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Clinical Results of Arthroscopic Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears

Published:January 30, 2013DOI:https://doi.org/10.1016/j.arthro.2012.10.022

      Purpose

      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,
      • Bedi A.
      • Dines J.
      • Warren R.F.
      • Dines D.M.
      Massive tears of the rotator cuff.
      • Oh J.H.
      • Kim S.H.
      • Kang J.Y.
      • Oh C.H.
      • Gong H.S.
      Effect of age on functional and structural outcome after rotator cuff repair.
      muscle atrophy,
      • Bedi A.
      • Dines J.
      • Warren R.F.
      • Dines D.M.
      Massive tears of the rotator cuff.
      • Goutallier D.
      • Postel J.M.
      • Bernageau J.
      • Lavau L.
      • Voisin M.C.
      Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan.
      • Melis B.
      • Wall B.
      • Walch G.
      Natural history of infraspinatus fatty infiltration in rotator cuff tears.
      • Melis B.
      • Nemoz C.
      • Walch G.
      Muscle fatty infiltration in rotator cuff tears: Descriptive analysis of 1688 cases.
      • Oh J.H.
      • Kim S.H.
      • Choi J.A.
      • Kim Y.
      • Oh C.H.
      Reliability of the grading system for fatty degeneration of rotator cuff muscles.
      and fatty infiltration.
      • Bedi A.
      • Dines J.
      • Warren R.F.
      • Dines D.M.
      Massive tears of the rotator cuff.
      • Oh J.H.
      • Kim S.H.
      • Kang J.Y.
      • Oh C.H.
      • Gong H.S.
      Effect of age on functional and structural outcome after rotator cuff repair.
      • Goutallier D.
      • Postel J.M.
      • Bernageau J.
      • Lavau L.
      • Voisin M.C.
      Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan.
      • Melis B.
      • Wall B.
      • Walch G.
      Natural history of infraspinatus fatty infiltration in rotator cuff tears.
      • Melis B.
      • Nemoz C.
      • Walch G.
      Muscle fatty infiltration in rotator cuff tears: Descriptive analysis of 1688 cases.
      • Oh J.H.
      • Kim S.H.
      • Choi J.A.
      • Kim Y.
      • Oh C.H.
      Reliability of the grading system for fatty degeneration of rotator cuff muscles.
      Various surgical treatments have been developed, including debridement and subacromial decompression,
      • Burkhart S.S.
      Arthroscopic debridement and decompression for selected rotator cuff tears. Clinical results, pathomechanics, and patient selection based on biomechanical parameters.
      • Rockwood Jr., C.A.
      • Williams Jr., G.R.
      • Burkhead Jr., W.Z.
      Debridement of degenerative, irreparable lesions of the rotator cuff.
      partial repair,
      • Burkhart S.S.
      Fluoroscopic comparison of kinematic patterns in massive rotator cuff tears. A suspension bridge model.
      • Burkhart S.S.
      • Nottage W.M.
      • Ogilvie-Harris D.J.
      • Kohn H.S.
      • Pachelli A.
      Partial repair of irreparable rotator cuff tears.
      • Duralde X.A.
      • Bair B.
      Massive rotator cuff tears: The result of partial rotator cuff repair.
      transposition of the subscapularis tendon,
      • Cofield R.H.
      Subscapular muscle transposition for repair of chronic rotator cuff tears.
      • Karas S.E.
      • Giachello T.L.
      Subscapularis transfer for reconstruction of massive tears of the rotator cuff.
      transplantation of the teres major muscle,
      • Celli L.
      • Rovesta C.
      • Marongiu M.C.
      • Manzieri S.
      Transplantation of teres major muscle for infraspinatus muscle in irreparable rotator cuff tears.
      supraspinatus muscle advancement,
      • Debeyre J.
      • Patie D.
      • Elmelik E.
      Repair of ruptures of the rotator cuff of the shoulder.
      deltoid flap reconstruction,
      • Dierickx C.
      • Vanhoof H.
      Massive rotator cuff tears treated by a deltoid muscular inlay flap.
      latissimus dorsi transfer,
      • Gerber C.
      Latissimus dorsi transfer for the treatment of irreparable tears of the rotator cuff.
      • Warner J.J.
      • Parsons I.M.
      Latissimus dorsi tendon transfer: A comparative analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears.
      • Gerber C.
      • Maquieira G.
      • Espinosa N.
      Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears.
      pectoralis major transfer,
      • Jost B.
      • Puskas G.J.
      • Lustenberger A.
      • Gerber C.
      Outcome of pectoralis major transfer for the treatment of irreparable subscapularis tears.
      grafting to the torn tendon,
      • Nasca R.J.
      The use of freeze-dried allografts in the management of global rotator cuff tears.
      • Neviaser J.S.
      • Neviaser R.J.
      • Neviaser T.J.
      The repair of chronic massive ruptures of the rotator cuff of the shoulder by use of a freeze-dried rotator cuff.
      • Heikel H.V.
      Rupture of the rotator cuff of the shoulder. Experiences of surgical treatment.
      • Ozaki J.
      • Fujimoto S.
      • Masuhara K.
