Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears: A Systematic Review


      To evaluate the preliminary clinical outcomes and complications of superior capsule reconstruction (SCR) for irreparable rotator cuff tears.


      A systematic review of PubMed, MEDLINE, EMBASE, and Cochrane databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting clinical outcomes of irreparable rotator cuff tears managed by SCR were included. Clinical outcome analyses of pre- and postoperative range of motion, American Shoulder and Elbow Surgeons scores, visual analog scale pain scores, and acromiohumeral intervals (AHIs) were performed and reported as range or frequency.


      Five studies (285 patients, 291 shoulders) of level III-IV evidence were included, with a weighted mean (± standard deviation) follow-up of 27.7 ± 17.3 months. Forward flexion improved from 91°-130° preoperatively to 147°-160° postoperatively, external rotation from 26°-41° to 41°-45°, and internal rotation from L4-L1 to L1. American Shoulder and Elbow Surgeons scores increased from 36-52.2 to 77.5-92, and visual analog scale pain scores decreased from 4.0-6.3 to 0.4-1.7. Radiographically, AHIs with acellular dermal allograft ranged from 4.5 to 7.1 mm preoperatively, improving to 7.6-10.8 mm immediately postoperation before decreasing to 6.7-9.7 mm by final follow-up. Complication and graft failure rates were 17.2% and 11.7%, respectively.


      Preliminary results of SCR show consistent improvement in shoulder functionality and pain reduction. However, a decrease in postoperative AHIs indicates dermal allograft elongation and persistent superior migration of the humerus, potentially contributing to later graft failure. Studies with longer follow-up will be essential to evaluate the long-term utility of SCR in the treatment of irreparable rotator cuff tears.

