Shoulder Superior Capsular Reconstruction Hybrid Graft Thickness Greater Than Preoperative Acromiohumeral Distance Increases Graft Retear Rate and Subacromial Erosion

Published:December 20, 2021DOI:


      To evaluate the impact of graft thickness on clinical outcomes and graft retear after superior capsular reconstruction (SCR) using a hybrid graft combining both fascia lata autograft and dermal allograft in patients with massive rotator cuff tear (MRCT).


      Between January 2017 and February 2019, this study enrolled 58 patients with MRCT who underwent SCR using a hybrid graft combining both fascia lata autograft and dermal allograft. We evaluated clinical outcomes and compared differences between the graft intact and the graft retear group. Moreover, subgroup analysis was performed for patients having a preoperative acromiohumeral distance (AHD) less than or equal to the used graft thickness (group 1) and the results were compared with those for preoperative AHD greater than the used graft thickness (group 2).


      Fifty-five patients who underwent MRCT with a mean age of 65.1 ± 5.7 years old were followed up during a mean period of 30.5 ± 6.5 (range, 24-37) months. There were significant differences in clinical outcome measures preoperatively and postoperatively (P < .05). There were no significant differences in clinical outcomes between the graft intact and graft retear groups (P > .05). The subgroup analysis revealed that the retear (68.6% vs 30.4%, P = .004) and subacromial erosion rates (91.4% vs 60.9%, P = .005) were significantly greater in for patients having a preoperative AHD less than or equal to the used graft thickness (group 1).


      SCR using a hybrid graft combining both fascia lata autograft and dermal allograft is promising with improved clinical scores (P < .05) irrespective of the graft integrity. The use of a graft with a thickness greater than a patient’s preoperative AHD could increase graft retear and subacromial erosion rates after SCR. However, there was no significant difference in clinical outcomes according to the relationship between used graft thickness and preoperative AHD.

      Level of Evidence

      Level IV, therapeutic case series.
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        • Kholinne E.
        • Jeon I.H.
        Arthroscopic superior capsular reconstruction of the shoulder: A narrative review.
        Ann Transl Med. 2021; 9: 268
        • Makovicka J.L.
        • Chung A.S.
        • Patel K.A.
        • Deckey D.G.
        • Hassebrock J.D.
        • Tokish J.M.
        Superior capsule reconstruction for irreparable rotator cuff tears: A systematic review of biomechanical and clinical outcomes by graft type.
        J Shoulder Elbow Surg. 2020; 29: 392-401
      1. Hammad AM, Phillips C, Wijdicks CA, Adams CR, Denard PJ. Two-year retrospective patient-reported outcomes following superior capsular reconstruction [published online May 27, 2021]. Arthroscopy.

