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The purpose of this systematic review is to characterize the complications associated with superior capsule reconstruction (SCR) for the treatment of functionally irreparable rotator cuff tears (FIRCTs).
Methods
This systematic review was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Two independent reviewers completed a search of PubMed, Embase, and Medline databases. Studies were deemed eligible for inclusion if they reported postoperative outcomes of arthroscopic SCR for FIRCTs and considered at least 1 postoperative complication. Statistical heterogeneity was quantified via the I2 statistic. Due to marked heterogeneity, pooled proportions were not reported. All complications and patient-reported outcomes were described qualitatively.
Results
Fourteen studies met the inclusion/exclusion criteria. The overall complication rate post-SCR ranged from 5.0% to 70.0% (I2 = 84.9%). Image-verified graft retear ranged from 8% to 70%, I2 = 79.4%), with higher rates reported when SCR was performed using allograft (19%-70%, I2 76.6%) compared to autograft (8%-29%, I2 = 66.1%). Reoperation (0%-36%, I2 = 73.4%), revision surgeries (0%-21%, I2 = 81.2%), medical complications (0%-5%, I2 = 0.0%), and infections (0%-5%, I2 = 0.0%) were also calculated.
Conclusions
SCR carries a distinct complication profile when used for the treatment of FIRCTs. The overall rate of complications ranged from 5.0% to 70.0%. The most common complication is graft retear with higher ranges in allografts (19%-70%) compared to autografts (8%-29%). The majority of studies reported at least 1 reoperation (range, 0%-36%), most commonly for revision to reverse shoulder arthroplasty.
Level of Evidence
Level IV, systematic review of Level IV or better investigations.
Chronic massive rotator cuff tears are often disabling for patients and difficult to manage for surgeons. These tears account for up to 40% of all rotator cuff tears evaluated in clinic,
Patients often present with severe pain, weakness, and loss of range of motion, which interferes with their activities of daily living and quality of life.
As a result, many patients with chronic massive rotator cuff tears fail nonoperative management and eventually undergo surgery. Traditional open and arthroscopic repair has resulted in disappointing outcomes, with tears being either irreparable intraoperatively or resulting in unacceptably high retear rates postoperatively, ranging from 25% to 94%.
Clinical and radiographic outcomes after arthroscopic repair of massive rotator cuff tears using a suture bridge technique: Assessment of repair integrity on magnetic resonance imaging.
These tears are now commonly referred to as functionally irreparable rotator cuff tears (FIRCTs).
Reverse total shoulder arthroplasty (RSA) is a suitable treatment for elderly, lower-demand patients with FIRCTs. However, in younger, active patients, RSA has demonstrated reduced long-term survivorship and higher complication rates,
Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: Long-term results at a minimum follow-up of ten years.
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.
Superior capsular reconstruction reverses profound pseudoparalysis in patients with irreparable rotator cuff tears and minimal or no glenohumeral arthritis.
Biomechanical effect of thickness and tension of fascia lata graft on glenohumeral stability for superior capsule reconstruction in irreparable supraspinatus tears.
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.
Superior capsular reconstruction for massive rotator cuff tear leads to significant improvement in range of motion and clinical outcomes: A systematic review.
Clinical and imaging outcomes after arthroscopic superior capsule reconstruction with human dermal allograft for irreparable posterosuperior rotator cuff tears: A minimum 2-year follow-up.
The variability in outcomes has been attributed to differences in surgical indications, technical considerations such as graft choice (allograft vs autograft), and surgeon experience.
However, there remains a paucity of data on the true complication profile following SCR for the treatment of FIRCTs. This information is essential to assist surgeons and patients in the surgical decision-making process when treating this difficult pathology. The purpose of this systematic review is to characterize the complications associated with SCR for the treatment of FIRCTs.
We hypothesized that (1) SCR is associated with highly variable rates of complications, including graft retear, reoperation, and revision surgery; (2) SCR is a medically safe intervention; and (3) allograft and autograft studies have similar complication profiles.
Methods
This systematic review was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
An English-language search of the PubMed (1966 to present), Embase (1947 to present), and Medline (1946 to present) databases was completed on May 5, 2020. Combinations of the terms “superior capsular reconstruction,” “tissue scaffold,” and “rotator cuff” were combined with the use of wildcard modifiers and medical subject headings (MeSH) such as “reconstructive surgical procedure” to identify relevant articles (Appendix 1). A secondary search was completed of the reference lists of the included studies as well as prior systematic reviews to ensure a complete data set was obtained.
