Superior capsular reconstruction

Five-Year Follow-up of Arthroscopic Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears

These authors, including the originator of the procedure,  assessed the 5 year functional and radiographic results of superior capsule reconstruction performed on 30 patients with irreparable cuff tears using fascia lata autograft.

Compared with preoperative values, ASES and JOA scores, active elevation, and acromiohumeral distance increased postoperatively at both 1 year (p < 0.001) and 5 years (p < 0.001).

The 1-year values increased by 54.0 points for the ASES score, 34.4 points for the JOA score, 53° for active elevation, and 5.7 mm for acromiohumeral distance,

The  5-year values increased by 63.3 points for the ASES score, 39.9 points for the JOA score, 66° for active elevation, and 4.7 mm for acromiohumeral distance. The ASES score was greater at 5 years postoperatively than it was at 1 year postoperatively (mean difference, 9.3 points; p = 0.03). At 5 years postoperatively, 11 of 12 patients returned to physical work, a rate of 92% (95% confidence interval [CI], 73% to 100%), and 8 of 8 patients returned to sports, a rate of 100% (95% CI, 79% to 100%).

None of the 27 patients who had graft healing showed progression of cuff tear arthropathy, but all 3 patients with a graft tear (10% [95% CI, 0% to 22%]) had severe cuff tear arthropathy at 5 years postoperatively.

In the 27 patients whose grafts remained intact, the graft thicknesses at 3 months, 1 year, and 5 years postoperatively did not differ (p = 0.67).

Comment: These authors emphasize the value of using a thick (8-9mm) fascia lata autograft (as shown in the figure below) to optimize healing, durability and the subacromial spacer effect of the graft.

They also point to the challenges in using superior capsular reconstruction in cases with more advanced preoperative pathology as shown in the case of graft failure below

Finally, they caution that their results with thick fascia lata allograft cannot be extrapolated to the use of thinner dermal allograft.

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A video of our approach to shoulders with irreparable cuff tears can be seen by clicking this link.

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Rotator cuff tears - are fascia lata grafts of value?

Bone healing potential of fascia lata autografts to the humeral head footprint in rotator cuff reconstruction based on magnetic resonance imaging and histologic evaluations

These authors sought to evaluate the bone healing potential of fascia lata autograft (FLA) by magnetic resonance imaging (MRI) 69 patients at > 6 months ( mean of 35.6 months,  range 10-78 months)) after surgery.

Based on MRI, retear cases were divided into type 1 (the graft did not remain on the greater tuberosity) and type 2 (the graft remained on the greater tuberosity).

Only 50% of the grafts were intact at followup: there were 35 intact repairs and 34 failures: 7 type 1 and 27 type 2 shoulders.

Comment: This study did not provide clinical evaluation of these 69 patients so we do not know if this procedure was of value to the patients or if healing of the graft affected the outcome. The added cost and complications of the use of a fascial graft are not mentioned. Harvest of fascia late is a morbid procedure and needs justification based on clinical benefit to the patient.

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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

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'

Does Augmentation with a Reinforced Fascia Patch Improve Rotator Cuff Repair Outcomes? CORR

Does Augmentation with a Reinforced Fascia Patch Improve Rotator Cuff Repair Outcomes? CORR

This is a study of the surgical repair of surgical incomplete (2/3 rds) release and acute repair of the infraspinatus tendon in young dogs. Thus it is not a study of 'rotator cuff repair outcomes' and the model is quite different than the clinical situation we encounter where the issue is usually a chronic defect with tendon tissue loss in individuals older than 60 years. The authors acknowledged support of the Musculoskeletal Transplant Foundation, which makes the patches used in this series of experiments.

Identical lesions were created on each side of the dogs' shoulders, one one side, the repair was reinforced with a "novel poly-L-lactic acid-reinforced (human) fascia patch" and the other without. It is of note that this patch was applied over a robust tendon to bone repair and was not used to bridge a defect in the rotator cuff or to reinforce a tenuous repair.  At 12 weeks, the ultimate load of augmented  repairs was 16% less than nonaugmented repairs.

Curiously, the authors conclude that "... these findings support the possibility that reinforced fascia patches would incorporate and provide (at least early) mechanical augmentation to rotator cuff repair in human patients." However, the value (benefit to the patient/cost) of the patches now commercially in rotator cuff surgery remains to be demonstrated in the clinical situation.

The most interesting aspect of this paper was the retraction of the tendon stump from the osseous repair site - even in this ideal rotator cuff repair model.  As early as three months after the repairs, 4 of 11 non augmented repairs and 6 of 11 augmented repairs had retracted by a centimeter or more! These results again emphasize how difficult it is to achieve durable reconstruction of the anatomy of the tendon insertion - even under idealized circumstances.

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Does Augmentation with a Reinforced Fascia Patch Improve Rotator Cuff Repair Outcomes? CORR

Does Augmentation with a Reinforced Fascia Patch Improve Rotator Cuff Repair Outcomes? CORR

In this study funded by the Musculoskeletal Transplant foundation, eleven dogs had partial release and acute repair of the infraspinatus tendon, one shoulder with augmentation with a fascial patch and one without augmentation. Immediately after surgery the ultimate load of augmented repairs was 296 ± 130 N (46% ± 25%) more than nonaugmented repairs. However at three months, the ultimate load of augmented repairs averaged 192 ± 213 N (15% ± 16%) less than nonaugmented repairs.

Somehow the authors made a bit of a long jump to conclude that "these findings support the possibility that reinforced fascia patches would incorporate and provide (at least early) mechanical augmentation to rotator cuff repair in human patients."

As we've pointed out before, partial release and acute repair of the healthy infraspinatus in a dog is not very similar to the repair of a torn rotator cuff in a human, so the value of this musculoskeletal transplant remains to be demonstrated.

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Use the "Search the Blog" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty,  and rotator cuff surgery.

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