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Editorial Commentary: Superior Capsular Reconstruction—Improved Superior Stability and Functional Deltoid Reverse Pseudoparalysis in Patients With Irreparable Rotator Cuff Tears

      Abstract

      Since I reported clinical and biomechanical improvement after superior capsular reconstruction (SCR) for irreparable rotator cuff tears in 2012 and 2013, many shoulder surgeons around the world have started to perform SCR. However, most of these surgeons are still on the learning curve, and their clinical results are not consistent because clinical outcomes after SCR are correlated with graft healing, which is affected by the surgeon's skill. In cases in which the graft does heal, active shoulder elevation increases after SCR even in patients with pseudoparalysis before surgery. These patients can elevate the arm using the deltoid muscle when superior shoulder stability is restored after SCR. When patients whose grafts have healed cannot elevate the arm even after SCR, they may have concomitant cervical radiculopathy, which causes real paralysis.
      Superior capsular reconstruction (SCR) for treating irreparable rotator cuff tears was first reported in 2012,
      • 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.
      introducing the biomechanical concept and effectiveness. This was then followed by a clinical outcome study in 2013 showing a significant improvement after SCR.
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      Since then, many shoulder surgeons around the world have adopted SCR. However, the clinical results have been inconsistent because clinical outcomes after SCR are correlated with graft healing,
      • Mihata T.
      • Lee T.Q.
      • Hasegawa A.
      • et al.
      Arthroscopic superior capsule reconstruction can eliminate pseudoparalysis in patients with irreparable rotator cuff tears.
      • Mihata T.
      • Lee T.Q.
      • Fukunishi K.
      • et al.
      Return to sports and physical work after arthroscopic superior capsule reconstruction among patients with irreparable rotator cuff tears.
      • Mihata T.
      Editorial commentary: Superior capsule reconstruction: Graft healing for success.
      which is affected by the surgeon's skill and the learning curve. When graft healing is achieved, active shoulder elevation increases after SCR even in patients with pseudoparalysis before surgery because these patients can elevate the arm using the deltoid muscle when superior shoulder stability is restored after SCR. Patients who have achieved graft healing but cannot elevate the arm may have concomitant cervical radiculopathy, which causes true paralysis.
      In this issue, Burkhart and Hartzler
      • Burkhart S.S.
      • Hartzler R.U.
      Superior capsular reconstruction reverses profound pseudoparalysis in patients with irreparable rotator cuff tears and minimal or no glenohumeral arthritis.
      published a study entitled “Superior Capsular Reconstruction Reverses Profound Pseudoparalysis in Patients With Irreparable Rotator Cuff Tears and Minimal or No Glenohumeral Arthritis.” In this study, the reported graft tear rate was low (complete tear, 0%; partial tear, 30%), which is greatly improved from their previous SCR study,
      • Denard P.J.
      • Brady P.C.
      • Adams C.R.
      • Tokish J.M.
      • Burkhart S.S.
      Preliminary results of arthroscopic superior capsule reconstruction with dermal allograft.
      in which the graft tear rate was 55% after SCR using a human dermal allograft. This shows that, even for highly skilled surgeons, SCR experience may play a role achieving a high healing rate. Furthermore, the reported human dermal allograft graft tear rate is higher than the rate for fascia lata autograft SCR (4.5%),
      • Mihata T.
      • Lee T.Q.
      • Hasegawa A.
      • et al.
      Arthroscopic superior capsule reconstruction can eliminate pseudoparalysis in patients with irreparable rotator cuff tears.
      suggesting that graft augmentation may improve graft healing and a lower graft tear rate and improved clinical outcomes may be expected. Because the current study was performed in patients with pseudoparalysis, it is important to note that the definition of pseudoparalysis has varied across publications. The most common definition is less than 90° of active shoulder elevation.
      • Boileau P.
      • Chuinard C.
      • Roussanne Y.
      • Bicknell R.T.
      • Rochet N.
      • Trojani C.
      Reverse shoulder arthroplasty combined with a modified latissimus dorsi and teres major tendon transfer for shoulder pseudoparalysis associated with dropping arm.
      • Denard P.J.
      • Ladermann A.
      • Brady P.C.
      • et al.
      Pseudoparalysis from a massive rotator cuff tear is reliably reversed with an arthroscopic rotator cuff repair in patients without preoperative glenohumeral arthritis.
      • Oh J.H.
      • Kim S.H.
      • Shin S.H.
      • et al.
      Outcome of rotator cuff repair in large-to-massive tear with pseudoparalysis: A comparative study with propensity score matching.
      However, this definition includes limited active elevation due to shoulder pain. In our previous publication addressing pseudoparalysis with fascia lata autograft SCR, we divided pseudoparalysis into 2 subgroups: (1) moderate pseudoparalysis, that is, no shoulder stiffness, less than 90° of active shoulder elevation, and the ability of patients to maintain more than 90° of elevation once the shoulder is elevated passively, and (2) severe pseudoparalysis, that is, no shoulder stiffness, less than 90° of active shoulder elevation, and the presence of a positive drop-arm sign (patients cannot maintain the abducted position because of muscle weakness).
      • Mihata T.
      • Lee T.Q.