Titles, abstracts, and full-text articles were reviewed independently by 2 investigators (M.S. and D.O.). If there was disagreement between the 2 reviewers, these were resolved by the senior author (J.W.).
Inclusion Criteria
Studies were deemed eligible for inclusion if they satisfied the following criteria: reported postoperative outcomes of arthroscopic SCR for irreparable rotator cuff tears and considered at least 1 postoperative complication. Case reports, review articles, editorials, commentary or gray literature source (ie, conference abstract or proceeding), animal or cadaveric studies, technique papers, and non-English-language publications were excluded. When multiple studies were published on the same patient cohort, all but 1 study (with the longest follow-up or most robust data set) representing that patient population were excluded.
Data Extraction and Quality Analysis
Data extraction was completed by 2 independent investigators (M.S. and S.Z.). Demographic data included the number of patients evaluated, patient age (mean and range), sex (proportion female), and length of follow-up (mean and range; Table 1). Preoperative parameters and clinical outcomes extracted included American Shoulder and Elbow Surgeons Shoulder score, pain as measured on a visual analog scale, Subjective Shoulder Value, Constant-Murley Shoulder Outcome Score (Constant), and radiographic or imaging outcomes as described by the authors. The surgical parameters analyzed included graft type (ie, dermal), graft source (autograft or allograft), graft thickness (mm), previous surgery and the number of tendons involved (supraspinatus, infraspinatus, subscapularis). The postoperative complications analyzed included graft retear, image verified graft retear, reoperation, revision surgery, infection, contracture, arthritis progression/humeral head elevation, persistent pain, thrombotic/pulmonary embolism (PE), and donor site morbidity.
“Reoperation” was defined as any surgical intervention during postoperative follow-up. This consisted of both “revision surgery,” defined as an intervention performed to address a clinical failure of the procedure, and “other complications,” where surgery was performed leaving the SCR intact (eg, irrigation and debridement for infection, biceps tenodesis). The “image verified graft retear” rate included only studies that routinely performed postoperative magnetic resonance imaging (MRI) with greater than 80% of the patient population at a minimum of 6 months. Adverse outcomes were defined as unique negative outcomes reported by individual studies that did not required specific treatment or further investigation. Adverse outcomes were extracted and reported but were not included in the overall rate of complications.
Following data extraction, assessment of methodologic quality of the included studies was completed by a single reviewer (M.S.) using the Methodological Index for Non-Randomized Studies.
This scale scores articles across 10 criteria compatible with the Consolidated Standards of Reporting Trials statement for randomized controlled trials yet allows for the inclusion of differing study designs (Table 3).
A total complication rate was defined as the total number of complications divided by the total sample size for each study. Individual complication rates were calculated by the number of patients who experienced the complication against the total sample size of each study. Heterogeneity analysis was completed through consideration of the I2 statistic
that ultimately precluded formal meta-analyses on complication proportions due to the high heterogeneity. Forest plots were generated for visual interpretation and ranges with the associated I2 statistic were presented in text for the complication proportions. All analyses were completed using StatsDirect software, version 3.2.8 (StatsDirect Ltd, BirkenHead, UK).
Results
A total of 414 studies met the search criteria, with 133 duplicates removed. Abstract screening of 281 studies resulted in 35 being considered for full-text review, and 19 studies were initially included (Fig 1). Mihata et al.
Superior capsular reconstruction reverses profound pseudoparalysis in patients with irreparable rotator cuff tears and minimal or no glenohumeral arthritis.
Frequently reported complications following SCR included graft retear (graft rupture, anchor loosening), revision surgery, reoperation, and infection. Less commonly, patients experienced “other” complications such as stiffness or medical complications such as stroke or deep vein thrombosis. The overall rate of complications post-SCR ranged from 5.0% to 70.0% (I2 = 77.3%; Fig 2) (507 shoulders; Table 2).
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.
Clinical and imaging outcomes after arthroscopic superior capsule reconstruction with human dermal allograft for irreparable posterosuperior rotator cuff tears: A minimum 2-year follow-up.
Can inadequate acromiohumeral distance improvement and poor posterior remnant tissue be the predictive factors of re-tear? Preliminary outcomes of arthroscopic superior capsular reconstruction.
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.
Clinical and imaging outcomes after arthroscopic superior capsule reconstruction with human dermal allograft for irreparable posterosuperior rotator cuff tears: A minimum 2-year follow-up.
Clinical and imaging outcomes after arthroscopic superior capsule reconstruction with human dermal allograft for irreparable posterosuperior rotator cuff tears: A minimum 2-year follow-up.
