliable because the rate of graft tear is high. Moore et al.
used MRI arthrograms to investigate the structural integrity of allograft reconstructions of massive rotator cuff tears; all 15 of their patients had complete failure of reconstruction. Sclamberg et al.
treated large and massive rotator cuff tears with open repair and porcine small intestine submucosa reinforcement or interpositional grafting; MRI showed that 10 of 11 patients had retears at 6 months after surgery. Soler et al.
Early complications from the use of porcine dermal collagen implants (Permacol) as bridging constructs in the repair of massive rotator cuff tears. A report of 4 cases.
used porcine dermal collagen implants for massive rotator cuff tears; they found graft failures in all 4 patients between 3 and 6 months after surgery.
reported that the AHD did not change significantly after conventional patch graft surgery in which the graft was attached medially to the torn tendon and laterally to the greater tuberosity in massive rotator cuff tears (AHD, 6.2 to 11.3 mm preoperatively and 6.7 to 12.8 mm postoperatively). Their radiographic results suggested that the superior stability disturbed by massive rotator cuff tears may not be restored after patch grafts to the torn tendon. The patch graft may consequently be abraded under the acromion or torn after surgery.
Our findings showed that the AHD was significantly increased, by 4.1 ± 1.7 mm, after ASCR. Furthermore, no graft tears or retears of the repaired rotator cuff tendon were seen in 20 of 24 shoulders (83.3%) during the follow-up period. Therefore, we believe that the graft used in the surgery is not abraded, because superior stability is restored by the reconstruction.
In the pilot biomechanical study, we investigated the proper tension of the reconstructed superior capsule. The graft tension in the medial-lateral direction increased with a decreasing abduction angle. However, the grafted fascia lata never tore by adduction when the graft was placed at 45° degrees of abduction. Conversely, our pilot study showed that an increased humeral abduction increases graft tension in the anterior-posterior direction, although the graft becomes lax in the medial-lateral direction. Therefore, the reconstructed superior capsule is tight regardless of glenohumeral abduction, preventing superior migration of the humerus.
investigated the clinical outcome after complete arthroscopic rotator cuff repair with the double-row technique. Their postoperative ASES shoulder index was 94.3, the JOA score was 95.0, and the UCLA rating scale was 32.9. In a clinical study by Boileau et al.,
the average UCLA score improved from 11.5 ± 1.1 to 32.3 ± 1.3 after arthroscopic complete rotator cuff repair. In our study, the average ASES shoulder index improved to 92.9, the JOA score to 92.6, and the UCLA score to 32.4 after ASCR. Hence, the functional outcomes of JOA, UCLA, and ASES after this technique may be comparable to the outcomes of arthroscopic complete rotator cuff repair.
The clinical presentation of irreparable rotator cuff tear includes a limited active shoulder range of motion and decreased shoulder muscle strength, as well as shoulder pain. Most surgical treatments relieve shoulder pain, but patients find it difficult to recover muscle strength in elevation and external rotation even after alternative types of surgery, including latissimus dorsi tendon transfer
In our patients, active shoulder range of motion and shoulder muscle strength had severely deteriorated before surgery. Preoperative active elevation was only 84° and shoulder abduction strength was only 3+. Our reconstruction increased active elevation to 157° and abduction strength to 5− in healed cases. These values were similar to those after arthroscopic complete repair for massive rotator cuff tears with severe fatty degeneration: In a clinical study by Burkhart et al.,
the mean active forward elevation increased to 156° and the mean forward elevation strength increased to 4.0.
Using a cadaveric shoulder, we observed the superior shoulder capsule and reconstructed superior capsule during shoulder abduction. The superior shoulder capsule did not impinge under the acromion during shoulder abduction because the waved superior capsule got into the glenohumeral joint (Fig 5). Similarly, the reconstructed superior capsule made of fascia lata waved by shoulder abduction and the protrusion got into the glenohumeral joint (Fig 5). Therefore, the graft does not kink in the subacromial space.
Fig 5Cadaveric shoulder reconstruction. Superior capsule. (A) 0° glenohumeral abduction; (B) 60° glenohumeral abduction. Reconstructed superior capsule using fascia lata. (C) 0° glenohumeral abduction; (D) 60° glenohumeral abduction. Dotted lines show bursal surface of the superior capsule and reconstructed superior capsule. White arrow in B and D shows the glenohumeral joint. (Ac, acromion; F, fascia lata; H, humeral head.)
assessed the functional results of arthroscopic repair of massive rotator cuff tears in patients who had stage 3 or 4 fatty degeneration of the rotator cuff musculature. When there was more than 75% fatty degeneration of the infraspinatus muscle, the postoperative active forward elevation was only 128.0° and the postoperative forward elevation strength was 2.8. Therefore, standard arthroscopic rotator cuff repair may not be a good option in infraspinatus tears with severe fatty degeneration. Our results with successful ASCR show that this procedure restores shoulder function even with degenerative changes of the infraspinatus. Therefore, for massive tears with severe fatty degeneration of the infraspinatus, our technique may be a good alternative to arthroscopic rotator cuff repair.
We performed MRI before surgery; at 3, 6, and 12 months after surgery; and yearly thereafter and used the final data in this study. In our series, rotator cuff muscle atrophy did not progress, even though the supraspinatus tendon was not repaired. We surmise that the superior capsule reconstruction restored the force coupling of the rotator cuff muscles owing to the suturing between the residual anterior supraspinatus tendon or subscapularis tendon and the graft and between the infraspinatus tendon and the graft. As a result, shoulder muscle strength and active range of motion recovered, and the rotator cuff muscles did not atrophy anymore after ASCR. Also, the deltoid muscle may work very well during shoulder abduction when the superior glenohumeral stability is restored. In a future study we will assess the mechanism of functional improvement after ASCR.
Limitations
There are some limitations of this study. First, we did not have a control group to compare the ASCR with arthroscopic rotator cuff repair or other conventionally used techniques. However, postoperative results after ASCR were similar to arthroscopic rotator cuff repair in previous reports, suggesting that ASCR may restore shoulder function as well as arthroscopic rotator cuff repair does. In a future study we will compare clinical results between ASCR and arthroscopic rotator cuff repair. Second, we can present only retrospective short-term results after ASCR in a limited number of patients. Mid- and long-term results in more patients will be necessary to establish this new technique. Third, the reliability of muscle strength measurement has not been confirmed. However, this method has been published
and a single surgeon evaluated muscle strength in all patients. Therefore, we believe that the current results of muscle strength should be reasonable. Fourth, the final follow-up varied from 24 to 51 months. However, we believe that the variability of the follow-up period did not affect current results because the clinical results did not change beyond 2 years postoperatively, and minimum follow-up of this study was 2 years after surgery. Fifth, the reproducibility of radiographic and MRI readings were not assessed in this study, although these methods have been widely used. Also, our evaluated scores did not include quality of life. In a future study, the reproducibility of radiographic and MRI readings and a quality of life questionnaire, such as the Western Ontario Rotator Cuff Index and the Short Form 36 Health Survey, will be investigated.
Conclusions
ASCR restored superior glenohumeral stability and function of shoulder joints with irreparable rotator cuff tears. Our results suggest that this reconstruction technique is a reliable and useful alternative treatment for irreparable rotator cuff tears.
Arthroscopic debridement and decompression for selected rotator cuff tears. Clinical results, pathomechanics, and patient selection based on biomechanical parameters.
Early complications from the use of porcine dermal collagen implants (Permacol) as bridging constructs in the repair of massive rotator cuff tears. A report of 4 cases.
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