<h3>Purpose</h3> To define clinically significant outcomes (CSO) thresholds for minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptomatic state (PASS) in patients undergoing superior capsular reconstruction (SCR) with an acellular dermal allograft. We also evaluated patient-specific variables predictive of achieving CSO thresholds. <h3>Methods</h3> The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), and subjective Constant-Murley (Constant) scores were collected preoperatively and at the most recent follow up for patients undergoing SCR from 2010 to 2019. A distribution-based approach was used to calculate MCID, and an anchor-based approach was used to calculate SCB and PASS. Logistic regression was used to determine factors associated with CSO achievement. <h3>Results</h3> Fifty-eight patients were identified (<i>n</i> = 39 males; <i>n</i> = 19 females) with a mean age of 53.4 ± 14.1 years at surgery and an average follow-up of 23 months. The MCID, SCB, and PASS were 11.2, 18.02, and 68.82 for ASES, 14.5, 23.13, and 69.9 for SANE, and 3.6, 10, and 18 for Constant, respectively. Subscapularis tear, female sex, and workers compensation (WC) status reduced odds of achieving MCID. Reduced odds of achieving Constant SCB were associated with older age, female sex, and WC status, while concomitant distal clavicle excision during SCR and lower preoperative ASES increased odds of achieving ASES SCB. Reduced odds for achieving ASES PASS were associated with female sex and WC status, while reduced odds for achieving SANE PASS were associated with subscapularis tearing preoperatively. <h3>Conclusion</h3> On the basis of calculated values for MCID, SCB, and PASS, subscapularis tearing, WC status, age, and sex are associated with failure to achieve clinically significant outcomes following SCR. Concomitant distal clavicle excision during SCR and lower preoperative ASES was predictive for achievement of MCID and SCB. By defining the thresholds and variables predictive of achieving CSOs following SCR, surgeons may better counsel patients prior to SCR. <h3>Level of Evidence</h3> Level IV, case series. 

Defining Clinically Significant Outcomes Following Superior Capsular Reconstruction With Acellular Dermal Allograft

Aims: Superior capsular reconstruction (SCR) is a treatment option for patients with massive irreparable rotator cuff tears. Different types of grafts from various donor sites have been described. There are no clinical studies comparing the different grafts available. The aim of this study is to compare the early clinical outcomes of patients who have undergone arthroscopic SCR with different types of grafts (allograft vs. autograft). Material and methods: This study is a retrospective analysis of data collected prospectively, from patients who underwent arthroscopic SCR with either a long head of biceps autograft (LHB) (n = 40) or an acellular dermal allograft (n = 40), between March 2015 and April 2018. The pre- and postoperative clinical data were compared between the 2 groups, as well as the incidence and type of complications. Results: All patients were monitored with a minimum follow-up of one year. Three patients (7.5%) in the autograft group, and 14 (35%) in the allograft group (p = 0.005) had a complication, of which 2 (5%) and 5 (12.5%) respectively, required revision surgery (p = 0.432). Linear regression ruled out any significant difference between the 2 groups, with respect to clinical scores. However, patients with a history of prior rotator cuff surgery had poorer results with regard to active elevation (β, -29.3; p = 0.020), internal rotation (β, -3.4; p = 0.003) and Subjective Shoulder Value (SSV) (β, -17.2; p = 0.023). Older patients, as well as men, are associated with poorer postoperative internal rotation (β, -0.1; p = 0.003 and β, -1.9; p = 0.039 respectively), and type D lesions are associated with poorer external rotation and postoperative SSV (β, -11.3; p = 0.012 and β, -12.4; p = 0.048 respectively), compared to type C lesions. Postoperative graft integrity was improved in the autograft group compared to the allograft group. (Grade 1: 65.8% vs. 2.9%; Grade 5: 5.3% vs. 28.6%; p Conclusions: In both groups, clinical scores improved after SCR in patients with irreparable rotator cuff tears. Fewer complications and revisions were observed with the autograft compared to the allograft. If the LHB was still in place during surgery, its use appears valid, given the reasonable cost and low rate of complications associated with it. If absent, an allograft is also an option, considering the potential clinical improvement. Level of evidence: III; Case-control study

Superior capsular reconstruction for irreparable rotator cuff tears: Autografts versus allografts.

