These authors provide the following "bullet points"after their review of the literature on superior capsular reconstruction (SCR):
» A massive rotator cuff tear is defined as a tear involving . 2 tendons or >. 5 cm of retraction.
» Superior capsular reconstruction is done with either a folded fascia lata autograft (6 to 8 mm in thickness) or acellular dermal allograft (3 to 4 mm in thickness). The graft is secured arthroscopically with anchors on the superior glenoid rim and multiple anchors on the humeral head with use of a transosseous-equivalent repair technique.
» Superior capsular reconstruction is indicated for younger patients with massive and irreparable rotator cuff tears involving the supraspinatus and infraspinatus with minimal arthritis, intact subscapularis, and a functional deltoid. Contraindications include bone defects, stiffness, and moderate to severe arthropathy.
» Arthroscopic superior capsular reconstruction with fascia lata autograft or humeral dermal allograft is a surgical option, with multiple studies showing statistically significant improvement in short-term outcomes for both pain and function among younger patients with massive irreparable rotator cuff tears. The long-term clinical effectiveness and value have yet to be determined.
» Biomechanical data suggest improved restoration of superior glenohumeral stability with decreased subacromial contact pressures in association with the use of the 8-mm fascia lata graft as compared with the 4-mm acellular humeral dermal allograft. In addition, fascia lata graft has shown less elongation and thinning than humeral dermal graft.
» Either fascia lata autograft or humeral dermal allograft may be used clinically for arthroscopic superior capsular reconstruction; however, a graft thickness of at least 3 mm is recommended to decrease the risk of radiographic and clinical failure.
» No comprehensive quality-of-life or cost-comparison analyses are available to compare superior capsular reconstruction, reverse total shoulder arthroplasty (rTSA), tendon transfer, and partial rotator cuff repair for the treatment of massive irreparable rotator cuff tears.
» The potential higher cost of superior capsular reconstruction and the lack of long-term clinical outcomes or revision data suggest that either an attempt at repair or primary arthroplasty may be more cost-effective than superior capsular reconstruction.
» Long-term outcome data are essential to determine the role of superior capsular reconstruction for young patients with massive irreparable rotator cuff tears.
» Superior capsular reconstruction using fascia lata autograft may provide a different biomechanical and biological healing environment compared to acellular dermal allograft. Thus, the clinical outcome data between the 2 graft methods should not be generalized.
The costs of the procedure were reported below.
» Superior capsular reconstruction is done with either a folded fascia lata autograft (6 to 8 mm in thickness) or acellular dermal allograft (3 to 4 mm in thickness). The graft is secured arthroscopically with anchors on the superior glenoid rim and multiple anchors on the humeral head with use of a transosseous-equivalent repair technique.
» Superior capsular reconstruction is indicated for younger patients with massive and irreparable rotator cuff tears involving the supraspinatus and infraspinatus with minimal arthritis, intact subscapularis, and a functional deltoid. Contraindications include bone defects, stiffness, and moderate to severe arthropathy.
» Arthroscopic superior capsular reconstruction with fascia lata autograft or humeral dermal allograft is a surgical option, with multiple studies showing statistically significant improvement in short-term outcomes for both pain and function among younger patients with massive irreparable rotator cuff tears. The long-term clinical effectiveness and value have yet to be determined.
» Biomechanical data suggest improved restoration of superior glenohumeral stability with decreased subacromial contact pressures in association with the use of the 8-mm fascia lata graft as compared with the 4-mm acellular humeral dermal allograft. In addition, fascia lata graft has shown less elongation and thinning than humeral dermal graft.
» Either fascia lata autograft or humeral dermal allograft may be used clinically for arthroscopic superior capsular reconstruction; however, a graft thickness of at least 3 mm is recommended to decrease the risk of radiographic and clinical failure.
» No comprehensive quality-of-life or cost-comparison analyses are available to compare superior capsular reconstruction, reverse total shoulder arthroplasty (rTSA), tendon transfer, and partial rotator cuff repair for the treatment of massive irreparable rotator cuff tears.