      • Tamai S.
      • Yoshimoto S.
      Reconstruction of chronic massive rotator cuff tears with synthetic materials.
      • Post M.
      Rotator cuff repair with carbon filament. A preliminary report of five cases.
      and reverse total shoulder arthroplasty.
      • Klein S.M.
      • Dunning P.
      • Mulieri P.
      • Pupello D.
      • Downes K.
      • Frankle M.A.
      Effects of acquired glenoid bone defects on surgical technique and clinical outcomes in reverse shoulder arthroplasty.
      • Farshad M.
      • Gerber C.
      Reverse total shoulder arthroplasty-from the most to the least common complication.
      • Simovitch R.W.
      • Zumstein M.A.
      • Lohri E.
      • Helmy N.
      • Gerber C.
      Predictors of scapular notching in patients managed with the Delta III reverse total shoulder replacement.
      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.
      • Bedi A.
      • Dines J.
      • Warren R.F.
      • Dines D.M.
      Massive tears of the rotator cuff.
      The most common signs of irreparable rotator cuff tears are pain from subacromial impingement,
      • Duralde X.A.
      • Bair B.
      Massive rotator cuff tears: The result of partial rotator cuff repair.
      • Gerber C.
      • Maquieira G.
      • Espinosa N.
      Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears.
      muscle weakness in the shoulder joint,
      • Duralde X.A.
      • Bair B.
      Massive rotator cuff tears: The result of partial rotator cuff repair.
      • Gerber C.
      • Maquieira G.
      • Espinosa N.
      Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears.
      and as a result, limitation of arm elevation.
      • Duralde X.A.
      • Bair B.
      Massive rotator cuff tears: The result of partial rotator cuff repair.
      • Gerber C.
      • Maquieira G.
      • Espinosa N.
      Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears.
      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.
      Figure thumbnail gr1
      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.
      Figure thumbnail gr2
      Fig 2Arthroscopic images of right shoulder from the posterior portal in patient 3. (Left) Rotator cuff tear. (Right) Arthroscopic superior capsule reconstruction. (H, humeral head; GT, greater tuberosity; ISP, infraspinatus tendon.)
      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.
      • Daniels L.
      • Worthingham C.
      Muscle testing.
      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).
      • Itoi E.
      • Minagawa H.
      • Yamamoto N.
      • Seki N.
      • Abe H.
      Are pain location and physical examinations useful in locating a tear site of the rotator cuff?.
      We assessed the muscle strength of shoulder abduction with the thumb up, which is known as the full can position.
      • McFarland E.G.
      Strength testing.
      • Kelly B.T.
      • Kadrmas W.R.
      • Speer K.P.
      The manual muscle examination for rotator cuff strength. An electromyographic investigation.
      We measured external rotation strength with the arm at the side.
      • Daniels L.
      • Worthingham C.
      Muscle testing.
      We recorded strength in lifting the hand off the back to assess the internal rotation strength.
      • Gerber C.
      • Krushell R.J.
      Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases.
      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),
      • Burkhart S.S.
      • Barth J.R.
      • Richards D.P.
      • Zlatkin M.B.
      • Larsen M.
      Arthroscopic repair of massive rotator cuff tears with stage 3 and 4 fatty degeneration.
      the Japanese Orthopaedic Association (JOA, a 100-point scoring system),
      • Ide J.
      • Takagi K.
      Early and long-term results of arthroscopic treatment for shoulder stiffness.
      and the University of California, Los Angeles (UCLA, a 35-point scaling system)
      • Ellman H.
      • Hanker G.
      • Bayer M.
      Repair of the rotator cuff. End-result study of factors influencing reconstruction.
      ; 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.
      • Ellman H.
      • Hanker G.
      • Bayer M.
      Repair of the rotator cuff. End-result study of factors influencing reconstruction.
      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.
      • Goutallier D.
      • Postel J.M.
      • Bernageau J.
      • Lavau L.
      • Voisin M.C.
      Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan.
      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,
      • Mihata T.
      • Fukuhara T.
      • Jun B.J.
      • Watanabe C.
      • Kinoshita M.
      Effect of shoulder abduction angle on biomechanical properties of the repaired rotator cuff tendons with 3 types of double-row technique.
      • Mihata T.
      • Watanabe C.
      • Fukinishi K.
      • et al.
      Functional and structural outcomes of single-row vs double-row vs combined double-row and suture-bridge repair for rotator cuff tears.
      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.

