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Could Disruption of the Shoulder Superior Capsule Be the “Essential Lesion” of Rotator Cuff Disease? Possibly, but Questions Remain…

      Abstract

      Rotator cuff disease remains a complex clinical problem with significant variation in pathology, clinical presentation, and management options. Functionally, humeral head depression is critical in restoring or maintaining arm elevation, and the shoulder superior capsule serves in this important function. Could disruption of the shoulder superior capsule be the “essential lesion” of rotator cuff disease? Possibly, but many questions remain unanswered, and substantial scientific evidence is required before we can assert with certainty that disruption of the superior capsule with resultant superior instability of the humeral head is the essential lesion of rotator cuff disease.
      Rotator cuff disease remains a treatment challenge for orthopaedic shoulder surgeons.
      • Hatta T.
      • Giambini H.
      • Hooke A.W.
      • et al.
      Comparison of passive stiffness changes in the supraspinatus muscle after double-row and knotless transosseous-equivalent rotator cuff repair techniques: A cadaveric study.
      • Murray I.R.
      • LaPrade R.F.
      • Musahl V.
      Biologic treatments for sports injuries II think tank—Current concepts, future research, and barriers to advancement, part 2: Rotator cuff.
      • Henry P.
      • Wasserstein D.
      • Park S.
      • et al.
      Arthroscopic repair for chronic massive rotator cuff tears: A systematic review.
      • Killian M.L.
      • Cavinatto L.M.
      • Ward S.R.
      • Havlioglu N.
      • Thomopoulos S.
      • Galatz L.M.
      Chronic degeneration leads to poor healing of repaired massive rotator cuff tears in rats.
      • Greenspoon J.A.
      • Petri M.
      • Warth R.J.
      • Millett P.J.
      Massive rotator cuff tears: Pathomechanics, current treatment options, and clinical outcomes.
      • Warth R.J.
      • Dornan G.J.
      • James E.W.
      • Horan M.P.
      • Millett P.J.
      Clinical and structural outcomes after arthroscopic repair of full-thickness rotator cuff tears with and without platelet-rich product supplementation: A meta-analysis and meta-regression.
      • Gasbarro G.
      • Ye J.
      • Newsome H.
      • et al.
      Morphologic risk factors in predicting symptomatic structural failure of arthroscopic rotator cuff repairs: Tear size, location, and atrophy matter.
      • Kim S.J.
      • Kim S.H.
      • Moon H.S.
      • Chun Y.M.
      Footprint contact area and interface pressure comparison between the knotless and knot-tying transosseous-equivalent technique for rotator cuff repair.
      • Lubowitz J.H.
      Editorial commentary: Biomechanical data does not translate to clinical rerupture rates after shoulder rotator cuff repair using different suture techniques.
      • Brown M.J.
      • Pula D.A.
      • Kluczynski M.A.
      • Mashtare T.
      • Bisson L.J.
      Does suture technique affect re-rupture in arthroscopic rotator cuff repair? A meta-analysis.

      Galasso O, Riccelli DA, De Gori M, et al. Quality of life and functional results of arthroscopic partial repair of irreparable rotator cuff tears [published online September 7, 2016]. Arthroscopy. doi:10.1016/j.arthro.2016.06.024.

      • Kim I-B
      • Kim M-W.
      Risk factors for retear after arthroscopic repair of full-thickness rotator cuff tears using the suture bridge technique: Classification system.
      • Grimberg J.
      • Kany J.
      • Valenti P.
      • Amaravathi R.
      • Ramalingam A.T.
      Arthroscopic-assisted latissimus dorsi tendon transfer for irreparable posterosuperior cuff tears.
      • Wang E.
      • Wang L.
      • Gao P.
      • Li Z.
      • Zhou X.
      • Wang S.
      Single-versus double-row arthroscopic rotator cuff repair in massive tears.

      Virk MS, Bruce B, Hussey KE, et al. Biomechanical performance of medial row suture placement relative to the musculotendinous junction in transosseous equivalent suture bridge double-row rotator cuff repair [published online August 25, 2016]. Arthroscopy. doi:10.1016/j.arthro.2016.06.020.

