Wednesday, July 8, 2020

Superior capsular reconstruction - where are we?

Arthroscopic superior capsule reconstruction with Teflon felt synthetic 1 graft for irreparable massive rotator cuff tears: Clinical and radiographic results at minimum 2-year follow-up

These authors, including the originator of the SCR, reviewed their two year minimum outcomes in 35 shoulders having arthroscopic superior capsule reconstruction with Teflon felt synthetic 1 graft for irreparable massive rotator cuff tears:

They reported that SCR using Teflon grafts of either one or three layers significantly improved 

the ASES score by 21, for one-layer graft; and by 31 for three-layer graft.

the VAS score for motion pain by 3.2,  and by 3.0.

and muscle strength in shoulder abduction by 11.9 N,  and by 10.9 N,

Active elevation at final  follow-up was significantly greater in the three-layer-graft group (142° ± 27°) than in the one-layer-graft group (107° ± 42°) (P = 0.006). 

One year after SCR, the acromiohumeral distance in the three-layer-graft group was significantly greater than preoperatively, whereas in the one-layer-graft group it was not. The acromiohumeral distance diminished with time.

On postoperative MRI, none of the patients in the three-layer-graft group had graft tears, while two patients had graft tear and one patient had severe synovitis after one-layer-graft SCR.

Comment: It is of interest that up to now the materials used for SCR have included biological autogenous fascia lata, biological acellular dermal matrix (GraftJacket, ArthroFlex ® SCR), and now the non-biological Teflon graft.

The study compared the results two non-randomized sets of patients operated on during different time intervals: in the first 15 cases (group 1), the synthetic graft was made from one layer (2.9 mm thick) of Teflon felt. The remaining 20 cases (group 2) were treated by SCR by using three layers (8.7 mm thick) of Teflon felt. It is otherwise unclear how patients wound up in each group, thus their comparability is uncertain.

Another issue is that the preoperative active elevation (flexion) for the shoulders treated ranged from 20 to 160 degrees. This is a huge variation. Shoulders with retained active elevation can be well managed with simpler, safer, and less expensive procedures than a SCR (see this link).  

In order to understand the value (effectiveness divided by the cost) of the growing number of different approaches to the irreparable cuff we will need higher quality studies that accurately characterize the preoperative to postoperative change for each patient, stratified by their preoperative shoulder function and pathology. 

To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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