Superior Capsule Reconstruction for Reinforcement Before Arthroscopic Rotator Cuff Repair Improves Cuff Integrity

Abstract

Objectives:We developed the superior capsule reconstruction (SCR) technique for surgical treatment of irreparable rotator cuff tears. In these patients, SCR restores shoulder stability and muscle balance, consequently improving shoulder function and relieving pain. In this study, we evaluated whether SCR for reinforcement before arthroscopic rotator cuff repair (ARCR) improves cuff integrity, especially in the case of severely degenerated supraspinatus tendon.Methods:A series of 32 consecutive patients (mean age, 69.0 years) with severely degenerated but reparable rotator cuff tears (medium size: 1-3 cm, and large size: 3-5 cm) underwent SCR using fascia lata autografts for reinforcement before ARCR. To determine the indications for SCR for reinforcement, the severity of degeneration in the torn supraspinatus tendon was assessed. We evaluated fatty degeneration in the muscle by using the Goutallier grade; we also scored retraction of the torn tendon (grade 0: no retraction; grade 1: torn edge on the greater tuberosity; grade 2: torn edge on the lateral half of the humeral head; grade 3: torn edge on the medial half of the humeral head; grade 4: torn edge on the glenoid) and tendon quality (grade 0: normal; grade 1: slightly thin, or slight fatty degeneration in the tendon part; grade 2: severely thin, or severe fatty degeneration in the tendon part; grade 3: severely thin, and severe fatty degeneration in the tendon part; grade 4: no tendon). In patients classified with grade 3 or 4 in at least two of these three categories, arthroscopic SCR was performed for reinforcement, after which the torn tendon was repaired over the fascia lata graft. To assess the benefit of SCR for reinforcement, the results from these 32 patients were compared with those after ARCR alone in 91 consecutive patients with medium (1-3 cm) to large (3-5 cm) rotator cuff tears (mean age, 66.7 years). Torn tendons were repaired by using double-row suture-bridges with and without SCR for reinforcement. By using t- and chi-square tests, we compared the American Shoulder and Elbow Surgeons (ASES) score, active shoulder range of motion (ROM), and cuff integrity (Sugaya MRI classification) between ARCR with and without SCR as well as between before surgery and at final follow-up (mean, 19 months; 12 to 40 months). A significant difference was defined as P < 0.05.Results:All 32 patients who underwent SCR before ARCR had no postoperative re-tear and demonstrated type I cuff integrity (sufficient thickness with homogeneously low intensity), whereas those treated with ARCR without SCR had a 5.5% incidence (5/91 all patients) of postoperative re-tear, and 22.1% (19/86 healed patients) had type II (partial high-intensity area) or III (insufficient thickness) cuff integrity. ASES score, active elevation, active external rotation, and active internal rotation increased significantly after ARCR both with and without SCR (P < 0.001) (Table). Postoperative ASES score and active ROM did not differ significantly between ARCR with and without SCR, but the Goutallier grade of the supraspinatus was significantly higher for ARCR with SCR (mean, 2.8) than for ARCR alone (mean, 2.1) (P < 0.0001).Conclusion:SCR for reinforcement prevented postoperative re-tear after ARCR and improved the quality of the repaired tendon on MRI. Furthermore, postoperative functional outcomes were similar in patients who underwent ARCR alone and those who also underwent SCR, even though degeneration of the torn tendons was greater in the latter group.TableASES score (points)ASES score (points)Active elevation (degrees)Active elevation (degrees)External rotation (degrees)External rotation (degrees)Internal rotationInternal rotationBeforeAfterBeforeAfterBeforeAfterBeforeAfterARCR with SCR (n=32)45.188.21331613849L4L1ARCR alone (n=91)34.490.61331695258L2T11