Irreparable massive rotator cuff tear (IMRCT) was one of the causes of shoulder dysfunction, despite technical improvement, the failure rate of IMRCT was still demonstrated to be high. Traditional treatments like non‐surgical treatments, partial rotator cuff repair, and tendon transfers could only achieve a slight improvement. A potential cause for high failure rate was the fact that traditional treatments cannot restore the superior stability of glenohumeral joint, and thus restricted the movement of shoulder joint severely. Superior capsular reconstruction (SCR) using a variety of grafts (autograft, allograft, xenograft, or synthetic grafts) provided a promising option for IMRCT. In surgery, graft was fixed medially to superior glenoid and laterally to the footprint of humeral greater tuberosity. SCR could increase the stability of the superior glenohumeral joint, decrease the subacromial pressure and acromiohumeral distance. This review summarized the relevant literature regarding the alternative grafts, surgery indications, operative techniques and clinical outcomes of SCR. we compared the different grafts, key surgical steps, the advantages and disadvantages of different surgical methods to provide clinicians with new surgical insights into the treatments of IMRCT. In conclusion, IMRCT without severe glenohumeral arthritis was the best suitable indication for SCR. The clinical outcomes were positive in the short‐term and middle‐term following‐up. More studies were necessary to determine long‐term results of this surgical procedure.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/os.12976

Advancement in Arthroscopic Superior Capsular Reconstruction for Irreparable Massive Rotator Cuff Tear.

Aims The aim of this study is to provide a detailed description of cases combining bridging patch repair with artificial ligament “internal brace” reinforcement to treat irreparable massive rotator...

Combining fascia lata autograft bridging repair with artificial ligament internal brace reinforcement : a novel healing-improvement technique for irreparable massive rotator cuff tears.

Objective Treatment of massive irreparable rotator cuff tears (RCT) has shown limited clinical success and a variety of subsequent complications. Superior capsule reconstruction (SCR) has been proved to reestablish superior stability but does not restore the dynamic force or shoulder kinematics. There are numerous reports of the short-term failure of SCR grafts at the glenoid side, which relate to the non-biological healing of grafts. To restore both dynamic and static stability and to provide biologic augmentation, an integrated procedure for massive irreparable RCT using an Achilles tendon-bone allograft (ATBA) was developed. Method This was a retrospect study completed between October 2019 and April 2020. A 71-year-old woman with massive and irreparable rotator cuff tears was enrolled in our study. The ATBA was folded into a double-layer structure. The superior layer (proximal portion) served as a bridge patch to dynamic the glenohumeral joint, while the inferior layer (distal portion) served as the superior capsule to restore static stability of glenohumeral joint. To enhance biologic healing on the glenoid side, we fixed the calcaneus of the graft on the superior-posterior side of the superior glenoid rim. The recovery of shoulder function (including strength, range of motion, acromiohumeral interval, and fatty infiltration) was assessed at 6 months postoperation. Result At 6-month follow-up, the patient's strength had improved significantly (from abduction of grade 3 preoperatively to grade 4 at 6 months). Radiographic analysis showed an increase in the acromiohumeral interval from 3 to 7 mm. Magnetic resonance imaging revealed an intact graft, with the thickness of the ligament part maintained (at 6-7 mm). Most importantly, recovery of atrophy and fatty infiltration of the supraspinatus were observed. No graft tears were observed on the glenoid side. Conclusion This technique could provide a preferable treatment option by restoring shoulder kinematics and augmentating biological healing for patients with massive irreparable RCT.

Arthroscopic Superior Capsule Reconstruction and Rotator Cuff Repair to Restore Static and Dynamic Stability of the Shoulder.

The technique of superior capsular reconstruction (SCR) using fascia lata autograft, described by Mihata et al. in 2012, has been an acceptable and effective method for treating irreparable massive rotator cuff tears, especially in cases with severe fatty infiltration and tendon retraction. After the SCR procedure of Mihata et al., it was found that some graft failure occurred with thinning and elongation during the follow-up time, which was called graft “creep.” To avoid graft creep and reduce graft failure rates after SCR, we created an arthroscopic SCR technique with a “sandwich” patch augmented with polyethylene terephthalate scaffold interspaced between 2 folded layers of fascia lata autograft.

Arthroscopic Superior Capsular Reconstruction Using "Sandwich" Patch Technique for Irreparable Rotator Cuff Tears.

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Arthroscopic Superior Capsular Reconstruction Using "Sandwich" Patch Technique for Irreparable Rotator Cuff Tears.