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Editorial Commentary: Superior Capsule Reconstruction: Graft Healing for Success

      Abstract

      In my experience, after superior capsule reconstruction for irreparable rotator cuff tears, if the graft heals, we can expect a successful outcome, such as an American Shoulder and Elbow Surgeons score of more than 90 points and a visual analog scale score of less than 1.0. To decrease the graft tear rate after surgery, I have found that a thicker, stiffer graft than can be achieved with a dermal allograft alone is required to restore superior stability in the glenohumeral joint. Furthermore, the graft size should be determined precisely from the size of the defect in the rotator cuff tendons.
      To my knowledge, “Preliminary Results of Arthroscopic Superior Capsule Reconstruction With Dermal Allograft” by Denard, Brady, Adams, Tokish, and Burkhart
      • Denard P.J.
      • Brady P.C.
      • Adams C.R.
      • Tokish M.J.
      • Burkhart S.S.
      Preliminary results of arthroscopic superior capsule reconstruction with dermal allograft.
      is the first study to report the clinical outcome of superior capsule reconstruction (SCR) of irreparable rotator cuff tears using dermal allografts. The most important result was that “100% of the patients with grafts that healed had a successful outcome, compared with 45.5% when the graft did not heal.” Furthermore, in the group that healed, postoperative pain was lower (visual analog scale 0.7 vs 2.6; P = .038) and the American Shoulder and Elbow Surgeons score was higher (90.0 vs 66.5; P = .027).
      These results are similar to those obtained with our fascia lata SCR.
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      Our postoperative clinical outcome scores in healed patients (ASES, 96.0 points; Japanese Orthopaedic Association score, 94.9 points; University of California at Los Angeles [UCLA], 34.0 points) were significantly better than those in unhealed patients who developed graft tears or retears of the repaired rotator cuff tendon (ASES, 77.1 points, P < .0001; Japanese Orthopaedic Association score, 81.1, P < .001; UCLA, 24.8, P < .00001).
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      This shows us that, regardless of the graft material, the important thing is to work out how to prevent graft tear after SCR.
      In the current study by Denard et al.,
      • Denard P.J.
      • Brady P.C.
      • Adams C.R.
      • Tokish M.J.
      • Burkhart S.S.
      Preliminary results of arthroscopic superior capsule reconstruction with dermal allograft.
      the acromiohumeral distance (AHD) did not change after SCR using a dermal graft, whereas in our fascia lata SCR, the AHD increased by an average of 4.1 mm at the final follow-up.
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      This result suggests that SCR using a dermal allograft did not improve superior stability, resulting in a higher rate of graft tear (55% after SCR using a dermal allograft) than after fascia lata SCR (3% to 5%). The thickness of the fascia lata SCR was 6 to 8 mm in our first study,
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      and our biomechanical study showed that SCR using a fascia lata graft 8 mm thick restores superior stability.
      • 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.
      • Mihata T.
      • McGarry M.H.
      • Kahn T.
      • Goldberg I.
      • Neo M.
      • Lee T.Q.
      Biomechanical role of capsular continuity in superior capsule reconstruction for irreparable tears of the supraspinatus tendon.
      • Mihata T.
      • McGarry M.H.
      • Kahn T.
      • Goldberg I.
      • Neo M.
      • Lee T.Q.
      Biomechanical effects of acromioplasty on superior capsule reconstruction for irreparable supraspinatus tendon tears.
      • Mihata T.
      • McGarry M.H.
      • Pirolo J.M.
      • Kinoshita M.
      • Lee T.Q.
      Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: A biomechanical cadaveric study.
      Because in Denard and colleagues' study the thickness of the dermal allograft was only 1 to 3 mm, to decrease the graft tear rate after SCR using a dermal allograft, graft augmentation, alternative suture constructs, or biologic augmentation may be needed to improve superior shoulder stability.
      In their report, Denard et al.
      • Denard P.J.
      • Brady P.C.
      • Adams C.R.
      • Tokish M.J.
      • Burkhart S.S.
      Preliminary results of arthroscopic superior capsule reconstruction with dermal allograft.
      state that the Hamada classification can be used to provide insight into the prognosis of SCR, and they conclude that the best indication for SCR is a Hamada grade of 1 or 2; it appears best to avoid SCR in cases that are of Hamada grade 3 or 4. In the authors' Hamada grade 1 or 2 cases, because the bony deformity and superior migration were not severe, arthroscopic SCR using a dermal allograft had a successful outcome in approximately 70% of cases, even though superior stability was not restored completely (no change in AHD). To use SCR for irreparable rotator cuff tears classified as Hamada grade 3 or 4, which have severe bony deformity and superior migration, I recommend a graft stiffer and thicker than a dermal allograft alone to achieve superior shoulder stability. In our experience, using a fascia lata SCR can improve shoulder function even in Hamada grade 3 or 4 tears.
      Denard et al. performed biceps tenodesis or tenotomy with SCR in every case, unless the tendon had been torn previously and was completely retracted. However, in our experience, the biceps does not need to be treated in SCR; in most of our cases, if the SCR heals, the biceps symptoms disappear, even without biceps tenodesis or tenotomy.
      SCR theoretically improves force coupling as well as superior stability, increasing functional outcome score. If a patient has an irreparable subscapularis tear, then the force coupling cannot be restored by SCR. (Posterior stability may become higher than anterior stability, because the graft is attached to the superior and posterior sides of the glenohumeral joint.) Therefore, Denard et al. advise caution in recommending SCR in patients with advanced preoperative atrophy of the subscapularis (i.e., grade 3 or 4 atrophy). However, in our experience, shoulder function improves after fascia lata SCR, even in patients with both irreparable subscapularis tears and irreparable posterior-superior (supraspinatus and infraspinatus) tears, suggesting that SCR can be used even in irreparable subscapularis tears. In some cases of irreparable subscapularis tear, we have found that postoperative muscle strength is less than that in patients with an intact subscapularis or reparable subscapularis, although it does not affect daily activity.
      SCR is a new surgical treatment for irreparable rotator cuff tears. Recently, many surgeons have performed SCR by using various types and sizes of graft. Furthermore, the fixation technique also varies among surgeons. To find the best graft and surgical technique, this clinical study by Denard et al. is useful.

      Supplementary Data

      References

        • Denard P.J.
        • Brady P.C.
        • Adams C.R.
        • Tokish M.J.
        • Burkhart S.S.
        Preliminary results of arthroscopic superior capsule reconstruction with dermal allograft.
        Arthroscopy. 2018; 34: 93-99
        • Mihata T.
        • Lee T.Q.
        • Watanabe C.
        • et al.
        Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
        Arthroscopy. 2013; 29: 459-470
        • 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.
        Arthroscopy. 2016; 32: 418-426
        • Mihata T.
        • McGarry M.H.
        • Kahn T.
        • Goldberg I.
        • Neo M.
        • Lee T.Q.
        Biomechanical role of capsular continuity in superior capsule reconstruction for irreparable tears of the supraspinatus tendon.
        Am J Sports Med. 2016; 44: 1423-1430
        • Mihata T.
        • McGarry M.H.
        • Kahn T.
        • Goldberg I.
        • Neo M.
        • Lee T.Q.
        Biomechanical effects of acromioplasty on superior capsule reconstruction for irreparable supraspinatus tendon tears.
        Am J Sports Med. 2016; 44: 191-197
        • Mihata T.
        • McGarry M.H.
        • Pirolo J.M.
        • Kinoshita M.
        • Lee T.Q.
        Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: A biomechanical cadaveric study.
        Am J Sports Med. 2012; 40: 2248-2255

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