      Specifically, limited surgical options are available for younger patients with large, functionally irreparable tears with minimal arthritis. Recently, there has been significant interest in superior capsular reconstruction (SCR) as a management option for this difficult patient group.
      • Mihata T.
      • McGarry M.
      • Pirolo J.
      • Kinoshita M.
      • Lee T.
      Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: A biomechanical cadaveric study.
      • Tokish J.M.
      • Beicker C.
      Superior capsule reconstruction technique using an acellular dermal allograft.
      • Mihata T.
      • McGarry M.H.
      • Kahn T.
      • Goldberg I.
      • Neo M.
      • Lee T.Q.
      Biomechanical effect of thickness and tension of fascia lata graft on glenohumeral stability for superior capsule reconstruction in irreparable supraspinatus tears.
      • Adams C.R.
      • Denard P.J.
      • Brady P.C.
      • Hartzler R.U.
      • Burkhart S.S.
      The arthroscopic superior capsular reconstruction.
      • Petri M.
      • Greenspoon J.A.
      • Millett P.J.
      Arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      • Thorsness R.
      • Romeo A.
      Massive rotator cuff tears: Trends in surgical management.
      • Rossi M.J.
      Editorial commentary: Superior capsular reconstruction for irreparable supraspinatus tear reveals improved biomechanics with a thicker graft placed in 15° to 45° of shoulder abduction.
      • Hirahara A.M.
      • Adams C.R.
      Arthroscopic superior capsular reconstruction for treatment of massive irreparable rotator cuff tears.
      In their expert opinion article “The Rotator Cuff and the Superior Capsule: Why We Need Both,” Adams et al.

      Adams CR, DeMartino AM, Rego G, Denard PJ, Burkhart SS. The rotator cuff and the superior capsule: Why we need both. Arthroscopy 2016;32:2628-2637.

      boldly declare that disruption of the superior capsule with resultant superior instability of the humeral head is the “essential lesion” of rotator cuff disease. The authors make a cogent argument supporting their thesis, and the article, found in this month's issue, is not to be missed.
      Essential lesion? This obvious reference by Adams et al.

      Adams CR, DeMartino AM, Rego G, Denard PJ, Burkhart SS. The rotator cuff and the superior capsule: Why we need both. Arthroscopy 2016;32:2628-2637.

      is to Bankart,
      • Bankart A.S.
      Recurrent or habitual dislocation of the shoulder-joint.
      who is often credited for identifying a lesion of the anterior, inferior shoulder glenoid as the “essential lesion” of anterior shoulder dislocation. To be fair, however, Bankart's observation has stood the test of time (since 1923), whereas only time will tell if the bold declaration of Adams et al. that disruption of the superior capsule is the essential lesion of rotator cuff disease will prove true when judged over the years.
      One thing that is for certain—as Adams et al.

      Adams CR, DeMartino AM, Rego G, Denard PJ, Burkhart SS. The rotator cuff and the superior capsule: Why we need both. Arthroscopy 2016;32:2628-2637.

      acknowledge—is that at this point in the debate, support for SCR is largely based on expert opinion, as we await publication of supportive clinical outcome data. We also note that Adams et al. have significant, and appropriately disclosed, commercial conflicts of interest that could bias their opinions. To be fair, however, SCR does not appear to be a “single-company technique,” as the SCR could be performed with instruments and implants available from more than one company. In addition, as we cover all bases, readers are urged to review the instructive and well-prepared technical note with video “Arthroscopic Superior Capsular Reconstruction for Massive Irreparable Rotator Cuff Repair” by Burkhart et al.

