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Evaluation of an Incorporated Superior Capsular Reconstruction Graft

A Case Report

Samade, Richard MD, PhD1; Jones, Grant L. MD1; Bishop, Julie Y. MD1

doi: 10.2106/JBJS.CC.18.00378
Case Reports
Free
Disclosures

Case: A 66-year-old man presented with 2 years of atraumatic right shoulder pain and difficulty with overhead activities. Radiographs and magnetic resonance imaging demonstrated Hamada stage I changes and a massive irreparable rotator cuff tear involving the supraspinatus and infraspinatus. He underwent superior capsular reconstruction with acellular human dermal matrix (SCR with ADM) allograft. Diagnostic arthroscopy and humeral avulsion of the glenohumeral ligament repair 1 year postoperatively showed that the SCR appeared intact and vascularized.

Conclusions: This is the first study to confirm visually that SCR with ADM allograft is well-vascularized and intact 1 year post-operatively.

1Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio

E-mail address for J.Y. Bishop: Julie.Bishop@osumc.edu

Investigation performed at The Ohio State University Wexner Medical Center, Columbus, Ohio

Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/A847).

Rotator cuff tears (RCTs) are typically a degenerative process, present in 25.6% of individuals in their 60s and with pain in 34.6% of patients1. The supraspinatus alone is torn in 72% of RCTs, and in 21% of RCTs, the supraspinatus, infraspinatus, and teres minor are all torn2. Massive RCTs, often defined as full-thickness tears of at least 2 tendons and/or retraction greater than 5 cm3,4, can have tolerable pain and function in well-selected low-demand patients3. However, arthropathy, decreased tendon excursion, muscular atrophy, and fatty infiltration of the rotator cuff develop over time and can complicate a future repair3-5. Re-tear rates following massive RCT repairs are reported to be as high as 94%, often due to the above-mentioned factors and overall poor tendon quality4,6-8.

Several alternative treatment options for symptomatic chronic massive RCTs have been investigated: debridement9,10, subacromial spacers11,12, partial RCT repair13,14, biceps tendon transfer15,16, pectoralis major transfer17,18, latissimus dorsi transfer19,20, and reverse total shoulder arthroplasty (RTSA)21,22. However, for younger and more active patients without arthropathy, these treatments have yielded inconsistent outcomes. Mihata and associates described superior capsular reconstruction (SCR) using fascia lata autograft in biomechanical and clinical studies, which provided superior stabilization of the glenohumeral joint and facilitated return to work and recreational sports23-26. However, the Mihata technique does require additional surgical time and patient morbidity with graft harvesting5.

Acellular human dermal matrix (ADM) allograft is an alternative to fascia lata autograft for SCR and has demonstrated improved pain and function27, signs of vascularization 3 months postoperatively28, and encouraging biomechanical and clinical results29-32. Arthroscopic postoperative evaluations of torn SCR with ADMs have been described33,34. However, we describe a comprehensive clinical, imaging, and arthroscopic evaluation (1 year postoperatively) of an intact and healed (as determined by visual evidence of vascularization, especially at attachment sites at the glenoid rim and greater tuberosity) SCR graft using human ADM.

The patient was informed that data concerning the case would be submitted for publication, and he provided consent.

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Case Report

Initial Presentation

A 66-year-old right-hand dominant man, with an active lifestyle as a landscaper, presented with 2 years of progressive atraumatic right shoulder pain and difficulty with overhead activities. He failed nonoperative treatments for pain, including activity modification, physical therapy, and a corticosteroid injection. The patient had 90° of active forward elevation (FE), 160° of passive FE, 40° of active external rotation (ER), and internal rotation (IR) to the L3 level in the right shoulder. His left shoulder demonstrated 170° of active FE, 70° of active ER, and IR to the T12 level. He had 4/5 strength to FE and ER in the right shoulder. He had negative subscapularis signs and Hornblower's signs. Preoperative radiographs of his right shoulder, which had no prior surgical interventions, revealed no fracture, dislocation, or arthropathy of the glenohumeral joint (Fig. 1). Magnetic resonance imaging (MRI) of the right shoulder showed no glenohumeral arthropathy, a complete and retracted tear of the supraspinatus with Goutallier grade 3 fatty atrophy35, and full-thickness tearing of the infraspinatus (Fig. 2). Given the patient's age, active lifestyle, lack of glenohumeral osteoarthritis, and massive RCT with muscular atrophy, we elected to proceed with RCT repair (if possible) versus SCR using Arthrex (Naples, FL) ArthroFLEX ADM. This option was attractive due to the lack of donor site morbidity with autograft harvest, and it was a joint-preserving option.

Fig. 1

Fig. 1

Fig. 2

Fig. 2

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Initial Treatment and Postoperative Course

A right shoulder diagnostic arthroscopy was performed and demonstrated no significant glenohumeral osteoarthritis, irreparable supraspinatus tendon retracted medial to the glenoid, and attached posterior portion of the infraspinatus (Fig. 3). The subscapularis tendon was intact, and the long head of biceps tendon had a significant tearing. Thus, subpectoral biceps tenodesis, subacromial decompression, infraspinatus repair, and arthroscopic SCR were indicated. For the SCR, two 1.4 mm all suture glenoid anchors were placed medial to the superior labrum (one at the coracoid base and one posterior to the first). The graft was arthroscopically passed lateral to medial, and a lateral row repair was done using 2 anchors (Fig. 4). Additionally, a side-to-side repair of the SCR graft to the infraspinatus was done using 3 sequentially tied FiberWire sutures (Fig. 4). The patient was immobilized for 6 weeks in a sling, then started physical therapy. Six months postoperatively, his right shoulder had 170° of active FE, 70° of active ER, and IR to the lumbosacral junction, all with 5/5 strength. The patient did well until a fall onto his right shoulder 1 year postoperatively. His right shoulder then had 30° of active FE (with 3/5 strength), 150° of passive FE, and 50° of active ER. There was no axillary nerve palsy. MRI sequences of the right shoulder demonstrated a new humeral avulsion of the inferior glenohumeral ligament (HAGL), no acute labral pathology, intact SCR graft, and intact subscapularis tendon. After discussion with the patient, right shoulder arthroscopy and open HAGL lesion repair were indicated due to several weeks of function-limiting pain and pseudoparalysis.

Fig. 3

Fig. 3

Fig. 4

Fig. 4

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Second Treatment and Postoperative Course

Repeat arthroscopy demonstrated intact and well-vascularized SCR graft at its anchor points and side-to-side repair with infraspinatus, from medial to lateral (Fig. 5). The humeral head had no superior migration and the HAGL lesion was visualized in the anterior–inferior glenohumeral joint. On the bursal side, the SCR graft was intact, with similar thickness (3 mm) to its preoperative state, appropriate graft tension, and good vascularity (Fig. 6). We then completed an open HAGL repair. After 6 weeks of postoperative immobilization, the patient was started on physical therapy. At 6 months postoperatively, his right shoulder had no instability, 170° of active FE, 70° of active ER, and IR to the T12 level. His preoperative pseudoparalytic presentation was attributed to inferior humeral head subluxation with attempted arm elevation (due to the HAGL lesion), which improved after repair.

Fig. 5

Fig. 5

Fig. 6

Fig. 6

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Discussion

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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