» The potential higher cost of superior capsular reconstruction and the lack of long-term clinical outcomes or revision data suggest that either an attempt at repair or primary arthroplasty may be more cost-effective than superior capsular reconstruction.
» Long-term outcome data are essential to determine the role of superior capsular reconstruction for young patients with massive irreparable rotator cuff tears.
» Superior capsular reconstruction using fascia lata autograft may provide a different biomechanical and biological healing environment compared to acellular dermal allograft. Thus, the clinical outcome data between the 2 graft methods should not be generalized.
The costs of the procedure were reported below.
Comment: Thoughts #1: The SCR, the graft is attached under some tension to the tuberosity and to the superior glenoid (black arrows). In theory (as shown in the diagram below) is that the tension in the graft couples with the pull of the deltoid to produce a rotational force on the humeral head resulting in abduction.
The issue is that when the arm is abducted, these two attachment points become closer together (see simulation of the effects of 57 degrees of abduction in the diagram below). This would seem to have two effects. (1) Because the graft is not contractile, abduction eliminates the necessary tension in the graft. (2) Because the graft is not contractile, abduction causes bunching up of the graft.
For the mathematically inclined reader, the radius of the humeral head is about 25 mm (see this link).
A radian is the arc of rotation equal to the radius of the circle; one radian is about 57 degrees. Thus if the arm is abducted 57 degrees, the attachment points of the SCR (black arrows) are approximated by an arc equal to the radius of the humeral head, or 25 mm (about one inch). This is the amount of slack created in the SCR graft by 57 degrees of glenohumeral abduction.
In contrast to the SCR with its non-contractile graft that has no excursion, the supraspinatus has an contractile excursion of 31 mm (see this link), enough to apply force to the tuberosity through an arc of over 70 degrees of glenohumeral abduction.
Thoughts #2: It is said that the indication for an SCR is "a massive and irreparable rotator cuff tear involving the supraspinatus and infraspinatus with minimal arthritis, intact subscapularis, and a functional deltoid". Is this the case?
We saw such a patient who had a chronic cuff tear, 80 degrees of active elevation, and these images showing "a massive and irreparable rotator cuff tear involving the supraspinatus and infraspinatus with minimal arthritis, intact subscapularis, and a functional deltoid".
He was placed on this exercise (see this link)
Two months later he returned with active elevation of 150 degrees, a comfortable shoulder and enthusiasm for continuing his rehab efforts.
Here's another example of the images for a man with a chronic massive cuff tear as shown below (from the same clinic day as the patient above).
In spite of his massive irreparable cuff tear, he had active elevation of 150 degrees.
For cases like these the result of non-operative management was at least as good as those reported for SCR without the cost and surgical risk.
For patients with symptomatic irreparable cuff tears and retained active elevation, the smooth and move procedure appears to be a cost-effective alternative to SCR (see this link and this link).
We have developed a simple set of guidelines for managing the spectrum of cuff disease that at this point do not include SCR. We use the guidelines below for discussing treatment options with our patients. We recognize that the presence of a cuff tear is not in and of itself an indication for surgery in that many cuff tears are either asymptomatic or responsive to non operative management.
Acute traumatic reparable rotator cuff tear
- consider acute rotator cuff repair (see this link)
Chronic cuff tear without arthritis
- gentle progressive stretching and strengthening (see this link)
- if unsatisfactory response to non-operative program:
- if tear is reparable - consider attempting repair
-if tear is irreparable
-if patient can actively elevate arm above horizontal, consider smooth and move
-if patient is unable to actively raise arm above horizontal, consider reverse total shoulder (see this link)
Chronic rotator cuff tear with arthritis
- gentle progressive stretching and strengthening
- if unsatisfactory response to non-operative program:
-if patient can elevate arm above horizontal and if coracoacromial arch is intact, consider CTA arthroplasty (see this link)
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
Use the "Search" box to the right to find other topics of interest to you.
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'