      Level of Evidence

      Level IV, systematic review of level III-IV studies.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Wani Z.
        • Abdulla M.
        • Habeebullah A.
        • Kalogriantis S.
        Rotator cuff tears: Review of epidemiology, clinical assessment and operative treatment.
        Trauma. 2016; 18: 190-204
        • Lädermann A.
        • Denard P.J.
        • Collin P.
        Massive rotator cuff tears: Definition and treatment.
        Int Orthop. 2015; 39: 2403-2414
        • Oh J.H.
        • Park M.S.
        • Rhee S.M.
        Treatment strategy for irreparable rotator cuff tears.
        Clin Orthop Surg. 2018; 10: 119-134
        • Anley C.M.
        • Chan S.K.
        • Snow M.
        Arthroscopic treatment options for irreparable rotator cuff tears of the shoulder.
        World J Orthop. 2014; 5: 557-565
        • Greenspoon J.A.
        • Petri M.
        • Warth R.J.
        • Millett P.J.
        Massive rotator cuff tears: Pathomechanics, current treatment options, and clinical outcomes.
        J Shoulder Elbow Surg. 2015; 24: 1493-1505
        • Sethi P.
        • Franco W.G.
        The role of superior capsule reconstruction in rotator cuff tears.
        Orthop Clin North Am. 2018; 49: 93-101
        • Ishihara Y.
        • Mihata T.
        • Tamboli M.
        • et al.
        Role of the superior shoulder capsule in passive stability of the glenohumeral joint.
        J Shoulder Elbow Surg. 2014; 23: 642-648
        • 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
        • 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
        • Chillemi C.
        • Mantovani M.
        • Gigante A.
        Superior capsular reconstruction of the shoulder: The ABC (Arthroscopic Biceps Chillemi) technique.
        Eur J Orthop Surg Traumatol. 2018; 28: 1215-1223
        • Boutsiadis A.
        • Chen S.
        • Jiang C.
        • Lenoir H.
        • Delsol P.
        • Barth J.
        Long head of the biceps as a suitable available local tissue autograft for superior capsular reconstruction: ‘The Chinese way.’.
        Arthrosc Tech. 2017; 6: e1559-e1566
        • Wall K.C.
        • Toth A.P.
        • Garrigues G.E.
        How to use a graft in irreparable rotator cuff tears: A literature review update of interposition and superior capsule reconstruction techniques.
        Curr Rev Musculoskelet Med. 2018; 11: 122-130
        • Slim K.
        • Nini E.
        • Forestier D.
        • Kwiatkowski F.
        • Panis Y.
        • Chipponi J.
        Methodological index for non-randomized studies (MINORS): Development and validation of a new instrument.
        ANZ J Surg. 2003; 73: 712-716
        • McHugh M.L.
        Interrater reliability: The kappa statistic.
        Biochem Med. 2012; 22: 276-282
        • Lee S.J.
        • Min Y.K.
        Can inadequate acromiohumeral distance improvement and poor posterior remnant tissue be the predictive factors of re-tear? Preliminary outcomes of arthroscopic superior capsular reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 2205-2213
        • Hirahara A.M.
        • Andersen W.J.
        • Panero A.J.
        Superior capsular reconstruction: Clinical outcomes after minimum 2-year follow-up.
        Am J Orthop. 2017; 46: 266-278
        • 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
        • Pennington W.T.
        • Bartz B.A.
        • Pauli J.M.
        • Walker C.E.
        • Schmidt W.
        Arthroscopic superior capsular reconstruction with acellular dermal allograft for the treatment of massive irreparable rotator cuff tears: Short-term clinical outcomes and the radiographic parameter of superior capsular distance.
        Arthroscopy. 2018; 34: 1764-1773
        • Chen K.H.
        • Chiang E.R.
        • Wang H.Y.
        • Ma H.L.
        Arthroscopic partial repair of irreparable rotator cuff tears: Factors related to greater degree of clinical improvement at 2 years of follow-up.
        Arthroscopy. 2017; 33: 1949-1955
        • Shon M.S.
        • Koh K.H.
        • Lim T.K.
        • Kim W.J.
        • Kim K.C.
        • Yoo J.C.
        Arthroscopic partial repair of irreparable rotator cuff tears: Preoperative factors associated with outcome deterioration over 2 years.
        Am J Sports Med. 2015; 43: 1965-1975
        • Venouziou A.I.
        • Kokkalis Z.T.
        • Sotereanos D.G.
        Human dermal allograft interposition for the reconstruction of massive irreparable rotator cuff tears.
        Am J Orthop. 2013; 42: 63-70
        • Gupta A.K.
        • Hug K.
        • Berkoff D.J.
        • et al.
        Dermal tissue allograft for the repair of massive irreparable rotator cuff tears.
        Am J Sports Med. 2012; 40: 141-147
        • Steinhaus M.E.
        • Makhni E.C.
        • Cole B.J.
        • Romeo A.A.
        • Verma N.N.
        Outcomes after patch use in rotator cuff repair.
        Arthroscopy. 2016; 32: 1676-1690
        • El-Azab H.M.
        • Rott O.
        • Irlenbusch U.
        Long-term follow-up after latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears.
        J Bone Joint Surg Am. 2015; 18: 462-469
        • Grimberg J.
        • Kany J.
        Latissimus dorsi tendon transfer for irreparable postero-superior cuff tears: Current concepts, indications, and recent advances.
        Curr Rev Musculoskelet Med. 2014; 7: 22-32
        • Sershon R.A.
        • Van Thiel G.S.
        • Lin E.C.
        • et al.
        Clinical outcomes of reverse total shoulder arthroplasty in patients aged younger than 60 years.
        J Shoulder Elbow Surg. 2014; 23: 395-400
        • Kiet T.K.
        • Feeley B.T.
        • Naimark M.
        • et al.
        Outcomes after shoulder replacement: Comparison between reverse and anatomic total shoulder arthroplasty.
        J Shoulder Elbow Surg. 2015; 24: 179-185
        • Ernstbrunner L.
        • Suter A.
        • Catanzaro S.
        • Rahm S.
        • Gerber C.
        Reverse total shoulder arthroplasty for massive, irreparable rotator cuff tears before the age of 60 years: Long-term results.
        J Bone Joint Surg Am. 2017; 99: 1721-1729
        • 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
        • Ono Y.
        • Davalos Herrera D.A.
        • Woodmass J.M.
        • Boorman R.S.
        • Thornton G.M.
        • Lo I.K.
        Graft augmentation versus bridging for large to massive rotator cuff tears: A systematic review.
        Arthroscopy. 2017; 33: 673-680
        • 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
        • Amini M.H.
        • Ricchetti E.T.
        • Iannotti J.P.
        • Derwin K.A.
        An update on scaffold devices for rotator cuff repair.
        Tech Shoulder Elb Surg. 2017; 18: 101-112
        • 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
        • Taniguchi N.
        • D’Lima D.D.
        • Suenaga N.
        • et al.
        Translation of the humeral head scale is associated with success of rotator cuff repair for large-massive tears.
        BMC Musculoskelet Disord. 2017; 18: 511
        • Shim S.B.
        • Jeong J.Y.
        • Kim J.S.
        • Yoo J.C.
        Evaluation of risk factors for irreparable rotator cuff tears in patients older than 70 including evaluation of radiologic factors of the shoulder.
        J Shoulder Elbow Surg. 2018; 27: 1932-1938

      Linked Article

      • Editorial Commentary: Superior Capsule Reconstruction: Grafts for Superior Capsular Reconstruction Must Be Thick and Stiff
        ArthroscopyVol. 35Issue 8
        • Preview
          To achieve a good functional outcome, including minimal graft tear, after superior capsule reconstruction, surgeons should carefully compare the biomechanical properties of all graft materials under consideration. In particular, graft stiffness affects postoperative stability in the glenohumeral joint, acromiohumeral distance, and graft healing. In my experience, a sufficiently stiff fascia lata graft is 6- to 8-mm thick and includes suture reinforcement and/or an augmentation patch. I believe that augmenting acellular dermal allografts in a similar way will decrease the incidence of graft elongation, persistent superior migration of the humoral head, and other complications after superior capsule reconstruction.
        • Full-Text
        • PDF