      • Hasegawa A.
      • et al.
      Arthroscopic superior capsule reconstruction can eliminate pseudoparalysis in patients with irreparable rotator cuff tears.
      Therefore, with our definition, severe pseudoparalysis is the "true" pseudoparalysis due to muscle weakness. Following this definition, in our previous study,
      • Mihata T.
      • Lee T.Q.
      • Hasegawa A.
      • et al.
      Arthroscopic superior capsule reconstruction can eliminate pseudoparalysis in patients with irreparable rotator cuff tears.
      average preoperative active elevation in patients with severe pseudoparalysis was 36.7° ± 19.1°. Therefore, active shoulder elevation of less than 45° used in the current study may be reasonable as a definition of true or "profound" pseudoparalysis.
      With respect to reversing pseudoparalysis, in our previous study of 88 patients with irreparable rotator cuff tears, pseudoparalysis was reversed in 96.4% of patients (27 of 28) with moderate preoperative pseudoparalysis (increased active elevation, 60°-150°) and in 93.3% of patients (14 of 15) with severe preoperative pseudoparalysis (increased active elevation, 70°-170°).
      • Mihata T.
      • Lee T.Q.
      • Hasegawa A.
      • et al.
      Arthroscopic superior capsule reconstruction can eliminate pseudoparalysis in patients with irreparable rotator cuff tears.
      Both patients with residual pseudoparalysis postoperatively had graft tears. Therefore, we concluded that graft healing is the key to eliminating pseudoparalysis in patients with irreparable rotator cuff tears. The findings of Burkhart and Hartzler
      • Burkhart S.S.
      • Hartzler R.U.
      Superior capsular reconstruction reverses profound pseudoparalysis in patients with irreparable rotator cuff tears and minimal or no glenohumeral arthritis.
      are consistent with this: The grafts were partially or completely intact at 1 year after SCR in all patients, and profound pseudoparalysis was completely reversed in all patients after arthroscopic SCR except for 1 patient with concomitant cervical spondylosis with ipsilateral radiculopathy. This finding also suggests that cervical radiculopathy should be considered when active shoulder elevation does not improve in patients with a healed graft after SCR. In our previous study, 7 of 100 patients (7%) with irreparable rotator cuff tears who underwent SCR had deltoid weakness attributed to cervical or axillary nerve palsy, which causes severely limited active shoulder elevation (real paralysis).
      • Mihata T.
      • Lee T.Q.
      • Hasegawa A.
      • et al.
      Arthroscopic superior capsule reconstruction can eliminate pseudoparalysis in patients with irreparable rotator cuff tears.
      In most of these patients, active shoulder elevation did not improve after SCR, and some patients subsequently underwent spine surgery.
      The most common symptoms of irreparable rotator cuff tears are pain from subacromial impingement and muscle weakness in the shoulder joint, both of which can limit 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 loss of the superior stability of the glenohumeral joint because of dysfunction of the rotator cuff muscles and a defect of the superior capsule. When superior shoulder stability is restored after SCR,
      • 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.
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      • Mihata T.
      • Lee T.Q.
      • Hasegawa A.
      • et al.
      Arthroscopic superior capsule reconstruction can eliminate pseudoparalysis in patients with irreparable rotator cuff tears.
      • Mihata T.
      • Lee T.Q.
      • Fukunishi K.
      • et al.
      Return to sports and physical work after arthroscopic superior capsule reconstruction among patients with irreparable rotator cuff tears.
      • 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 effects of acromioplasty on superior capsule reconstruction for irreparable supraspinatus tendon 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.
      • Bui C.N.H.
      • Akeda M.
      • et al.
      A biomechanical cadaveric study comparing superior capsule reconstruction using fascia lata allograft with human dermal allograft for irreparable rotator cuff tear.
      the patient can elevate the arm using the deltoid muscle. A cadaveric biomechanical study showed that SCR using a dermal graft could improve superior stability,
      • Mihata T.
      • Bui C.N.H.
      • Akeda M.
      • et al.
      A biomechanical cadaveric study comparing superior capsule reconstruction using fascia lata allograft with human dermal allograft for irreparable rotator cuff tear.
      explaining why active shoulder elevation increased after SCR using a dermal graft in the current study. However, the acromiohumeral distance did not change after SCR using a dermal graft in the study by Burkhart and Hartzler,
      • Burkhart S.S.
      • Hartzler R.U.
      Superior capsular reconstruction reverses profound pseudoparalysis in patients with irreparable rotator cuff tears and minimal or no glenohumeral arthritis.
      whereas the acromiohumeral distance increased by an average of 4.1 mm after fascia lata SCR at final follow-up.
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      Therefore, the graft might be abraded under the acromion during repetitive elevation during daily life because of a narrow subacromial space. Long-term follow-up is needed after SCR using a dermal graft.
      In conclusion, arthroscopic SCR can restore superior glenohumeral stability and improve shoulder function among patients with irreparable rotator cuff tears with or without pseudoparalysis. In the absence of a postoperative graft tear, arthroscopic SCR reverses preoperative pseudoparalysis when the patients have a functional deltoid muscle.

