The title of this article on superior capsular reconstruction (the insertion of material between the humeral head and acromion)
states that it is a "critical analysis review".
It points out that the cost of this procedure is very high
and points out that no comprehensive quality-of-life or cost-comparison analyses are available to compare superior capsular reconstruction to other methods of treating massive rotator cuff tears.
Remarkably this critical review does not identify the indications for this procedure. The review includes the results from patients that had an average of over 130 degrees of active elevation before the procedure.
As we have pointed previously, a much more cost-effective procedure for massive cuff tears with retained active elevation is the smooth and move procedure.
Significant improvement in patient self-assessed comfort and function as early as six weeks after the smooth and move procedure for shoulders with irreparable rotator cuff tears and retained active elevation
These authors point out that it has been previously documented that the smooth and move procedure—smoothing the proximal humeral surface while maintaining the coracoacromial arch—can provide clinically significant long-term improvement in function for patients having irreparable rotator cuff tears with retained active elevation (see previous blog post that is reproduced below).
In this study they sought to demonstrate that clinically significant gains in comfort, function, and active motion can be realized as early as 6 weeks after this procedure. They conducted a prospective cohort study of the 6-week clinical outcomes for 48 patients enrolled prior to a smooth and move procedure for irreparable rotator cuff tears. Prior rotator cuff repair had been attempted in 28 (70%).
In 40 patients with preoperative and 6-week postoperative measurements, the Simple Shoulder Test scores improved from an average of 3.4 ± 2.8 preoperatively to 5.7 ± 3.5 at 6 weeks (p < 0.001), an improvement that exceeded the published values for the minimal clinically important difference (MCID).
The clinical outcomes were not worse for the 18 shoulders with irreparable tears of both the supraspinatus and infraspinatus.
This video (used with permission of the patient) shows his function 6 weeks after surgery.
This study should be considered along with a prior study, which is discussed below.
Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty
These authors sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation (>100 degrees) can be durably improved using a conservative surgical procedure that smoothes the interface between the proximal humeral convexity and the concave undersurface of the coracoacromial arch followed by immediate range of motion exercises.
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How you can support progress in shoulder surgery
You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'
These authors point out that it has been previously documented that the smooth and move procedure—smoothing the proximal humeral surface while maintaining the coracoacromial arch—can provide clinically significant long-term improvement in function for patients having irreparable rotator cuff tears with retained active elevation (see previous blog post that is reproduced below).
In this study they sought to demonstrate that clinically significant gains in comfort, function, and active motion can be realized as early as 6 weeks after this procedure. They conducted a prospective cohort study of the 6-week clinical outcomes for 48 patients enrolled prior to a smooth and move procedure for irreparable rotator cuff tears. Prior rotator cuff repair had been attempted in 28 (70%).
In 40 patients with preoperative and 6-week postoperative measurements, the Simple Shoulder Test scores improved from an average of 3.4 ± 2.8 preoperatively to 5.7 ± 3.5 at 6 weeks (p < 0.001), an improvement that exceeded the published values for the minimal clinically important difference (MCID).
The clinical outcomes were not worse for the 18 shoulders with irreparable tears of both the supraspinatus and infraspinatus.
In 30 patients with preoperative and 6-week postoperative objective measurements of active motion, the average abduction improved from 93(± 43) to 123(± 47)° (p = 0.005) and the average flexion improved from 102(± 46) to 126(± 44)° (p = 0.023).
They concluded that in addition to its previously documented long-term effectiveness for shoulders with irreparable rotator cuff tears and retained active elevation, this study demonstrates that the smooth and move procedure provides clinically significant improvement as early as 6 weeks after surgery.
They concluded that in addition to its previously documented long-term effectiveness for shoulders with irreparable rotator cuff tears and retained active elevation, this study demonstrates that the smooth and move procedure provides clinically significant improvement as early as 6 weeks after surgery.
They present the case example of a 71 year old physician photographer with a failed prior cuff repair attempt. Here is the preoperative radiograph
At surgery he had no supraspinatus or infraspinatus. The debris shown below was removed from his humeroscapular motion interface
This video (used with permission of the patient) shows his function 6 weeks after surgery.
Eight weeks after surgery he was photographing north of the Arctic Circle. Here's one of his photos.
