Massive irreparable RCTs, especially those chronic and degenerative in etiology, necessitate careful consideration of different treatment options for each individual patient. For elderly and low-demand patients, pain relief can be achieved with nonoperative treatment, debridement, partial RCT repair, biceps tendon tenotomy, or RTSA3,11-14,21,22,36,37. In contrast, surgical options for younger and higher-demand patients include biceps tendon transfer (if there is no tendon pathology)16, pectoralis major transfer (for anterior RCTs)17,18, latissimus dorsi transfer (for superior–posterior RCTs)19,20, and SCR with autograft23-26 or ADM27-32. Arthroplasty is not advised in younger and higher-demand patients without glenohumeral osteoarthritis37.
The success rate of SCR with ADM and potential indications beyond age and activity level were explored in 86 patients retrospectively31 and in 59 patients prospectively32. In the Pennington study, superior capsular distance (arc length between the superior glenoid and medial greater tuberosity on anteroposterior radiographs) is reduced after SCR, and they hypothesized that this aids the success of concomitant repairs in massive RCTs31. The Denard study defined SCR success if the final American Shoulder and Elbow Surgeons (ASES) scores exceeded 50, ASES scores increased 17 points postoperatively, and no revision SCR or RTSA was required32. The 75.5% success rate in patients with Hamada stage 1 or 2 changes and 44.4% in those with Hamada stage 3 or 4 changes38 led them to recommend against SCR for greater than stage 2 changes32.
In addition to the successes using SCR, complications and second-look observations after SCR failure have been reported and should be considered. Mihata et al., using SCR with fascia lata autograft, noted tears in 4.2% of SCR grafts, and differences in outcomes in healed versus torn SCR grafts25. One re-evaluation described an SCR with ADM with a traumatic tear, necessitating revision repair between the infraspinatus and graft 6 months postoperatively33. Similarly, Zerr also described a tear of an SCR with ADM 8 months postoperatively, requiring revision reattachment of the graft to the glenoid and side-to-side repair to infraspinatus34.
Our patient was a high-functioning individual with preserved acromiohumeral interval and no radiographic or arthroscopic evidence of arthropathy of the glenohumeral joint. Per the conclusions of Pennington et al.31 and Denard et al.32, he was a good candidate for SCR, and we chose ADM allograft to preclude the morbidity of tendon transfer or harvest. The patient's pseudoparalysis and pain due to the HAGL lesion precluded a thorough instability examination, but his severe function-limiting pain and MRI findings were indications for surgery, consistent with other investigators39. It is possible that SCR graft failure was avoided by graft healing imparting sufficient strength, the force being directed more anterior–inferior (away from the SCR graft), or a combination of these 2 factors. Biopsies of SCR with ADMs in canine subjects40 and in a patient with a graft tear 3 months postoperatively28 demonstrated cellular infiltration at 6 weeks and similar gross and histologic appearance of graft and native tendon by 6 months. Due to these previous findings and absence of graft failure in our case, we elected not to perform an intraoperative biopsy; however, these data would have strengthened our findings. Although previous studies used history, examination, and/or MRI to assess SCR graft integrity postoperatively, this case report is novel in its arthroscopic confirmation of graft integrity and vascularization 1 year postoperatively with accompanying improvement in shoulder range of motion and strength compared to the preoperative baseline.
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