Can inadequate acromiohumeral distance improvement and poor posterior remnant tissue be the predictive factors of re-tear? Preliminary outcomes of arthroscopic superior capsular reconstruction.
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.
Clinical and imaging outcomes after arthroscopic superior capsule reconstruction with human dermal allograft for irreparable posterosuperior rotator cuff tears: A minimum 2-year follow-up.
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.
Can inadequate acromiohumeral distance improvement and poor posterior remnant tissue be the predictive factors of re-tear? Preliminary outcomes of arthroscopic superior capsular reconstruction.
Clinical and imaging outcomes after arthroscopic superior capsule reconstruction with human dermal allograft for irreparable posterosuperior rotator cuff tears: A minimum 2-year follow-up.
Can inadequate acromiohumeral distance improvement and poor posterior remnant tissue be the predictive factors of re-tear? Preliminary outcomes of arthroscopic superior capsular reconstruction.
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.
ADH, acromial humeral distance; ASES, American Shoulder and Elbow Surgeons Score; NR, not reported; SSV, Subjective Shoulder Value; VAS, visual analog scale.
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.
Clinical and imaging outcomes after arthroscopic superior capsule reconstruction with human dermal allograft for irreparable posterosuperior rotator cuff tears: A minimum 2-year follow-up.
Can inadequate acromiohumeral distance improvement and poor posterior remnant tissue be the predictive factors of re-tear? Preliminary outcomes of arthroscopic superior capsular reconstruction.
The image-verified graft retear rate (8 studies, 271 shoulders) showed relatively higher rates of graft retear using allograft (19%-70%, I2 = 76.6%; Fig 3B ) when compared to those that used autografts (8%-29%, I2 = 66.1%; Fig 3C), respectively. The study by Lee et al.
Can inadequate acromiohumeral distance improvement and poor posterior remnant tissue be the predictive factors of re-tear? Preliminary outcomes of arthroscopic superior capsular reconstruction.
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.
Clinical and imaging outcomes after arthroscopic superior capsule reconstruction with human dermal allograft for irreparable posterosuperior rotator cuff tears: A minimum 2-year follow-up.
Can inadequate acromiohumeral distance improvement and poor posterior remnant tissue be the predictive factors of re-tear? Preliminary outcomes of arthroscopic superior capsular reconstruction.
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.
Clinical and imaging outcomes after arthroscopic superior capsule reconstruction with human dermal allograft for irreparable posterosuperior rotator cuff tears: A minimum 2-year follow-up.
Can inadequate acromiohumeral distance improvement and poor posterior remnant tissue be the predictive factors of re-tear? Preliminary outcomes of arthroscopic superior capsular reconstruction.
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.
Clinical and imaging outcomes after arthroscopic superior capsule reconstruction with human dermal allograft for irreparable posterosuperior rotator cuff tears: A minimum 2-year follow-up.
Can inadequate acromiohumeral distance improvement and poor posterior remnant tissue be the predictive factors of re-tear? Preliminary outcomes of arthroscopic superior capsular reconstruction.
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.
Clinical and imaging outcomes after arthroscopic superior capsule reconstruction with human dermal allograft for irreparable posterosuperior rotator cuff tears: A minimum 2-year follow-up.
Clinical and imaging outcomes after arthroscopic superior capsule reconstruction with human dermal allograft for irreparable posterosuperior rotator cuff tears: A minimum 2-year follow-up.
Clinical and imaging outcomes after arthroscopic superior capsule reconstruction with human dermal allograft for irreparable posterosuperior rotator cuff tears: A minimum 2-year follow-up.
The CVA occurred in the immediate postoperative period and was due to withheld warfarin prior to the operation in a patient with a mechanical heart valve.
The patient who developed a PE was successfully treated with anticoagulation and the patient with a DVT was described as experiencing “donor-site claudication,” for which no treatment was listed.
Five studies listed adverse outcomes that were not included in the overall complications. Adverse outcomes were unique to the individual study and required no treatment or further investigation.
defined as less than a 17-point improvement in American Shoulder and Elbow Surgeons Shoulder score, with 19 of 59 and 6 of 41 patients experiencing an unsuccessful outcome, respectively. In comparison, Woodmass et al.
described donor site–related morbidity, with 12 of 21 patients reporting harvest site pain and 16 of 21 patients reporting harvest site changes (eg, deformity, numbness, pain).