      Supplementary Data

      References

        • 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
        • 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.
        • Lee T.Q.
        • Hasegawa A.
        • et al.
        Arthroscopic superior capsule reconstruction can eliminate pseudoparalysis in patients with irreparable rotator cuff tears.
        Am J Sports Med. 2018; (363546518786489)
        • Mihata T.
        • Lee T.Q.
        • Fukunishi K.
        • et al.
        Return to sports and physical work after arthroscopic superior capsule reconstruction among patients with irreparable rotator cuff tears.
        Am J Sports Med. 2018; 46: 1077-1083
        • Mihata T.
        Editorial commentary: Superior capsule reconstruction: Graft healing for success.
        Arthroscopy. 2018; 34: 100-101
        • Burkhart S.S.
        • Hartzler R.U.
        Superior capsular reconstruction reverses profound pseudoparalysis in patients with irreparable rotator cuff tears and minimal or no glenohumeral arthritis.
        Arthroscopy. 2019; 35: 22-28
        • Denard P.J.
        • Brady P.C.
        • Adams C.R.
        • Tokish J.M.
        • Burkhart S.S.
        Preliminary results of arthroscopic superior capsule reconstruction with dermal allograft.
        Arthroscopy. 2018; 34: 93-99
        • Boileau P.
        • Chuinard C.
        • Roussanne Y.
        • Bicknell R.T.
        • Rochet N.
        • Trojani C.
        Reverse shoulder arthroplasty combined with a modified latissimus dorsi and teres major tendon transfer for shoulder pseudoparalysis associated with dropping arm.
        Clin Orthop Relat Res. 2008; 466: 584-593
        • Denard P.J.
        • Ladermann A.
        • Brady P.C.
        • et al.
        Pseudoparalysis from a massive rotator cuff tear is reliably reversed with an arthroscopic rotator cuff repair in patients without preoperative glenohumeral arthritis.
        Am J Sports Med. 2015; 43: 2373-2378
        • Oh J.H.
        • Kim S.H.
        • Shin S.H.
        • et al.
        Outcome of rotator cuff repair in large-to-massive tear with pseudoparalysis: A comparative study with propensity score matching.
        Am J Sports Med. 2011; 39: 1413-1420
        • Duralde X.A.
        • Bair B.
        Massive rotator cuff tears: The result of partial rotator cuff repair.
        J Shoulder Elbow Surg. 2005; 14: 121-127
        • Gerber C.
        • Maquieira G.
        • Espinosa N.
        Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears.
        J Bone Joint Surg Am. 2006; 88: 113-120
        • 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 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.
        • 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.
        • Bui C.N.H.
        • Akeda M.
        • et al.
        A biomechanical cadaveric study comparing superior capsule reconstruction using fascia lata allograft with human dermal allograft for irreparable rotator cuff tear.
        J Shoulder Elbow Surg. 2017; 26: 2158-2166

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