      Postoperative Protocol

      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.
      • Hamada K.
      • Fukuda H.
      • Mikasa M.
      • Kobayashi Y.
      Roentgenographic findings in massive rotator cuff tears. A long-term observation.
      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.
      • Neer II, C.S.
      • Craig E.V.
      • Fukuda H.
      Cuff-tear arthropathy.
      There were 10 shoulders in stage 1, 12 shoulders in stage 2, one shoulder in stage 3, and one shoulder in stage 4b (Table 2).
      Table 2Summary of Patients
      ShoulderSexAge (yr)JobDuration of Symptom (mo)OperationTorn TendonTear SizeBiceps Pathologic Condition/TreatmentHamada Classification
      • Simovitch R.W.
      • Zumstein M.A.
      • Lohri E.
      • Helmy N.
      • Gerber C.
      Predictors of scapular notching in patients managed with the Delta III reverse total shoulder replacement.
      (Stage)
      1Male60Manual worker12PrimarySSP, ISPLargeIntact2
      2Female56Manual worker3PrimarySSP, ISPLargeIntact2
      3Male63Manual worker5PrimarySubS, SSP, ISPMassiveSubluxation/reposition2
      4Female69Housewife10PrimarySSP, ISPMassiveIntact2
      5Female70None3PrimarySSP, ISPLargePartial tear/debridement1
      6Male67None24PrimarySSP, ISPLargeIntact2
      7Female73Farmer3PrimarySubS, SSP, ISPMassiveIntact1
      8Male52Manual worker72PrimarySubS, SSP, ISPMassiveDislocation/reposition1
      9Male77None96PrimarySSP, ISPMassiveComplete tear4b
      10Male67None6PrimarySubS, SSP, ISPMassiveDislocation/tenodesis2
      11Female64None24PrimarySubS, SSP, ISPMassiveIntact1
      12Female54Housewife6RevisionSSP, ISPLargeIntact1
      13Male66Carpenter8PrimarySSP, ISPMassiveIntact2
      14Male60Carpenter3PrimarySubS, SSP, ISPMassiveComplete tear2
      15Male61Carpenter5PrimarySubS, SSP, ISPMassiveComplete tear3
      16Female75None17PrimarySSP, ISPLargeIntact1
      17Male71Farmer36PrimarySSP, BP, TeresMassiveComplete tear2
      18Female66Farmer3PrimarySubS, SSP, ISPMassiveComplete tear1
      19Female74None13PrimarySubS, SSP, ISPMassiveComplete tear2
      20Male59Manual worker3PrimarySSP, ISPLargePartial tear/debridement1
      21Male60Desk work120PrimarySSP, ISPLargeIntact2
      22Male55Desk work12RevisionSSP, ISPLargeIntact1
      23Female70None19RevisionSSP, ISPLargeDislocation/reposition2
      24Female74None20RevisionSSP, ISPLargeComplete tear1
      ISP, infraspinatus; Primary, primary surgery; Reposition, repositioned after subscapularis repair; Revision, revision surgery; SSP, supraspinatus; SubS, subscapularis; Teres, teres minor.