Discussion
SCR is associated with a highly variable rate of complications, ranging from 5.0% to 70%. The most common complication following SCR included image verified graft retear, with higher ranges among those treated with allografts (19%-70%) compared to those treated with autografts (8%-29%). Other complications included reoperation (0%-36%) and medical complications (0%-5%).
FIRCTs represent a challenging pathology with multiple treatment options, including debridement and subacromial decompression,
Arthroscopic debridement and decompression for selected rotator cuff tears: Clinical results, pathomechanics, and patient selection based on biomechanical parameters.
Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: Long-term results at a minimum follow-up of ten years.
Ek ETH Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: Results after five to fifteen years.
Arthroscopic management of massive rotator cuff tears: An evaluation of debridement, complete, and partial repair with and without force couple restoration.
in 2013 as a joint-preserving treatment option for patients with FIRCTs demonstrating promising postoperative clinical outcomes. Subsequent studies have reported highly variable rates of complications, including graft retears, reoperations, and revision surgeries.
This systematic review characterized the risk profile of SCR for the treatment of FIRCTs. A total of 14 studies (507 shoulders) met the study criteria, yielding an overall complications rate ranging from 5% to 70% (I2 = 77.3%).
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.
Clinical and imaging outcomes after arthroscopic superior capsule reconstruction with human dermal allograft for irreparable posterosuperior rotator cuff tears: A minimum 2-year follow-up.
Can inadequate acromiohumeral distance improvement and poor posterior remnant tissue be the predictive factors of re-tear? Preliminary outcomes of arthroscopic superior capsular reconstruction.
In the current study, graft retear was the most common complication following SCR, with at least 1 retear occurring in each of the 14 studies analyzed (5%-70%; Table 2). This high variability is at least partially explained by the differences in methodology and reporting. For instance, while some studies only imaged patients who presented with persistent pain or poor function, other studies performed routine MRI on 100% of their patients at final follow-up. In an effort to reduce this bias, an “image-verified graft retear” rate was calculated by evaluating only studies where >80% of patients had undergone a postoperative MRI at a minimum 6-month follow-up. The majority of studies demonstrated an image-verified graft retear rate of 20% or greater (Fig 3A). Variability in graft retear rates can also be explained by differences in fixation techniques utilized by the studies included in our analysis. For example, some studies found that anchor loosening primarily occurred at the glenoid,
Clinical and imaging outcomes after arthroscopic superior capsule reconstruction with human dermal allograft for irreparable posterosuperior rotator cuff tears: A minimum 2-year follow-up.
Can inadequate acromiohumeral distance improvement and poor posterior remnant tissue be the predictive factors of re-tear? Preliminary outcomes of arthroscopic superior capsular reconstruction.
was more common. This variability can be attributed in part to differences in surgical technique. Although patients who experience a graft retear may demonstrate an improvement in pain and function when compared to their preoperative status, patients with healed SCR grafts demonstrate improved patient-reported outcomes at 2 years, highlighting the continued need to improve healing rates.
Superior capsular reconstruction reverses profound pseudoparalysis in patients with irreparable rotator cuff tears and minimal or no glenohumeral arthritis.
When controlling for graft type, the range of image-verified graft retear was higher in patients who underwent an allograft reconstruction (19%-70%) when compared to autograft reconstructions (8%-29%). This may reflect graft incorporation with autograft tissue, allowing for more reliable integration and durability.
reported autografts to have superior maximum tensile strength with regard to soft tissue bone healing when compared to allografts. The difference in failure rates may also be attributed to the difference in graft thickness that typically parallels graft type. Currently, dermal allografts are available in thicknesses ranging from 1 to 3 mm.
Conversely, iliotibial band autografts are harvested intraoperatively and typically shaped to measure 8 mm in thickness. Biomechanical data have demonstrated that 8-mm fascia lata autografts provide greater rotator cuff stability via a reduction in both superior peak contact pressure and superior translation, compared to 4-mm facia lata autografts.
Biomechanical effect of thickness and tension of fascia lata graft on glenohumeral stability for superior capsule reconstruction in irreparable supraspinatus tears.
who reported that thinner grafts (1 mm) are more susceptible to failure (60%) when compared to reconstructions performed using thicker (3-mm) grafts (32%).
Reoperations were reported in 83% of the included studies (range, 0%-36%) with revision surgery accounting for the majority of reoperations (Fig 4A,B). The most common revision surgery following SCR was RSA followed by revision SCR and LDT (Table 2). While the rate of reoperation is high, FIRCTs are a challenging pathology, and the alternative reconstructive interventions (rotator cuff repair, tendon transfer, RSA) share a similar reoperation profile. According to Duralde et al.
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