This study should be considered along with a prior study, which is discussed below.
Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty
These authors sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation (>100 degrees) can be durably improved using a conservative surgical procedure that smoothes the interface between the proximal humeral convexity and the concave undersurface of the coracoacromial arch followed by immediate range of motion exercises.
The typical pathology in these cases is shown in the figure below.
In 77 shoulders with previously unrepaired irreparable tears, Simple Shoulder Test (SST) scores improved from an average of 4.6 (range 0–12) to 8.5 (range 1–12) (p < 0.001). Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points.
While future clinical research will hopefully clarify the indications for the superior capsular reconstruction and other more complex procedures, the advantages of the smooth and move procedure lie in its simplicity, its avoidance of tissue autograft or commercially available decellularized dermal allograft, its lack of postoperative 'down time', its high rate of durable improvement, and the fact that it does not preclude other surgical options should it fail to yield the desired result.
The surgical approach is through a deltoid splitting incision that preserves the deltoid origin, the acromion and the coracoacromial ligament.
The coracoacromial arch is preserved to avoid the complication of anterosuperior escape that is commonly encountered when acromioplasty is performed in the presence of a large cuff tear.
The surgery includes smoothing of the prominence of the greater tuberosity that is exposed in cuff tears along with resection of adhesions in the humeroscapular motion interface and a gentle manipulation under anesthesia to resolve the stiffness that is commonly associated with chronic cuff tears. Immediate active assisted and active motion are encouraged immediately after surgery. Because no repair or reconstruction has been performed, activities, including deltoid strengthening can be resumed as soon as they are comfortable.
They reviewed 151 patients with a mean age of 63.4 (range 40–90) years at a mean of 7.3 (range 2–19) years after this surgery. The patient data are shown below, contrasting the patients that did and did not improve by the MCID of 2 in the Simple Shoulder Test
For 74 shoulders with irreparable failed prior repairs, SST scores improved from 4.0 (range 0–11) to 7.5 (range 0–12) (p < 0.001). Fifty-four patients (73%) improved by the MCID of 2 SST points.
They provided this case example. A rancher in his mid 60s had a right rotator cuff reconstruction with freeze-dried acellular human dermal collagen tissue matrix that subsequently became infected. He presented to us with a painful stiff right shoulder. At surgery there was extensive scar throughout the humeral scapular motion interface. The subscapularis was detached but was reconstructible. The supraspinatus was absent. The upper 2/3 of the infraspinatus was absent as well. The tuberosities were prominent. He had a smooth and move procedure at which time the abundant scar in the humeral scapular motion interface was debrided. The previous sutures and Graft Jacket were excised. The bursa was removed. The prominent tuberosities were resected using a rongeur and a burr. A manipulation under anesthesia was performed to assure a full passive range of motion. Passive and active range of motion exercises were started immediately after surgery. Three years later he reported excellent shoulder comfort and function and sent us this photo of his return to one of his favorite activities
They concluded that smoothing of the humeroscapular interface can durably improve symptomatic shoulders with irreparable cuff tears and retained active elevation > 100 degrees. They point out that this conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears.
Comment: Currently surgeons are actively pursing a variety of methods for managing patients with symptomatic irreparable rotator cuff tears, including marginal convergence, patch grafts, superior capsular reconstructions, degrading subacromial 'balloons' tendon transfers and reverse shoulder arthroplasty. Each of these procedures is more complex than the smooth and move procedure described in this article and none offers the opportunity for immediate postoperative resumption of active use of the shoulder.
These results from 151 patients having the smooth and move procedure can be contrasted to those from 24 patients having a 'superior capsular reconstruction' using an 8 mm fascia lata graft harvested from the patients thigh have been reported by Mihata et al (see this link). After the superior capsular reconstruction it is recommended that an abduction pillow be used for 4 weeks after the reconstruction with active exercises not started until 8 weeks after surgery.
Of note is that standard dermal grafts that used instead of fascial lata are often <2mm depending on the company selling them.
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We have a new set of shoulder youtubes about the shoulder, check them out at this link.
Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link
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Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link
Use the "Search" box to the right to find other topics of interest to you.
How you can support progress in shoulder surgery
You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'