      Clinical Results

      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
      ShoulderASES ScoreJOA ScoreUCLA Score
      PreoperativePostoperativePreoperativePostoperativePreoperativePostoperative
      143.310063.51001835
      213.310028.5100535
      31010026.597435
      416.710044971034
      516.7954392734
      621.710049.5971234
      78.31003095635
      826.710035.5100535
      913.39543.593933
      1028.310049.5951335
      11201005899.51335
      1243.310068.51001835
      132088.337.592.5731
      1418.396.74494834
      1551.796.770.5921734
      1621.79549.595735
      1733.378.365.576.51725
      181576.73283522
      1910703879.5528
      2063.310056.51001535
      2118.3100641001235
      2228.3100571001135
      23206554.572.5921
      243.371.749.571.5428
      Average23.592.948.392.69.932.4
      SD14.411.313.09.04.74.3
      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).
      Figure thumbnail gr3
      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.
      Table 4Summary of Patients' Shoulder Range of Motion
      ShoulderActive Elevation (°)Active External Rotation (°)Active Internal Rotation (°)
      PreoperativePostoperativePreoperativePostoperativePreoperativePostoperative
      11401802050ST12
      2201601060ST10
      320170205090T12
      4501802030L5T12
      5601503040L3L3
      6901702030L5L3
      7301603030SL3
      8201702090L5T10
      9801502020T12T12
      101201503050SL3
      111401704060T12T12
      121601703040T7T5
      1340120−1030L3L4
      14601603040L3L2
      151601605040T12S
      16501603030L5L2
      171601503020L3L3
      183080020ST12
      19401103020L3L4
      201601602050T12T12
      211501503050L4T12
      221001706060T12T12
      2340503030T12L2
      2490903020ST10
      Average841482640L3L1
      SD52.233.414.117.2
      NOTE. Postoperative designates the final follow-up (mean, 34.1 months; range, 24 to 51 months after surgery).
      SD, standard deviation.
      Table 5Summary of Patients' Shoulder Muscle Strength
      ShoulderAbduction (Grade)External Rotation (Grade)Internal Rotation (Grade)
      PreoperativePostoperativePreoperativePostoperativePreoperativePostoperative
      MMT10 scaleMMT10 scaleMMT10 scaleMMT10 scaleMMT10 scaleMMT10 scale
      147510475−947510
      23−3510475−95−9510
      33−35103−351047510
      43−35103−34747510
      534474747510510
      6475−9475−9510510
      73−351022510510510
      83−351047510510510
      93−35−93−35−95−9510
      10475104−651047510
      11475−9475−95−95−9
      12510475−9475−9510
      133−347224747510
      143−35−9345−947510
      155−95105−95105−9510
      163−35104751047510
      1747474734510510
      183−3333−347475−9
      19344734475−95−9
      20475103451047510
      215−95105−9510510510
      223−35−93−35105−9510
      233434344747510
      243−3473−35−9510510
      Average3+55−93+55−94+8510
      NOTE. Manual muscle testing (MMT) is on a scale of 0 to 5; 10 scale is converted MMT 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. Postoperative designates the final follow-up (mean, 34.1 months; range, 24 to 51 months after surgery).
      MMT, manual muscle testing.
      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
      ShoulderAHD (mm)Structural IntegrityPreoperative Goutallier Grading SystemPostoperative Goutallier Grading System
      PreopPostopSSPSubSISPTeresSSPSubSISPTeres
      15.09.8Healed40204020
      24.68.0Healed40004000
      34.110.7Healed31203120
      4418.3Healed40404040
      56.210.5Healed42204110
      63.110.4Healed40204020
      75.712.4Healed31102010
      85.510.5Healed34203420
      92.47.2Healed32303230
      105.09.1Healed42304230
      115.910.2Healed41304130
      129.313.2Healed40204020
      131.38.0ISP retear40424042
      142.96.3Healed43404340
      151.46.3Healed44404440
      166.08.9Healed42404240
      171.42.3ISP retear42413241
      185.48.4ISP retear42404240
      193.67.7Healed43304330
      207.210.3Healed32203220
      213.79.6Healed41104110
      228.210.7Healed40204020
      231.72.4Graft tear40204020
      247.18.9Healed30203020
      Average4.68.73.81.32.60.13.71.32.50.1
      SD2.22.60.41.31.10.40.61.31.20.4
      NOTE. Postoperative designates the final follow-up (mean, 34.1 months; range, 24 to 51 months after surgery).
      AHD, acromiohumeral distance; ISP, infraspinatus; Postop, postoperative; Preop, preoperative; SSP, supraspinatus; SubS, subscapularis; Teres, teres minor.