      Burkhart SS, Denard PJ, Adams CR, Brady PC, Hartzler RU. Arthroscopic superior capsular reconstruction for massive irreparable rotator cuff repair. Arthrosc Tech. Forthcoming. doi:10.1016/j.eats.2016.08.024.

      in this month's Arthroscopy Techniques (www.arthroscopytechniques.org), our companion journal. Likewise, readers may read and view previously published Arthroscopy Techniques articles regarding SCR by Tokish and Beicker,
      • Tokish J.M.
      • Beicker C.
      Superior capsule reconstruction technique using an acellular dermal allograft.
      Petri et al.,
      • Petri M.
      • Greenspoon J.A.
      • Millett P.J.
      Arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      and Hirahara and Adams
      • Hirahara A.M.
      • Adams C.R.
      Arthroscopic superior capsular reconstruction for treatment of massive irreparable rotator cuff tears.
      as cited earlier.
      Returning to “The Rotator Cuff and the Superior Capsule: Why We Need Both,” Adams et al.

      Adams CR, DeMartino AM, Rego G, Denard PJ, Burkhart SS. The rotator cuff and the superior capsule: Why we need both. Arthroscopy 2016;32:2628-2637.

      assert, “The superior capsule is attached to the undersurface of the supraspinatus and infraspinatus muscle-tendon units, and it resists superior translation of the humeral head…[and it is] the defect in a superior capsule that is the ‘essential lesion’ in a superior rotator cuff tear, as opposed to the defect in the rotator cuff itself.” They further “propose that rotator cuff repair must restore the normal [superior] capsular anatomy to provide normal biomechanics of the joint and thus a positive clinical outcome.”
      Yet, rotator cuff disease represents a spectrum of pathologic patterns that may occur as a result of various pathologic mechanisms. In addition, there is significant variation in clinical symptoms associated with a rotator cuff tear. As Editors who are obligated to encourage and publish but also to question new ideas, and who ourselves have repaired rotator cuff tears with positive outcomes absent (knowingly) having repaired the superior capsule, we wonder: Is it really possible that there exists a single essential lesion of rotator cuff disease? And, if yes, is it likely that disruption of the superior capsule is such a lesion?
      We have additional bases for such questions. Some patients have improvement in pain and function after rotator cuff repair despite failure of the rotator cuff (and presumably the superior capsule) to heal.
      • Rhee Y.G.
      • Cho N.S.
      • Yoo J.H.
      Clinical outcome and repair integrity after rotator cuff repair in patients older than 70 years versus patients younger than 70 years.
      Similarly, some patients who have known full-thickness tears of the superior rotator cuff (and presumably the superior capsule) may be asymptomatic.
      • Burkhart S.S.
      • Esch J.C.
      • Jolson S.R.
      The rotator crescent and rotator cable: An anatomic description of the shoulder's “suspension bridge.”.
      In addition, in patients who have partial bursal-sided tears, intratendinous tears, or small full-thickness tears in which the rotator cable
      • Burkhart S.S.
      • Esch J.C.
      • Jolson S.R.
      The rotator crescent and rotator cable: An anatomic description of the shoulder's “suspension bridge.”.
      (and presumably the superior capsule) remains intact, pain can be significant and functionally limiting.
      • Snyder S.J.
      • Pachelli A.F.
      • Del Pizzo W.
      • Friedman M.J.
      • Ferkel R.D.
      • Pattee G.
      Partial thickness rotator cuff tears: Results of arthroscopic treatment.
      • Strauss E.J.
      • Salata M.J.
      • Kercher J.
      • et al.
      The arthroscopic management of partial-thickness rotator cuff tears: A systematic review of the literature.
      • Xiao J.
      • Cui G.Q.
      Clinical and magnetic resonance imaging results of arthroscopic repair of intratendinous partial-thickness rotator cuff tears.
      • Xiao J.
      • Cui G.
      Clinical and structural results of arthroscopic repair of bursal-side partial-thickness rotator cuff tears.
      • Lawson-Smith M.
      • Al-Maiyah M.
      • Goodchild L.
      • Fourie J.M.
      • Finn P.
      • Rangan A.
      Do partial thickness, bursal side cuff tears affect outcome following arthroscopic subacromial decompression? A prospective comparative cohort study.
      • Kim Y.S.
      • Lee H.J.
      • Bae S.H.
      • Jin H.
      • Song H.S.
      Outcome comparison between in situ repair versus tear completion repair for partial thickness rotator cuff tears.
      • Lo I.K.Y.
      • Gonzales D.M.
      • Burkhart S.S.
      The bubble sign: An arthroscopic indicator of an intratendinous rotator cuff tear.
      Lastly, in reviewing the technique for SCR, Burkhart et al.