        • Alarcon J.F.
        • Uribe-Echevarria B.
        • Clares C.
        • et al.
        Superior capsular reconstruction with autologous fascia lata using a single lateral-row technique is an effective option in massive irreparable rotator cuff tears: Minimum 2-year follow-up.
        Arthroscopy. 2021; 37: 2783-2796
        • Frank R.M.
        • Cvetanovich G.
        • Savin D.
        • Romeo A.A.
        Superior capsular reconstruction: Indications, techniques, and clinical outcomes.
        JBJS Rev. 2018; 6: e10
        • Yamamoto N.
        • Itoi E.
        Treatment of irreparable rotator cuff tears with superior capsular reconstruction.
        J Exp Orthop. 2021; 8: 23
        • 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
        • Woodmass J.M.
        • Wagner E.R.
        • Borque K.A.
        • Chang M.J.
        • Welp K.M.
        • Warner J.J.P.
        Superior capsule reconstruction using dermal allograft: Early outcomes and survival.
        J Shoulder Elbow Surg. 2019; 28: S100-S109
        • Guttmann D.
        • Graham R.D.
        • MacLennan M.J.
        • Lubowitz J.H.
        Arthroscopic rotator cuff repair: The learning curve.
        Arthroscopy. 2005; 21: 394-400
        • 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
        • Scheiderer B.
        • Kia C.
        • Obopilwe E.
        • et al.
        Biomechanical effect of superior capsule reconstruction using a 3-mm and 6-mm thick acellular dermal allograft in a dynamic shoulder model.
        Arthroscopy. 2020; 36: 355-364
        • 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
        • Hirahara A.M.
        • Andersen W.J.
        • Panero A.J.
        Superior capsular reconstruction: Clinical outcomes after minimum 2-year follow-up.
        Am J Orthop (Belle Mead NJ). 2017; 46: 266-278
        • Makovicka J.L.
        • Patel K.A.
        • Tokish J.M.
        Superior capsular reconstruction with the addition of an acromial acellular dermal allograft spacer.
        Arthrosc Tech. 2018; 7: e1181-e1190
        • Cline K.E.
        • Tibone J.E.
        • Ihn H.
        • et al.
        Superior capsule reconstruction using fascia lata allograft compared with double- and single-layer dermal allograft: A biomechanical study.
        Arthroscopy. 2021; 37: 1117-1125
        • Abd Elrahman A.A.
        • Sobhy M.H.
        • Abdelazim H.
        • Omar Haroun H.K.
        Superior Capsular reconstruction: Fascia lata versus acellular dermal allograft: A systematic review.
        Arthrosc Sports Med Rehabil. 2020; 2: e389-e397
        • 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
        • Haefeli M.
        • Elfering A.
        Pain assessment.
        Eur Spine J. 2006; 15 (suppl 1): S17-S24
        • Bot S.D.
        • Terwee C.B.
        • van der Windt D.A.
        • Bouter L.M.
        • Dekker J.
        • de Vet H.C.
        Clinimetric evaluation of shoulder disability questionnaires: A systematic review of the literature.
        Ann Rheum Dis. 2004; 63: 335-341
        • Wylie J.D.
        • Beckmann J.T.
        • Granger E.
        • Tashjian R.Z.
        Functional outcomes assessment in shoulder surgery.
        World J Orthop. 2014; 5: 623-633
        • Ellman H.
        • Hanker G.
        • Bayer M.
        Repair of the rotator cuff. End-result study of factors influencing reconstruction.
        J Bone Joint Surg Am. 1986; 68: 1136-1144
        • Goutallier D.
        • Postel J.M.
        • Bernageau J.
        • Lavau L.
        • Voisin M.C.
        Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan.
        Clin Orthop Relat Res. 1994; : 78-83
        • Yoshida M.
        • Collin P.
        • Josseaume T.
        • et al.
        Post-operative rotator cuff integrity, based on Sugaya's classification, can reflect abduction muscle strength of the shoulder.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 161-168
        • Moon S.G.
        • Hong S.H.
        • Choi J.Y.
        • et al.
        Grading anterior cruciate ligament graft injury after ligament reconstruction surgery: Diagnostic efficacy of oblique coronal MR imaging of the knee.
        Korean J Radiol. 2008; 9: 155-161
        • Park Y.B.
        • Park Y.E.
        • Koh K.H.
        • Lim T.K.
        • Shon M.S.
        • Yoo J.C.
        Subscapularis tendon repair using suture bridge technique.
        Arthrosc Tech. 2015; 4: e133-e137
        • Donigan J.A.
        • Wolf B.R.
        Arthroscopic subacromial decompression: Acromioplasty versus bursectomy alone—does it really matter? A systematic review.
        Iowa Orthop J. 2011; 31: 121-126
        • Tokish J.M.
        • Beicker C.
        Superior capsule reconstruction technique using an acellular dermal allograft.
        Arthrosc Tech. 2015; 4: e833-e839
        • Mihata T.
        Editorial Commentary: Superior capsule reconstruction: Grafts for superior capsular reconstruction must be thick and stiff.
        Arthroscopy. 2019; 35: 2535-2536
        • Kim J.O.
        • Lee J.H.
        • Kim K.S.
        • Ji J.H.
        • Koh S.J.
        • Lee J.H.
        Rotator cuff bridging repair using acellular dermal matrix in large to massive rotator cuff tears: Histologic and clinical analysis.
        J Shoulder Elbow Surg. 2017; 26: 1897-1907
        • Vredenburgh Z.D.
        • Prodromo J.P.
        • Tibone J.E.
        • et al.
        Biomechanics of tensor fascia lata allograft for superior capsular reconstruction.
        J Shoulder Elbow Surg. 2021; 30: 178-187
        • He H.B.
        • Wang T.
        • Wang M.C.
        • et al.
        Tendon-to-bone healing after repairing full-thickness rotator cuff tear with a triple-loaded single-row method in young patients.
        BMC Musculoskelet Disord. 2021; 22: 305
        • Goetti P.
        • Denard P.J.
        • Collin P.
        • Ibrahim M.
        • Hoffmeyer P.
        • Lädermann A.
        Shoulder biomechanics in normal and selected pathological conditions.
        EFORT Open Rev. 2020; 5: 508-518
        • Cvetanovich G.L.
        • Gowd A.K.
        • Liu J.N.
        • et al.
        Establishing clinically significant outcome after arthroscopic rotator cuff repair.
        J Shoulder Elbow Surg. 2019; 28: 939-948
        • Mihata T.
        • Lee T.Q.
        • Hasegawa A.
        • et al.
        Five-year follow-up of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
        J Bone Joint Surg Am. 2019; 101: 1921-1930
        • Lim S.
        • AlRamadhan H.
        • Kwak J.M.
        • Hong H.
        • Jeon I.H.
        Graft tears after arthroscopic superior capsule reconstruction (ASCR): Pattern of failure and its correlation with clinical outcome.
        Arch Orthop Trauma Surg. 2019; 139: 231-239
        • Burkhart S.S.
        • Pranckun J.J.
        • Hartzler R.U.
        Superior capsular reconstruction for the operatively irreparable rotator cuff tear: Clinical outcomes are maintained 2 years after surgery.
        Arthroscopy. 2020; 36: 373-380
        • de Campos Azevedo C.I.
        • Andrade R.
        • Leiria Pires Gago Ângelo A.C.
        • Espregueira-Mendes J.
        • Ferreira N.
        • Sevivas N.
        Fascia lata autograft versus human dermal allograft in arthroscopic superior capsular reconstruction for irreparable rotator cuff tears: A systematic review of clinical outcomes.
        Arthroscopy. 2020; 36: 579-591.e2
        • de Campos Azevedo C.I.
        • Ângelo A.C.L.P.G.
        • Vinga S.
        Arthroscopic superior capsular reconstruction with a minimally invasive harvested fascia lata autograft produces good clinical results.
        Orthop J Sports Med. 2018; 6 (2325967118808242)
        • 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
        • Sommer M.C.
        • Wagner E.
        • Zhu S.
        • et al.
        Complications of superior capsule reconstruction for the treatment of functionally irreparable rotator cuff tears: A systematic review.
        Arthroscopy. 2021; 37: 2960-2972
        • 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
        • Singh S.
        • Reeves J.
        • Langohr G.D.G.
        • Johnson J.A.
        • Athwal G.S.
        The effect of the subacromial balloon spacer on humeral head translation in the treatment of massive, irreparable rotator cuff tears: A biomechanical assessment.
        J Shoulder Elbow Surg. 2019; 28: 1841-1847