      MRI Findings

      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.
      Figure thumbnail gr4
      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.
      • Moore D.R.
      • Cain E.L.
      • Schwartz M.L.
      • Clancy Jr., W.G.
      Allograft reconstruction for massive, irreparable rotator cuff tears.
      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.
      • Sclamberg S.G.
      • Tibone J.E.
      • Itamura J.M.
      • Kasraeian S.
      Six-month magnetic resonance imaging follow-up of large and massive rotator cuff repairs reinforced with porcine small intestinal submucosa.
      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.
      • Soler J.A.
      • Gidwani S.
      • Curtis M.J.
      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.
      Audenaert et al.
      • Audenaert E.
      • Van Nuffel J.
      • Schepens A.
      • Verhelst M.
      • Verdonk R.
      Reconstruction of massive rotator cuff lesions with a synthetic interposition graft: A prospective study of 41 patients.
      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.
      Sugaya et al.
      • Sugaya H.
      • Maeda K.
      • Matsuki K.
      • Moriishi J.
      Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair. A prospective outcome study.
      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.,
      • Boileau P.
      • Brassart N.
      • Watkinson D.J.
      • Carles M.
      • Hatzidakis A.M.
      • Krishnan S.G.
      Arthroscopic repair of full-thickness tears of the supraspinatus: Does the tendon really heal?.
      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
      • Moursy M.
      • Forstner R.
      • Koller H.
      • Resch H.
      • Tauber M.
      Latissimus dorsi tendon transfer for irreparable rotator cuff tears: A modified technique to improve tendon transfer integrity.
      and partial repair.
      • Burkhart S.S.
      • Nottage W.M.
      • Ogilvie-Harris D.J.
      • Kohn H.S.
      • Pachelli A.
      Partial repair of irreparable rotator cuff tears.
      • Duralde X.A.
      • Bair B.
      Massive rotator cuff tears: The result of partial rotator cuff repair.
      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.,
      • Burkhart S.S.
      • Barth J.R.
      • Richards D.P.
      • Zlatkin M.B.
      • Larsen M.
      Arthroscopic repair of massive rotator cuff tears with stage 3 and 4 fatty degeneration.
      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.
      Figure thumbnail gr5
      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.)
      Burkhart et al.
      • Burkhart S.S.
      • Barth J.R.
      • Richards D.P.
      • Zlatkin M.B.
      • Larsen M.
      Arthroscopic repair of massive rotator cuff tears with stage 3 and 4 fatty degeneration.
      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
      • Itoi E.
      • Minagawa H.
      • Yamamoto N.
      • Seki N.
      • Abe H.
      Are pain location and physical examinations useful in locating a tear site of the rotator cuff?.
      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.

      Supplementary Data

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