      Burkhart SS, Denard PJ, Adams CR, Brady PC, Hartzler RU. Arthroscopic superior capsular reconstruction for massive irreparable rotator cuff repair. Arthrosc Tech. Forthcoming. doi:10.1016/j.eats.2016.08.024.

      recommend the use of a dermal allograft, which may exceed the anatomic and biomechanical properties of the normal superior capsule and result in a nonanatomic functional restraint. Perhaps SCR should be confined to limited indications, as a “salvage” procedure, when more conventional rotator cuff repair options are limited.
      That said, early reports of outcomes after SCR have been favorable, and we hold senior and corresponding author (and Arthroscopy Association of North America Past President) Stephen S. Burkhart, M.D., in the highest regard as an expert on this topic, for many good and obvious reasons, and as specifically evidenced by his cited publications.
      • Adams C.R.
      • Denard P.J.
      • Brady P.C.
      • Hartzler R.U.
      • Burkhart S.S.
      The arthroscopic superior capsular reconstruction.

      Adams CR, DeMartino AM, Rego G, Denard PJ, Burkhart SS. The rotator cuff and the superior capsule: Why we need both. Arthroscopy 2016;32:2628-2637.

      Burkhart SS, Denard PJ, Adams CR, Brady PC, Hartzler RU. Arthroscopic superior capsular reconstruction for massive irreparable rotator cuff repair. Arthrosc Tech. Forthcoming. doi:10.1016/j.eats.2016.08.024.

      • Burkhart S.S.
      • Esch J.C.
      • Jolson S.R.
      The rotator crescent and rotator cable: An anatomic description of the shoulder's “suspension bridge.”.
      • Lo I.K.Y.
      • Gonzales D.M.
      • Burkhart S.S.
      The bubble sign: An arthroscopic indicator of an intratendinous rotator cuff tear.
      Although, as with any new procedure, long-term clinical data are necessary to validate outcomes and indications, and although skepticism is required for the reasons iterated earlier, if there is an essential lesion of rotator cuff disease, it would not surprise us in the least that Dr. Burkhart and his team would be among the first, and among the most clear and compelling authors, to make the importance of SCR evident to Arthroscopy readers.

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        • Giambini H.
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        • et al.
        Comparison of passive stiffness changes in the supraspinatus muscle after double-row and knotless transosseous-equivalent rotator cuff repair techniques: A cadaveric study.
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        • Petri M.
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        • Kany J.
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        Arthroscopic-assisted latissimus dorsi tendon transfer for irreparable posterosuperior cuff tears.
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        • Esch J.C.
        • Jolson S.R.
        The rotator crescent and rotator cable: An anatomic description of the shoulder's “suspension bridge.”.
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        • Pachelli A.F.
        • Del Pizzo W.
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        • Pattee G.
        Partial thickness rotator cuff tears: Results of arthroscopic treatment.
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      Linked Article

      • The Rotator Cuff and the Superior Capsule: Why We Need Both
        ArthroscopyVol. 32Issue 12
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          Tears of the rotator cuff are frequent. An estimated 250,000 to 500,000 repairs are performed annually in the United States. Rotator cuff repairs have been successful despite fatty infiltration and atrophy of the rotator cuff muscles. Although the emphasis in rotator cuff repair has historically focused on re-establishing the tendon attachment, there is growing interest in and understanding of the role of the superior capsule. The superior capsule is attached to the undersurface of the supraspinatus and infraspinatus muscle-tendon units, and it resists superior translation of the humeral head.
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